Catástrofes Perioperatorias 2019 PDF

Charles J.
Fox, III
Elyse M. Cornett
G.E. Ghali
Editors
Catastrophic
Perioperative
Complications
and Management
A Comprehensive Textbook
https://t.me/Anesthesia_Books
Catastrophic Perioperative Complications
and Management
Charles J. Fox, III
Elyse M. Cornett
G. E. Ghali
Editors
Catastrophic
Perioperative
Complications
and Management
A Comprehensive Textbook
Editors
Charles J. Fox, III Elyse M. Cornett
Department of Anesthesiology Department of Anesthesiology
LSU Health Shreveport LSU Health Shreveport
Shreveport, LA Shreveport, LA
USA USA
G. E. Ghali
Department of Oral and Maxillofacial
Surgery/Head and Neck Surgery
Louisiana State University Health Sciences
Center – Shreveport
Shreveport, LA
USA
ISBN 978-3-319-96124-8 ISBN 978-3-319-96125-5 (eBook)

https://doi.org/10.1007/978-3-319-96125-5
Library of Congress Control Number: 2019930728
© Springer Nature Switzerland AG 2019

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V
Contents
1 Sleep Apnea....................................................................................................................................... 1
J. Arthur Saus, Katelyn R. Hopper, and Barron J. O’Neal Jr.
2 Postoperative Visual Loss: Anatomy, Pathogenesis,

and Anesthesia Considerations............................................................................................ 19
Andrew J. Brunk, Ken P. Ehrhardt Jr, Jeremy B. Green, Susie M. Mothersele,
and Alan David Kaye
3 Substance Abuse............................................................................................................................ 31
Elyse M. Cornett, Rebecca A. Moreci, Nadejda Korneeva, and Mark R. Jones
4 Awareness.......................................................................................................................................... 45
Tomas Carvajal, Lopa Misra, Michael Molloy, and Veerandra Koyyalamudi
5 Shared Airway: Techniques, Anesthesia Considerations,

and Implications............................................................................................................................. 61
Jennifer E. Woerner, Andrew T. Meram, and Spencer Armuth
6 Dental Injury: Anatomy, Pathogenesis, and Anesthesia

Considerations and Implications......................................................................................... 83
G. E. Ghali, Andrew T. Meram, and Blake C. Garrett
7 Complications of General Anesthesia............................................................................... 95

Jeffrey P. Cardinale, Nigel Gillespie, and Liane Germond
8 Pain Management......................................................................................................................... 105

Michael Franklin, J. Arthur Saus, Yury Rapoport, and Nicholas Darensburg
9 Regional Anesthesia/MAC........................................................................................................ 121

Treniece Eubanks, Yury Rapoport, Leslie Robichaux, Farees S. Hyatali,
and Tomasina Parker-Actlis
10 Massive Perioperative Hemorrhage: Considerations

in Clinical Management............................................................................................................. 133
Usama Iqbal, Jaime Sanders, Longqiu Yang, Mingqiang Li,
Marcus Zebrower, and Henry Liu
11 Cardiovascular System Damaging Events...................................................................... 151

J. Arthur Saus, Harish Siddaiah, and Farees S. Hyatali
12 Airway and Respiratory System Damaging Events................................................... 161

Evangelyn Okereke, Shilpadevi Patil, and Gregory Allred
13 Burns in the Operating Room................................................................................................. 177

Kraig S. de Lanzac and Joseph R. Koveleskie
VI Contents
14 Eye Injury............................................................................................................................................ 197

Chizoba N. Mosieri and Mary E. Arthur
15 Severe Peripheral Nerve Injury............................................................................................. 213

Rayhan Tariq, S. Nini Malayaman, Hong Yan, Usama Iqbal, Mingqiang Li,
16 Catastrophic Perioperative Complications and Management

in the Trauma Patient.................................................................................................................. 227
Elyse M. Cornett, Matthew B. Novitch, Julia B. Kendrick, Jennifer M. Kaiser,
Patricia D. Toro-Perez, Alex B. Shulman, Forrest Ericksen, Christopher Zeman,
and Alan David Kaye
17 Obstetrics............................................................................................................................................ 245
R. Edward Betcher and Karen Berken
18 Catastrophic Complications in Pediatric Anesthesiology..................................... 261

Sonja A. Gennuso, Brendon M. Hart, Hiroki Komoto, and Tomasina Parker-Actlis
19 Ambulatory and Office-Based Surgery............................................................................ 275

Joshua E. Dibble and Arthur L. Calimaran
20 Remote Locations.......................................................................................................................... 287

Mary E. Arthur and Chizoba N. Mosieri
21 Equipment Problems................................................................................................................... 305

Benjamin Homra and Allison Clark
22 Perioperative Medication Errors.......................................................................................... 317

Blas Catalani, Steven Boggs, and Ezekiel Tayler
23 Physiologic Monitoring: Technological Advances Improving

Patient Safety................................................................................................................................... 327
Jeffrey A. Planchard
24 Quality of Care in Perioperative Medicine..................................................................... 339

Matthew R. Eng, Tayyab Khan, and Ramla Farooq
25 Professional Liability................................................................................................................... 347

Jonathan P. Eskander, Tara Marie P. Eskander, and Julia A. LeMense
26 Medical Malpractice..................................................................................................................... 355

J. L. Epps and Courtney E. Read
27 Closed Claims Project Overview........................................................................................... 371

Adam P. Roth, Patrick O. McConville, and Robert Craft
VII
Contents
28 Peer Review in Perioperative Medicine............................................................................ 389

Ophélie Loup and Markus M. Luedi
29 Perioperative Complications Chapter: Shared Decision-Making

and Informed Consent................................................................................................................ 397
William K. Hart, Robert C. Macauley, Daniel A. Hansen, and Mitchell H. Tsai
Supplementary Information
Index�� 409
Contributors
Gregory Allred, DO Jeffrey P. Cardinale, MD, PhD

LSU Health Shreveport Ochsner Clinic Foundation
Shreveport, LA, USA New Orleans, LA, USA
Spencer Armuth, DMD, MD Tomas Carvajal, MD

Department of Oral and Maxillofacial Department of Anesthesiology
Surgery/Head and Neck Surgery and Perioperative Medicine, Mayo Clinic
Louisiana State University Health Sciences Phoenix, AZ, USA
Shreveport, LA, USA Blas Catalani, III, MD
Department of Anesthesiology
Mary E. Arthur, MD University of Tennessee Health Science Center
Department of Anesthesiology Memphis, TN, USA
and Perioperative Medicine
Medical College of Georgia Augusta University Allison Clark, MD
Augusta, GA, USA Ochsner Clinic Foundation
Jefferson, LA, USA
Karen Berken, MD
Department of Obstetrics/Gynecology Elyse M. Cornett, PhD
Louisiana State University Health Sciences Department of Anesthesiology
Center-Shreveport LSU Health Shreveport
Shreveport, LA, USA Shreveport, LA, USA
R. Edward Betcher, MD, FACOG Robert Craft, MD

Department of Obstetrics/Gynecology Department of Anesthesiology
Louisiana State University Health Sciences University of Tennessee Graduate
Center-Shreveport School of Medicine
Shreveport, LA, USA Knoxville, TN, USA
Steven Boggs, MD, FASA, MBA Nicholas Darensburg, MD

University of Tennessee Health Science Center LSU Health Shreveport
Memphis, TN, USA Shreveport, LA, USA
Andrew J. Brunk, MD Kraig S. de Lanzac, MD, FASA

Department of Anesthesiology Tulane University School of Medicine
Louisiana State University School of Medicine Department of Anesthesiology
New Orleans, LA, USA New Orleans, LA, USA
Rebecca A. Moreci, BS, MA Joshua E. Dibble, DO

LSU Health Shreveport Department of Anesthesiology
Shreveport, LA, USA University of Mississippi Medical Center
Jackson, MS, USA
Arthur L. Calimaran, MD
Department of Anesthesiology Ken P. Ehrhardt Jr, MD
University of Mississippi Medical Center Department of Anesthesiology
Jackson, MS, USA Louisiana State University School of Medicine
New Orleans, LA, USA
IX
Contributors
Matthew R. Eng, MD Liane Germond, MD
LSU Health Science Center, University Medical Ochsner Clinic Foundation
Center New Orleans New Orleans, LA, USA
G. E. Ghali, DDS, MD, FACS
J. L. Epps, MD Department of Oral and Maxillofacial
Department of Anesthesiology Surgery/Head and Neck Surgery
The University of Tennessee Medical Center Louisiana State University Health Sciences
Knoxville, TN, USA Center – Shreveport
Shreveport, LA, USA
Forrest Ericksen
Medical College of Wisconsin Nigel Gillespie, MD
Milwaukee, WI, USA Department of Anesthesiology
Ochsner Clinic Foundation
Jonathan P. Eskander, MD, MBA New Orleans, LA, USA
Department of Anesthesiology, LSU Health
Shreveport, LA, USA Jeremy B. Green, MD
Tara Marie P. Eskander, MPH Louisiana State University School of Medicine
Chesapeake, VA, USA New Orleans, LA, USA
Treniece Eubanks, MD Daniel A. Hansen, MD
LSU Health Shreveport The Mayo Clinic
Shreveport, LA, USA Scottsdale, AZ, USA
Ramla Farooq, MD Brendon M. Hart, DO

Department of Family Medicine Department of Anesthesiology
Jackson Park Hospital LSU Health Shreveport
Chicago, IL, USA Shreveport, LA, USA
Michael Franklin, DO William K. Hart, MD
College of Medicine, University of Florida The University of Vermont Larner
Gainesville, FL, USA College of Medicine
Burlington, VT, USA
Blake C. Garrett, DDS, MD
The University of Michigan Medical School
Ann Arbor, MI, USA
Louisiana State University Health
Sciences Center – Shreveport
Benjamin Homra, MD
Shreveport, LA, USA
Ochsner Clinic Foundation
Jefferson, LA, USA
Sonja A. Gennuso, MD
Katelyn R. Hopper, MD
LSU Health Shreveport
Shreveport, LA, USA
Shreveport, LA, USA
X Contributors
Farees S. Hyatali, MD Veerandra Koyyalamudi, MBBS

LSU Health Shreveport and Perioperative Medicine Mayo Clinic
Shreveport, LA, USA Phoenix, AZ, USA
Usama Iqbal, MD Julia A. LeMense, JD, LLM, MPH

Department of Anesthesiology & New York, NY, USA
Perioperative Medicine
Drexel University College of Medicine, Mingqiang Li, MD
Hahnemann University Hospital Department of Anesthesiology
Philadelphia, PA, USA Xiangyang Central Hospital
Xiangyang, Hubei, China
Mark R. Jones, MD
Harvard Medical School, Beth Israel Henry Liu, MD
Deaconess Medical Center Department of Anesthesiology &
Department of Anesthesia, Perioperative Medicine
Critical Care and Pain Medicine Drexel University College of Medicine,
Boston, MA, USA Hahnemann University Hospital
Philadelphia, PA, USA
Jennifer M. Kaiser
Medical College of Wisconsin Ophélie Loup, MD
Milwaukee, WI, USA Department of Cardiovascular Surgery
Bern University Hospital Inselspital,
Alan David Kaye, MD, PhD University of Bern
Department of Anesthesiology Bern, Switzerland
Louisiana State University School of Medicine
New Orleans, LA, USA Markus M. Luedi, MD
Julia B. Kendrick, MD Bern University Hospital Inselspital,
Department of Anesthesiology University of Bern
LSU Health Shreveport Bern, Switzerland
Shreveport, LA, USA
S. Nini Malayaman, MD
Tayyab W. Khan, MD Department of Anesthesiology &
Town Square Anesthesia, Perioperative Medicine
Community First Medical Center Drexel University College of Medicine,
Chicago, IL, USA Hahnemann University Hospital
Hiroki Komoto, DO
Department of Anesthesiology Robert C. Macauley, MD
LSU Health Shreveport Department of Palliative Medicine
Shreveport, LA, USA Oregon Health Sciences University
Portland, OR, USA
Nadejda Korneeva, PhD
Patrick O. McConville, MD
Department of Emergency Medicine
The University of Tennessee Medical Center
Shreveport, LA, USA
Knoxville, TN, USA
Joseph R. Koveleskie, MD, FASA
University of Queensland, Ochsner Clinical
School, Department of Anesthesiology
XI
Contributors
Andrew T. Meram, MD Jeffrey A. Planchard, MD, MBA

Department of Oral and Maxillofacial Department of Anesthesiology
Surgery/Head and Neck Surgery Springhill Medical Center
Louisiana State University Health Sciences Mobile, AL, USA
Shreveport, LA, USA Yury Rapoport, MD
Lopa Misra, DO LSU Health Shreveport
Department of Anesthesiology Shreveport, LA, USA
and Perioperative Medicine Mayo Clinic
Phoenix, AZ, USA Courtney E. Read, JD
Watson Roach Batson Rowell and
Michael J. Molloy, MD Lauderback, P.L.C.
Department of Anesthesiology Knoxville, TN, USA
and Perioperative Medicine Mayo Clinic
Phoenix, AZ, USA Leslie Robichaux, MD
Chizoba N. Mosieri, MD, MBBS LSU Health Shreveport
Department of Anesthesilogy LSU Health Shreveport, LA, USA
Shreveport, LA, USA
Adam P. Roth, MD
Susie M. Mothersele, MD Department of Anesthesiology
Department of Anesthesiology The University of Tennessee Medical Center
Louisiana State University School of Medicine Knoxville, TN, USA
Jaime Sanders, MD
Matthew B. Novitch, BS Department of Anesthesiology &
Medical College of Wisconsin Perioperative Medicine
Milwaukee, WI, USA Drexel University College of Medicine,
Hahnemann University Hospital
Barron J. O’Neal Jr., MD Philadelphia, PA, USA
LSU Health Shreveport J. Arthur Saus, FASA
Shreveport, LA, USA Department of Anesthesiology
Evangelyn Okereke, MD Shreveport, LA, USA
LSU Health Shreveport Alex B. Shulman
Shreveport, LA, USA Medical College of Wisconsin
Milwaukee, WI, USA
Tomasina Parker-Actlis, MD
Department of Anesthesiology Harish Siddaiah, MD
LSU Health Shreveport Department of Anesthesiology
Shreveport, LA, USA LSU Health Shreveport
Shreveport, LA, USA
Shilpadevi Patil, MD
Department of Anesthesiology Rayhan Tariq
LSU Health Shreveport Department of Anesthesiology &
Shreveport, LA, USA Perioperative Medicine
Drexel University College of Medicine,
Hahnemann University Hospital
XII Contributors
Ezekiel Tayler, DO Longqiu Yang, MD
Department of Anesthesiology & Department of Anesthesiology
Cardiothoracic Surgery Huangshi Central Hospital
Lankenau Medical Center Huangshi Shi, Hubei Province, China
Wynnewood, PA, USA
Hong Yan, MD
Patricia D. Toro-Perez Department of Anesthesiology
Medical College of Wisconsin Wuhan Central Hospital
Milwaukee, WI, USA Wuhan, Hubei, China
Mitchell H. Tsai, MD, MMM, FASA Marcus Zebrower, MD

Department of Anesthesiology Department of Anesthesiology &
The University of Vermont Larner Perioperative Medicine
College of Medicine Drexel University College of Medicine,
Burlington, VT, USA Hahnemann University Hospital
Department of Orthopedics and Rehabilitation
The University of Vermont Larner Christopher Zeman
College of Medicine Medical College of Wisconsin
Burlington, VT, USA Milwaukee, WI, USA
Jennifer E. Woerner, MD
Louisiana State University Health
Sciences Center – Shreveport
Shreveport, LA, USA
1 1
Sleep Apnea
J. Arthur Saus, Katelyn R. Hopper, and Barron J. O’Neal Jr.
1.1 Identifying Patients with OSA – 8

1.1.1 Common Questionnaires – 8
1.1.2 Anesthetic Management – 10
1.1.3 The American Academy of Sleep Medicine Defines
Mild OSA as AHI 5–15, Moderate OSA as AHI 15–30,
and Severe OSA as AHI >30 – 10
1.1.4 Patients with Moderate-to-Severe OSA on CPAP Therapy
Should Continue CPAP in the Preoperative Period – 10
1.2 Consequences of Untreated OSA (Renal) – 12
1.3 Consequences of Untreated OSA (Endocrine) – 13
1.4 Review Questions – 13
1.5 Answers – 14
References – 14

C. J. Fox, III et al. (eds.), Catastrophic Perioperative Complications and Management,
https://doi.org/10.1007/978-3-319-96125-5_1
2 J. A. Saus et al.
Sleep apnea is a sleep disorder characterized with hypertension. When considering a group of
1 by respiratory pauses or periods of hypopnea hypertensive patients from the general popula-
(shallow breathing) during sleep. An episode of tion, and not just to those presenting for surgery,
hypopnea is not considered to be clinically signifi- 3–4% of the women and 7–9% of the men are
cant unless there is a 30% (or greater) reduction in expected to be diagnosed with moderate-to-severe
flow lasting for 10 s or longer and accompanied by obstructive sleep apnea. Some estimates state that
a 4% (or greater) desaturation in the person’s O2 obstructive sleep apnea has been identified in up
levels or if it results in arousal or fragmentation to 24% of adult surgical patients and note that
of sleep. obesity is a major risk factor, with up to 71% of
Each respiratory pause can last for a few sec- morbidly obese suffering from obstructive sleep
onds to a few minutes, and they happen many apnea [7]. Factors that increase vulnerability for
times a night [1]. In the most common form, the disorder include age, male sex, obesity, fam-
this follows loud snoring [2]. There may also be a ily history, menopause, craniofacial abnormali-
choking or snorting sound as breathing resumes. ties, and certain health behaviors such as cigarette
As it disrupts normal sleep, those affected may smoking and alcohol use. The prevalence of snor-
experience sleepiness or feel tired during the day ing and sleep apnea increases with age, with a peak
[3]. In children, obstructive sleep apnea (OSA) between the ages of 55 and 60 years old; women
may cause problems in school or hyperactivity [4]. start to snore later in life than do men, with an
When considering obstructive sleep apnea, increased prevalence following menopause [6].
there should first be a clarification of the differ- Often, sleep apnea is undiagnosed, even though
ence between the terms “sleep apnea” and “apnea.” chronically present. The only “symptom” patients
While the term “apnea” refers to the suspension may even notice is tiredness during the day, morn-
of breathing or absence of spontaneous breathing, ing headaches, difficulty concentrating, and feeling
and may be performed voluntarily in the awake irritable, depressed, or having mood swings or per-
patient, “sleep apnea” is not associated with a sonality changes [4]. This “tiredness” is frequently
conscious voluntary choice. Certainly, similari- due to continual disruptions of the normal sleep
ties exist, as usually there is often no change or pattern during the night, as an apneic episode
minimal change in the gas volume contained in causes transient arousal from the deeper stages of
the lungs in either situation. While movement natural sleep. As the breathing patterns become
of the muscles associated with inhalation is usu- shallow, or even transiently interrupted, a person
ally voluntarily ceased during intentional apnea, will often partially arouse from a deep stage of sleep
during sleep apnea there are frequently continued to a lighter stage, until normal breathing resumes. At
attempts to breathe, with the associated contrac- that point, the patient may again return to a deeper
tion of these muscles of respiration. During these stage of sleep, only to have the process repeat again
continued attempts though, no overt gas exchange a short while later. Because this person does not
occurs due to airway obstruction. In sleep apnea, spontaneously arouse to the stage of actual wakeful-
the episodes of apnea may last for 10 s or lon- ness, this pattern may not be recognized, and may
ger, and there may be as many as 300–500 epi- go on for a prolonged period, with the only notice-
sodes each night. Sleep apneas can be caused by able symptom being that of “tiredness” during the
obstruction of the upper airways, especially the day. Beyond just the sensation of tiredness, exces-
pharynx, or by impaired central nervous system sive daytime sleepiness may occur; this may inter-
respiratory drive [5]. Depending on the patency fere with job responsibilities, making it difficult to
of the airways, there may or may not be a flow pay continual sharp attention to critical tasks such
of gas between the lungs and the environment. as operating machinery or driving a car [8].
Concurrently though, gas exchange within the Although obstructive sleep apnea is more
lungs and cellular respiration is not affected, at common in patients who are overweight, this
least not in the early stages of the episode. condition is not restricted to obese or morbidly
Sleep apnea is probably a more common obese patients. Nighttime snoring suggests at
problem in patients presenting for surgery than least a partial airway obstruction during sleep.
is realized. It is estimated that 9% of middle-aged Even small children with enlarged tonsil tissue
women and 24% of middle-aged men have sleep in the throat may experience obstructive sleep
apnea [6]. It is an established risk factor associated apnea. Any condition that causes partial airway
Sleep Apnea
3 1
obstruction, whether from hypertrophied tissue A type of central sleep apnea was described in
from an infection or just from excessive tissue “Ondine,” the 1938 play by French dramatist, Jean
presence in the pharyngeal and hypopharyngeal Giraudoux, based on the story of “Undine” from
area due to any hereditary or acquired condition, 1811 by the German romanticist Friedrich de la
can result in obstructive sleep apnea. Sleep apnea Motte Fouque (and actually traces back to even
does not even have to arise from hypertrophy of earlier European folk tales). This play presented
tissue in the airway. Central sleep apnea, felt to be the nymph, Ondine, who tells her future husband
due to modification in the way signals to breathe Ritter Hans, whom she had just met, that “I shall
are processed in the brain, may occur along with be the shoes of your feet ... I shall be the breath
obstructive airway conditions or have no associa- of your lungs.” However, after their honeymoon,
tion with any other airway condition. Sleep apnea Hans is reunited with his first love, Princess
can raise a patient’s risk for high blood pressure, Bertha, and Ondine leaves Hans. Ondine’s father,
coronary heart disease with resulting heart attack the King of the Sea, inflicted a curse on Hans, her
or heart failure, cardiac arrhythmias, stroke, obe- unfaithful husband, so that he would have to con-
sity, diabetes, and death [9]. sciously remember to breathe. Due to this, he was
Three forms of sleep apnea are described: unable to sleep [11]. On meeting Ondine again,
obstructive (OSA), central (CSA), and a combi- on the day of his wedding to Bertha, Hans tells her
nation of the two called mixed. OSA is the most that “all the things my body once did by itself, it
common form [2]. Risk factors for OSA include does now only by special order ... a single moment
being overweight, a family history of the condi- of inattention and I forget to breathe.” Apparently,
tion, allergies, a small airway, and enlarged tonsils Ondine truly took his breath away, for following
[6]. During obstructive sleep apnea, breathing her kiss, Hans apparently forgets to take his next
is interrupted by a blockage of airflow, while in breath and dies.
central sleep apnea, breathing stops due to a lack Central hypoventilation syndrome (CHS) is a
of effort to breathe [2]. Opioid administration respiratory disorder that may result in respiratory
during surgery or in the perioperative period arrest during sleep. Congenital central hypoven-
certainly increases the risk of the latter, especially tilation syndrome (CCHS) and sudden infant
during the immediate postoperative period in the death syndrome (SIDS) were long considered
postanesthesia care unit. rare disorders of respiratory control. The study
People with sleep apnea may not be aware they of genes related to autonomic dysregulation and
have it; in many cases it is first observed by a fam- the embryologic origin of the neural crest led to
ily member [2]. Sleep apnea is often diagnosed the discovery of PHOX2B as the disease-defining
with an overnight sleep study [10]. For a diagnosis gene for CCHS [13].
of sleep apnea, more than five episodes an hour Central hypoventilation syndrome can either
must occur [11]. be congenital or acquired later in life and is fatal if
Treatment may include lifestyle changes, untreated. Symptoms of congenital hypoventila-
mouthpieces, breathing devices, and surgery [2]. tion syndrome usually become apparent shortly
Lifestyle changes may include avoiding alcohol, after birth [11]. Acquired central hypoventila-
losing weight, smoking cessation, and sleeping tion syndrome can develop as a result of severe
on one’s side. Breathing devices include the use of injury or trauma to the brain or brainstem [12].
a CPAP machine to deliver Continuous Positive Congenital cases are very rare and involve a failure
Airway Pressure. of autonomic control of breathing. In 2006, there
With no considerations of gender differences, were only about 200 known cases worldwide, and
obstructive sleep apnea affects 1–6% of adults and with further investigations, by 2008, only 1000
2% of children [5, 12]. It affects males about twice total cases were known [11]. Although rare, cases
as often as females [5]. While people at any age can of long-term untreated central hypoventilation
be affected, it occurs most commonly among those syndrome have been reported. It is also known as
55–60 years old [2, 5]. Central sleep apnea affects Ondine’s curse.
less than 1% of people [13]. Without treatment During sleep, the drive to maintain a pat-
sleep apnea may increase the risk of heart attack, ent upper airway is diminished. When this is
stroke, diabetes, heart failure, irregular heartbeat, combined with the susceptibility to collapse, the
obesity, and motor vehicle collisions [2]. result is obstruction. There is a decrease in the
4 J. A. Saus et al.
responsiveness of the body to maintain wakeful- structure, soft tissue, vascular structures, and
1 ness ventilation, a decrease in diameter of the mucosal factors. Neuromuscular support is
upper airway causing increased resistance, as well derived from motor tone for ventilation and mus-
as an increase in the compliance of the pharynx cle activity in the upper airway itself. Structurally,
promoting collapse. In anesthesiology, this results the upper airway is enclosed not only by the soft
in perioperative considerations and complica- tissues but also by the mandible, maxilla, skull
tions that may be partially avoided or improved base, and cervical spine. Anatomic changes to this
with an understanding of the pathophysiology craniofacial structure can result in narrowing of
and risks involved with obstructive sleep apnea. the upper airway, leaving one more susceptible
Sleep-related changes range from healthy to obstruction during sleep. Examples of such a
individuals who experience a small increase in change would include retrognathia or inferior
PaCO2, to those who develop motion of the soft displacement of the hyoid. The soft tissues sur-
tissue with inspiration leading to turbulent air- rounding the upper airway include skin, adipose,
flow which causes snoring, to complete collapse vascular, and lymphatic tissue. An increase in
or obstructive sleep apnea. In anesthesiology, amount of these tissues or increased pressure on
all patients on this spectrum are seen, and it is the upper airway will subsequently result in nar-
necessary to manage sleep apnea not only peri- rowing. An increase in pressure exerted by the tis-
operatively but also intraoperatively, particularly sues promotes upper airway collapse and can be
in MAC sedation cases where the airway is not secondary to large tongue, size of the pharyngeal
protected. walls, adipose tissue, large tonsils, vascular con-
The muscle activity in the upper airway is gestion, etc.
reduced while asleep. This has little effect on peo- In patients with unfavorable anatomy prone to
ple who are in good health, but in those who are collapse, hypoxia and hypercapnia may cause vas-
susceptible, this results in narrowing of the upper cular volume to increase thereby further increas-
airway. The tensor palatini muscle relaxes, which ing the soft tissue pressures exerted on the upper
results in a tendency toward obstruction of the airway lumen. This increase in vascular volume
upper airways and causes a decrease in inspira- may also be caused by other comorbidities such as
tory flow upon sleep onset. congestive heart failure, hypertension, and renal
Upper airway narrowing results in increased disease, for which lying flat may cause a rostral
resistance as well as compliance, leaving the air- shift in volume. This rostral shift in volume may
way prone to collapse. This narrowing causes be seen in various positions required for surgery,
airflow to become turbulent and results in a including supine and prone position.
limitation to the flow. The turbulent flow results In the upper airway, the tensor palatini muscle
in resonant motion of the tissue in the soft palate is responsible for tensing the pharyngeal wall
and soft tissue in the upper airway. This combi- thereby decreasing the degree to which the pha-
nation of movement of the soft tissue with tur- ryngeal opening can be compressed. During sleep,
bulent flow and limitation to airflow results in this muscle relaxes causing the upper airway to
what is universally recognized as snoring. Even become more susceptible to collapse, and in cer-
in healthy patients, noisy breathing can be heard tain individuals can result in transmural pressures
during sleep or sedation secondary to the turbu- on the pharynx by the soft tissues overcoming the
lent airflow. intraluminal pressures which maintain patency
In patients who do not snore, airflow is not of the upper airway. The genioglossus muscle is
limited, just as it is not limited in the wakeful responsible for dilating the pharynx in prepara-
state. In those who do snore and have airflow tion for inspiration. Relaxation of this muscle
limitations, there is a much higher risk of airway during sleep can result in narrowing of the phar-
collapse. Complete closure may occur in patients ynx and thereby increasing inspiratory r esistance.
with extreme airway narrowing during sleep, During sleep, there is also a decrease in
which leads to obstructive sleep apnea. the tonic activity of the upper airway muscles
The patency of the upper airway is maintained that reflexively increase during wakefulness in
by the structural foundation of the airway as well response to a negative pressure in the upper air-
as its neuromuscular support. The structure of way during inspiration. During REM sleep atonia
the upper airway is determined by craniofacial of all muscles involved in pharyngeal patency
Sleep Apnea
5 1
and respiration occurs, with the exception of the circumference of the neck and the adipose tissue
diaphragm. This can accentuate hypoventilation within the pharyngeal wall increases, so do the col-
and hypoxia. Following the induction of general lapsing pressures on the lumen of the upper airway.
anesthesia, apnea tends to occur more quickly This applies to any cause for redundant tissue in
in patients with susceptible airways. Obstructive the upper airway, such as for those with large ton-
sleep apnea (OSA) can lead to desaturations more sils or adenoids and obesity. Other structural risks
quickly than anticipated, and difficulty reopen- include short mandibles, an abnormal maxilla, or
ing the airway with positive pressure may be a wide craniofacial base. In children, in addition
experienced. Devices and techniques are used to large tonsils and adenoids, cerebral palsy and
fairly often to assist ventilation. Examples of these other neuromuscular disorders may play a role in
include oral airways or nasopharyngeal airways obstructive sleep apnea. Nasal passage obstruction
(also known as nasal trumpets) which combat the via structural abnormalities or congestion are also
relaxed musculature and excess tissue. Assisted risk factors for OSA. Smoking has been shown
positive pressure ventilation prior to apnea helps to be a risk factor for OSA in that it potentiates
stent the airway open and usually prevents com- pulmonary disease such as COPD, limiting one’s
plete collapse (similar to the CPAP machine). responsiveness to sleep-related increase in PaCO2
To maintain alveolar ventilation when there is and ventilatory motor drive. It also is thought to
an increase in airway resistance, the patient must narrow the airway by increasing inflammation
increase work of respiration. During sleep the and fluid in the upper airway tissues. Increasing
body may not recognize this change in resistance age is a risk factor for OSA, as upper airway tissues
readily, and effort of breathing does not increase become increasingly compliant with normal age-
to compensate. This results in decreased alveolar related changes. The male gender is twice as likely
ventilation and rise in PaCO2. In those without to develop OSA although overweight women
OSA, this increase in PaCO2 would restore their remain at risk and menopause has been shown to
ventilatory drive; however, in those with OSA, it be an independent risk factor for OSA.
may not, resulting in worsening hypercapnia. Not only can obesity-related factors become a
During non-rapid eye movement sleep, inter- family trait, but heritable craniofacial anomalies
costal and abdominal muscles (accessory muscles) also make family history a risk factor for obstruc-
play a larger role in maintaining tidal volume than tive sleep apnea. Congestive heart failure, end-stage
during wakefulness. During rapid eye movement renal disease, and pregnancy can all increase the risk
sleep, a loss of accessory muscle activity occurs. of obstructive sleep apnea as they promote a rostral
Therefore, an even greater decrease in ventilation shift of vascular volume in the recumbent posi-
accompanies REM sleep. The natural increase in tion. Pulmonary diseases such as COPD, asthma,
PaCO2 associated with decrease in ventilation and pulmonary fibrosis also increase risk of OSA
during sleep is termed physiologic hypercapnia, as secondary to decreased ventilatory motor drive and
it is seen even in healthy individuals. The PaCO2 reflexive ventilation with increased PaCO2 during
is noted to increase by 4–5 mmHg during sleep in sleep. Acromegaly is a risk factor as the tongue is
all patients, including those without sleep apnea. large and upper airway tissues are in abundance.
In patients with obesity or pulmonary disease Stroke, hypothyroidism, and polycystic ovarian dis-
such as COPD, the changes that are seen during ease are also recognized risk factors for OSA.
sleep are exaggerated and can lead to obstruction, During anesthesia preoperative evaluations,
hypoxia, and worsening ventilation- perfusion there is a recurring need to evaluate patients for
mismatch [6, 14, 15]. risk factors, signs, and symptoms of obstructive
When considering risk factors for sleep apnea, sleep apnea. This impacts perioperative man-
the strongest risk factor, obesity, is usually the one agement, particularly the pain management
that generally is felt to be the most obvious. The strategies and intraoperative induction technique
risk of OSA in these patients increases proportion- and extubation criteria [14, 16].
ally with body mass index (BMI) or more spe- Untreated OSA has been linked to the develop-
cifically with neck circumference. For men, risk is ment of coronary artery disease, cardiac arrhyth-
increased with a neck circumference greater than mias, hypertension [17, 18], and even heart failure
17 inches and for women, risk is increased with a [19]. Although it is impossible to pinpoint OSA
neck circumference greater than 15 inches. As the as causative for each of these, it has been shown
6 J. A. Saus et al.
that with treatment of OSA, cardiovascular outgrowth factor. Increased levels of homocysteine
1 comes have improved [20, 21]. The individual and blood glucose along with insulin resistance
with OSA experiences periods of apnea during and decreasing HDL levels have also been noted.
sleep, resulting in hypoxia and hypercapnia. This Studies have shown elevated troponin-I levels in
individual is subsequently awakened from sleep, patients with increasingly severe OSA and hypox-
which restores the patency of their upper airway. emia suggesting myocardial injury. In patients with
As the individual returns again to sleep, this cycle preexisting coronary artery disease, it has been
repeats itself. These cycles of obstruction, apnea, shown that those with OSA are at higher risk of
and arousal from sleep have effects on all bodily developing major cardiac adverse events [25–27].
systems [15, 22]. The hypoxemia and hypercap- OSA has been described as a modifiable risk
nia associated with OSA stimulate chemorecep- factor for atrial fibrillation, both new onset and
tors which increase respiratory rate. Additionally, reoccurrence after cardioversion or ablation. This
impaired venous return to the heart, changes in may be in part caused by OSA-related hypox-
cardiac output, and arousal from sleep occur. All emia and hypercapnia, autonomic dysfunction,
of these phenomena are thought to cause a great and exaggerated negative intrathoracic pressures
increase in sympathetic activity during sleep in which can be transmitted across the atria during
patients with OSA. This autonomic dysfunction inspiration while obstructed.
causes an increase in circulating plasma catechol- During apneic events of sleep, hypoxia can
amines and hypertension. Blood pressure does delay depolarization of the heart, causing the
not decrease during sleep in these patients, as it patient to become bradycardic. When the sympa-
typically does during sleep in healthy individuals. thetic system is suddenly activated after an apneic
It has been shown that patients who are treated period, the patient becomes tachycardic. This bra-
with CPAP have a lower risk of developing hyper- dycardic-tachycardic trend along with respiratory
tension than those who are untreated [23]. acidosis can cause QT prolongation and can trig-
Interestingly, it has also been shown that the ger atrial and ventricular arrhythmias. The brady-
hypertension associated with OSA seems to be more cardia seen during apneic periods can be so severe
resistant to antihypertensive medications [24]. that asystole results, particularly if the patient has
In patients with OSA, treatment with CPAP preexisting conduction defects. Sudden cardiac
has actually been shown to decrease blood pres- death can occur in some instances, and preexist-
sure regardless of baseline. A meta-analysis ing ventricular tachycardia or ectopy is a risk fac-
demonstrated that systolic blood pressure was tor for such an event in someone with OSA.
reduced by 2.6 mmHg with CPAP. Although this Individuals with OSA are at risk of developing
may seem quite small, a 1–2 mmHg decrease in pulmonary hypertension, and the development
blood pressure has been shown to significantly of pulmonary hypertension adversely impacts
reduce the risk of myocardial infarction, stroke, prognosis. The survival rates in patients who have
and heart failure. The effects are amplified when developed pulmonary hypertension are lower
combined with an antihypertensive regimen [25]. than those who have not. In an observational
For patients who have more profound sleep study, it was determined that the 1-, 4-, and 8-year
apnea, with greater depths and durations of asso- survival rates with pulmonary hypertension were
ciated hypoxemia, treatment with CPAP tends 93%, 75%, and 43%, whereas survival rates in
to result in more significant reductions in their those without pulmonary hypertension were
elevated blood pressure. These effects on blood 100%, 90%, and 76% [28]. CPAP and weight loss
pressure have not only been shown with the use of surgeries have been shown to reduce pulmonary
CPAP but also for other treatments of OSA such artery systolic pressure and vascular resistance.
as upper airway surgeries or the use of devices It is thought that secondary to the nocturnal
which advance the mandible. stresses imparted on the body in an individual with
OSA increases the risk of a cardiovascular OSA, morning coagulation markers are elevated,
event by inducing or worsening hypertension causing such individuals to be two to three times
and increasing inflammatory mediators such as more likely to develop venous thrombosis [29].
C-reactive protein, “adhesion molecules,” inflam- In anesthesiology, care is provided for many
matory and anti-inflammatory cytokines, matrix patients with untreated OSA. Awareness of the
metalloproteinase-9, and vascular endothelial associated cardiovascular complications may help
Sleep Apnea
7 1
manage these patients more effectively. In par- The fragmentation of sleep with OSA caus-
ticular, when associated with sleep apnea, aware- ing daytime sleepiness and cognitive impairment
ness of minor EKG changes that may indicate causes increased risk in daytime activities such
ischemia, QT prolongation, or the beginning of as driving or using machinery. Cognitive dys-
an arrhythmia, along with DVT prophylaxis and function associated with OSA includes dimin-
hypertension management, potentially improves ished reaction time, motor performance, speed
the overall intraoperative management of the of processing information, attention, working
patient. These relatively minor cardiovascular memory, executive function, retention of mem-
findings, when considered out of context, may not ory, visuospatial learning, and level of alertness.
be considered as significant risks. This cognitive dysfunction as a whole is likened
OSA is known to cause daytime sleepiness, to intoxication [34]. In children the cognitive dys-
hypersomnolence, and cognitive impairment. function mirrors ADHD and includes inability to
These symptoms may be readily identified in hold attention, hyperactivity, aggressive behav-
patients with Pickwickian syndrome. Pickwickian iors, and impulsivity. Interestingly, despite sig-
syndrome, also known as obesity hypoventilation nificant improvements in cognitive dysfunction
syndrome (OHS), is similar in pathophysiology to with treatment of OSA, long-term damage has
OSA; however, OHS occurs during waking hours. been found on neuroimaging in the hippocam-
Patients with this syndrome experience chronic pal, prefrontal, cingulate, and parietal areas sug-
hypoventilation even while awake, and approxi- gesting permanent effects of untreated OSA [31,
mately 90% of patients with OHS have concurrent 35]. This knowledge should remind the anesthe-
obstructive sleep apnea [30]. Symptoms of this syn- tist to be hypervigilant with monitoring patients
drome include daytime somnolence, headaches, for seizures and for stroke in the perioperative
depression, shortness of breath, and acrocyanosis period. It should also remind everyone caring
[31]. The name, Pickwickian syndrome, came from for the patient with OSA to maintain increased
Charles Dickens’ first novel, The Posthumous Papers awareness of cognitive dysfunction that may have
of the Pickwick Club (more commonly known as impacts on perioperative functioning.
The Pickwick Papers) in which he described Joe, a It has been described that patients with OSA
character from the book, in 7 Chap. 4:
experience prolonged apneic periods for up to
1 week postoperatively. This may influence the
»» The object that presented itself to the eyes decision for the surgical setting and postoperative
of the astonished clerk, was a boy–a wonder-
management, particularly in light of the need for
fully fat boy–habited as a serving lad, stand-
analgesic opioids [36]. In one study, ventilatory
ing upright on the mat, with his eyes closed
dysfunction was noted to be most significant on
as if in sleep. He had never seen such a fat
the second and third postoperative nights, depict-
boy, in or out of a travelling caravan; and this,
ing the need for prolonged monitoring during
coupled with the calmness and repose of his
the recovery period in patients with OSA [37]. In
appearance, … smote him with wonder.
the ambulatory setting, even in patients who had
Joe is constantly hungry, very red in the face, and been undiagnosed, it was found that patients who
is always falling asleep in the middle of tasks. are high risk for OSA required an increased level
of care in the perioperative setting. These patients
»» “Sleep!” said the old gentleman, ‘he’s always were found to be more difficult to intubate, were
asleep. Goes on errands fast asleep, and
more likely to require vasopressors intraopera-
snores as he waits at table.” “How very odd!”
tively, and were more likely to require oxygen in
said Mr. Pickwick. “Ah! odd indeed,” returned
PACU [38].
the old gentleman; “I’m proud of that boy–
In several studies, however, patients with OSA
wouldn’t part with him on any account–he’s a
who underwent surgery in the ambulatory setting
natural curiosity!”
did not tend to require unanticipated hospital
The risk of stroke, and therefore neurologic dam- admission more frequently than their counter-
age, is also increased in obstructive sleep apnea parts. They were also not found to have increased
[32, 33]. There is a demonstrated association rate of cardiovascular or respiratory complica-
between OSA and seizure disorder. Treating coex- tions compared to those patients without OSA
isting OSA enhances treatment of seizures. [22]. It has been demonstrated that patients with
8 J. A. Saus et al.
OSA who have surgery in the hospital setting may patients with obstructive sleep apnea [24, 41].
1 have more serious and frequent postoperative This guideline notes that a reduction in periop-
complications including arrhythmia, myocardial erative complications may result from correctly
infarction, respiratory distress, and prolonged identifying patients at high risk for OSA to focus
ICU stays. It is thought that to reduce the risk of on perioperative precautions and interventions.
such complications, the patient may be treated The majority of patients with OSA present-
with CPAP in the perioperative period, particu- ing for surgery are undiagnosed, and it is often
larly if they are on CPAP at home. The positive impractical, due to time and cost constraints, to
effects of perioperative prophylactic CPAP have undergo formal polysomnography testing (the
also been shown in those patients who have been “gold standard”) [42]. Screening tools, includ-
undiagnosed with OSA but who are suspected ing STOP-Bang, P-SAP, Berlin, and ASA check-
to be at high risk [27]. In high-risk patients or list, have been formulated and validated for this
those with known OSA, it is recommended that purpose; however, screening tools vary in accu-
in PACU oxygen saturation and hemodynamics racy across different populations and may not
be monitored carefully for 2 h postoperatively, have the same accuracy when implemented in
with the patient’s head elevated 30° and with early clinical practice. Questionnaires are used most
implementation of CPAP in the instance of any commonly and have modest accuracy compared
desaturation. to clinical models using simple clinical measure-
It is well accepted that opioids should be mini- ments [24, 41].
mized where possible, as intraoperative use of The STOP-Bang questionnaire has been found
opioids tends to increase the risk of postoperative to be the most validated screening tool in surgi-
respiratory depression [39]. If patient- controlled cal patients, sleep clinic patients, and the general
systemic opioids are used, continuous background population. In a meta-analysis of clinical screen-
infusions should be used with extreme caution ing tools for OSA, the STOP-Bang was identified
or avoided entirely. If the patient is to remain as being easy to use, having a favorable diagnostic
in-hospital postoperatively in addition to PACU odds ratio. A STOP score ≥2 with BMI >35 kg/m2
monitoring, the patient should be kept on contin- or male sex is associated with greater risk of OSA
uous supplemental oxygen administration (unless [24, 41]. This threshold is a good starting point
contraindicated by the surgical procedure); pulse for many institutions, but may need to be altered
oximetry and CPAP should be implemented, to adjust for specific patient populations due to
regardless if they had previously been prescribed the inverse relationship between sensitivity and
CPAP or not [39]. In one study, nasal CPAP was specificity in any diagnostic test.
implemented in patients having a wide variety
of surgeries preoperatively and was continued
after extubation for 24–48 h postoperatively. This 1.1.1 Common Questionnaires
study concluded that there were no postoperative
complications for these patients related to the The STOP-Bang questionnaire (. Table 1.1) is a

use of CPAP, and they maintained the ability to patient-completed survey with yes/no questions
have sedatives, analgesics, and anesthetic agents assessing subjective symptoms and clinical signs:
administered as needed without further consider- snoring, tiredness, observed apnea, high blood
ation of the patient’s OSA status [40]. pressure, BMI (>35 kg/m2), age (>50), neck cir-
cumference (>40 cm), and gender (male). High
risk is determined by more than five affirmative
1.1 Identifying Patients with OSA answers to the questions presented.
The Perioperative Sleep Apnea Prediction
Given the increased perioperative risks for (P-SAP; see . Table 1.2) score validates six of the

patients with sleep apnea undergoing general eight elements of STOP-Bang, but it also uses the
anesthesia, ASA guidelines stress the importance presence of diabetes and the upper airway physi-
of perioperative diagnosis and management of cal exam findings of Mallampati score and thy-
these patients. The Society of Anesthesia and Sleep romental distance. It also uses yes/no questions.
Medicine (SASM) recently published a guideline A P-SAP score >4 out of 9 is indicative of sleep
on preoperative screening and assessment of adult apnea.
Sleep Apnea
9 1
.. Table 1.1 STOP-Bang questionnaire
Yes/No
Snoring (Do you snore loudly?) □ □
Tiredness (Do you often feel tired, fatigued, or sleepy during daytime?) □ □
Observed apnea (Has anyone observed that you stop breathing or choke or gasp during your □ □
sleep?)
High blood pressure (Do you have or are you being treated for high blood pressure?) □ □
BMI (Is your body mass index >35 kg/m2?) □ □
Age (Are you older than 50 years?) □ □
Neck circumference (Is your neck circumference greater than 40 cm [15.75 inches]?) □ □
Gender (Are you male?) □ □
Score 1 point for each positive response

Scoring interpretation: 0–2 = low risk; 3–4 = intermediate risk; ≥5 = high risk
.. Table 1.2 P-SAP questionnaire

Box 1.1 ASA Checklist
Category 1: Predisposing physical characteristics
Yes/No
A. BMI ≥ 35
B. Neck circumference >43 cm (17 in) men and
Male gender □ □
>40 cm (16 in) women
History of snoring □ □ C. Craniofacial abnormalities affecting the airway
D. Anatomical nasal obstruction
“Thick” neck □ □ E. Tonsils touching or nearly touching the midline
Mallampati 3 or 4 □ □ Category 2: History of apparent airway obstruction
during sleep
Hypertension (treated or untreated) □ □
A. Snoring
Type II diabetes (treated or untreated) □ □ B. Frequent snoring
C. Observed pauses in breathing during sleep
BMI ≥ 30 □ □ D. Awakens from sleep with choking sensation
E. Frequent arousals from sleep
Age ≥ 43 □ □
Category 3: Somnolence
Thyromental distance < 4 cm □ □
A. Frequent somnolence or fatigue despite
adequate “sleep.”
Score ≥ 4 is indicative of sleep apnea
B. Falls asleep easily in a non-stimulating environ-
ment.
C. [Parent or teacher comments that the child
appears sleepy during the day.]
The ASA checklist (7 Box 1.1) is divided into

D. [Child is often difficult to arouse at typical wak-
three categories – predisposing physical charac- ing time.]
teristics, history of airway obstruction during If two or more responses in the first category
sleep, and somnolence. Two out of three positive are positive, then category 1 is positive.
categories are indicative of OSA. If two or more responses in the second cat-
egory are positive, then category 2 is positive.
In addition to these questionnaires, the Berlin If one or more responses in the third category
Questionnaire coupled with sleep testing is used are positive, then category 3 is positive.
to establish the diagnosis of sleep apnea. Patients High risk for OSA: At least two categories are
with sleep apnea may present for surgery without positive. Low risk: zero or one category positive.
receiving a prior diagnosis. The diagnosis of sleep *Responses in brackets apply ONLY to pediatric
patients
apnea may be difficult to distinguish from normal
10 J. A. Saus et al.
variations in sleep behavior [43]. The Berlin myocardial infarction. Patients scheduled for elec-
1 Questionnaire, developed in 1996, screens for tive surgery who are at higher risk for OSA may be
sleep apnea based on ten questions across three referred for preoperative polysomnography.
categories. Each category contains between two The diagnosis and severity of sleep apnea
and five questions [44]. should be confirmed both with obtaining the
Category 1 presents four questions which deal patient’s history and physical and reviewing sleep
with snoring and also asks if there was awareness study results. A commonly used severity index is
that anyone had witnessed pauses in the patient’s AHI – the number of complete breathing cessa-
breathing during sleep. Positive responses in this tions (apnea) and partial obstructions (hypopnea)
category include presence of snoring, snoring that per hour of sleep. To be considered as an apnea epi-
occurs at least three times a week or more, snor- sode, the pauses in breathing must last for at least
ing that is louder than talking, snoring that can 10 s and be associated with a decrease in blood
be heard in adjacent rooms, snoring that is loud oxygenation. The AHI score is calculated as the
enough to bother other people, or any witnessed average number of apnea events per hour of sleep.
apnea episodes more than three times a week dur- The diagnosis of OSA is based on AHI ≥ 5 and
ing sleep. either excessive daytime sleepiness or two other
Category 2 questions the presence of tired- symptoms of OSA (choking/gasping during sleep,
ness or fatigue that is noticed following sleep, recurrent nighttime awakenings, unrefreshing
or the sensation of feeling tired or fatigued dur- sleep, daytime fatigue, or impaired concentration).
ing normal waking hours. A response of at least
three or four times per week to either question
constitutes a positive response. This category 1.1.3 The American Academy
then questions whether “nodding off ” or falling of Sleep Medicine Defines Mild
asleep has occurred while driving a vehicle and, if OSA as AHI 5–15, Moderate
so, how often this is noted to occur (if occurring OSA as AHI 15–30, and Severe
more than three or four times a week, this also
OSA as AHI >30
constitutes a positive response in this category of
questions).
It may be necessary to refer some patients to
Category 3 questions if the individual has a
sleep medicine for reassessment, especially those
diagnosis of high blood pressure and asks for the
patients who are non-compliant with CPAP, those
calculated body mass index. Scoring of each cat-
with recent OSA exacerbations, and those who
egory of questions is done separately; a positive
have recently undergone OSA-related airway
response to at least two questions in either the
surgery.
first or second category is a positive response to
that section. The third section is scored as a posi-
tive response if the patient has a BMI greater than
30 or has hypertension. If two or more categories 1.1.4 Patients with Moderate-to-
demonstrate a positive score, the patient is con- Severe OSA on CPAP Therapy
sidered to have a high likelihood of sleep apnea. Should Continue CPAP
An alternate approach to scoring considers more in the Preoperative Period
than five positive responses from all categories
to be indicative of obstructive sleep apnea. This Preoperative considerations should include
survey has a disadvantage of being lengthy with anticipation of a difficult airway, the use of short-
similar sensitivity and specificity to the other active anesthetic agents (e.g., propofol, remifen-
three tests. tanil, desflurane), careful management of opioid
administration, verification of full reversal of
neuromuscular blockade prior to extubation, and
1.1.2 Anesthetic Management extubation in a non-supine position [45].
Current guidelines encourage anesthesiolo-
Patients with sleep apnea are at increased risk of gists and surgeons to evaluate for OSA well before
complications postoperatively including adverse surgery. The evaluation should be initiated in a
respiratory events, arrhythmias, hypertension, and pre-anesthesia clinic or via direct consultation
Sleep Apnea
11 1
Preoperative Evaluation
Patient with presumptive

Patient with known OSA
diagnosis of OSA
Optimized comorbid conditions

Optimized comorbid
Patients with non-optimized and postoperative pain can be
conditions and able to use
comorbid conditions managed predominately by using
CPAP after discharge
non-opioid analgesia
Not suitable for ambulatory

Proceed with Proceed with
surgery, may benefit from
ambulatory surgery ambulatory surgery
diagnosis and treatment
.. Fig. 1.1 Preoperative evaluation. (Adapted from Joshi et al. [46])
from the surgeon. A preoperative interview obstructive sleep apnea, as it has been shown to
allows practitioners to gather a thorough patient lower the risk of postoperative complication [39];
history and physical, including data concern- however, data on other techniques including non-
ing the patient’s sleep habits and OSA screen- invasive positive pressure ventilation (NIPPV),
ing. This might include an appropriate survey or mandibular advancement and oral appliances,
diagnostic measure or information from a formal and preoperative weight loss are not sufficient to
sleep study. The evaluation should include all promote their use. NIPPV can be considered if
past medical history with records if available, an patients do not respond to CPAP [39].
inquiry into past airway or anesthetic complica-
tions, documentation of the presence of hyperten- 1.1.4.2 Intraoperative Considerations
sion and cardiovascular problems, and any other Difficult tracheal intubation occurs eight times
congenital or acquired medical comorbidities. more frequently in OSA patients than non-OSA
Performing an OSA survey and gathering per- patients. In general, all patients should be ade-
tinent physical findings (airway classification, quately preoxygenated before induction of anes-
nasopharyngeal characteristics, neck circumfer- thesia, but this becomes even more important in
ence, tongue and tonsil size) are encouraged. The the patient with a known history of obstructive
decision must be made between the anesthesi- sleep apnea. Adequate preoxygenation simply
ologist and the surgeon whether to manage the allows a few more minutes to accomplish airway
patient based on clinical criteria alone or whether instrumentation prior to oxygen desaturation.
to pursue further diagnostic studies and initiate Sometimes, these few extra minutes are critical
specific OSA treatment prior to the procedure. and potentially lifesaving. To improve the direct
Literature is insufficient as to which patients with laryngoscopic view, the practitioner may build
OSA can be managed on an inpatient vs outpa- a progressively elevated ramp under the patient
tient basis (. Fig. 1.1) [39].
from the scapula to the head, aligning the tra-
gus with the sternal notch in a line parallel to the
1.1.4.1 Preoperative Considerations floor. Commercial devices are available for this,
Preoperative preparation is aimed at optimizing but this can also be accomplished by blankets
the patient’s physical status. Initiating continu- which are stacked progressively higher as they
ous positive airway pressure (CPAP) should be approach the patient’s head. Airway adjuncts
considered, particularly in patients with severe must be readied in advance such as video
laryngoscopy, flexible fiber-optic bronchoscopy, is during the recovery period of an OSA patient
1 or even laryngeal masks. It must be kept in mind when most airway emergencies occur. Routine
however that flexible fiber-optic bronchoscopy post-op monitoring of blood pressure, heart rate,
requires patient and equipment preparation, so respiratory rate, and oxygen saturation should be
it is very difficult to use this as an emergency employed. Maintaining semi-upright or sitting
“rescue technique” for an intubation failure fol- positioning and continuing preop airway tech-
lowing anesthesia induction. OSA patients are niques (CPAP, NIPPV) are recommended [39].
sensitive to respiratory depressant effects of OSA patients who receive opioids are 12–14 more
anesthetic agents due to redundant tissue and times as likely to experience oxygen desatura-
airway collapse and blunting of the physiologic tions than those patients who receive exclusively
response to hypoxia and hypercarbia. All central non-opioid analgesics. To avoid the over-admin-
depressant drugs diminish the action of the pha- istration of systemic opioids, regional/neuraxial
ryngeal dilator muscles thereby promoting pha- analgesia, or patient-controlled analgesia (PCA)
ryngeal collapse in OSA patients. For this reason, without a basal rate can be considered. Neuraxial
short-acting anesthetic agents are preferred over analgesia (spinal or epidural anesthesia) must
longer-acting agents. Extubation should be per- be used with caution, keeping in mind rostral
formed only after the patient is fully conscious spread of local anesthetics can contribute to either
with a patent airway and full reversal of neuro- immediate or delayed respiratory depression.
muscular blockade. When extubating, an oro- Supplemental oxygen should be administered
pharyngeal or nasopharyngeal airway should be continuously until the patient can maintain base-
in place, and additional trained personnel should line oxygen saturation on room air. Patients with
be readily available for management of two-per- OSA should not be discharged to an unmonitored
son mask ventilation [45]. setting until they are no longer at risk for respi-
The literature cannot definitively endorse ratory depression [39]. To determine this, the
exact anesthetic techniques as they apply specifi- patient’s respiratory function should be observed
cally to OSA patients. Nonetheless, the potential while in an unstimulating environment, prefer-
for post-extubation airway compromise must be ably while asleep, and monitoring for the risk of
considered in selecting intraoperative medica- respiratory depression should be maintained until
tions. When possible and practical, consideration the patient is no longer at risk for postoperative
should be given to management of superficial pro- respiratory depression [39].
cedures with local or regional nerve blocks with
or without moderate sedation. Preop techniques
(e.g., CPAP, oral appliances) should be continued 1.2 Consequences of Untreated OSA
during the procedure. Spinal/epidural anesthe- (Renal)
sia is also recommended over general anesthesia
whenever applicable [39]. Finally, general anes- The prevalence of chronic kidney disease (CKD)
thesia with a secure airway is recommended and OSA has increased over the last two decades,
over deep sedation without a secure airway, and associated with an aging population and an
awake extubation is preferable to deep extubation. increased prevalence of obesity. OSA-related
Extubation and recovery should be attempted in hypertension and cardiovascular disease may
positions other than supine – either lateral or have detrimental effects on renal function. The
semi-upright. In any case, careful titration of renal system is vulnerable to hypoxia, and recur-
respiratory depressants and sedatives, especially rent nocturnal hypoxemia may contribute to kid-
opioids, is crucial in managing postoperative air- ney disease through a multitude of effects on:
way compromise [39]. 55 Sympathetic nervous system activation
55 Hypertension
1.1.4.3 Postoperative Considerations 55 Low-grade systemic inflammation
Patients with obstructive sleep apnea are at 55 Oxidative stress
increased susceptibility to respiratory depres- 55 Accelerated atherosclerosis
sion based on severity of OSA, perioperative 55 Endothelial dysfunction
administration of sedatives and opioids, and
55 Activation of the renal renin-angiotensin
the invasiveness of the operative procedure. It system
Sleep Apnea
13 1
Hypoxia is considered an initiator of events lead- identified as an independent risk factor for the
ing to renal failure, causing inflammatory, apop- development of insulin resistance, glucose intol-
totic, and fibrotic responses [47]. This increases erance, and type II diabetes. Disorders of glucose
interstitial injury and promotes loss of peritubu- homeostasis in these patients are probably medi-
lar capillaries, which furthers hypoxia and leads ated by chronic intermittent hypoxia through the
into a vicious cycle. Hypoxia and frequency of activation of the sympathetic nervous system,
arousals during sleep are significantly associ- hypothalamic-pituitary-adrenal axis, pro-inflam-
ated with CKD, indicating that changes follow- matory paths, and oxidative stress [51, 52].
ing arousal may be deleterious with prolonged While all of this appears to present a some-
blood gas disturbances and breathing instability what bleak picture for the patient with sleep
[47, 48]. apnea, especially when coming for a surgical
procedure, there may be hope demonstrated by
research from Brigham and Women’s Hospital in
1.3 Consequences of Untreated OSA Boston, MA. The HeartBEAT Study, published
(Endocrine) in the June 12, 2014, issue of the New England
Journal of Medicine, compared treatments for
Obstructive sleep apnea is independently asso- sleep apnea in 318 patients, ages 45–75 years old,
ciated with metabolic syndrome; 74–85% of with moderately severe obstructive sleep apnea,
patients with OSA also have metabolic syndrome to see whether the risk of heart disease could
[49]. OSA itself may be a newly realized compo- be lowered by CPAP or nocturnal supplemen-
nent of metabolic syndrome. It has been observed tal oxygen, in comparison with sleep hygiene
that patients with moderate-to-severe OSA who and healthy lifestyle education of the patient.
are then treated with CPAP show a lowering The results of this research, which was funded
blood pressure and a partial reversal of metabolic by the American Recovery and Reinvestment
abnormalities associated with the metabolic syn- Act of 2009, found the use of continuous posi-
drome. OSA is associated with abnormal lipid tive airway pressure, CPAP, was superior to just
profiles including low HLD, high LDL, and high providing supplemental oxygen, and resulted
triglycerides. Treatment with CPAP results in the in significantly lower blood pressure compared
improvement of dyslipidemia, glucose metabo- to either nocturnal supplemental oxygen or an
lism, and insulin resistance. There is evidence educational control treatment [10]. They noted
that hypoxia due to OSA is independently associ- that previous studies had already documented
ated with dyslipidemia through the generation of that treatment of sleep apnea with CPAP had
stearoyl-coenzyme A desaturase-1 and reactive been shown to reduce blood pressure in patients
oxygen species, resulting in the peroxidation of with previously untreated hypertension and in
lipids and sympathetic system dysfunction [50]. those with treatment-resistant hypertension. For
Systemic inflammatory markers are higher in those patients with sleep apnea, the use of CPAP,
OSA patients than in controls. LDL metabolism both at home and during hospitalization, cur-
may be altered by cytokines (e.g., IL-1), result- rently appears to be the best approach to mini-
ing in alteration of endothelial cell cholesterol mizing risks and complications. Future research
metabolism, thereby promoting atherosclerosis may provide even better approaches to minimize
[50]. problems for these patients.
In the United States, 40% of people with OSA
will develop diabetes. This association is inde-
pendent of other comorbidities such as age, sex, 1.4 Review Questions
and obesity. Treatment with CPAP can improve
glucose tolerance in people with sleep apnea. ?? 1. How common is sleep apnea in middle-
Intermittent hypoxia has been shown in animal aged patients presenting for surgery?
studies to play a key role in metabolic dysfunction A. 3–4% of all middle-aged patients
associated with sleep apnea. Human data show B. 9% of middle-aged women and 24% of
acute (30 min) and prolonged (up to 180 min) middle-aged men
increases in plasma glucose levels during acute C. 3% of women and 7% of men
exposure to intermittent hypoxia. OSA has been D. Greater than 40%
?? 2. No gas exchange with ambient air occurs ?? 8. Which preop preparation for a patient
1 during sleep apnea because sleep apnea with obstructive sleep apnea has been
results in closure of the opening to the tra- shown to lower risk?
chea and lungs. A. Initiate (or continue) CPAP.
A. True B. Initiate noninvasive positive pressure
B. False ventilation (NIPPV).
C. Institute use of mandibular advance-
?? 3. Obstructive sleep apnea is expected to ment appliances.
be found only in obese or morbidly obese D. Weight loss.
patients who are middle aged or older.
A. True
B. False 1.5 Answers
?? 4. In which patient might postoperative vv 1. B

CPAP in PACU be beneficial?
A. A patient with OSA who uses CPAP at vv 2. B
home
B. A patient who is morbidly obese and vv 3. B
has hypertension
C. A patient who snores loudly while vv 4. D
sleeping
D. All of the above vv 5. D
?? 5. Which of the following makes smoking a vv 6. C

risk factor for OSA?
A. Smoking increases the amount of vv 7. D
redundant tissue in the upper airway.
B. Preexisting pulmonary disease. vv 8. A
C. Inflammation of the upper airway.
D. B and C.
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19 2
Postoperative Visual Loss:

Anatomy, Pathogenesis,
and Anesthesia
Considerations
Andrew J. Brunk, Ken P. Ehrhardt Jr, Jeremy B. Green,
Susie M. Mothersele, and Alan David Kaye
2.1 Introduction and History of Postsurgical

Vision Loss – 20
2.2 Anatomy of the Eye – 20

2.2.1 Basic Structures – 20
2.2.2 Vascular Supply – 21
2.3 Ophthalmologic Injuries – 21

2.3.1 Anterior and Posterior Ischemic Optic Neuropathy – 21
2.3.2 Central Retinal Artery Occlusion/Retinal Vascular
Occlusion – 23
2.3.3 Cortical Blindness – 24
2.4 Prevention of Postoperative Blindness – 25
2.5 Medicolegal Issues: Historic Considerations

and Concerns – 26
2.6 Conclusion – 27
2.8 Answers – 28
References – 28

https://doi.org/10.1007/978-3-319-96125-5_2
20 A. J. Brunk et al.
Key Points patients experiencing irreversible

55 Several different ophthalmologic injuries blindness.
55 Prevention is paramount; avoiding
2 can cause postoperative visual loss, with
anterior and posterior ischemic neuropa- direct pressures on the globe, position-
thy being the most common. ing the head above the level of the
55 Cardiac surgery and prone spinal sur- heart, and avoiding hypovolemia can
gery are associated with higher rates help reduce the risk of postoperative
of postoperative visual loss than other visual loss.
procedures; however, the complication is 55 Postoperative visual loss is a well-docu-
still relatively uncommon. mented source of medical malpractice
55 Treatment options for postopera- claims, and clinicians should discuss the
tive visual loss are limited, with many potential complication with patients.
Case
A 66-year-old female with a past back tenderness to palpation, experiences intraoperative hypo-
medical history including heart peripheral edema, weak peripheral tension. Following the procedure,
failure with a reduced ejection pulses, and an audible S3. Her pre- the patient is transported to the
fraction, type 2 diabetes mel- operative labs show H/H 7.5/22.5. PACU. There, the patient notifies
litus, peripheral vascular disease, The surgery is performed in the her nurse that she cannot see out
anemia of chronic disease, prone position. The procedure of her right eye. Ophthalmology
osteoporosis, and multilevel lasts over 7 h and is complicated is consulted, and examination
vertebral collapse is scheduled by substantial blood loss near- reveals optic disc swelling. Unfor-
for posterior multilevel lumbar ing 4 L, and the patient requires tunately, a year following the sur-
and thoracic fusion. The patient’s intraoperative transfusion. gery, the patient’s vision remains
preoperative exam is notable for Despite resuscitation the patient impaired.
2.1 Introduction and History ASA Task Force on Perioperative Visual Loss was
of Postsurgical Vision Loss established, which has provided practice adviso-
ries for clinicians [5].
Visual loss is an uncommon but potentially dev-
astating postsurgical complication. Since the
first case report was published in the late 1940s, 2.2 Anatomy of the Eye
there have been numerous studies on the topic.
The effects range from permanent visual loss to 2.2.1 Basic Structures
complete resolution of impairment [1–3]. The
pathophysiology of the damage is incompletely Familiarity with some pertinent anatomy of the eye
understood, but several types of ophthalmologic and visual pathways allows a better understanding
injuries have been recognized, suggesting there of the injuries seen in postoperative visual loss. The
may be multiple etiologies [4]. The relative rar- human eye is made up of three layers (. Fig. 2.1).

ity of perioperative visual loss has made research The outer layer includes the cornea, sclera, and
somewhat challenging. Most publications are case limbus. The middle layer includes the iris, ciliary
reports, case series, and case-control studies. To body, and choroid. The retina, the sensory part of
facilitate further exploration of the subject, the the eye, is the inner third layer. Visual processing
ASA Committee on Professional Liability estab- begins with the passage of light through the cornea
lished the ASA Postoperative Visual Loss (POVL) and then through the anterior chamber, which lies
Registry in 1999 – a database that includes detailed between the cornea and iris. It then tracks through
patient and surgical information on related cases. the opening in the iris known as the pupillary aper-
With the publication of additional findings, an ture. Subsequently, light travels through the lens
Postoperative Visual Loss: Anatomy, Pathogenesis, and Anesthesia Considerations
21 2
Cornea
Iris
Canal of Schlemm
Angle
Lens
Sclera
Choroid
Vitreous humor
Pigment
epithelium
Retina
Macula
Optic nerve
Fovea
.. Fig. 2.1 Anatomy of the human eye. (Drawing of the Eye. National Eye Institute, National Institutes of Health)
and vitreous humor to reach the retina. The optic the anterior optic nerve vulnerable to ischemia in
nerve, which can be subdivided into the anterior the setting of arterial hypotension. The posterior
and posterior optic nerves, transmits the signal optic nerve has less blood flow than its anterior
from the retina to the brain where neurological counterpart. Pial branches derived from the oph-
pathways lead to the occipital lobe, as well as other thalmic artery provide its supply [4].
structures involved in the processing of vision [6].
2.3 Ophthalmologic Injuries

2.2.2 Vascular Supply
2.3.1 Anterior and Posterior
The vasculature supplying the retina arises from Ischemic Optic Neuropathy
the ophthalmic artery. The central retinal artery
enters the posterior optic nerve and travels ante- The most common cause of postoperative vision
riorly to the optic disc. The central retinal artery loss is anterior and posterior ischemic optic
then branches into arteriolar and capillary beds neuropathy in non-ophthalmic procedures. This
supplying the retina. A second retinal vascular type of ocular injury is more common in high-
supply originates with the long and short poste- risk cardiac and spine fusion surgeries. It has also
rior ciliary arteries, which divide to form a capil- been seen with increasing prevalence in patients
lary bed within the choroid. Both vascular sources having orthopedic procedures for lower extremity
are required for normal vision [4]. joint replacements [7]. Shen et al.’s 10-year study
Perfusion of the anterior optic nerve comes revealed increased incidence of ischemic optic
largely from the posterior ciliary arteries. The neuropathy in patients with risk factors including
long posterior arteries lack anastomoses, leaving male gender, anemia, and age greater than 50 [7].
In the general population, ischemic optic neu- in AION but should be ordered to rule out other
ropathy can be divided into two types: arteritis and pathologies which can cause postoperative vision
nonarteritis. The arteritic type is almost always loss [14].
2 from giant cell arteritis, which is not seen after a No treatments have been proven to help
surgical procedure and is associated with systemic reverse the vision loss associated with anterior
inflammatory vasculitis of unknown etiology ischemic optic neuropathy. An ophthalmology
occurring in older people. The non-arteritic form consult is necessary at the onset of symptoms.
is most common and is the type seen after surgical High-dose oral steroids and oxygen therapy have
procedures. Ischemic optic neuropathy is further been utilized but have not proven to be benefi-
classified as anterior ischemic optic neuropathy or cial. Surgical intervention has not been proven to
posterior ischemic optic neuropathy [8]. be helpful. The visual loss is normally perma-
Postoperative anterior ischemic optic neu- nent although in rare cases, some patients have
ropathy (AION) is a painless loss of vision after regained some vision loss [15].
surgery related to insufficient blood supply to Posterior ischemic optic neuropathy (PION)
the optic nerve and optic disc. The incidence of is painless vision loss related to a vulnerable vas-
AION compiled from large studies is 42/172,569 cular area or infarction at optic nerve posterior to
(0.024%) after cardiac procedures and 1/126,666 the lamina cribrosa. The vision loss is normally
(0.00079%) after spinal cases [9]. AION is most noticed upon awaking from a procedure and is
common in patients with risk factors of cardio- most commonly total bilateral blindness [10]. The
vascular disease and in high-risk cardiac or spine overall incidence of PION after surgery from large
surgery requiring prone positioning. The exact compiled studies is 7/140,768 (0.005%) in spine
etiology and risk factors of this type of injury cases, 10/164,282 (0.0061%) in cardiac cases, and
remain unclear. Other risk factors are thought to 4/126,666 (0.0032%) in all other cases [9]. Many
include prolonged surgery, sleep apnea, anemia, different risk factors are associated with PION but
and arterial hypotension requiring vasopressors like its counterpart AION, the exact risk factors
[10]. Anatomic abnormalities of circulatory sup- are unclear. Perioperative anemia and hypoten-
ply of the optic nerve and a small optic cup to disc sion are thought to lead to PION. It is commonly
ratio may also contribute to the development of believed that a decrease in blood pressure and
AION after surgery [11]. Although risk factors are oxygen-carrying capacity limits oxygen supply to
not certain, it appears that patients with a predis- the posterior optic nerve [9]. Prone spinal proce-
position for risk factors linked to ischemia seem dures and surgeries in the Trendelenburg positon
to be the most likely mediators for postoperative can lead to PION by increasing venous pressure
AION [10]. to the orbits [9, 16]. Excessive blood loss and mas-
Diagnosis of anterior ischemic optic neu- sive fluid replacement in cases requiring prone
ropathy must be differentiated from its posterior positioning have also been noted as likely risk
counterpart, as well as other ocular pathologies. factors for developing posterior ischemic optic
Vision loss in AION is usually seen immediately neuropathy [17].
after the procedure, but it is not uncommon for Posterior ischemic optic neuropathy is typi-
a patient to start having symptoms an entire day cally seen upon awakening from a surgical pro-
after the procedure. When this occurs, it is nor- cedure in the operating room or after extubation
mally sudden and progresses over the course of in intensive care unit. Diagnosis should be made
the next few days [12]. The diagnosis of AION is after complete history and physical exam. The
clinical and based off of history, physical exam, patient’s history should include either complete
and ophthalmologic exam. Important aspects of vision loss or, less commonly, partial visual field
the patient’s history are age, cardiovascular risk deficit after surgical procedure. Other risk fac-
factors, timing of visual loss, and recent history of tors should be noted such as type of surgery,
procedure or surgery [12]. Physical exam findings amount of blood loss, fluid resuscitation during
include afferent pupillary light reflex deficit; visual surgery, and cardiovascular risk factors. Physical
field defects, including scotoma or even com- exam findings in PION are similar to that of
plete vision loss; and a dilated fundoscopic exam AION demonstrating visual field deficits and
demonstrating optic disc swelling and splinter afferent pupillary light deficit. A main differ-
hemorrhages [10, 13]. An MRI is unremarkable ence between PION and its anterior counterpart
23 2
is a normal optic disc and fundoscopic exam in inadequate circulation, ischemic damage to the
PION, whereas AION shows optic disc swelling optic disc and retina ensues.
and hemorrhaging [17, 18]. Treatment for PION While ischemic optic neuropathy is currently
starts with an immediate ophthalmology con- the most common underlying injury leading
sultation, which should be sought for all cases to postoperative visual loss, previous reports of
and causes of postoperative blindness. An urgent vision loss were attributed to retinal ischemia.
MRI with gadolinium should be ordered to rule Hypotension and ocular compression were iden-
out other causes of visual loss such as pituitary tified as suspected etiologies [1–3]. An early pub-
apoplexy. Additional recommended manage- lication described a series of eight neurosurgical
ment is to monitor and to treat any aberrant patients suffering unilateral postoperative vision
vital signs, hemoglobin levels, and/or inadequate loss. These surgeries were performed in sitting
oxygenation. These recommended treatments or prone position using a horseshoe headrest,
for posterior ischemic optic neuropathy are not which was believed to place direct pressure on the
proven as compared with AION. Visual loss is patients’ eyes, contributing to retinal ischemia. In
normally lifelong with little to no vision gained support of this hypothesis, the authors demon-
throughout a patient’s lifetime after the initial strated that ocular compression and hypotension
insult [19, 20]. cause retinal ischemia in monkeys [3]. This work
leads to the term “headrest syndrome” for central
retinal artery occlusion in patients undergoing
2.3.2 entral Retinal Artery
C surgery with a horseshoe headrest. These early
Occlusion/Retinal Vascular reports raised awareness among anesthesiologists,
Occlusion leading some to modify their equipment and
patient positioning to avoid the complication [3].
As previously described, the central retinal Despite new precautions, CRAO continues
artery arises from the ophthalmic artery and to be a concern. A large population-based study
supplies blood to the optic disc and the retina. published in 2009 identified a retinal vascular
Conceptually, central retinal artery occlusion occlusion rate of 1.54 per 10,000 discharges fol-
(CRAO) is like an ocular stroke (. Fig. 2.2).
lowing spinal, orthopedic, cardiac, and general
When occluded by embolus or when faced with surgery over a 10-year period. Older age, male
gender, and blood transfusion were associated
with higher prevalence. Of the types of surgeries
analyzed, cardiac surgery had the highest inci-
dence of retinal vascular occlusion at 6.67 per
10,000 cases [7]. A separate retrospective study
covering a 10-year period specifically examined
retinal artery occlusion following cardiac surgery.
The results, published in 2016, revealed an inci-
dence of 7.77 per 10,000 cases [21].
CRAO normally presents with painless mon-
ocular vision loss. If the central retinal artery is
occluded but a cilioretinal artery is present – an
anatomical variation reported in close to 50% of
patients – central vision might be spared [22].
The diagnosis is suspected when patients awaken
from anesthesia and complain of unilateral visual
deficits. Periorbital and eyelid edema, propto-
sis, ecchymosis, and corneal abrasion have been
reported in patients with postoperative CRAO
.. Fig. 2.2 Central retinal artery occlusion. (David and can be additional clues to suggest excessive
G. Cogan Ophthalmic Pathology Collection – Selected
Cases. (n.d.). Retrieved 15 June 2017, from 7 https://

ocular compression or trauma [2, 3, 23]. A his-
cogancollection.nei.nih.gov/dctcCoganDetails.xhtml tory of carotid disease, or blindness following a
(Cogan Collection, NEI/NIH)) procedure with higher risk of embolization, could
place embolic CRAO higher on the differential documented causes of perioperative visual loss
diagnosis. Once the diagnosis is suspected, imme- (POVL) [7]. Most notably associated with car-
diate ophthalmologic evaluation is indicated [5]. diac and spinal procedures, cortical blindness is
2 Ophthalmoscopic examination may show arte- primarily caused by a disruption of blood flow to
riolar narrowing, retinal pallor or opacities in the the parieto-occipital region of the brain via one of
posterior pole, optic disc edema, and a cherry- two possible mechanisms: embolism or watershed
red spot at the macula [4, 22, 24]. Intra-arterial infarct.
emboli can additionally be seen, suggesting the A study by Shen et al. revealed the overall
diagnosis [4]. incidence of POVL secondary to cortical blind-
Management of postoperative visual loss can ness to be 0.38 per 10,000 discharges [7]. The
begin even before differentiating between which retrospective study used data from nearly six
ophthalmologic injury has taken place. Inspired million patients from the Nationwide Inpatient
oxygen can be increased and blood pressure opti- Sample (NIS) who underwent knee arthroplasty,
mized, though it is unclear what ultimate benefit cholecystectomy, hip/femur surgical treatment,
these interventions offer [4]. For CRAO specifi- spinal fusion, appendectomy, colorectal resection,
cally, mannitol, IV acetazolamide, and 5% CO2 in laminectomy without fusion, coronary artery
oxygen have been used to decrease intraocular bypass grafting, or cardiac valve procedures. Age
pressure and increase oxygen delivery [4, 22, 23]; less than 18 was found to be a major risk factor
however, outcomes following these interventions for the development of cortical blindness, with an
seem comparable to untreated patients. Ocular incidence of 4.3 per 10,000 cases. As compared
massage has also been suggested, with the poten- to those >18 years of age, patients <18 were 64
tial to lower intraocular pressure or dislodge times more likely to develop visual disturbances
emboli. A Cochrane Review article published in from cortical blindness. Other risk factors include
2009 evaluated two randomized controlled trials the type of surgical procedure performed. Spinal
for CRAO treatment. Enhanced external coun- fusions were shown to have an incidence of 1.50
terpulsation (EECP) versus placebo and oral per 10,000 cases with an increased risk of 19.1 fold
pentoxifylline versus placebo were studied. Oral as compared to abdominal surgeries. Similarly,
pentoxifylline resulted in improved retinal artery cardiac and non-fusion orthopedic procedures
flow, and EECP improved retinal perfusion in the were found to have an increased risk of POVL of
hours following its use; however neither treat- 12.7 times and 5.42 times, respectively, as com-
ment documented improved visual acuity in these pared to abdominal procedures.
small trials [25, 26, 27]. Additionally, the patients Additionally, a higher score in the Charlson
examined in these randomized controlled trials risk index (. Table 2.1), a measure of one’s

were not postoperative patients, potentially lim- comorbidities, is associated with higher rates of
iting the applicability of the results. In another
randomized controlled trial, local intra-arterial
fibrinolysis for the treatment or CRAO was com- .. Table 2.1 Charlson risk index
pared to placebo. This study conducted by the
Condition Weight
European Assessment Group for Lysis in the Eye
(EAGLE) was terminated early as the two treat- Myocardial infarct, heart failure, 1
ment approaches were similarly effective, with a peripheral vascular disease, cerebrovas-
significantly higher rate of adverse reactions in cular disease, dementia, chronic
the fibrinolysis arm [28]. Given that there is poor pulmonary disease, connective tissue
disease, ulcer disease, mild liver disease,
efficacy of treatments for CRAO, prevention of or diabetes
this devastating complication is paramount.
Hemiplegia, moderate/severe renal 2
disease, diabetes with end organ
damage, any tumor, leukemia, or
2.3.3 Cortical Blindness lymphoma
Moderate or severe liver disease 3

While not as common as ischemic optic neu-
ropathy and central retinal artery occlusion, AIDS 6
cortical blindness still remains one of the most
25 2
cortical blindness. A score of 1 is associated with and safe [31, 32]. Neurologic improvement was
a 2.18-fold increase, while a score of ≥2 increases seen in 5 of 13 patients (38%), while another
the risk visual disturbance by over 5 times. report showed a risk for surgical site bleeding of
As noted, vision is generated via transduction only 25%. The use of mechanical thrombectomy
of light by photoreceptors in the retina to electri- or embolectomy has been proposed, particularly
cal signals, which are subsequently transmitted in cases when the administration of intra-arterial
through the optic nerves. After traveling through tPA is contraindicated, but there are few studies
the optic canal, the nerve fibers meet in the optic available to evaluate the proposed efficacy [33].
chiasm where decussation, or crossing over of the The narrow window for treatment highlights the
fibers, occurs, before a majority of the fibers travel importance of rapid identification of those suffer-
via the optic tract to the lateral geniculate nucleus ing from cortical blindness and the importance
of the thalamus. From the LGN, the visual sig- for prevention via risk factor identification and
nal is carried via optic radiations to the primary maintenance of intraoperative hemodynamic sta-
visual cortex located in the occipital lobe. Any bility.
vascular insult to this region, most commonly
via embolization of the posterior cerebral arter-
ies, or via hypotension and subsequent watershed 2.4 Prevention of Postoperative
infarcts of the parieto-occipital regions, can result Blindness
in cortical visual loss.
A unilateral insult to the occipital lobe, typi- Prevention of postoperative blindness is the
cally secondary to an embolic event, results in key to limiting its occurrence, because in most
contralateral homonymous hemianopia or loss of cases of postoperative vision loss, there are no
the contralateral visual field [9]. Bilateral infarcts, effective treatments. The American Society of
usually as a result from profound perioperative Anesthesiologists created a Perioperative Visual
hypotension, can have a wide spectrum of symp- Loss Task Force in 2005 to create a practice advi-
tomatology, ranging from difficulty in visual judg- sory to prevent postoperative vision loss, espe-
ment of size, movement, and distance to optic cially from anterior and posterior ischemic optic
ataxia to complete vision loss although this is neuropathy [5]. Practice advisories, such as this
noted to be a rare occurrence [29]. Because dam- task force, are not supported by scientific lit-
age is occurring in the cerebrum and not the optic erature, unlike practice standards and guidelines.
nerve, physical exam will show normal pupillary This task force focused on advisories for prone
light reflexes, as well as a normal funduscopic spinal procedures because of the high-risk nature
exam. Imaging of the head, either via computed of these surgeries. The task force articulated that
tomography (CT) or magnetic resonance imaging there are no identifiable high-risk patient char-
(MRI), will be consistent with infarction of the acteristics. The task force noted that patients are
occipital cortex in the result of emboli or with an deemed high risk when having spinal surgeries,
infarction in the watershed regions of the parieto- when it is anticipated the surgery will be longer
occipital lobes if associated with profound hypo- than normal or the surgery is anticipated to have
tension. a large amount of blood loss. The task force agreed
The prognosis of cortical blindness ranges that neurology or ophthalmology consultation
from short episodes of transient ischemic-like prior to surgery for these patients would not be
attacks with return of function to complete and beneficial. Physicians should inform high-risk
permanent blindness [9]. Given the nature of patients undergoing prolonged cases with an
the insult, visual loss that has not demonstrated anticipated large volume of blood loss that there
return of function after a few months is typically is a small risk of permanent vision loss after the
permanent [30]. procedure. If a high-risk patient is undergoing a
Management of cortical blindness depends prone spinal surgery, the advisory suggests that
on the etiology with only a few ideal treatment the head of the patient be kept in a neutral posi-
options, regardless of the nature of the insult. tion without flexion or extension at the neck.
Multiple case reports suggest that timely admin- Additionally, it is suggested to keep the patient’s
istration of intra-arterial tPA following acute head at or above the level of the heart. The task
perioperative ischemic stroke may be efficacious force suggests checking serial hemoglobin and
hematocrit values in patients that have signifi- or head down positioning, surgeries that involve
cant blood loss, although they agree that no spe- large volume blood loss with large amounts of
cific value is associated with postoperative vision fluid administration, hypotension, and anemia
2 loss. Both colloids and crystalloids are appropri- [35]. While not all variables are controllable,
ate to maintain euvolemia when patients have the clinician should try to optimize pre-existing
significant blood loss. Central venous pressure conditions prior to elective surgeries, avoid hypo-
monitoring should be used in high-risk patients tension, and ensure anemia (prior to surgery or
to monitor volume status [5, 20]. The task force surgically induced) is treated appropriately.
suggests avoiding direct pressure on the globe, Using data collected from the Closed Claims
as increased pressure on the eye has proven to Project, intraoperative hypotension and anemia
increase the risk of central retinal artery occlu- were examined using a sample of 100 patients who
sion [5]. Corneal abrasions can be prevented by did not experience POVL [38]. Selected patients
taping the patient’s eyes closed immediately after had undergone spinal fusion operations from sev-
induction of anesthesia. Ensuring that the eyes of eral academic centers and were matched for year
patients are closed should prevent foreign bodies of surgery. Analysis using clinic blood pressure
from potentially damaging the eyes. Although prior to procedure as baseline revealed that over
some physicians put lubrication ointment on half of the subjects had the lowest MAP greater
patients’ eyes before taping them closed, studies than or equal to 30% below baseline and 38% had
have not found this to be significantly beneficial systolic BP <90 for a minimum of 15 nonconsecu-
[34]. Future studies potentially will lead us to tive minutes. Patients were also found to have a
more preventative measures to reduce the risk of mean preoperative hematocrit of 39.8+/− 5% with
postoperative vision loss. intraoperative being 30.7+/− 5.9% [38]. Blood
pressure and hematocrit level have both been tied
to ischemic optic neuropathy, but the role they
2.5 Medicolegal Issues: Historic play remains unclear, and no strict cutoffs have
Considerations and Concerns been identified as causal. Additional data must be
collected to have a better understanding of how
Postoperative vision loss (POVL) after a non- each factors into the mediation or modulation of
ophthalmologic procedure is relatively rare, vision loss. Blood pressure and hematocrit can be
although POVL can be devastating with effects optimized both in the operating room and prior
varying from permanent disability to full recov- to surgery. The clinician should maintain strict
ery. POVL has often been a source of malpractice parameters throughout the procedure and ensure
claims, making it difficult to study as most claims proper documentation of interventions taken to
are kept closed [35]. The American Society of protect the patient from harm.
Anesthesiology established the POVL Closed In 2013, Lee et al. used the Closed Claims
Claims Project registry in 1999 to help facilitate Project database to investigate trends in the
the reporting and studying of POVL. The regis- severity of injuries to the visual pathway to deter-
try consisted of volunteer ASA Anesthesiologists mine whether complications arising from changes
reviewers who worked with malpractice insurance in surgical practice were reflected in medicolegal
organizations to examine and report malpractice claims against anesthesiologists [39]. They com-
claims involving POVL [36]. Reviews of claims pared claims from 1980 to 1994 to similar claims
took place on a 1–3 year cycle with anonymity and between 1995 and 2011. In each timeframe, post-
confidentially respected. Of the data collected on operative vision loss represented 4% of claims
POVL, ischemic optic neuropathy was a common reported to the Project. They found that higher
diagnosis resulting in litigation. Ischemic optic severity of injury to the visual pathway corre-
neuropathy often does not resolve or improve lated with a more than threefold increase in the
with time [37]. True cause is yet to be identified, median payments made to the plaintiff [39]. The
but it is postulated that factors that could contrib- increased incidence of reported POVL strongly
ute include pre-existing conditions such as diabe- correlates to the increased frequency of spinal
tes mellitus, male gender, obesity, atherosclerosis, fusion operations [35].
hypertension, positioning which elevates blood Another aspect impacting litigation is com-
pressure to the head such as prone positioning munication between the patient and physician
27 2
prior to surgery. Making sure patients are fully The eye consists of three layers, the outer made
informed about the possible risk of postoperative up of the cornea, sclera, and limbus; the middle
vision loss before the operation is to take place including the iris, ciliary body, and choroid; and
allows patients the opportunity to discuss any the inner, consisting of the sensory portion, the
questions or concerns they might have. This retina. The optic nerve exits the posterior aspect
also allows the physician the chance to discuss of the eye and transmits signals from the retina to
how any risk can be mitigated both prior to and the occipital lobe [6]. The vascular supply of the
during the procedure. The concept of informed eye arises from the ophthalmic artery. The central
consent is not novel and has evolved over many retinal artery and long and short posterior ciliary
years. In 1957, Professor Allan H. McCoid of The arteries supply the retina, with both sources being
University of Minnesota Law School published required for normal vision [4].
an article following the decision of the California Injuries to the visual pathway include anterior
District Court of Appeals for the First District in and posterior ischemic optic neuropathy, central
Salgo v. Leland Stanford, Jr. University Board of retinal artery occlusion/retinal vascular occlu-
Trustees. Both recognized that under certain cir- sion, cortical blindness, and posterior reversible
cumstances, a physician could be liable to a patient encephalopathy syndrome. Anterior ischemic
for failure to disclose sufficient information prior optic neuropathy is painless vision loss after sur-
to undertaking treatment [40]. Subsequently, gery due to insufficient blood supply to the optic
it was further defined in 1972 in Canterbury v. nerve and disc. Posterior optic neuropathy is
Spence. The plaintiff, Canterbury, suffered a rup- painless vision loss due to a vulnerable vascular
tured disc in 1958 and was operated on by Dr. area or infarct at the optic nerve posterior to the
Spence. As a result of the procedure and a fall lamina cribrosa. Both anterior and posterior isch-
in the hospital, Canterbury suffered from partial emic optic neuropathies are normally observed
paralysis below the waist. Canterbury brought directly following a procedure. Posterior ischemic
suit stating that Spence failed to inform of the optic neuropathy often results in complete bilat-
possibility of paralysis prior to surgery. The court eral blindness [10]. Central retinal artery occlu-
concluded that “the standard measuring perfor- sion/retinal vascular occlusion is the result of
mance of that duty by physicians, as by others, is occlusion by embolus or inadequate blood supply
conduct which is reasonable under the circum- to the optic disc and retina and normally presents
stances. Reasonable care requires disclosure of all with painless monocular vision loss. Cortical
risks that are ‘material’ to the patient’s decision blindness results from lack of sufficient blood
and what disclosures fall within the scope of the flow to the occipital cortex via the posterior cere-
obligation is to be left to the jury. A risk is material bral arteries. This condition is more associated
when a reasonable person, in what the physician with the potential of recovery of some degree of
knows or should know to be the patient’s posi- the vision lost. Posterior reversible encephalopa-
tion, would be likely to attach significance to the thy syndrome is characterized by vision loss with
risk in deciding whether to forego the proposed associated headache, confusion, and seizures.
therapy” [41]. A survey of patients who recently Pathogenesis is unclear, but vasoconstriction and
underwent prolonged prone spinal cases within hypoperfusion leading to ischemia and vasogenic
the Mayo Clinic hospital system revealed that edema have been proposed mechanisms [43].
86% of responders would prefer to have POVL Prevention of POVL is paramount as in many
discussed with them face-to-face prior to the day cases no treatments have proven to be effective in
of surgery [42]. improving impairment. In 2005, the ASA created
the Perioperative Visual Task Force and released
a practice advisory to prevent POVL with the
2.6 Conclusion prime focus on prone spinal procedures [5]. The
task force summarized that there are no spe-
POVL is an uncommon but devastating compli- cific patient characteristics that would identify a
cation of surgery. Many hypotheses have been patient as high risk. Risk is deemed higher when
proposed, but the pathophysiology of POVL is procedures are prolonged and involve an antici-
incompletely understood, suggesting that mul- pated large volume of blood loss. Patients who
tiple factors may contribute to injury [4]. are to undergo higher-risk procedures should
be kept at a neutral spine with the head kept at vv 2. A – The posterior ciliary arteries and
or above the level of the heart. Serial hematocrit central retinal artery supply the retina. The
should be checked, and central venous pres- posterior ciliary artery supplies the
2 sure monitoring can be used to monitor volume anterior optic nerve.
status. Volume resuscitation can be done with
colloids, crystalloids, and blood products to vv 3. D – Female gender has not a known risk
maintain euvolemia [5]. factor for postoperative vision loss.
Postoperative vision loss claims have increased
with the growing number of spinal fusion surger-
ies [35]. In a survey conducted of patients follow- References
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31 3
Substance Abuse
Elyse M. Cornett, Rebecca A. Moreci, Nadejda Korneeva,
and Mark R. Jones
3.1 Introduction – 32
3.2 Screening for Substance Use and Abuse – 32

3.2.1 Overall Perioperative Considerations – 33
3.2.2 Individual Drugs of Abuse – 34
3.3 Summary – 40
3.5 Answers – 41
References – 41

https://doi.org/10.1007/978-3-319-96125-5_3
32 E. M. Cornett et al.
be delayed in the presence of certain substances,

Key Points while other situations may necessitate urgent
55 24 million Americans have abused an decision-making. There is no cure for addiction,
illicit drug. but there are effective treatments for addiction,
55 Cannabis is the most frequently abused and there are ways to manage patients that are
drug. addicted to substances. Therefore, healthcare pro-
3 55 Some physicians underestimate the viders should be aware of the variety of drugs of
prevalence of alcohol dependence in abuse that can present in patients and of how to
certain populations, e.g., women and treat these patients.
younger patients. Healthcare providers have opportunities to
55 Tight control of opioids in patients who help make positive and supportive changes in
are exposed to medication for the first the lives of their patients who abuse substances.
time during the perioperative period is Healthcare providers can screen their patients
important to prevent the development to identify signs of drug abuse or dependence
of opioid-dependence and associated and talk with patients about the negative effects
drug overdose and death. of misusing prescription drugs. They can also
55 Any surgical patient that smokes has a talk with the families of patients who abuse sub-
20% increased risk of hospital mortality stances to facilitate a support network. Overall,
and 40% increased risk of complications. the healthcare provider should not only be aware
55 Detailed patient history and screening of ways in which to treat a patient who presents
can help to elucidate whether a patient with substance abuse but also how they might be
is acutely intoxicated or a chronic sub- able to foster the health of the patients after they
stance user and can help a healthcare leave the operating room. This chapter will dis-
provider choose the best treatment cuss a variety of drugs that a healthcare provider
approach for the patient. may encounter in the operating room and how to
properly treat a patient that has abused/presented
with the substance.
3.1 Introduction 3.2 creening for Substance Use

S
and Abuse
23.5 million persons aged 12 or older needed treat-
ment for an illicit drug or alcohol abuse problem Many patients with substance use disorders
in 2009 (9.3% of persons aged 12 or older) accord- (SUDs) have a higher risk for adverse events
ing to the Substance Abuse and Mental Health such as postsurgical complications, infections,
Services Administration’s (SAMHSA’s) National and death. However, only a small percentage of
Survey on Drug Use and Health. Of these, only patients will volunteer information regarding
2.6 million (11.2% of those who needed treat- prior substance use. In approximately 66% of
ment) received treatment at a specialty facility. patients using illegal substances, anesthesiologists
Additionally, substance abuse is costly totaling were unaware of their use prior to surgery [1].
over $740 billion annually related to crime, lost This presents potential problems for both the sur-
work productivity, and healthcare. Major drugs geon and the anesthesiologist in managing these
of abuse include but are not limited to alcohol, patients.
opioids, stimulants, cannabinoids, hallucinogens, It is therefore recommended that physicians
and nicotine. regularly screen all patients for substance use or
Acute and chronic substance abuse in patients abuse, even if it is not overtly evident that the
introduces unique challenges to the healthcare patient is using or abusing substances [2]. The
provider and healthcare team. Patients can pres- goals of screening patients include identifying
ent with respiratory, cardiovascular, central ner- those who have a substance use disorder, diag-
vous system, hematological, renal, and hepatic nosing related disorders, and developing a plan
system distress. Some procedures may have to for management of the disorder [2].
Substance Abuse
33 3
Initial screening can include interviews, [3]. Screening for opioid dependence includes
laboratory tests, and specific screening ques- objective instruments such as COWS (Clinical
tionnaires. When conducting interviews, the Opiate Withdrawal Scale), subjective physician
physician must be cautious in their approach. interviews, physical examination, and nonspecific
Many times, these patients are hesitant to reveal laboratory evaluations [2].
information secondary to embarrassment or The surgeon and anesthesiologist’s aware-
distrust. ness of substance use disorders in their patients
When comparing various substances, patients will allow them to individualize and adjust the
will admit nicotine use and dependency more patient’s care pre-, peri-, and postoperatively.
often than other drugs [3]. There are two common This will improve the patient’s quality of care
methods to evaluate this in more detail: standard- including minimizing complications, shortening
ized questionnaires such as the Fagerström [4] or avoiding ICU length of stay, and improving
and the COHb biomarker [5] for acute smoking. outcomes.
Postoperative pulmonary and/or cardiovascular
complications, as well as wound infections, are
higher in patients who smoke. Therefore adequate 3.2.1 Overall Perioperative
screening is recommended [6]. Considerations
It is also possible that some physicians
underestimate the prevalence of alcohol depen- While screening patients for substance abuse
dence in certain populations, e.g., women and ahead of time is necessary and important, not all
younger patients [7]. One screening tool for patients that present to the operating room will
alcohol dependence is the CAGE or AUDIT be medically optimized. In fact, many patients
questionnaires which can have higher rates of that present to the emergency room under the
detection when approaching the patient on mul- influence of substances are trauma patients, and
tiple occasions prior to their surgery. The second many are also polydrug users, meaning they are
tool is laboratory tests including carbohydrate- under the influence of many substances at one
deficient transferrin (CDT) + gamma-glutamyl time, which complicates their treatment regi-
transpeptidase (CGT) for males while adding men [8]. When the healthcare provider is devel-
mean corpuscular volume (MCV) when test- oping a plan there are several characteristics of
ing females. Surgery can activate the HPA axis substance use/abuse that can pose similar prob-
(the stress response), and this response can be lems in the operating room, regardless of sub-
further strengthened in patients with alcohol stance. These are outlined in 7 Box 3.1, below.

dependence [3], again demonstrating the need Each of these factors must be considered when
for screening. a patient presents to the hospital with substance
Patients that use illegal substances are not use or abuse. Regardless of the substance, these
only at a higher risk because of the potential phenomena can occur with all of the substances
complications mentioned above but also because discussed in this chapter and can all produce
of the comorbidities that they possess. These distinct side effects and/or challenges for the
comorbidities include psychiatric, chronic infec- healthcare team.
tions with possible multiresistant strains and
combined usage with legal substances such as
alcohol or tobacco [3]. As previously mentioned,
some patients. Therefore, the physician taking the
social/drug history should stress confidentiality Box 3.1 Perioperative Considerations for
and warn of potential risks. Substance Abuse
Lastly, opioid use disorders pose a significant 55 Withdrawal
problem with postoperative analgesia require- 55 Tolerance
ments. The baseline therapy is replacement 55 Difficult pain control management
treatment with methadone. These patients face a 55 Acute toxicity vs chronic toxicity
55 Patient compliance issues
slightly increased risk for relapse, followed by an 55 Patient judgment impairment
increased risk of death when tolerance decreases
3.2.2 Individual Drugs of Abuse to understand that alcohol abuse patients are not
all the same (low vs moderate vs high consump-
3.2.2.1 Alcohol tion) and complication risks change based on
their clinical profile. Knowing this information
Incidence will help the physician advise the patient on how
to minimize their risk. To lower these risks for
3 When considering alcohol as a potential risk fac-
patients with high alcohol consumption, some
tor for surgical complications, one must consider
how prevalent these patients are. It is well known suggest that the patient abstain from alcohol for
that sometimes physicians underestimate and 4 weeks prior to surgery [10], while others advise
may overlook alcohol abuse in certain patient that risk could remain high for up to 1 year prior
populations, including women, younger patients, [11]. Regardless, the patients who are at high risk
higher income/education, and private insurance. must be identified prior to surgical preop so that
At least one in ten surgical patients has some level the patient can reduce/eliminate their drinking
of alcohol abuse/dependency [7]. Alcohol use and possibly receive treatment.
disorders fall on a spectrum, ranging from abuse
Treatment
to harmful and dangerous use involving others.
These disorders are under-detected, making it dif- In one study, alcohol withdrawal syndrome was
ficult to prevent surgical complications [7]. noted in 82% of patients with chronic alcohol
abuse, and they had a greater than 50% rate of var-
Perioperative Complications ious postoperative complications [12]. As alcohol
Patients with alcohol abuse are at a higher risk for withdrawal and associated morbidity is a feared
perioperative complications. There are inconsis- complication following surgery, one possible
tent opinions on whether the severity of the alco- treatment option is single-agent benzodiazepine
hol use plays a role in the likelihood and severity prophylaxis, specifically lorazepam [12]. Current
of the complication [9]. treatments target mainly the symptoms of alcohol
These complications are broken into various withdrawal syndrome and not the actual depen-
categories. Surgical field (e.g., surgical site infec- dency. Other symptomatic treatments include
tions (SSIs), graft failure), infections other than alpha-2-agonists, neuroleptics, and olanzapine.
SSIs (pneumonia (PNA), urinary tract infection Some anti-craving medications are also avail-
(UTI), sepsis), pulmonary, and general morbid- able: acamprosate, naltrexone, or disulfiram [13].
ity complications have statistically higher risk of However, all of the treatments listed above may
occurrence, while cardiovascular (myocardial not decrease risks of other postoperative compli-
infarction cardiac arrest), neurologic (stroke, cations, so further studies must be continued to
coma, delirium), postoperative bleeding, and find other prophylactic options [14].
general mortality have not been found to have any
increased associations [9]. 3.2.2.2 Benzodiazepines
Studies have also demonstrated that patients
with low-to-moderate alcohol use do not have the Incidence
same risk as patients with high alcohol consump- Benzodiazepines are frequently prescribed for a
tion (defined as AUDIT >5–8, >2 drinks most variety of conditions including anxiety, insom-
days, and/or alcohol abuse/dependency diagno- nia, and epilepsy. They are also commonly used
sis). Additionally, surgery type (abdominal, tho- during procedures, providing anxiolytic and
rax, head and neck, orthopedic, transplant, etc.) amnestic effects. Interestingly, the number of ben-
may be a factor but does not appear to have a zodiazepine prescriptions has decreased in the last
direct association with alcohol consumption and 20 years, while the quantity of drug -per -prescrip-
further risk [9]. tion has increased [15]. This points to overuse or
There are potential theories as to why patients misuse, as benzodiazepines are not indicated for
with high alcohol consumption are at increased long-term use, defined as >6 months. The popu-
risk of these complications. Alcohol reduces the lation of benzodiazepine users is heterogeneous,
immune response, decreases coagulation, and comprised of younger adults purchasing street
has an enhanced effect of HPA activation (the drugs as well as elderly patients using the same
stress response) during surgery. It is important class of drugs to improve sleep. Some predictors
Substance Abuse
35 3
for who will use benzodiazepines include females, unstable. If these patients have comorbid medical
elderly, history of smoking, and insurance cov- conditions or history of seizures, inpatient ser-
erage [16]. Concurrent use of benzodiazepines vices may be recommended.
and opioids has increased in the last 10–15 years. Patients may experience benzodiazepine with-
However, there is also evidence that patients use drawal syndrome, which includes general with-
alcohol or OTC medications for sleep in conjunc- drawal symptoms such as palpitations, sweating,
tion with benzodiazepines [17]. Alprazolam is and tremors as well as specific symptoms related
commonly prescribed and also commonly abused to the neurological/psychological and gastroin-
[15]. Other benzodiazepines include clonazepam, testinal systems.
lorazepam, midazolam, and diazepam. The pre- Other management strategies which can be
scription is usually written as PRN, meaning the performed simultaneously with the mainstay
patient can take as many (or as few) as they wish. treatment include staged dispensing (only small
quantities), benzodiazepine substitution (usually
Perioperative Considerations with a longer half-life drug such as diazepam),
Benzodiazepines (BZDs) can be used preopera- patient monitoring (awareness of doctor shop-
tively as an anxiolytic + sedative or perioperatively ping), pharmacotherapy, and psychotherapy [15].
as an amnestic agent. Midazolam is a common Both pharmacotherapies like anticonvulsants and
choice due to its rapid onset, short duration of psychotherapies such as CBT can be used for the
action, and short elimination half-life. treatment of withdrawal symptoms.
Pediatric patients can also use midazolam,
keeping in mind the dosage requirement may 3.2.2.3 Opioids
be lowered [18]. Additionally, elderly patients
metabolize and eliminate drugs less efficiently, Incidence
which could result in BZD build up and accumu- In 1999, pain was introduced as a fifth vital sign
lation of toxic metabolites. Amnesia and further along with body temperature, pulse, respiration,
complications may occur even if these patients and blood pressure [20]. Since then, in parallel
were appropriately prescribed. Additionally, con- with the dramatic increase in opioid prescriptions,
current use of other substances (opioids, alcohol, the rate of admission of treatment-seeking patients
etc.) in a patient of any age can result in unwanted for opioid addiction and opioid-overdose death
additive or synergistic effects. Therefore, physi- nearly quadrupled in 2010 [21]. In 2012, approxi-
cians must be cognizant and cautious of these mately 16,000 deaths were linked to prescribed
potential factors. opioids, while in 2015 this number increased to
52,000 deaths [22]. It is estimated that 46 people
Treatment die every day from prescription opioids and that
Discontinuation and maintenance therapy are two opioid analgesics are linked to more deaths than
main treatment approaches for benzodiazepine deaths from cocaine and heroin combined or
dependence. The choice relies on multiple factors from both suicide and motor vehicle crashes. The
including whether the patient is a low or high risk CDC recommends prescribing opioids to patients
of harm and relapse [15]. The discontinuation with the most serious cases of pain, such as cancer
approach involves gradual weaning, as abrupt and end-of-life care. However, in the USA doctors
cessation is not recommended due to potential routinely prescribe opioids for more common ail-
life-threatening seizures and other complications. ments like arthritis and back pain. A recent study
This approach is suggested for low-risk patients of prescriptions dispensed during 2008 by 37,000
who may have a less severe dependence, who are retail pharmacies revealed geographic areas in
not currently using other drugs or alcohol, and the USA with the highest opioid prescription
who have never attempted this previously [19]. rate: counties located in Appalachia and in the
The process of tapering is not standardized, but southern and western states [23]. Authors found
there are suggestions based on the risk of relapse, a positive correlation between opioid prescrip-
expected duration, and tolerability. Maintenance tion rate and proportion of the “population that is
therapy is reserved for higher-risk patients who white non-Hispanic or African American, poor,
are already on diazepam substitution, who have uninsured, and living in urban areas.” The stron-
concurrent drug abuse, or who are psychiatrically gest correlation was found between the rate of
opioid prescription rate and the number of physi- opioid-sparing effects [31]. It was emphasized
cians practicing in a certain area, especially sur- that different surgical procedures might require
geons and pediatricians. According to the Express a unique combination of these non-opioid adju-
Script report, the number of opioid prescriptions vants. Regional anesthesia (including peripheral
dropped by 9% between 2009 and 2013. However, and neuraxial blocks) and analgesia were also
patients on prescribed opioids take a higher dose associated with lower opioid use and decreased
3 of opioid and for a longer period. Almost 30% of PONV [31–33].
patients on opioids are also using other prescrip-
tion drugs that may lead to a harmful combina- 3.2.2.4 Stimulants
tion (e.g., benzodiazepines).
Incidence
Perioperative Complications Cocaine and methamphetamine abuse continue
Considering that the opioid epidemic is associ- to be a worldwide problem. The world drug
ated with morbidity and mortality, it is important report states that there are currently 33 million
to minimize the amount of perioperative opioid methamphetamine users and 19 million cocaine
administration to control pain. Tight control of users. The US Drug Abuse Warning Network
opioids in patients who are exposed to medica- (DAWN) monitors cocaine- and methamphet-
tion for the first time during the perioperative amine-related emergency room visits. In 2011,
period is important to prevent the development DAWN reported 505,224 cocaine and 102,961
of opioid-dependence-associated drug overdose methamphetamine-related emergency room vis-
and death. In surgical patients with a history of its. Furthermore, methamphetamine visits have
chronic pain and prolonged administration of nearly doubled since 2007. Stimulant use disor-
opioids, it is important to take into account their der is a diagnosis in the DMS-IV and refers to a
drug tolerance and to find the adequate scheme variety of problems associated with cocaine and
of opioid administration for analgesia prevent- methamphetamine including impaired control,
ing overdose. Recently, concern regarding the risky use, social impairment, tolerance, and with-
effect of chronic opioid exposure on neurologic drawal. A recent study compared cocaine-related
complication has emerged. A toxic effect of opi- emergency room visits to methamphetamine-
oids on the central nervous system (CNS) has related emergency room visits and treported that
been described in a growing number of studies. out of 3103 urine toxicology screens and 20,203
Leukoencephalopathy, axon demyelination, and emergency room visits, the prevalence of meth-
lesions in white matter have been documented amphetamine use was seven times higher than
not only for heroin abusers but also for metha- cocaine [34]. Stimulants can be divided into two
done [24–26], morphine [27], and oxycodone [28] major categories: amphetamine stimulants and
overdosed patients. In 2016, the CDC published non-amphetamine stimulants. Amphetamines
guidelines for prescribing opioids by primary care are both direct releasers and reuptake inhibitors
clinicians to “improve the safety and effectiveness of dopamine, norepinephrine, and epinephrine.
of pain treatment, and reduce the risks associated Non-amphetamine stimulants block the reuptake
with long-term opioid therapy, including opioid of dopamine and norepinephrine. The distinction
use disorder, overdose, and death” [29]. However, between these mechanisms is important clini-
since there is currently no commonly accepted cally, as amphetamines tend to cause a much more
surgical guideline for the management of periop- rapid and larger increase in the release of cat-
erative pain, surgeons and residents rely mostly echolamines than non-amphetamines. Stimulant
on their experience and training [29, 30]. drugs also have peripheral alpha and beta actions,
for example, oral administration of amphetamine
Treatment can increase systolic and diastolic blood pressures
Use of non-opioid adjuvant medication and and reflex bradycardia [35]. Stimulant CNS effects
regional anesthesia was suggested as a part of include increased alertness, stimulation of respi-
perioperative pain treatment to decrease opioid ratory centers, decreased fatigue, and euphoria.
use. Among non-opioid adjuvants, dexmedetomi- Cocaine blocks electrical impulses in nerve cells
dine, clonidine, ketamine, pregabalin, lidocaine, which can produce a local anesthetic effect. It does
and esmolol are recognized for their perioperative so by blocking sodium channels, thus preventing
Substance Abuse
37 3
neuronal cell’s ability to undergo depolarization, on the morning of surgery, patients who presented
and this is also evident in the cardiac system. with a positive urine drug screen for cocaine
Cocaine-induced sodium-channel blockade can were not an indication for canceling a case [41].
predispose patients to QT interval prolongation, On the other hand, a 2012 study of 300 patients
which may result in torsades de pointes [36]. who underwent elective surgeries reported that
Chronic abuse of stimulants leads to tolerance, over half of the cocaine-positive patients required
and cross-tolerance to other sympathomimetic vasopressors and antihypertensives intraopera-
drugs can also occur. tively [42]. Cocaine can also cause physical prob-
lems. Chronic nasal cocaine administration can
Perioperative Complications cause septal destruction and soft palate necrosis,
Intraoperatively, patients will require a decrease in nosebleeds, and reduced blood flow to major
sympathetic tone. Amphetamines can reduce the organs leading to tissue necrosis [43].
patient’s sympathetic reflex integrity, via down-
regulation of endogenous catecholamines, and as Treatment
a result, refractory hypotension can result [37]. The management of children on chronic amphet-
Postoperative hypotension can also occur. Of amine therapy should involve avoidance or care-
particular concern to the anesthesiologist is the ful titration of cardiac depressor anesthetic drugs
patient’s decreased response to ephedrine after [44]. Direct-acting vasopressors, e.g., epinephrine
chronic amphetamine use. Interactions between or phenylephrine, are preferable because of possi-
stimulants and other drugs commonly used by ble cross-tolerance to other indirect vasopressors
anesthesiologists in the operating room may be such as ephedrine. Premedication or pre-treat-
unpredictable and can lead to cardiovascular ment with atropine may also be useful. And in the
collapse. A 1979 case report discussed a patient case mentioned above, the amphetamine-atropine
who underwent a cesarean delivery and was also interaction can be treated with noradrenaline and
a chronic amphetamine abuser. The patient died milrinone. There is recent surprising evidence that
of cardiac arrest, suggesting patients who abuse methylphenidate can speed recovery from general
amphetamine may have a predisposition to car- anesthesia in an animal study. Rats receiving IV
diovascular instability [38]. Furthermore, a 2008 methylphenidate 5 min before discontinuation of
report of a ten-year-old child on long-term meth- isoflurane recovered faster than controls [45]. The
ylphenidate therapy for ADHD presented a car- experiment further showed the methylphenidate-
diac arrest during induction of general anesthesia induced signs of arousal in rats that continued to
with sevoflurane [39]. There is also evidence for an receive isoflurane at a dose sufficient to maintain
interaction of amphetamine with atropine, where unconsciousness.
a patient taking fenproporex without a prescrip- Nitroglycerin treatment can be used for
tion (to lose weight) was administered atropine cocaine-induced cardiac arrhythmia [46]. Patients
and which caused supraventricular tachycardia, that present with hypertension or tachycardia
arterial hypotension, and acute lung edema [40]. can be treated with furosemide, a loop diuretic,
Amphetamines can also cause deleterious physi- which may decrease preload in patients with car-
cal effects. “Meth mouth” is a side effect of chronic diomyopathy. Phenylephrine is a selective alpha-1
methamphetamine abuse and is caused by xero- adrenergic receptor agonist and is the drug of
stomia, poor oral hygiene, and poor diet. Patients choice for hypotensive patients.
can present with loose or missing teeth that can be
further dislodged during intubation or extubation. 3.2.2.5 Nicotine
There is controversy regarding the safety of
cocaine-positive patients undergoing general Incidence
anesthesia. A 2006 non-randomized, blinded According to the CDC, 15% of adults 18 years and
study investigating 40 UDS cocaine-positive older (16.7% of men and 13.6% of women) were
patients compared to an equal number of drug- current cigarette smokers in 2015. Characteristics
free controls found that cardiovascular stability of current smokers include males 25–45, living
during general anesthesia was not significantly below the poverty line, has a GED, either unin-
different between the groups [36]. Another study sured or on Medicaid, and history of disability or
by the Veterans Association further solidified that psychological diagnosis [47, 48]. Each day, over
3000 kids (<18 years old) start smoking ciga- to the lungs, allowing for tapering to occur [54].
rettes. However, the CDC reports that almost 70% However, the unknown abuse potential and dif-
of adults do want to quit. Approximately one in ficult product design make this a less desirable
three patients is reported to have a nicotine use first-choice treatment. The final potential treat-
disorder (NUD) [3]. If the physician suspects ment for nicotine dependence is a new nicotine
NUD, they are encouraged to pursue screening as vaccine being studied [55]. The antigen is linked
3 these patients are more likely to admit this when to a carrier, introduced into the body, which
compared to other drugs of abuse. then stimulates the immune system to mount a
response against the nicotine.
Perioperative Complications
Any surgical patient that smokes has a 20% 3.2.2.6 Cannabis
increased risk of hospital mortality and 40%
increased risk of complications [49]. Patients with Incidence
NUD are more commonly admitted to the ICU According to the National Survey on Drug Use
following surgical procedures and tend to result and Health report, cannabis is the most commonly
in cardiopulmonary complications or wound used illicit drug in the USA [56]. Cannabis is most
infections. Certain surgical procedures generally often consumed in the form of “marijuana” plant
have higher risk in these patients: hernia proce- or hashish (the delta-9- tetrahydrocannabinol
dures > orthopedic prostheses > cholecystectomy [THC]-containing resin of the inflorescences).
(laparoscopic) [50]. In 2013, almost 20 million people of 12 years old
Smoking cessation is recommended in these and older in the USA used cannabis in the preced-
patients for at least 4 weeks prior to surgery until ing month [56]. A gateway analysis revealed that
4 weeks post procedure, which is the minimal the use of cannabis leads to an increased risk of
time period shown to decrease the risk of postop- abusing other illicit drugs, especially among the
erative complications [50]. adolescent population, but it rapidly declines with
If the patient did not stop smoking prior to age. A recent review by the National Academies
surgery or they are not using any intervention/ of Sciences, Engineering, and Medicine (NASEM)
treatment, physicians should consider physo- indicates the use of cannabis at young ages, or
stigmine to avoid postoperative nausea/vomiting heavy daily use of cannabis, is associated with
(PONV) complications and treat postoperative various adverse effects [57]. There are two major
pain. This is a cholinergic agent that crosses the syndromes associated with intensive use of can-
blood brain barrier, inducing analgesia alone or nabis: the cyclic vomiting syndrome (CVS) in
as an adjuvant to opiates [51]. adults [58, 59] and the cannabinoid hyperemesis
syndrome (CHS) [60, 61] that are characterized
Treatment by recurrent episodes of nausea, vomiting, and
It is suggested that the patient detox and/or crampy abdominal pain. Also, prolonged use of
abstain from nicotine use for at least 4–6 weeks even low doses of cannabinoids may lead to the
before surgery [3]. One option is nicotine replace- development of drug dependence, psychosis,
ment therapy (NRT) which is a first-line treatment panic and anxiety attacks, a deficit of attention,
for decreasing nicotine use but can also be used concentration, learning and memory, coordina-
pre- and postoperatively for PONV. NRT comes tion impairment, and development of signs of
in a variety of forms including a transdermal withdrawal.
patch, acute dosing products, gum, lozenge, sub-
lingual tablet, oral inhaler, and nasal spray. These Perioperative Complications
therapies serve to lower motivation and usage of Medical cannabis is proposed to be used in pain
tobacco products, as well as lower the subsequent management with inhaled cannabis been more
withdrawal symptoms that result [52]. Nicotine tolerable than oral cannabinoids. Several meta-
preloading is a more recent therapy involving analyses indicated that orally administered can-
starting NRT while the patient is still smoking nabinoids and inhaled cannabis provide moderate
(pre-cessation therapy) [53]. Another recent, yet benefits in the treatment of chronic pain and spas-
somewhat controversial therapy, is a true pulmo- ticity associated with neuropathy, cancer, diabetes,
nary inhaler. This would deliver nicotine directly and multiple sclerosis [62–67]. However, there is
Substance Abuse
39 3
no commonly accepted guideline for the use of lead to fever, tachycardia, tachypnea, and hyper-
medical cannabis in each specific case. According glycemia [70]. Inhaled PCP is associated with
to the 2017 NASEM report, “there is conclu- nystagmus, tachycardia, and hypertension and
sive or substantial evidence to support cannabis even could lead to cerebral hemorrhage and coma
being effective for the treatment of chronic pain [71]. Toxic effects of ketamine include nystagmus,
in adults, moderate evidence that cannabinoids apnea, severe bladder toxicity, and cardiovascular
(primarily nabiximols) are effective for improv- dysfunction [72].
ing short-term sleep outcomes in individuals with
chronic pain associated with obstructive sleep Perioperative Complications
apnea syndrome, fibromyalgia, chronic pain, and Prior physical examination of the patient for the
multiple sclerosis” [57]. However, there is limited presence of signs associated with the use of the
evidence supporting the correlation between can- hallucinogens such as confusion, violent behavior,
nabinoids and better outcome after a traumatic nystagmus, or tachycardia will help the physician
brain injury or intracranial hemorrhage [57]. to estimate whether to perform drug screening
Moreover, the report indicated a statistical asso- test for this patient. If the patient has tested posi-
ciation between cannabis smoking and worsen- tive for the hallucinogens and the surgery is not
ing respiratory symptoms, motor vehicle crashes, urgent, then the operation should be delayed.
and increased risk of overdose injuries in the Also, since ketamine is a PCP derivative, patients
pediatric population, as well as the development intoxicated with PCP should not be treated with
of schizophrenia or other psychoses [57]. Oral ketamine.
cannabinoids do not reduce acute postoperative
pain and are therefore not currently useful during Treatment
the postoperative period. More research is needed If the operation cannot be delayed or placing the
to explore the potential benefits of cannabinoids patient in a quiet environment is not effective to
during the perioperative period. suppress psychosis, there are several agents that
can be used to calm the patient. Benzodiazepines
Treatment (lorazepam or diazepam) are the medication
There are several cannabinoid-based therapies of choice since they suppress the activity of the
utilized in the clinical settings: Cesamet® (nabi- central nervous system (CNS) by enhancing the
lone) is prescribed to treat nausea in cancer action of gamma-aminobutyric acid (GABA).
patients, Marinol® (dronabinol) is prescribed to Antihypertensive agent clonidine decreases the
treat nausea in patients undergoing to chemo- severity of hallucinogen persisting perception
therapy [68], and Sativex® is prescribed to patients disorder (HPPD). Clonidine also suppresses
with multiple sclerosis with moderate to severe sympathetic activity stimulated by LSD use. The
spasticity [65]. neuroleptic agent haloperidol can produce a sig-
nificant improvement in hallucinogen-induced
3.2.2.7 Hallucinogens anxiety, hallucinations, and cognitive confusion
[73]. However, haloperidol has adverse psy-
Incidence chomimetic effects and is not indicated in LSD
Hallucinogens are a group of drugs that alter the intoxication. Chlorpromazine is more efficient
state of consciousness associated with mystical at reducing somatic and psychological tension in
experience, vivid images, and synesthesia and PCP-induced psychosis [73].
could lead to confusion, violent behavior and
psychosis, paranoid reactions, and depression. 3.2.2.8 MDMA/Ecstasy
According to the National Survey on Drug Use
and Health, more than 15% of US population Incidence
aged 12 or older has used hallucinogens in their Ecstasy is the common name for MDMA,
lifetime in 2016 [69]. The most popular halluci- 3,4-methylenedioxy-methamphetamine. The use
nogens are lysergic acid diethylamide (LSD) and of MDMA has decreased in 12–17-year-olds in
phencyclidine (PCP), and ketamine. Although recent years but remains steadily used among
the abuse potential of hallucinogens is low, their adults. In 2014, 50% of over 500,000 adults sur-
use is associated with toxic effecst. LCD could veyed were current ecstasy users. The National
Survey on Drug Use and Health 2014 survey risk if a MAO inhibitor and a serotonin reuptake
reported that 7% of individuals age 12+ had tried inhibitor are also on board. Some of these agents
MDMA at least once in their lifetime, 1% of the include opioids, pethidine, tramadol, methadone,
population had used it in the past year, and 0.2% dextromethorphan, and propoxyphene, which
had used it in the past month [74]. MDMA is all inhibit serotonin reuptake [83, 84]. Serotonin
abused because it produces feelings of euphoria, syndrome can also exacerbate hyperthermia in
3 pleasure, and heightened emotional and sensory MDMA users, and in severe cases, the health-
experiences. MDMA works through a variety of care provider should provide the following to the
mechanisms that alter dopamine, serotonin, and patient: deep sedation, paralysis, and ventilation.
norepinephrine signaling. It can be administered Patients may also present with hyponatremia and
orally in pill or capsule form and is often cut with cerebral edema, which can be treated with fluid
other substances like caffeine, atropine, ketamine, restriction, or in the case of a severely ill patient,
and diphenhydramine [75]. a hypertonic saline solution may be required
[85]. Acute MDMA toxicity can be managed with
Perioperative Complications activated charcoal up to 1 h post-ingestion and
MDMA is a derivative of amphetamine, which should be followed by vigilant fluid replacement
is why these drugs share many similar effects, to prevent hypotension.
e.g., increased heart rate, hyperthermia, tachy-
cardia, sweating, and increased impulsivity [76].
Clinically, patients with exposure to MDMA will
3.3 Summary
present with tachycardia, hypertension, confu-
sion, mydriasis, ataxia, dry mouth, nystagmus,
Substance abuse and addiction are a worldwide
sweating, and bruxism. There is an association
problem. Anesthesiology healthcare providers
between MDMA and cerebral hemorrhage, cere-
should be aware of this problem and the risks
bral venous sinus thrombosis, and aplastic anemia
that substance abuse can impose on patient
[77]. MDMA is also associated with pneumotho-
care. Patients of all types may present with sub-
rax, pneumomediastinum, and esophageal tear
stance abuse including emergency room patients,
[78]. There is limited evidence for the etiology of
pregnant women, children, and the elderly.
MDMA-associated sudden death. However, it is
Minimization of pre-, intra-, and postoperative
likely that the sympathomimetic effects of the drug
risks associated with anesthesia and substance
contribute to dysrhythmia, which can ultimately
abuse are of the utmost importance, and detailed
lead to death. There is also evidence for hyperpy-
patient history and screening can help to eluci-
rexia, rhabdomyolysis, and multiple organ failure
date whether a patient is acutely intoxicated or
[79]. These occurrences are likely due to excessive
a chronic substance user. Healthcare providers
exertion and inadequate fluid replacement which
should remain vigilant regarding new informa-
could disrupt thermoregulation.
tion related to drugs of abuse and respective
Treatment healthcare implications.
Dantrolene has been used to treat MDMA-
induced hypyrexia [80]. And while there is vary-
ing evidence for the effect of dantrolene on the 3.4 Review Questions
rate of cooling in patients that experience heat
stroke independent from MDMA [81], there ?? 1. A 38-year-old male has an appointment
is evidence to suggest that more rapid cooling with you, his orthopedic surgeon, to
of patients with MDMA-induced hyperpyrexia determine if he is a candidate for elective
was achieved in the presence of dantrolene surgery. As the surgeon, you are perform-
[82]. Serotonin syndrome is another complica- ing a comprehensive history and physical
tion associated with MDMA. This syndrome is exam to obtain a general assessment of
characterized by a rapid onset of confusion, dia- the patient and determine if he is a good
phoresis, diarrhea and cardiovascular instabil- candidate for this procedure. Which of
ity, increased muscle tone, rigidity, tremor, and the following is the best approach to his
myoclonus. These patients are particularly at appointment?
Substance Abuse
41 3
A. Because he is a well-educated, Cau- B. Stress to the patient that smoking ces-
casian man who appears well spoken sation is very important in decreasing
and with no overt symptoms of abuse his postsurgical complications, and
or withdrawal, you decide that you will you are willing to help him achieve this
quickly ask some general questions with use of NRT (nicotine replacement
about the use of various substances therapy). You do suggest pushing the
and then move on with the exam. surgery back to 4 weeks, which should
B. You begin to ask questions regarding still leave him enough time to heal,
substance use, and the patient denies especially if there are fewer complica-
using any substances, including alco- tions.
hol, tobacco products, and opioids. C. Advise that the nicotine vaccine is the
Nonetheless, you continue with CAGE newest and most common treatment
and Fagerström questionnaires, as well for smoking cessation. If he uses this,
as laboratory tests for benzodiazepines, you would even be willing to do the
alcohol, and opioids. You don’t want to surgery in the next 2 weeks.
miss anything. D. Tell him that nicotine use doesn’t inter-
C. The patient admits to occasional alco- fere with surgical outcomes; since most
hol use and smokes cigarettes socially, people these days smoke, surgeons
but he denies dependency or use of have come up with ways to prevent
any other substances. After explaining any complications in these patients.
to him the importance of this history You counsel him that smoking cessa-
regarding surgical risk and postopera- tion may be a good goal for the future,
tive complications, he admits to smok- but there’s no rush for him to quit in
ing more frequently than he previously the next few weeks.
stated. At this point, you proceed with
further questionnaires and potentially
work with him on cessation of sub- 3.5 Answers
stances prior to surgery.
D. The patient denies use of any sub- vv 1. C
stances rather quickly and appears
defensive. This is a red flag to you, so vv 2. B
instead of proceeding with further
questionnaires, you decide it would be
best to lecture him on all the possible References
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3 parison of haloperidol and chlorpromazine in the 81. Bouchama A, Cafege A, Devol EB, Labdi O, El-Assil K,
treatment of phencyclidine psychosis. J Clin Pharma- Seraj M. Ineffectiveness of dantrolene sodium in the
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de Ecstasy. Rev Bras Anestesiol. 2006;56(2):183–8. analgesics and serotonin toxicity. BJA Br J Anaesth.
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lowing Ecstasy (methylenedioxymetamphetamine,
45 4
Awareness
Tomas Carvajal, Lopa Misra, Michael Molloy,
and Veerandra Koyyalamudi
4.1 Awareness, Recall, and Dreams – 46
4.2 Incidence – 46
4.3 Risk Factors for Awareness – 46

4.3.1 Patient Related – 46
4.3.2 Surgery Related – 48
4.3.3 Anesthesia Related – 50
4.4 Monitoring for Intraoperative Awareness – 52
4.5 Clinical Signs of Awareness – 52
4.6 Processed Electroencephalogram (EEG) – 52
4.7 Evoked Potential Monitoring – 53
4.8 Intraoperative Awareness and Medicolegal

Consequences – 53
4.9 Psychological Sequelae of Awareness Under

Anesthesia – 54
References – 55

https://doi.org/10.1007/978-3-319-96125-5_4
46 T. Carvajal et al.
4.1 Awareness, Recall, and Dreams between 1 and 2/1000 general anesthetics [5–10].
A higher incidence has been reported in cardiac
Awareness under general anesthesia (AAGA) is (1:43), pediatric (1:135), and obstetric anesthesia
infrequent and occurs when patients become con- (1:384) [11–13]. The significantly lower incidence
scious while undergoing surgery and may result in in the NAP5 audit could possibly be explained to
recall of their surroundings, events, and, at times, the lack of patient interviews and the dependence
pain related to their surgery postoperatively. on anesthesiologist’s recollection of events and
Awareness generally occurs where there is an reliance on retrospective data when conducting
4 imbalance between the depth of anesthesia being the survey.
provided and the degree of stimulus to which a
patient is being exposed. Although the incidence
of awareness or recall may be reduced with preven- 4.3 Risk Factors for Awareness
tive measures, it may not possible to completely
obviate the risk. In the absence of pain, awareness Elucidating the specific risk factors for intraoper-
is less traumatic for patients. Additionally, inabil- ative awareness is a complex task, given the small
ity to move due to muscle relaxation also has a relative incidence of awareness. Current prospec-
profoundly stressful effect on patients. tive studies are largely underpowered, and the
Recall is defined as the patient’s ability to vast majority of published literature is based on
retrieve stored memories and maybe exhibited case reports and case series studies.
as either explicit or implicit memory. Explicit According to epidemiological studies, the risk
memory refers to the patient’s ability to recall factors for accidental intraoperative awareness
specific events while under general anesthesia. during general anesthesia (AAGA) can be classi-
On the other hand, implicit memory refers to fied or categorized in three main groups:
alterations in patient behavior without being able 1. Patient related
to recall specific event. It is important to note that 2. Surgery related
dreaming is not considered a form of intraopera- 3. Anesthesia technique related
tive awareness and important to differentiate this
from true intraoperative awareness and recall. Alternatively, in one of the largest studies per-
Dreams have been excluded from the definition formed in the United Kingdom, NAP5 audit [3]
of intraoperative awareness by the ASA Practice categorized the risk factors based on the three
Advisory for intraoperative awareness [1]. main phases of anesthesia: induction of anesthe-
sia, maintenance of anesthesia, and emergence
from anesthesia.
4.2 Incidence
Studies have shown a large variability in the inci- 4.3.1 Patient Related
dence of AAGA. This could be possibly due to the
various risk profiles of patients, the variation in 4.3.1.1 Gender
anesthetic plan which may be influenced by sur- Female patients have been shown to have a higher
gical requirements, and different methodologies risk for AAGA. Domino et al. [14] after review-
involved in the assessment for awareness post- ing 4183 anesthesia-related claims in the United
operatively [2]. For example, the fifth National States found that 77% of claims involved female
Audit Project (NAP-5) in the United Kingdom, a patients. Mihai et al. [15] analyzed closed claims
very large retrospective study that did not include in the United Kingdom and revealed a similar
patient interviews, reported incidence of aware- finding. The NAP5 audit [3] comparatively ana-
ness to be 1 in 19,000 anesthetics [3]. The most lyzed 300 reports of AAGA and found that 65%
common tool used to establish the incidence of occur in women.
AAGA has been the Brice interview, conducted Numerous other studies have concluded a
immediately after surgery and often repeated up higher incidence of AAGA in female patients.
to three times within a month [4]. Studies have Morimoto et al. [16] reported after surveying 172
consistently shown the incidence of AAGA to be anesthesiologists, 24 cases of AAGA in which 76%
Awareness
47 4
were women. Ghoneim et al. [17] reviewed 271 In contrast, a questionnaire survey conducted
cases of reported AAGA and found that aware via the Internet involves 85,156; a majority of
patients were more likely to be female. Other patients reporting awareness (67%) were older
studies quoted an incidence at least 3 times higher than 50 years old [16]. Additionally, Pollard et al.
in the female gender [18–20]. [26] showed that in 211,842 anesthetics delivered
to adult population, there were 6 cases of AAGA
4.3.1.2 Age with a higher incidence in older patients (55.5
Studies have shown a higher incidence of aware- versus 46 years).
ness in children versus the adult population
(1% vs 0.2%) [21]. In a prospective cohort study 4.3.1.3 Previous History of Awareness
involving 864 children aged 5–12 years who had Under General Anesthesia
undergone general anesthesia, 28 reports were A previous history of AAGA is a predominant
generated for an incidence of 0.8%. In another risk factor that increases the incidence of a new
prospective study, data obtained from interviews episode [1, 7, 18, 27]. Ghoneim et al. [17] in 2009
with 410 children (aged 6–16 years) confirmed described that history of awareness was present
the incidence of awareness was 1.2% [22]. Cited in 1.6% of reported cases. Morimoto et al. [16]
reasons for a dramatic increase in incidence in found that 8.3% of the cases of AAGA had previ-
children in the above studies include the use of ous episodes. Avidan et al. [6] described in a study
induction rooms with transport to the operating with high-risk population, 11.1% had some his-
room and patients who required increased airway tory of previous AAGA. The NAP5 audit reported
manipulation. In an attempt to negate institutional up to 5% of the cases may have had an intrinsic
procedural bias, Malviya et al. showed a similar basis, given personal previous episodes or strong
incidence of 0.8% when evaluating a cohort from family history of AAGA [3]. Other observational
three different institutions [23]. Predisposition study noted an adjusted fivefold higher incidence
to awareness in children under anesthesia could in patients with previous AAGA [28].
possibly be due to the differences in anesthetic
pharmacology in children and differences in the 4.3.1.4 History of Other Medication
practice of pediatric anesthesia when compared and Substance Use
to adult anesthesia. For example, it has been Selected specific patient populations might be
found that a threefold higher minimum alveolar “resistant” or require a greater amount of anes-
concentration of sevoflurane is needed to main- thetic drugs and therefore could be more at a
tain a BIS value below 50 (MACBIS50) in children higher risk of AAGA. These patients include but
when compared to adults [24]. not limited to a younger age, tobacco smoking, or
There are conflicting results as to whether age long-term use of specific substances (alcohol, opi-
of the adult patient may have a bearing on the ates, cocaine, benzodiazepines, or amphetamines)
incidence of intraoperative awareness. Due to the [1, 19, 28–32].
inherent variability in study methods (high vari- Chronic analgesic use (opioids especially,
ability in age cutoffs), it is difficult to come to a in the setting of high doses) might translate to
definite conclusion if there is a difference in inci- inadequate analgesia during a surgical procedure,
dence in the younger adult population versus the resulting in a higher level of cortical stimulation
geriatric population. that may increase risk of AAGA [1, 7, 33].
The ASA closed claims database showed a Chronic alcohol use has been shown to
higher incidence of AAGA in those younger than increase the MAC requirements of several inhaled
60 years of age (89%) [14]. The NAP5 audit (fifth anesthetics; this has been proposed as the mecha-
National Audit Project (accidental awareness nism causal of higher risk of AAGA in this spe-
during general anesthesia)) reported an increased cific population [29, 32, 34, 35].
incidence in younger patients (25–55 years old) The “resistant” patient population has been
[3]. Similar results were seen in a study by Errando studied by Ezri et al. [36]. Investigators concluded
et al. who reported that patients with intraopera- that in patients with different genetic back-
tive awareness tended to be younger (mean (sd), grounds, the immobilizing dose of anesthetic may
42.3 (20.5) years old vs 50.0 (18.1) years old) [25]. vary by as much as 24%.
4.3.1.5 Physical Condition and ASA The ASA Practice Advisory for awareness [1]
Physical Status Classification states that patients at increased risk for awareness
Several studies have demonstrated increased risk include those with a history of difficult intubation
of AAGA in patients with ASA class greater than 2 or anticipated difficult intubation.
[8, 37]. Sebel et al. [8] showed an increased risk of Conflicting evidence was reported by Avidan
AAGA in ASA Classification III and IV patients [6] where none of the reported 27 cases of AAGA
undergoing major surgery. Likewise, a prospec- had a history of or anticipated difficult intubation.
tive study [26] described a higher incidence of
4 AAGA in patients with ASA Classifications III, 4.3.1.7 Weight: Body Mass Index
IV, and IVE. Weight or more specifically body mass index
Similarly, the incidence of AAGA is greater in (BMI) is a controversial risk factor.
patients who are given a lower dose of anesthetic It was previously believed to be a risk fac-
drug due to comorbidities such as hemodynami- tor [19, 29]. Presumed causes are often difficult
cally unstable, hypothermic, chronically ill, or airway, prolonged time for induction, hesitation
acutely intoxicated patients [38–40]. on dosing guided by total body weight, and use
The ASA Practice Advisory for Awareness [1] of light anesthesia given presence of restrictive
acknowledges that ASA physical status of IV or pulmonary disease or cardiovascular comorbid
V and limited hemodynamic reserve are high-risk conditions.
conditions for AAGA. However most recent studies suggest this
In contrast, other studies showed no relation- might not be the case. Ghoneim et al. [17] reviewed
ship between higher ASA physical status classifi- 271 AAGA cases and found no association with
cation and risk of AAGA. In the United Kingdom obesity when comparing to historical controls.
NAP5 audit [3], after studying 167 cases of AAGA In Avidan et al. [6] study, BMI was not statisti-
(including medication errors and ICU cases but cally significantly different in patients with AAGA
excluding MAC/sedation cases), ASA physi- than those patients without AAGA. Another ret-
cal status was not associated with increased risk rospective study [28] found that higher BMI was
of AAGA. Another prospective study with 4001 associated with AAGA but only in unmatched,
anesthetic cases [25] (with a reported crude 1% unadjusted analysis.
incidence of AAGA) found that ASA physical In contrast, the recent, in NAP5 audit [3],
status had no influence on the incidence. Another investigators found that obesity was in fact a risk
large prospective study [10] with 11,785 anesthetic factor for AAGA, particularly in the obstetric
cases found 19 cases of AAGA, with an ASA phys- population, mentioning that over three times,
ical status mean of 1.36 (range 1–3, median 1). as many obese patients experienced AAGA than
generally undergo anesthesia. Likewise, a prospec-
4.3.1.6 Difficult Airway tive study [26] described that 50% of their AAGA
The overall population incidence of difficult air- cases occurred in obese patients (BMI > 30).
way is fairly significant, reported somewhere
between 4.5% and 7.5% [41]. Although the degree
of difficulty in securing the airway contributing 4.3.2 Surgery Related
to AAGA is unclear, several authors report it as
being a risk factor [1, 18, 19, 33]. 4.3.2.1 Obstetric and Gynecologic
In Ghoneim et al. [17] in a review of AAGA Surgery
cases, prolonged laryngoscopy and difficult intu- One of the concerns of general anesthesia in
bation were present in 4.5%. There was a signifi- obstetric cases is the effects of anesthetic drugs
cant high proportion of AAGA cases associated on the fetus/newborn and on the uterine muscle
with failed, prolonged, or difficult airway man- before and after delivery. A common practice
agement in the NAP5 audit [3]. Additionally in is to limit anesthetic drug delivery to negate
10.5% of patients with AAGA reported by Sandin these effects. Obstetric surgery has been amply
et al. [10], AAGA was deemed secondary to a dif- described as a risk factor for AAGA [17, 7, 30,
ficult airway. And in a more recent prospective 32, 38, 42–44]. Obstetric surgery has an increased
observational study, 8% of the AAGA cases had incidence of AAGA, described from around
difficult intubation related to the episode [25]. 0.26% to as high as 28% [38, 42, 43, 13, 45, 46]
Awareness
49 4
significant fluctuation in incidence based on era, group [11] demonstrated an AAGA incidence of
type of obstetric case, and reporting bias. 0.5% in about 1218 cardiac surgery patients.
Both elective and emergency surgeries have Dowd et al. [51] demonstrated the lowest
increased risk of AAGA in the obstetrics popula- incidence of AAGA in cardiac surgery patients
tion [42, 46]. Additionally, specific to gynecologic undergoing CPB (0.3%), achieved by balanced
surgery, there is a reported higher AAGA risk anesthetic technique providing continuous
reported by some authors [17]. inhaled (isoflurane) or intravenous (propofol)
NAP5 audit [3] confirmed that obstetrics anesthetic before, during, and after CPB.
anesthesia is a high risk for AAGA (it was the sur- More recently Myles et al. [7] reported an
gical specialty most overrepresented in the AAGA incidence of about 0.45% AAGA in cases where
cases sample). This finding was supported by the majority underwent coronary artery bypass
Errando et al. [25], who prospectively investigated grafting (CABG). Wang et al. [52] reported
4001 anesthetics and reported that Cesarean sec- that an incidence of awareness of patients who
tion was a statistically significant factor associated received off-pump CABG, CABG under cardio-
with AAGA (p = 0.019). pulmonary bypass (CPB), and septal repair or
Multiple explanations for this increased risk valve replacement under CPB was 9.6%, 4.7%,
have been established and mostly are related and 4%, respectively. Authors concluded that the
to other previously described risk factors for majority of AAGA occurs before bypass grafting
AAGA. These include, but not limited to, utiliza- or CPB.
tion of low-dose anesthetic to avoid some of the In summary, cardiothoracic surgery has been
tocolytic effects, hemodynamic instability or acute and continues to be considered as a high-risk
bleeding, rapid sequence induction (RSI), univer- factor for AAGA. Incidence has been declining
sal utilization of NMBD, omission of opioids on in recent years, perhaps due to changes in anes-
a significant portion of the anesthetic, difficult thetic management, education, and vigilance.
airway management, obesity, and high incidence Despite this it still has an overall incidence that is
of emergent/urgent cases, among others [1, 3, much higher than reported in non-cardiothoracic
17, 44, 13, 45]. This might explain why the use of surgery.
regional anesthesia has dramatically increased in
recent years, with a simultaneous decline in the 4.3.2.3 Trauma and Emergency
use of general anesthesia for obstetrics cases [47] Surgery
(Birnbach and Browne [96]). Major trauma and emergency surgery are fre-
quently associated with hemodynamic instability
4.3.2.2 Cardiothoracic Surgery that occasionally necessitates reducing the dose
Cardiothoracic surgery by itself has been of anesthetic given. Additionally, hypothermia,
described as a risk factor for AAGA [1, 17–19, hypovolemia, acute intoxications, brain trauma,
48]. Additionally, it might be related to patient and multiple injuries are factors present that may
comorbidity (see “Physical Condition” above) and affect the anesthetic dose administered.
the need for cardiac surgery patients to be under Bogetz et al. [39] demonstrated that the inci-
cardiopulmonary bypass (CPB). dence of AAGA of surgery in victims of major
Upon review of the published cases of AAGA, trauma is considerable, ranging from 11% to 43%
Ghoneim et al. [17] found an increased incidence in the cases studied, particularly in cases where
during cardiac surgery. Pollard et al.’s [26] study in anesthesia is interrupted or severely reduced.
academic centers also revealed increased risk and Interestingly AAGA occurred despite significant
incidence in cardiac surgery. hypotension, thought to be protective due to the
Incidence of AAGA during cardiac surgery has proportional decrease in cerebral perfusion pres-
been reported to be 1.14–23% [38, 48, 49]. Ranta sure. Myles et al. [7] studied high-risk AAGA
et al. [50] reported an incidence of 4% AAGA, patients, which included acute trauma with
particularly in young population undergoing hypovolemia. Ghoneim et al. [17] also found an
cardiac surgery. But after introduction of some increased incidence during trauma surgery. The
preventive techniques, there was an incidence NAP5 audit [3] revealed (after reviewing 110
reduction to 1.5%, in the 303 cardiac surgery certain/probable cases of AAGA) that emergent/
patients. Subsequently in a larger study, the same urgent surgery (p < 0.0001) and out-of-hours
surgery (p < 0.0001) were also risk factors. Out of In the largest prospective observational study
hours surgery was also reported by other studies as with 4001 patients, Errando et al. [25] showed
a significant risk factor for AAGA (P = 0.013) [25]. higher incidence of AAGA in patients admin-
istered with TIVA, in comparison with those
4.3.2.4 Other Types of Surgeries/ administered with a balanced anesthesia (intrave-
Procedures nous induction drug plus a halogenated inhaled
Other types of surgery have been described agent).
as a risk factor for AAGA. Surgery types also Morimoto et al. [16] after surveying 172 anes-
4 reported to be of higher risk, including cervi- thesiologists and reviewing 85,000 cases reported
cal, cranial, facial surgery (including otorhino- 24 cases of AAGA. In 21 cases (88%) TIVA was
laryngology) and bronchoscopy/jet ventilation used, whereas inhaled agent was used only in 2
procedures [7, 53, 54]. Possible reasons include cases where AAGA was reported (9%).
the use of total intravenous anesthesia (dis- NAP5 audit [3] also demonstrated that TIVA
cussed below), which is common especially (including target-controlled, manually controlled
when neuro-monitoring is utilized as in neu- infusion and fixed-rate infusions as well as bolus
rosurgery or when airway management by the techniques) resulted in increased number of AAGA
pulmonologist or surgeon precludes the use of incidences. In particular, when switching inhaled
inhalation agents, for example, during the use anesthetics to TIVA for transport, the highest risk
of jet ventilation. profile was found to be when TIVA was associated
with neuromuscular blocking agents.
In contrast, a large study of patients receiving
4.3.3 Anesthesia Related TIVA (propofol- and opioid-based anesthesia)
[59] for short-stay surgical procedures found no
4.3.3.1 Total Intravenous Anesthesia occurrence of AAGA in a cohort of 5216 cases.
(TIVA) Although only 7% of the cases required neuro-
TIVA is considered a significant risk factor for muscular blocking drugs (NMBD). Supporting
AAGA. However, studies have shown contrasting the previous statement, a prospective study [60]
results. analyzed 1000 cases of TIVA (propofol, alfentanil,
The first reported case of AAGA under TIVA and NMBD) and found the same incidence of
was a patient undergoing repeat emergency car- AAGA as general inhaled anesthesia with NMBD
diac surgery, where they utilized high-dose fen- (0.2%). Sandin et al. [61] also published a review
tanyl combined with diazepam and oxygen [55]. of five cases of AAGA under TIVA and concluded
Subsequently, there have been other reports of an that all of them were caused primarily by lack of
increased incidence of AAGA when anesthesia experience and could have been prevented.
was maintained only with high-dose fentanyl [56] The general consensus is that TIVA is con-
or utilizing intermittent IV boluses [29]. sidered a risk factor of AAGA, mainly related to
A repeatedly cited case of AAGA during pro- delayed infusion starts delay in achievement of
pofol TIVA was Kelly et al.’s [57] description of therapeutic levels, inadequate induction doses,
a patient undergoing a micro-laryngeal surgery. suboptimal administration modes, failure of
But this is not an isolated event; multiple studies delivery mechanism, and/or inexperience with
have been published that relate AAGA with TIVA, this anesthetic technique.
providing support for the high-risk statement.
Miller et al. [58] developed a randomized 4.3.3.2 Neuromuscular Blocking
double-blinded clinical trial to study the effects of Drugs (NMBD)
midazolam on a specific TIVA protocol, but the NMBD are considered one of the largest risk fac-
study was halted due to an increased incidence of tors for AAGA. If complete muscle paralysis is
AAGA (19.1%). present, a somewhat useful sign of anesthetic depth
Domino et al. [14] reviewed close to 4200 is abolished which in turn infers an increased risk
anesthesia related claims in the United States and for AAGA. In fact, probably the first report of
showed that cases of AAGA were more likely to AAGA was using a NMBD (Curare) [62].
involve anesthetic techniques using no volatile In the NAP5 audit [3], the incidence of AAGA
anesthetic (OR = 3.20, 95% CI = 1.88–5.46). was 1:8000 when neuromuscular blockade was
Awareness
51 4
used and 1:136,000 without the use of neuromus- 4.3.3.4 Failure of Equipment, Misuse,
cular blockade. and Mistakes
The association of NMBD and AAGA was sta- Defective anesthesia systems or failure of equip-
blished long before large studies like the NAP5. ment may result in inadequate anesthetic delivery
Hutchinson [63] review of 656 patients found to the patient, posing a risk for AAGA [29, 66].
eight cases of AAGA mainly in patients receiving Equipment failure in developed countries is
nitrous oxide and large doses of NMBD. Similarly, rapidly decreasing [19]; more frequently the risk
Guerra et al. [29] presented several cases of AAGA of AAGA is more likely related to misuse than
with the use of inhaled nitrous oxide and NMBD failure [14, 66, 67]. Recently Wang et al. [68]
alone. In the 1990s, nitrous oxide was used less demonstrated that not using inhaled anesthetic
frequently, and Liu et al. [27] reviewed more than concentration monitoring increased the risk of
1000 anesthetics and found only two cases of AAGA from 0.164% to 1.14%.
AAGA, and both were related to NMBD shortly Medication error and syringe swaps have also
after induction. Domino et al. [14] after reviewing been described as a risk factor for AAGA or even
79 cases of AAGA demonstrated that those cases a more frequently direct cause of “awake paraly-
were more likely to involve anesthetic techniques sis” [14].
using NMBD (OR = 2.28, 95% CI = 1.22–4.25). NAP5 audit [3] reported 17 cases of “awake
More recently, Sandin et al. published a paralysis,” due to drug error/medication swaps.
study [10] involving 12,000 Swedish patients; Additionally they attributed a large portion of the
AAGA incidence was 0.10% in the absence of cases of AAGA under TIVA to failure to deliver
NMBD, compared with 0.18% in the presence of the intended dose of drug, which could be possi-
NMBD. This was again supported by Sebel et al. bly due to a problem with the intravenous cannula
[8], where 65% cases of AAGA received NMBD. or infusion pump.
Although the risk of AAGA with NMBD and
its association has been established, it is impor- 4.3.3.5 Inhaled Anesthesia: Nitrous
tant to note that there are many reports of AAGA Oxide
in the setting of no NMBD being administered. Other common scenario where there has been
an increased incidence of AAGA is when inhaled
4.3.3.3 Light Depth of Anesthesia anesthesia is maintained only using nitrous oxide
A commonly cited risk factor for AAGA is light as a sole agent. This finding has been described
anesthesia, intentionally performed in condi- multiple times, in case reports when utilizing
tions where higher doses are not achievable (see nitrous oxide as main anesthetic in combination
“Physical Condition” above). But cases of AAGA with ketamine [69] or with high-dose narcotics
seemed to be more often related to failure in [70] resulting in AAGA. Utting [71] described
vaporizers, lack of monitoring anesthetic gas, or that, when used alone, inhalation anesthesia with
clinical knowledge failure [19, 38]. nitrous oxide was associated with a 2% risk of
Light anesthesia might also occur when there AAGA. Errando et al. [25] also showed increased
is failure to recognize the concentration of agent AAGA in the described mixed anesthesia group
administered and is lower in comparison with the (any intravenous induction drug on induction
dialed in concentration [19]. This occurs fairly with nitrous oxide with oxygen maintenance).
common when gas or vaporizer monitors are not Similarly Hutchinson [63] reported eight cases of
used [14]. A study by Bergman et al. [64] revealed AAGA where nitrous oxide was the main inhaled
that in cases of AAGA, up to 13% had a failure in anesthetic.
nitrous supply or there was no volatile concentra-
tion monitoring. 4.3.3.6 Transport and Remote
Ranta et al. in 1998 [65] reported that the use Locations
of smaller doses than usual (isoflurane and propo- Classically induction of anesthesia was performed
fol) was seen more frequently in the AAGA group. in the “induction room” or “anesthetic room,” a
Ghoneim [19] stated, after reviewing previously concept that is still used in many countries, includ-
published cases, that absence of volatile anesthetic ing the United Kingdom. NAP5 audit [3] revealed
or propofol during maintenance of anesthesia was that transfer of the patient from anesthetic room
related to AAGA in 23% of the cases. to operative theatre was a major factor in many
AAGA cases; associated factors include emergent 4.5 Clinical Signs of Awareness
induction, rapid sequence intubation, transport
or remote locations, use of short-acting induction Clinical signs used to evaluate for intraopera-
drugs, trainees delivering anesthesia, presence of tive awareness include purposeful movements to
a difficult airway, and avoidance of opioid with command or stimulation, eye opening, eyelash
induction. reflexes, pupillary responses, perspiration, and
Other published literature demonstrated tearing. Vital signs such as the heart rate and
transport as a risk factor [27]. blood pressure are more commonly relied upon
4 when the patient has been administered muscle
4.3.3.7 Premedication relaxation. However, such signs can be easily
Several studies have shown an association of lack masked by the concurrent administration of many
of premedication and AAGA. But overall there is drugs either preoperatively or intraoperatively.
lack of consensus [1]. For example, anticholinergic and narcotics cause
In a study by Wilson et al. [20], 11% of 490 either mydriasis or meiosis. Anticholinergics may
patients had mental disturbances during anes- also reduce secretions, lacrimation, and sweat-
thesia, of which 1% had AAGA. There was no ing. Antihypertensives (beta-blockers, calcium
difference in premedication regimen, anesthetic channel blockers, ACE-inhibitors) may mask the
agent used, type of surgery, or demographics (age, hypertension and tachycardia manifestations of
gender) between the cases with and cases without “light anesthesia.” Hypovolemia either from dehy-
AAGA. dration or from blood loss or the use of neuraxial
Errando et al. [25] found that benzodiazepine blockade may lead to hypotension masking the
premedication was associated with a lower inci- hypertension that may be seen with an inadequate
dence of AAGA. anesthetic depth.
Wilson et al. [72] evaluated 150 obstetric In fact, a closed claims analysis by Domino
cases, 3% had AAGA with narcotic premedica- et al. showed the absence of hypertension and
tion, in comparison with 21% that had AAGA tachycardia in a majority of cases of recall under
with no premedication, with no other statistical anesthesia in the database [14]. The author’s anal-
significant difference in the anesthetic care of ysis found that a rise in blood pressure was seen in
both groups. only 15% of cases, an increased heart rate in only
In the cases reviewed by Ghoneim et al. [17], 7%, and motor movements was observed in only
benzodiazepines and pre-induction medications 2%. Clinical signs are thus very unreliable in dis-
were used less in the AAGA cases. cerning “light anesthesia,” and despite presumed
adequate depth of anesthesia, awareness under
anesthesia may still occur.
4.4 Monitoring for Intraoperative
Awareness
4.6 Processed
Immediate detection of intraoperative aware- Electroencephalogram (EEG)
ness at the time of occurrence is not feasible.
Awareness under anesthesia is usually confirmed Processed EEG has been postulated as a more
postoperatively after obtaining information reliable tool in identifying those patients who
from the patient. Therefore, anesthesiologists may be under-anesthetized. One commonly
should rely on indirect measurements and used device is the Bispectral Index® (BIS; Aspect
observations. Medical Systems, Natick, MA, USA). The BIS
Physiological and motor responses do not monitor processes an electroencephalographic
accurately indicate the presence of an aware signal (using a proprietary algorithm) to calculate
patient. Anesthetic drugs, cardiovascular medica- a number that provides a measure of the patient’s
tions such as beta-blockers, and the use of neu- level of consciousness. BIS values range from 0 to
romuscular blocking agents frequently negate the 100, the higher number reflecting a more awake
ability to detect awareness based on patient’s vital patient. BIS values below 40 indicate a deep hyp-
signs and purposeful motor movement. notic state. BIS values between 40 and 60 have
Awareness
53 4
been advocated to prevent anesthesia awareness auditory cortex, and to the frontal cortex. Mid-
[73]. Evidence that these devices detect and pre- latency auditory evoked potentials (MLAEP)
vent intraoperative awareness is contradictory. occur 10–100 ms post auditory stimulus [78].
Ekman et al. compared 4945 anesthetized patients Studies have shown a dose-dependent sup-
utilizing EEG monitoring with a historical control pression of MLAEP with both intravenous and
group without EEG monitoring and showed a inhalation anesthetics leading to the notion that
fivefold reduction of the risk of awareness [74]. In MLAEP measurements could be a useful depth
the B-aware study involving 2500 patients, investi- of monitoring tool [78, 79]. The effectiveness of
gators detected a 82% risk reduction in awareness MLAEP monitoring in reducing intraoperative
with EEG monitoring [7]. However, in a recent awareness in humans needs further validation.
single center randomized prospective study, in
patients at a high risk of awareness, BIS monitor-
ing was not found to be associated with a lower 4.8 Intraoperative Awareness
incidence of AAGA or a reduction in the admin- and Medicolegal Consequences
istration of volatile anesthetic [5]. Regarding
BIS monitoring, both the National Institute for Intraoperative awareness is an unwanted out-
Health and Care Excellence (United Kingdom) come for both the patient and the anesthesiolo-
and the Food and Drug Authority (United States) gist. Explicit, or conscious, memories experienced
say that the use of BIS monitor “may” help guide under general anesthesia are one of the most
anesthetic administration thereby reducing the important causes of patient dissatisfaction [80].
probability of awareness [75, 76]. The reliability Fortunately, not every case of recall leads to a mal-
of BIS monitoring in preventing AAGA is thus practice claim. One out of 25 claims resulted from
questionable. negligent care, and these numbers drop when the
The prediction probability Pk value has been standard of care is followed [81–83]. Interestingly,
recommended as an appropriate measure for there is a large disparity when comparing the
evaluating and comparing the performance of incidence statistics of intraoperative awareness,
anesthetic depth indicators [77]. Prediction prob- which now occurs in less than 1 in every 700
ability has a value of 1 when the indicator predicts general anesthetics [8], and the evaluation of
anesthetic depth perfectly and a value of 0.5 when closed claims, which are only approximately 10
the indicator predicts a 50:50 chance. The Pk val- per year [84]. It is uncertain why there is such a
ues for BIS monitor between awake and loss of difference between the incidence and the claims
response ranged from 0.72 to 1.00 and from 0.79 filed with the ASA Closed Claims database, but it
to 0.97 between an anesthetized state and first is important to note that only one third of anes-
response [33]. thesiologists are captured based on claims from
Other spontaneous EEG monitors include liability insurers. Theoretically, this disparity is
entropy (GE Healthcare Technologies, Waukesha, secondary to both the nature and severity of the
WI, USA) with reported Pk values of 0.83–0.97 injuries associated with intraoperative recall and
for loss of consciousness and Narcotrend (GE the compensation of these claims. Not surpris-
Healthcare Technologies, Waukesha, WI, USA) ingly, patients who experience this adverse event
with Pk values 0.93–0.99 between awake and loss and do not suffer long-term sequelae choose not
of response and from 0.94 to 0.99 between an to pursue a malpractice suit. As previously stud-
anesthetized state and first response [33]. BIS is by ied, an empathetic apology from the provider
far the most studied depth of anesthesia monitor. offers the benefit of both preventing escalation of
the situation and is therapeutic to the individual
who has suffered [85, 86]. The other protective
4.7 Evoked Potential Monitoring factor is the requirement of negligence by the
anesthesiologist to be proven for the tort system.
Auditory evoked potentials consist of a series of Common causes leading to a patient filing a
waves (positive and negative) that represent the claim against the provider include poor com-
transmission and processing of an auditory stim- munication, unmet expectations, and financial
ulus from the cochlea, through the brain stem, the pressures faced by the individual. Studies have
shown that 50% of patients who filed a claim felt to 2007 dollars) in recent claims was $71,500, with
they had a poor relationship with their physician a range of $924 to $1,050,000 [92]. This is a dras-
[87]. Thus, this supports the notion that provid- tic increase from the median payment of $26,065,
ers who provide open communication with their evident from Domino et al. in 1999 [14]. Again, it
patients are less likely to be sued. University of is unclear why the payments for awareness have
Michigan Health System (UMHS) implemented a increased, especially since these trends have not
program that included full disclosure and offered been observed for other anesthesia complications.
compensation to individuals for medical errors. ASA Committee on Professional Liability
4 After implementing this program, a study found initiated the development of the Anesthesia
that average monthly rate of new claims decreased Awareness Registry in October 2007 to help phy-
from 7.03 to 4.52 per 100,000 patient encounters sicians understand the patient’s perspective of
(rate ratio [RR], 0.64 [95% CI, 0.44 to 0.95]) [88]. intraoperative awareness. An important discov-
It is important to remain empathetic, as providers ery from the Anesthesia Awareness Registry is
who dismissed the patient’s concerns are likely to that some patients contacted the registry after an
exacerbate injury and contribute to initiation of a intraoperative awareness event, but upon review
malpractice claim by the individual [85, 89, 90]. of their medical records, it was revealed that they
The legal system and lawyers act as gatekeep- had received regional anesthesia or monitored
ers for malpractice claims. A United States survey anesthesia care [92]. This realization demon-
found that attorneys are reluctant to take on cases strates that one of the main issues with regard
in which expected financial compensation was to this adverse event is poor communication
less than $61,700 (adjusted to 2007 dollars) [87] between the physician and patient and addressing
and a Canadian study found that the threshold individual expectations.
was $107,000 dollars (adjusted to 2007 dollars)
[91]. This makes sense as the legal system has
most plaintiff lawyers work on contingency-fee 4.9 Psychological Sequelae
basis, which means the attorneys are paid with a of Awareness Under Anesthesia
percentage of the award as a fee and earning noth-
ing if they lose the case. Given the context of intraoperative awareness,
Data from the Closed Claims Project includes there are concerns for psychologic sequelae. A
ongoing evaluation of adverse anesthetic out- study published in General Hospital Psychiatry
comes obtained from the files of 37 participat- by Osterman et al. found that patients reported
ing liability insurance companies. Intraoperative intraoperative experiences including an inability
awareness only represents 2% of all claims filed. to communicate, helplessness, terror, and pain
Comparing the recent claims filed in the Closed [93]. Post-awareness individuals had significant
Claims database and those previously published postoperative distress related to feeling unable
by Domino et al. in 1999, the majority of patients to communicate, unsafe, terrified, abandoned,
who filed claims for awareness were female, with and betrayed. Due to these outcomes, one could
an ASA classification I-II, less than 60 years old, expect that patients might develop mental con-
and underwent elective surgery [14]. The new ditions, such as post-traumatic stress disorder
data shows that the proportion of individuals (PTSD) as a potential result.
pursuing legal action and undergoing obstetric Osterman et al. [93] demonstrated that 9 of
or gynecologic surgery decreased from 30% to 16 subjects (56.3%) met diagnostic criteria for
20%, but the proportion of claims associated with PTSD. Another study by C. Lennmarken [94],
cardiac surgery increased from 5% to 21%. This demonstrated that four of the nine patients who
shift creates an unanswered problem, as patients were interviewed 2 years after intraoperative
undergoing cardiac procedures have previously awareness were still severely disabled due to psy-
been recognized as being among the highest risk chiatric sequelae. These studies demonstrate a
for the occurrence of awareness [49]. It is currently high incidence of long-term sequelae following
unclear why there has been a rise in intraoperative AAGA.
awareness claims with regard to cardiac surgery. Multiple studies demonstrated a rate of
From the Closed Claims Project, we know PTSD between 2% and 71% [95]. Further evalu-
that the median payment (adjusted for inflation ation found that patients with postoperative
Awareness
55 4
psychological sequelae, which may be inclusive 7. Myles P, Leslie K, McNeil J, Forbes A, Chan M. Bispec-
of PTSD, ranged from 20% to 84%. The broader tral index monitoring to prevent awareness during
anaesthesia: the B-Aware randomised controlled trial.
psychological sequelae of AAGA included vague Lancet [Internet]. 2004 [cited 2017 Nov 27];363 had
complaints including “after effects,” “sleep dis- undergone general anesthesia, 28 reports were gener-
turbances,” and “temporary emotional distress.” ated (9423):1757–63. Available from: http://www.ncbi.
Leslie et al. in a prospective evaluation of patients nlm.nih.gov/pubmed/15172773.
in the B-aware trial found that five out of the seven 8. Sebel PS, Bowdle TA, Ghoneim MM, Rampil IJ, Padilla RE,
Gan TJ, et al. The incidence of awareness during anes-
patients who developed awareness and were avail- thesia: a Multicenter United States Study. Anesth Analg
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tor was that the incidence of PTSD in the control 9. Wennervirta J, Ranta SO-V, Hynynen M. Awareness
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61 5
Shared Airway: Techniques,

Anesthesia Considerations,
and Implications
Jennifer E. Woerner, Andrew T. Meram, and Spencer Armuth
5.2 Patient Evaluation – 63
5.3 Open Airway Techniques – 64

5.3.1 Monitored Anesthesia Care (MAC) or Intravenous
Conscious Sedation (IVCS) – 64
5.3.2 Mask Ventilation – 66
5.3.3 Insufflation/Spontaneous Respiration – 66
5.3.4 Jet Ventilation – 67
5.3.5 Laryngeal Mask Airway (LMA) – 67
5.4 Intubation Techniques – 69

5.4.1 Standard Endotracheal Tubes – 69
5.4.2 Nasal RAE – 70
5.4.3 Microlaryngoscopy Tubes – 70
5.4.4 Laser-Resistant Endotracheal Tubes – 70
5.4.5 Reinforced Endotracheal Tubes – 71
5.4.6 Videolaryngoscopy – 71
5.4.7 Fiber-Optic-Guided Intubation – 71
5.4.8 Surgical Airways – 72
5.5 Complications – 73
5.5.1 Failed Intubation – 73
5.5.2 Laryngospasm – 73
5.5.3 Foreign Body Aspiration – 74
5.5.4 Surgical Fire – 75
5.5.5 Vocal Cord Paralysis – 77

https://doi.org/10.1007/978-3-319-96125-5_5
5.6 Prevention of Complications – 77
5.6.1 Capnography – 77
5.6.2 Pre-tracheal Auscultation – 78
5.6.3 Throat Pack – 78
5.6.4 Suturing the Endotracheal Tube – 78
5.8 Answers – 79
References – 79
Shared Airway: Techniques, Anesthesia Considerations, and Implications
63 5
5.1 Introduction
Key Points
55 Shared airway anesthesia refers to the A shared airway during anesthesia refers to the
anesthesiologist maintaining the airway anesthesiologist maintaining the airway and venti-
and ventilation of the patient as the sur- lation of the patient as the surgeon performs proce-
geon performs procedures in the same dures in the same anatomic space. This is commonly
anatomic space. Shared airway anesthe- encountered in pediatric surgery, otolaryngology,
sia is commonly encountered in pediatric oral and maxillofacial surgery, and dentistry under
surgery, otolaryngology, oral and maxil- general anesthesia. Sharing the airway during
lofacial surgery, and dentistry. anesthesia, both inside and outside the operating
55 Minimizing risk during shared airway room, with surgeons performing head and neck or
procedures begins with a thorough pre- intraoral procedures can be challenging and lead
operative assessment, including a full his- to an increased risk for possible complications.
tory, physical, and airway examination. This type of situation requires careful planning by
55 Open airway techniques encountered both the anesthesia and surgical teams, along with
during shared airway anesthesia include open communication between providers. Head
(1) monitored anesthesia care, (2) mask and neck procedures can be performed under the
ventilation, (3) insufflation with sponta- continuum of anesthesia from minor sedation to
neous respiration, (4) jet ventilation, and general anesthetic. Overall, security of the airway
(5) laryngeal mask airway. for these patients should be seen as an institutional
55 Standard cuffed endotracheal tubes are responsibility, and all possible weak points should
often not ideal for various head and neck be identified through all phases of care [1].
procedures. For maxillofacial trauma According to a closed claims analysis by the
cases, where maxillomandibular fixation American Society of Anesthesiologists, adverse
is required, nasotracheal intubation is outcomes, within the operating room and during
the preferred airway. non-operating room anesthesia (NORA), are most
55 For shared airway cases with difficult commonly associated with respiratory events [2,
airways, videolaryngoscope-guided 3]. Within the operating room and during NORA,
intubation, fiber-optic-guided intuba- they represent 37% and 38% of all injury cases,
tion, or a surgical airway may have to be respectively [2, 3]. Cases occurring outside the
considered as alternatives to standard operating room most commonly occurred within
intubation techniques. the gastrointestinal (GI) suite [3]. It is important
55 Shared airway procedures involving lasers to recognize that a majority of the published data
require the use of a cuffed laser-resistant represents anesthesia administered by anesthe-
tube. The cuff should be filled with saline, siologists, but does not account for anesthetics
which is tinted with methylene blue. performed outside of the operating room by other
55 The emergent surgical airway of choice, trained medical professionals. The American
in patients older than 12 years, is a crico- Association of Oral and Maxillofacial Surgeons
thyroidotomy. published a 10-year closed claims study, including
55 Complications encountered in shared air- data from 1989–1998, which showed respiratory
way anesthesia include failed intubation, events as the highest incidence of adverse events.
laryngospasm, foreign body aspiration, Considering the additional difficulty associated
surgical fire, and vocal cord paralysis. with shared airway procedures, the focus of this
55 The gold standard for intraoperative chapter will be to discuss safe practice regardless
monitoring of a patient’s ventilation is of provider type or location.
waveform capnography.
55 Throat packs can be used in shared
airway anesthesia to prevent aspiration 5.2 Patient Evaluation
of blood, oral secretions, surgical debris,
and instrumentation. However, throat Preoperative assessment of the surgical patient is
packs must be removed to prevent risk of imperative in minimizing risk during shared air-
airway obstruction following extubation. way procedures. Fortunately, most head and neck
procedures are considered “low-risk” anesthetics
64 J. E. Woerner et al.
and are often performed on healthy patients [1]. controversial whether short procedures should
The preoperative assessment should include a full be canceled due to recent URI, but it may be pru-
history and physical examination. Additionally, a dent to consider rescheduling longer procedures
full anesthetic/airway history should be obtained and those that involve surgical management of
to include any previous complications, difficult the airway [7].
intubations, or airway compromise. If available, A complete social history to include the use
previous anesthetic records should be reviewed. A of alcohol, tobacco, or illicit drugs is necessary.
previous history of difficult airway management Of these, tobacco use is the most relevant during
is often the best predictor of future complications shared airway procedures. Not only does smoking
and can identify a need for additional planning impair healing and compromise the cardiovas-
5 and precautions [4]. This process should also
determine if there are any existing medical condi-
cular system; it increases the risk of respiratory
events during and following anesthesia. In a
tions that can impact airway management [5]. shared airway procedure or an airway that may
Any symptoms relating to the head and neck be considered difficult, this can have a deleteri-
or intraoral procedure to be performed should ous effect. Schwilk and colleagues reviewed over
also be considered as a potential source of air- 26,000 anesthetic procedures for respiratory
way compromise during anesthesia. Many shared events and found an incidence of 5.5% in smok-
airway procedures are on patients that may have ers and only 3.1% in non-smokers. Complications
airway compromise such as voice disorders, for- included re-intubation, bronchospasm, laryn-
eign body aspiration, trauma to the maxillofacial gospasm, and hypoventilation [8]. Numerous
region, papillomas, vocal cord dysfunction, tra- studies have shown that smoking cessation for
cheal stenosis, or tumors [6]. When radiological more than 4 weeks prior to surgery reduces the
studies are necessary for surgical evaluation or risk of respiratory and wound complications and,
planning, it is often helpful to utilize cone beam with cessation of over 8 weeks, complication rates
computed tomography (CBCT), traditional com- approach that of non-smokers [9].
puted tomography (CT) scans, or magnetic reso- As part of the physical exam, a full head and
nance imaging (MRI) to assess the patency and neck exam should be performed along with a
anatomy of the patient’s airway. These radiology thorough airway evaluation. The airway examina-
studies can aid in the planning process when: tion should include at a minimum the maximum
deviation of the airway exists, tumors or pathol- incisal opening, Mallampati-Samsoon classifica-
ogy that may alter or decrease airway volume tion, damaged or loose teeth, range of motion of
exists, or bony and/or anatomic deformities exist the neck, thyromental distance, tracheal devia-
that may impair intubation or ventilation. In cer- tion or neck masses, facial hair, and assessment
tain cases, a three-dimensional volumetric airway of tonsillar size. Airway examination features
analysis can be obtained to further assist in the associated with the potential for a difficult airway
planning process. The use of cone beam CT is with potential to escalate into a “cannot venti-
well documented in the orthodontic and oral and late” or “cannot intubate” situation are listed in
maxillofacial surgery literature, describing volu- . Table 5.1 [10–15].

metric airway changes following expansion of the

palate and orthognathic surgery for either dento-
facial deformities or obstructive sleep apnea. 5.3 Open Airway Techniques
A recent history of an upper respiratory tract
infection (URI), particularly in the pediatric 5.3.1 Monitored Anesthesia Care
population, is also essential. Recent URI can (MAC) or Intravenous
predispose a patient to having a reactive air- Conscious Sedation (IVCS)
way and increases the risk for laryngospasm or
bronchospasm during induction or emergence According to the ASA, monitored anesthesia care
from anesthesia. This can also increase the risk (MAC) is defined as a planned procedure where
for prolonged intubation following longer surgi- local anesthesia is administered, along with seda-
cal procedures. These adverse anesthetic events tion and analgesia [16]. MAC produces a similar
can further complicate shared airway proce- level of anesthesia as moderate conscious seda-
dures and possibly postoperative healing. It is tion, except the provider must be capable of
65 5
.. Table 5.1 Difficult Airway Risk Factors
Difficult mask ventilation Difficult direct laryngoscopy
Age >55 years old Reported history of difficult intubation, aspiration pneumonia, or

dental/oral trauma following intubation
Obstructive sleep apnea/snoring Obstructive sleep apnea/snoring
Previous head and neck radiation, Previous head and neck radiation, surgery, or trauma
surgery, or trauma
A beard Congenital disease such as Down syndrome, craniofacial syndromes,

cleft lip and palate, or Pierre Robin syndrome
Edentulism Rheumatologic disease such as scleroderma, spondylitis, or rheumatoid

arthritis
Body mass index >26 kg/m2 Obesity
Current head and neck tumor or Poor flexion and extension of neck/cervical spine disease
infection
History of head and neck burns
Current head and neck tumor or infection
Mallampati class III or IV
Limited maximum incisal opening (<30 mm)
Dentofacial deformities (high-arched palate, retrognathia)
Thyromental distance (<60 mm)
Macroglossia
Short neck
References: [1–5]
converting to general anesthesia if necessary or still respond purposefully to commands, main-

rescuing the patient’s airway if it becomes com- tain a patent airway, and support cardiovascular
promised at any time. MAC is often administered function.
in the operating room setting by a separate anes- The best way to reduce airway complications
thesia provider, but IVCS is often administered is through prevention and early recognition of
during office-based procedures utilizing a team obstruction. In 2017, the ASA assigned a Joint Task
model. Both techniques are commonly employed Force to create Practice Guidelines for Moderate
during shared airway procedures. The anesthesia Procedural Sedation and Analgesia for use by all
provider must have a solid understanding of the providers who perform moderate procedural
procedure to be completed and any potential risk sedation and analgesia in any inpatient or out-
to the airway. For example, during dental restora- patient setting. The task force consisted of fifteen
tions, there may be a need to irrigate the oral cav- members, to include physician anesthesiologists,
ity or utilize instrumentation that could possibly a cardiologist, dentist anesthesiologist, emergency
be aspirated if precautions are not taken. physician, gastroenterologist, oral and maxillofa-
A moderate level of sedation and analgesia cial surgeon, radiologist, an ASA staff method-
is often favorable in shared airway procedures ologist, and two consulting methodologists for
because it allows the patient to undergo pro- the ASA Committee on Standards and Practice
longed or stimulating procedures without signifi- Parameters. Of the members, anesthesiologists,
cant anxiety, discomfort, or pain. The patient may dental anesthesiologists, gastroenterologists, and
have a depressed level of consciousness but can oral and maxillofacial surgeons often perform
shared airway procedures under moderate seda- ventilation is often performed with a chin lift
tion. Therefore, many of the Practice Guidelines for and jaw thrust; one must be cautious in exten-
Moderate Procedural Sedation and Analgesia apply sive facial trauma cases or when cervical spine
to improving safety during these types of proce- fractures are encountered. As discussed previ-
dures or in patients based on scientific evidence. ously, the use of oral and nasal airways can be
In regard to the actual administration of moder- utilized during mask ventilation. If chin lift and
ate sedation and analgesia, patient monitoring is jaw thrust fail to open the airway, oral and nasal
probably the most important factor in recognizing airways can be utilized as helpful adjuncts to
and preventing a potential complication. Upon relieve obstruction and improve ventilation dur-
review of the literature, the task force found three ing mask ventilation [20].
5 supported monitoring techniques: (1) continually
monitored ventilatory function with end-tidal car-
Mask ventilation is a commonly employed
technique in the pediatric population to provide
bon dioxide (capnography), which has been shown inhalational anesthesia to atraumatically obtain
to reduce the number of hypoxic events as defined intravenous access. It is also commonly utilized
as oxygen saturation <90%, (2) pulse oximetry as for shared airway procedures as an intermittent
being effective in detecting oxygen levels during apnea technique for short duration cases in an
moderate sedation, and (3) electrocardiography easily ventilated patient, such as suture removal,
which can adequately detect arrhythmias, prema- extraction of primary teeth, nasopharyngoscopy,
ture ventricular contractions, and bradycardia. By and frenectomies [20].
instituting these recommendations, along with the Difficulty in mask ventilation is typically
other parameters relating to the administration of encountered when there is either obstruction of
moderate sedation, the practitioner can hopefully the upper airway or inability to maintain a seal
prevent any major complications [17, 18]. around the ventilation mask. Some of these fac-
Other adjuncts that can be utilized during tors are outlined in . Table 5.1. If a patient is

moderate sedation to help maintain a patent potentially difficult to mask ventilate, it should
airway are oro- or nasopharyngeal airways. Oral not be chosen as the primary mode of airway
airways can relieve obstruction by preventing pos- management [20]. Other potential complications
terior displacement of the tongue. Unfortunately, include the lack of control over the airway, poten-
oral airways are excellent for mask ventilation but tial for aspiration, and soiling of the airway from
often stimulate a patient’s gag reflex during lighter surgical debris or the oral cavity.
planes of anesthesia. Nasal airways are lubricated
and placed through one of the nares. If properly
chosen, it should be long enough to traverse the 5.3.3 Insufflation/Spontaneous
nasopharynx without impinging on the glottis. Respiration
During moderate sedation or MAC, the nasal
airway is often better tolerated as it does not This technique combines administration of anes-
stimulate the gag reflex but still improves airway thetic gas along with administration of local anes-
patency [19]. thesia. The volatile gases are insufflated through
either small catheters above the larynx, endotra-
cheal tubes placed through the nose and into the
5.3.2 Mask Ventilation oropharynx, or a port on the laryngoscope to a
spontaneously breathing patient. This technique is
Mask ventilation can be used as the primary commonly employed in laser airway cases for sub-
airway management technique during short glottic stenosis in the pediatric population. Once
anesthetics, during the preoxygenation phase, the patient reaches an adequate plane of anesthe-
as a temporary measure to help obtain a more sia, the airway can be manipulated. The complica-
definitive airway, as a means to induce anesthe- tion profile for this technique is similar to that for
sia in the pediatric population, and as a rescue mask ventilation but also carries a risk associated
technique when a difficult airway is encoun- with airway laser surgery to include laryngospasm
tered. One drawback to mask ventilation is that or bronchospasm from lighter planes of anesthe-
it does not prevent aspiration. Considering mask sia and the potential for airway fires.
67 5
5.3.4 Jet Ventilation on the site in which the catheter is placed as the
gas emerges into the airway. These complications
Jet ventilation can be administered in a variety of are outlined in . Fig. 5.1. Shared complications

ways and is a common technique when perform- by all three sites include barotrauma, air emphy-
ing surgery in the larynx, trachea, or bronchus. sema, and pneumothorax, though the farther
It involves intermittent administration of high- distal the catheter enters the airway, the greater
pressure air or oxygen at either a high frequency the risk. Regardless of site, jet ventilation does not
or low frequency, with rates of 100–150 or 15–25 provide a secure airway and still has potential for
breaths per minute, respectively [21]. The patient aspiration [21–23].
is commonly induced by either inhalational,
intravenous, or a combination of techniques. The
airway is then insufflated via a subglottic cannula, 5.3.5 Laryngeal Mask Airway (LMA)
supraglottic cannula, or transtracheal ventila-
tion or through the endoscopy equipment itself. The laryngeal mask airway (LMA) is an interme-
When a patient with known tracheal stenosis is diate between endotracheal intubation and mask
undergoing an airway procedure, it is important ventilation. It is inserted within the hypopharynx
that the patient be under general anesthesia and a without direct visualization with a laryngoscope
rigid scope used for bronchoscopy to perform the [25, 26]. An LMA is used in approximately 1/3 of
procedure and ventilate the patient. Otherwise, all surgical cases within the United States and is
the airway can deteriorate into complete obstruc- often chosen when a more secure airway is nec-
tion [21, 22]. essary for shorter procedures [25, 26]. It is an
Jet ventilation requires the anesthesiologist excellent alternative to mask ventilation during
and surgeon to communicate throughout the shared airway procedures because it eliminates
procedure to ensure successful treatment of the tongue obstruction, has been shown to decrease
patient and ensure their safety [21–23]. Anesthetic the number of oxygen desaturations, frees up the
induction is often performed and the airway is hands of the anesthesia provider, does not require
maintained with an LMA until the surgeon is administration of a paralytic, and reduces the
ready to start. In the case of subglottic or trans- environmental gas exposure [26–28]. An LMA is
tracheal jet ventilation, the catheter is then placed also a great option in patients that are obese or
and the LMA removed. For supraglottic jet ven- difficult to intubate [28]. The LMA can also be
tilation, the LMA is removed and the rigid scope used to intubate through blindly or utilizing a
with ventilation capability is placed. The depth flexible scope. During emergence from anesthe-
of general anesthesia is typically maintained via sia, the LMA can be left in place until the patient
total intravenous anesthesia (TIVA) and paralyt- has completely recovered and airway reflexes have
ics to allow for adducted, motionless vocal cords. returned [25, 27]. One drawback to the LMA is
Antisialagogues are also administered to control that it does not prevent aspiration, and there
secretions. Once the procedure is completed, the is the potential for damage to the surrounding
LMA is replaced prior to emergence for a smooth mucosa, the vocal chords, or the recurrent laryn-
awakening [21]. geal nerve [25–27]. Another potential drawback
According to Cozine and colleagues, who per- may include the inability to access the surgical site
formed a multi-institutional study that examined within the oropharynx, hypopharynx, or larynx
over 15,000 CO2 laser airway surgeries, jet ven- [29]. Although, numerous studies have shown,
tilation was found to have a very low complica- with proper selection, an LMA can be utilized for
tion rate. Overall, the rate was 1.18%; half of those procedures in any of these regions of the airway
complications were ventilation-related (pneumo- [30–32]. In a study by Gupta et al., properly sized
thorax 0.25% and hypoxia 0.15%), and the other flexible cuff LMAs used for adenotonsillectomy
half were unrelated to ventilation. In comparison were not visible once the Boyle-Davis mouth gag
to modes of ventilation other than jet ventilation, was placed, and the only time surgical access was
no single mode was found to be superior. The only impaired was if an LMA was chosen that was
death within their study was due to an airway fire too large. [32] There are also numerous studies
during endotracheal intubation [24]. The compli- demonstrating the use of an LMA in oral surgery,
cation profile for jet ventilation is also dependent dental rehabilitation procedures, nasal and sinus
DIFFICULT AIRWAY ALGORITHM

1. Assess the likelihood and clinical impact of basic management problems:
• Difficulty with patient cooperation or consent
• Difficult mask ventilation
• Difficult supraglottic airway placement
• Difficult laryngoscopy
• Difficult intubation
• Difficult surgical airway access
5 2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult
airway management.
3. Consider the relative merits and feasibility of basic management choices:
• Awake intubation vs. intubation after induction of general anesthesia
• Non-invasive technique vs. invasive techniques for the initial approach to intubation
• Video-assisted laryngoscopy as an initial approach to intubation
• Preservation vs. ablation of spontaneous ventilation
4. Develop primary and alternative strategies:
AWAKE INTUBATION INTUBATION AFTER
INDUCTION OF GENERAL ANESTHESIA
Airway approached by Invasive Airway
Noninvasive intubation Access(b)* Initial intubation Initial intubation
attempts Attempts UNSUCCESSFUL
successful* FROM THIS POINT ONWARDS
Succeed* FAIL CONSIDER:
1. Calling for help.
2. Returning to
Cancel Consider feasibility Invasive spontaneous ventilation.
Case of other options(a) airway access(b)* 3. Awakening the patient.
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE
CONSIDER/ATTEMPT SGA
SGA ADEQUATE* SGA NOT ADEQUATE

OR NOT FEASIBLE
NONEMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful EMERGENCY PATHWAY
Ventilation not adequate, intubation unsuccessful
IF BOTH
Alternative approaches FACE MASK Call for help
to intubation(c) AND SGA
VENTILATION
BECOME Emergency noninvasive airway ventilation(e)
INADEQUATE
Successful FAIL after
Intubation* multiple attempts Successful ventilation* FAIL
Emergency
Invasive Consider feasibility Awaken invasive airway
airway access(b)* of other options(a) patient(d) access(b)*
.. Fig. 5.1 ASA difficult airway algorithm

69 5
surgery, and sleep apnea surgery without imped- practitioner, and improved resuscitative efforts in
ing access to the surgical site and has actually neonates [25].
been shown to prevent soiling of the upper airway For some patients undergoing oral and max-
with blood, irrigation, or contaminates during illofacial or head and neck surgical procedures,
these types of procedures [27, 33–37]. they may have certain physical exam findings
Safeguarding the shared airway is probably (outlined in . Table 5.1) delineating them as a

most important in laryngeal surgery. Often times, difficult airway. An LMA may be the option of
even small endotracheal tubes can make access to choice in this patient population as outlined in
this area difficult. For that reason, there has been the ASA difficult airway algorithm. For example,
emphasis on utilizing an LMA with or without a patient with features which make them difficult
combination with other airway techniques to to mask ventilate, such as retrognathia or edentu-
ventilate a patient during laryngeal surgery. For lism, may benefit from elective use of an LMA as a
a simple exam under anesthesia and biopsy of the routine airway because the LMA does not require
larynx, it may be easiest to place the LMA and mandibular support and bypasses the obstruc-
then visualize the area with flexible bronchoscopy tion of the tongue [28, 43, 44]. In patients that
[38–40]. Techniques have also been described are obese or have a “difficult airway,” the use of an
for laryngeal laser surgery, such as placing a intubating LMA has been shown to be a success-
transglottic or transtracheal jet ventilation can- ful technique as a rescue device or as a conduit for
nula followed by an LMA. The LMA is used to fiber-optic intubation [25, 45, 46].
ventilate the patient during transfer and set up.
The LMA can then be removed and jet insuffla-
tion employed while the laser is being utilized, 5.4 Intubation Techniques
followed by replacement of the LMA to maintain
ventilation during the recovery phase [25]. The Endotracheal intubation is still the technique of
use of the LMA allows the surgeon to have access choice for most major head and neck procedures,
to the larynx without traumatizing the vocal for procedures requiring the patient be placed
chords or stimulating the patient and airway [41]. into maxillomandibular fixation, and for shared
The use of the LMA has also become popular airway procedures of longer duration [25]. LMAs
in the difficult airway and was added to the dif- are often not secure enough for these longer sur-
ficult airway algorithm by the ASA in 1996 [28]. gical cases and can alter the neck and pharyngeal
There are numerous case reports showing an anatomy, impairing the ability of the surgeon to
LMA can be used to maintain or restore ventila- perform open procedures [25, 47]. Due to the
tion in an adult with a difficult airway and reduced increased likelihood of a head and neck surgery
desaturation frequencies in the pediatric popula- patient presenting with a difficult airway, standard
tion [42]. We find the utilization of the LMA in intubation techniques are often not suitable. There
key points of the ASA algorithm: (1) as a conduit is often a necessity to alter the type or size of the
for endotracheal intubation during general anes- endotracheal tube, improve patient positioning,
thesia on a recognized difficult airway; (2) in an or use other methods such as videolaryngoscope-
unrecognized difficult airway where the patient guided intubation, fiber-optic-guided intubation,
can be mask ventilated, but intubation has failed; or a surgical airway. The type of endotracheal
(3) in an unrecognized difficult airway where the tube and method for gaining access to the airway
patient can be mask ventilated, but the LMA is should be a discussion between the surgeon and
used as a fiber-optic conduit; (4) in an emergency the anesthesiologist that occurs preoperatively.
situation on an unrecognized difficult airway
where the patient cannot be mask ventilated, so
the LMA is used as a ventilator device; and (5) in 5.4.1 Standard Endotracheal Tubes
an emergency situation on an unrecognized dif-
ficult airway where the patient cannot be mask Standard cuffed endotracheal tubes are often not
ventilated, so the LMA is used as a fiber-optic ideal for various head and neck procedures. For
conduit [28] (. Fig. 5.1). Benefits to the LMA
laryngeal procedures, they are often too large
in emergent situations include ease of insertion, and prevent the surgeon from being able to work
a higher insertion success for the inexperienced within the larynx. Standard tubes are also prone
to compression when being manipulated within

the oral cavity or airway or requiring the use of
a mouth gag such as a Dingman or Boyle-Davis.
Also, during maxillofacial procedures, where
the patient’s occlusion will require assessment,
these tubes often prevent the surgeon from plac-
ing the patient into maxillomandibular fixation.
Fortunately, there are a plethora of tube types and
sizes to work around these patient and anatomic
considerations.
5
.. Fig. 5.2 Proper head wrap placement for use of nasal
5.4.2 Nasal RAE
RAE
Nasotracheal intubation is often the technique

to prevent a pressure ulcer from forming during
of choice for maxillofacial trauma, dentofacial
long procedures or times of hypotensive anesthe-
deformities, temporomandibular joint recon-
sia that is often employed during head and neck
struction, and other procedures requiring maxil-
procedures (. Fig. 5.2). One other drawback of
lomandibular fixation. It can also be employed for

the nasal RAE is that it cannot be used if extended

procedures requiring improved visualization and
periods of intubation are required due to the pos-
access to the oral cavity. For patients with limited
sibility of pressure ulcers or necrosis forming
mouth opening or undergoing an awake fiber-
within or around the nose.
optic intubation, it is often the technique of choice
[48]. A patient can be intubated nasally via direct
laryngoscopy, blind intubation, or videolaryngos-
5.4.3 Microlaryngoscopy Tubes
copy or with fiber-optic guidance. Though con-
troversial, nasal intubation is generally avoided
Microlaryngoscopy tubes are commonly used for
in base of skull fractures, especially if a cerebro-
endoscopic procedures and typically have a small
spinal fluid leak is evident. This recommendation
internal diameter (4–5 mm) but are longer (31 cm)
is based on a handful of case reports describing
than standard tubes [21]. These tubes are cuffed
intracranial penetration of the nasotracheal tube
to prevent manipulation while the surgeon works
upon intubation [48–50]. If nasal tube placement
around them in the airway. Due to their small
is necessary for reconstruction or a surgical air-
diameter, increased airway resistance typically
way is contraindicated, the airway can be placed
occurs. Therefore, these tubes can only be used for
by atraumatically advancing a red rubber cath-
short periods of time. Even though these tubes are
eter through the nose and into the oropharynx to
small and can be worked around, approximately 5%
guide the endotracheal tube during placement, or
of the time, posterior lesions can be obscured [21].
fiber-optic intubation can be used to avoid pen-
etrating the base of skull [48, 51–53].
It is important when using a nasal RAE that
the correct size of endotracheal tube is chosen. 5.4.4 Laser-Resistant Endotracheal
If the nasal RAE is too short, it may creep supe- Tubes
riorly to the vocal chords and impair ventilation
during either patient positioning or the surgical The carbon dioxide laser is the most commonly
procedure. Once the correct nasotracheal tube is employed laser during shared airway procedures
placed, a right angle adapter is attached to posi- [54]. It is typically used for ablating lesions and
tion the tube superiorly over the forehead. A head resurfacing the mucosa or skin and as an instru-
wrap is often placed to secure the tube to the fore- ment to make very precise incisions with the
head, prevent it from dislodging during surgery, addition of a surgical handpiece. Utilizing a laser
and keep it from interfering with access to the in or around the airway produces a particular
surgical field. It is important that the forehead is dilemma because the three necessary elements
properly padded when the head wrap is secured for an operating room fire, ignition source, fuel,
71 5
and oxidizers, are all in close proximity [54–56]. direct laryngoscopy, these scopes have improved
Previously, metallic tape was used to wrap stan- visualization of the larynx and improved success
dard endotracheal tubes transforming them into of intubation in the difficult airway [57–60]. There
laser-resistant tubes. Laser-resistant endotracheal are numerous design variations to mimic existing
tubes are FDA-approved and prefabricated with blade shapes, incorporate channels for endotra-
protective layering. These are all-metal tubes or cheal tube passage, or improve visualization in
nonmetal tubes with metallic overlay. These tubes certain anatomic situations. Regardless of design,
are often used during airway procedures requir- no single videolaryngoscope has been deemed
ing the use of a laser to prevent an airway fire. superior. Of interest in shared airway proce-
There are numerous varieties, and most are not dures where the airway may be considered “dif-
necessarily laser-proof, but laser-resistant. It is ficult” is the GlideScope (Verathon, Bothell, WA).
important to remember that cuffed laser-resistant The GlideScope has an acute 60-degree curve to
tubes have vulnerable areas both at the tip and at assist in visualization of an anterior glottis with-
the cuff. The anesthesiologist must ensure that the out manipulation of the cervical spine or airway.
cuff remains unharmed, and the surgeon must be Therefore, this device may be useful in maxillofa-
cognizant of it to be careful they do not violate cial trauma patients, limited interincisal opening
it during the surgical procedure. According to or trismus, cervical spine immobility, or patients
the ASA, “the tracheal cuff should be filled with with a craniofacial or dentofacial deformity.
saline rather than air, when feasible.” Other good
practice measures include (1) tinting the saline
within the cuff with methylene blue so that viola- 5.4.7 Fiber-Optic-Guided Intubation
tion can be recognized early, (2) placing the cuff
as far away from the surgical site as possible, and When unable to visualize the airway via direct
(3) placing moist gauze packs around the endo- or videolaryngoscopy, fiber-optic-guided intuba-
tracheal tube and cuff [55, 56]. tion with the flexible fiber-optic bronchoscope is
an effective and proven technique for establish-
ing airway access [61]. In its Practice Guidelines
5.4.5 Reinforced Endotracheal Tubes for Management of the Difficult Airway, the
ASA cites observational studies that report suc-
Reinforced endotracheal tubes are an excellent cessful intubation via fiber-optic techniques in
choice for shared airway procedures. These ET 87–100% of difficult airways [42]. This technique
tubes are commonly utilized during intraoral, can be used to achieve endotracheal intubation
major head and neck reconstruction, cleft, and via either the nasal or oral route. Although fiber-
craniofacial procedures. When mouth gags or optic intubation can be used after the induction
retractors are used, these tubes are able to bet- of general anesthesia, in many clinical scenarios,
ter resist compression and prevent lumen occlu- awake fiber-optic intubation (AFOI) with topical
sion. This is especially important in cleft palate or regional anesthesia is the chosen approach for
and pharyngeal reconstruction that utilizes the management of a difficult airway. AFOI elimi-
Dingman retractor. In children that have erup- nates the risks associated with induction of gen-
tion of their lower mandibular incisors, the oral eral anesthesia prior to securement of the airway.
RAE that is used to secure the airway can easily be These risks include inadequate ventilation or
compressed between the teeth and the retractor. oxygenation, loss of upper airway patency, and
This has the potential to increase peak pressure failed intubation. Common indications for AFOI
and decrease tidal volumes. include patients with a recorded history of diffi-
cult intubation or any patient with upper airway
abnormalities that foretell a difficult airway, such
5.4.6 Videolaryngoscopy as limited mouth opening, decreased thyromental
distance, congenital deformities, head and neck
The invention of videolaryngoscopy has greatly neoplasms, or craniofacial trauma [62].
improved the ability to visualize difficult airways Once the decision has been made to proceed
with direct laryngoscopy and is included in the with an AFOI, further consideration must be
ASA difficult airway algorithm. In comparison to given to patient position and preparation, need
for local and/or regional anesthesia, and use of dilating the incision with hemostats and insert-
sedatives. In general, AFOI can be performed ing the appropriate cannula into the airway [64].
with the patient supine or seated upright. The In the wire-guided or Seldinger technique, the
nasal approach is preferred for better visual- cricothyroid membrane is initially pierced by
ization of the larynx and is often employed in a locator needle, which is then used to insert a
patients with trismus, macroglossia, and ret- guide wire into the trachea. An airway catheter
rognathia or when the endotracheal tube can- with an internal dilator can be slowly placed
not obstruct the surgical field. The tissues of the into the airway over the guide wire. This alterna-
nose, naso- and oropharynx, and larynx can tive approach can be employed with healthcare
then be numbed with any combination of topi- providers uncomfortable or inexperienced with
5 cal or aerosolized anesthetics as well as regional
blocks. These blocks include the glossopha-
the surgical approach [63]. It is critical to keep
in mind that the cricothyroidotomy is an emer-
ryngeal nerve block, superior laryngeal nerve gent, temporizing technique and in most cases
block, or transcricoid block. Antisialagogues, should not represent long-term, permanent air-
such as glycopyrrolate, atropine, or scopol- way management. Lastly, the cricothyroidotomy
amine, can also be used to decrease salivary and is contraindicated in patients less than 12 years
mucus secretions in an effort to improve visu- of age due to the pediatric airway being the nar-
alization. Lastly, to improve patient tolerance rowest at the level of the cricoid cartilage and the
and induce anxiolysis and amnesia, sedatives subsequent risk of laryngeal injury [64].
may be administered to patients undergoing In children, due to the anatomical limita-
AFOI. Rapid-onset, short half-life sedatives, tions discussed in the previous paragraph, the
such as midazolam or dexmedetomidine, are preferred invasive airway is the needle crico-
often the agents of choice. These sedatives pro- thyroidotomy with percutaneous transtracheal
duce the desired effects while minimizing risk ventilation. This is achieved by palpating the cri-
of respiratory depression and ensuring adequate cothyroid membrane and inserting an 18-gauge
ventilation in the awake patient [62]. needle through the membrane into the airway.
The needle can then be attached to a 3 mL
syringe, which is then connected to a ventila-
5.4.8 Surgical Airways tor circuit via an adaptor from an endotracheal
tube [63]. It is important that this technique
The establishment of a surgical airway should be not be used in patients, adult or pediatric, with
considered when endotracheal intubation fails or complete upper airway obstruction due to risk
when traditional endotracheal intubation is not a of increased intrathoracic pressures and subse-
viable option due to the unique requirements of quent complications [64].
the case. According to the ASA’s difficult airway Outside of the emergent setting, a surgical
algorithm, in patients with inadequate face mask airway can be electively used for primary air-
and/or supraglottic ventilation along with failed way management in cases where endotracheal
intubation, the final intervention is emergency intubation is unlikely to succeed. Elective place-
invasive airway access [42]. Options for invasive ment is often recommended in certain types of
access include cricothyroidotomy via open or head and neck surgeries. Instances where elective
wire-guided techniques or needle cricothyroid- placement of a surgical airway can be indicated
otomy with percutaneous transtracheal ventila- include surgeries addressing large tumors of the
tion [63]. head and neck, laryngotracheal injuries, maxillo-
In the emergent setting, the American facial trauma, inflammatory swelling of the upper
Trauma Life Support guidelines recommend airway, or craniofacial deformities. The preferred
the cricothyroidotomy for airway control. This approach for the elective surgical airway is the
procedure can be done via an open, surgical tracheotomy. Exact surgical technique for the
approach or a wire-guided technique. Surgically, tracheotomy may vary depending on surgeon
the first step is making a vertical skin incision preference, but the ultimate objective is making
overlying the cricothyroid membrane followed an incision in the anterior tracheal wall, usually
by a horizontal incision through the mem- between the 2nd and 3rd tracheal rings, allowing
brane itself. The procedure is then completed by cannulation of the airway [64].
73 5
5.5 Complications can complicate ventilation or intubation, such
as decreased incisal opening, damaged or loose
In general, respiratory compromise and loss of teeth, limited range of motion of the neck, short-
airway are among the most common reasons for ened thyromental distance, tracheal deviation,
anesthesia malpractice claims [65]. These events neck masses, mandibular retrognathia, facial hair,
have been recorded by the ASA Closed Claims or enlarged tonsils [68, 69]. In the event that a
database and contribute to many of the claims for provider encounters a difficult airway, which one
death and brain damage [66]. Complications that study estimated occurs in 15.4% of maxillofacial
can lead to respiratory compromise in the peri- surgery cases, it is vital that the principles of the
operative period include failed intubation, loss ASA’s difficult airway algorithm are appropriately
of airway due to laryngospasm or foreign body applied [42, 68]. Before intubation is attempted,
aspiration, surgical fire, and vocal cord paralysis. one must consider the merits of electively pro-
These complications are not unique to shared ceeding with an awake intubation or placing a
airway anesthesia, but their risk of occurrence is surgical airway as opposed to traditional endotra-
certainly heightened in shared airway cases where cheal intubation following induction of general
the surgeon operates in intimate proximity to the anesthesia. However, if initial attempts at intuba-
airway. Another complication that deserves dis- tion are unsuccessful, the difficult airway algo-
cussion in relation to shared airway anesthesia rithm instructs providers to consider calling for
is dental injury, which commonly occurs during additional help, awakening the patient, placing an
direct laryngoscopy in patients with poor denti- LMA, attempting alternate forms of intubation,
tion. For a detailed discussion of this topic, please or – if all other approaches fail – placement of a
refer to the chapter on dental injury included in surgical airway [42]. It is imperative that any pro-
this text. vider involved with treating the airway be well-
versed in the tenets of this algorithm.
5.5.1 Failed Intubation

5.5.2 Laryngospasm
A failed intubation is defined as the inability of
the anesthesiologist to introduce an endotracheal Laryngospasm is a complication that can be
tube into the trachea. Fortunately, failure to intu- encountered in an anesthetic situation where the
bate is an exceedingly rare occurrence [67]. A airway is not secured with an endotracheal tube.
review of literature places the rate of intubation These situations include pre- and post-intubation,
failure at 0.05% to 0.35% [68]. Failure to intubate open airway general anesthesia, and monitored
in itself is not a fatal outcome, if adequate oxygen- anesthesia care. Laryngospasm is characterized by
ation of the patient can be maintained with mask a spasm of the intrinsic muscles of the larynx that
ventilation. However, it is in the “cannot intubate- can lead to sustained closure of the vocal cords.
cannot ventilate” scenarios that catastrophic It represents a protective physiologic reflex that
outcomes can quickly occur. In these scenarios, prevents aspiration into the lower airway [70].
the airway cannot be secured due to inability to Laryngospasm is a life-threatening complication
intubate, and mask ventilation is inadequate to that can quickly lead to hypoxia, bradycardia,
support the patient, leading to poor oxygenation negative pressure pulmonary edema, cardiac
and eventual respiratory collapse [69]. arrest, and death [71]. The classic presentation
Two key factors that can prevent providers of a laryngospasm is a high-pitched stridor that
from finding themselves in a dangerous “cannot is accompanied by oxygen desaturation, difficulty
intubate-cannot ventilate” scenario are a thor- ventilating, and paradoxical rise of the chest and
ough preoperative evaluation and a fundamen- abdomen. It is important to keep in mind that
tal understanding of the ASA’s difficult airway although stridor is considered nearly pathogno-
algorithm. As discussed earlier in this chapter, monic for laryngospasm, a complete obstruction
preventing a failed intubation begins with a com- of the glottic opening can be marked by silence
plete physical exam that includes determining with no high-pitched stridor [70].
the patient’s Mallampati-Samsoon classification The two most common causes of laryngo-
and identification of any anatomical features that spasm are local irritation of vocal cords and
inadequate depth of anesthesia [70]. Sources of or monitored anesthesia care in the operating
irritants include blood and oral secretions that room, where there is no endotracheal tube to
can contaminate the larynx during otolaryngo- protect the airway. Dental procedures have been
logical or oral surgical procedures. One study shown to be the second most common reason
reported that nearly 22% of spasms were precipi- for foreign body aspiration into the airway [76].
tated by blood and secretions from surgical pro- Common objects aspirated during dental or oral
cedures [72]. Vomiting or regurgitation, airway surgical procedures include teeth, implant parts
suction catheters, and instrumentation of the air- and screws, small instruments, burs, restorative
way have also been reported to irritate the vocal materials, impression material, crowns, dentures,
cords leading to spasm. In children, an irritant to and endodontic files [77, 78]. Outside of den-
5 be constantly aware of is a recent history of upper
respiratory tract infection. Literature shows that
tistry, fractured tracheotomy tubes, nasopharyn-
geal airways, respiratory care equipment, broken
children with an upper respiratory tract infection instruments, and bronchoscopy parts have been
are two to five times more likely to experience reported as aspirated objects [75]. Beyond the
a laryngospasm [71]. A spasm can also occur if proximity of foreign bodies to the airway, other
the airway is stimulated, such as during extuba- risk factors for aspiration include supine position-
tion, while the patient is at an insufficient depth ing, sedation, unexpected patient movement, and
of anesthesia. Thus, extubation should only occur poor lighting [78].
if the patient is either at a plane of anesthesia that Common signs and symptoms of aspiration
is deep enough to blunt laryngeal reflexes or at a include gagging, choking, coughing, inspiratory
point when the patient has awakened from anes- stridor, paradoxical breathing, hoarseness, or uni-
thesia and has regained control of their laryngeal lateral wheezing on auscultation. In severe cases
musculature [73]. of aspiration, with significant airway obstruc-
If a laryngospasm is suspected, the following tion, cyanosis, decreased oxygen saturation, and
initial steps should be performed (1): remove tracheal shift can be observed. Several steps can
any irritating stimuli from the mouth or airway be taken to prevent iatrogenic aspiration. The
(2), provide positive pressure ventilation with a cornerstone of prevention has been the pharyn-
face mask and 100% oxygen (3), and apply chin geal screen or throat pack. More on this topic is
lift or jaw thrust by placing firm digital pressure recorded in subsequent sections of this chapter.
bilaterally behind the earlobe along the posterior Whenever feasible, that patient should be seated
mandible. Should these initial measures prove upright in a dental chair, or reverse Trendelenburg
inadequate, treatment can be continued by deep- position should be used in the operating room to
ening the plane of anesthesia with an I.V. bolus of limit supine positioning. All small instruments
propofol. Additionally, a small bolus of succinyl- should be ligated with a small length of dental
choline dosed at 0.1. mg/kg can be given to induce floss, allowing quick retrieval of the instrument
muscle relaxation and break the spasm. If these upon displacement. Dentures should always be
steps are not successful, the final intervention removed [78]. All instruments should be peri-
would be providing an intubating dose of succi- odically inspected for evidence of fatigue or wear
nylcholine (1 mg/kg) and intubating the patient which could make them prone to fracture [75,
[70, 73, 74]. 79]. Lastly, proper use of surgical counts should
be employed to prevent retained foreign objects
that could be aspirated.
5.5.3 Foreign Body Aspiration The first step in the management of a sus-
pected aspiration is determining the stability of
Foreign body aspiration is a medical emergency the patient. If the patient is stable and showing
that can lead to immediate airway obstruction no signs of respiratory distress, radiographs of
[75]. In shared airway anesthesia, where surgeons the chest and abdomen should be obtained to
are often operating in or around the airway with ascertain location of the object [78]. Two-view
small instruments and fine materials, the risk of chest X-rays (posterior-anterior and lateral) are
aspiration is always present. The risk of aspiration required to confirm exact location of any object
is particularly elevated in open airway anesthesia, in the airway. If the object has been ingested into
such as conscious sedation in the dental office the GI tract, the object is usually allowed to pass
75 5
naturally unless it is pointed or there is concern Common fuel sources reported in the claims anal-
for impaction in the esophagus. In these situa- ysis included endotracheal tubes, oxygen masks,
tions, endoscopic retrieval is indicated. Should nasal cannula, gauze, drapes, alcohol-based prep
radiographs reveal the object lodged in the air- solution, hair, and surgical gowns [82].
way, the patient needs to be scheduled for urgent Preventing surgical fires depends on man-
removal via bronchoscopy to prevent sequelae aging the limbs of the fire triad. First, attempt
such as obstruction, abscess formation, or pneu- to minimize the formation of an oxidizer-rich
monia [79]. Bronchoscopy is effective in more atmosphere around the surgical site. Since oxy-
than 90% of cases [77, 79]. If the patient is deemed gen is the predominant oxidizer in surgical fires,
unstable and exhibiting signs of respiratory dis- the inspired oxygen concentration – at a mini-
tress, the most important step is providing respi- mum – should be kept below 50% [80]. Other
ratory support until definitive bronchoscopy can steps to limit the amount of oxidizing agents
be performed. Ventilation can be assisted with include the use of scavenging systems, sealed gas
face mask and Ambu bag, or if there is concern delivery systems like cuffed endotracheal tubes or
of complete airway occlusion and inability to LMAs whenever feasible, and moistened gauze or
ventilate, then an emergent surgical airway must sponges in the oropharynx to trap any leakage of
be placed [78]. Following removal of the foreign flammable gas [80, 81]. Considerations for igni-
body, radiographs should be taken to confirm tion source management include never using an
complete removal [79]. electrosurgical source to enter the airway and fol-
lowing laser surgery safety recommendations as
described in previous paragraphs of this chapter
5.5.4 Surgical Fire [81]. Fuel sources can be managed by moistening
any form of gauze, sponge, or packing used in the
In shared airway anesthesia, one of the most feared surgical field. Dry forms of these materials dem-
and catastrophic complications is the surgical onstrate increased flammability. When lasers are
fire. Literature reports that the annual incidence in use, ensure that a laser-resistant endotracheal
of surgical fires in US hospitals is approximately tube is in use. Lastly, allow sufficient time for alco-
650 fires per year. Many more cases go unreported hol-based skin preps to dry to prevent ignition of
or are considered near misses [80]. As expected, volatile vapors produced by these preps [81, 82].
these fires are more common in head and neck Should a surgical fire occur, the ASA’s Practice
surgeries where all elements of the fire triad (fuel, Advisory for the Prevention and Management of
oxidizer, and ignition source) are in close prox- Operating Room Fires (. Fig. 5.3) outlines the

imity. Consequently, head and neck surgeries are steps required to manage any surgical fire. The
considered high fire-risk procedures [81]. first step is recognition of early signs of fire.
In a closed claims analysis of surgical fires, These warning signs include unexpected smoke,
electrocautery was shown to be the most com- unusual odors, unusual sounds like “pops” or
mon ignition source (90%). Other ignition “snaps,” discoloration of drapes or breathing cir-
sources reported include surgical lasers, heated cuits, and unexpected flames or sparks. If any of
probes, argon beams, light cables, and defibrilla- these signs are present, the procedure should be
tors. Oxygen was the oxidizing agent in 95% of halted immediately and investigated further. If a
all electrocautery fires. The most common cause fire is present in the airway or breathing circuit,
of surgical fires was electrocautery-induced fire the ASA recommends taking the following steps
during monitored anesthesia care, where supple- as rapidly as possible: (1) removal of the endotra-
mental oxygen was being delivered via an open cheal tube or other airway device, (2) halting the
delivery system (i.e., nasal cannula or face mask). flow of all airway gases, (3) removal of all flam-
Electrocautery fires were less commonly reported mable and burning materials from the airway,
in general anesthesia cases where oxygen was able and (4) pouring of saline or water in the patient’s
to leak out of a closed-circuit system due to an airway. Should these steps not extinguish the fire,
uncuffed endotracheal tube or presence of cuff the ASA recommends use of a carbon dioxide fire
leak. According to the claims analysis, the majority extinguisher in, on, or around the patient. Once
of these fires occurred during shared airway pro- the fire is extinguished, reestablish mask venti-
cedures, such as tracheotomies or tonsillectomies. lation and avoid flammable oxygen and nitrous
OPERATING ROOM FIRES ALGORITHM

Fire • Avoid using ignition sources 1 in proximity to an oxidizer-enriched atmosphere 2
Prevention: • Configure surgical drapes to minimize the accumulation of oxidizers
• Allow sufficient drying time for flammable skin prepping soloutions
• Moisten sponges and gauze when used in proximity to ignition sources
YES Is this a High-Risk Procedure? No
An ignition source will be used in proximity to an
oxidizer-enriched atmosphere
• Agree upon a team plan and team roles for preventing and managing a fire
5 • Notify the surgeon of the presence of, or an increase in, an oxidizer-enriched atmosphere
• Use cuffed tracheal tubes for surgery in the airway; appropriately prepare laser-resistant tracheal tubes
• Consider a tracheal tube or laryngeal mask for monitored anesthesia care (MAC) with moderate to deep
sedation and/or oxygen-dependent patients who undergo surgery of the head, neck, or face.
• Before an ignition source is activated:
Announce the intent to use an ignition source
Reduce the oxygen concentration to the minimum required to avoid hypoxia3
Stop the use of nitrous oxide4
Fire Management:
Early Warning Signs of Fire5
Fire is not present; HALT PROCEDURE

Continue procedure Call for Evaluation
FIRE IS PRESENT
AIRWAY 6 FIRE: NON-AIRWAY FIRE:

IMMEDIATELY, without waiting IMMEDIATELY, without waiting
• Remove tracheal tube • Stop the flow of all airway gases
• Stop the flow of all airway gases • Remove drapes and all burning and
• Remove sponges and any other flammable flammable materials
material from airway • Extinguish burning materials by pouring
• Pour saline into airway saline or other means
If Fire is Not Extinguished on First Attempt

Use a CO2 fire extinguisher 7
Fire out If FIRE PERSISTS: activate fire alarm, evacuate patient, Fire out
close OR door, and turn off gas supply to room
• Re-establish ventilation • Maintain ventilation

• Avoid oxidizer-enriched atmosphere if • Assess for inhalation injury if the patient is
clinically appropriate not intubated
• Examine tracheal tube to see if fragments may
be left behind in airway
• Consider bronchoscopy
Assess patient status and devise plan for management
1
Ignition sources include but are not limited to electrosurgery or electrocautery units and lasers.
2
An oxidizer-enriched atmosphere occurs when there is any increase in oxygen concentration above room air level,
and/or the presence of any concentration of nitrous oxide.
3
After minimizing delivered oxygen, wait a period of time (e.g., 1-3 min) before using an ignition source. For oxygen
dependent patients, reduce supplemental oxygen delivery to the minimum required to avoid hypoxia. Monitor
oxygenation with pulse oximetry, and if feasible, inspired, exhaled, and/or delivered oxygen concentration.
4
After stopping the delivery of nitrous oxide, wait a period of time (e.g., 1-3 min) before using an ignition source.
5
Unexpected flash, flame, smoke or heat, unusual sounds (e.g., a “POP,” snap or “foomp”) or odors, unexpected
movement of drapes, discoloration of drapes or breathing circuit, unexpected patient movement or compint.
6
In this algorithm, airway fire refers to a fire in the airway or breathing circuit.
7
A CO2 fire extinguisher may be used on the patient if necessary.
.. Fig. 5.3 Airway fire algorithm

77 5
oxide if possible. The endotracheal tube should that can be taken to prevent their occurrence. In
then be examined to determine if any fragments the paragraphs below, three more strategies are
were left in the airway. Bronchoscopy can be con- discussed that can help prevent catastrophic com-
sidered if there are concerns of retained foreign plications.
material or debris in the airway [81].
5.6.1 Capnography
5.5.5 Vocal Cord Paralysis
Capnography is the real-time, continuous moni-
Iatrogenic damage to the airway is a known compli- toring of a patient’s inhaled and exhaled concentra-
cation of tracheal intubation. A closed claims anal- tions of carbon dioxide [73, 87]. It is considered the
ysis of airway injuries by the ASA revealed that the gold standard for monitoring the patient’s ventila-
larynx is the most common site of injury (33% of tion in both intubated and non-intubated cases. The
cases). The most common type of laryngeal injury ASA’s Practice Guidelines for Moderate Procedural
was vocal cord paralysis. Other reported injuries Sedation and Analgesia recommends continuous
include granulomas, hematomas, and arytenoid monitoring of ventilatory function capnography to
dislocation. Eighty percent of the injuries occurred prevent hypoxic events [17, 18].
with routine, non-difficult tracheal intubations [83, Capnography provides an indirect assess-
84]. Risk factors for vocal cord paralysis include ment of patient’s alveolar ventilation, pulmo-
patients over the age of 50, prolonged intubations nary perfusion, and gaseous diffusion across
greater than 6 h, and patients with a prior history the respiratory membrane [87]. Changes in the
of diabetes mellitus or hypertension [84]. exhaled concentrations of carbon dioxide can
Vocal cord paralysis – secondary to dam- alert an anesthetist to many impending com-
age to the recurrent laryngeal nerve – can pres- plications. Absence of end-tidal carbon dioxide
ent as unilateral or bilateral injuries. Unilateral (ETCO2) following intubation can signal failed
paralysis can be characterized by dysphonia, intubation due to cannulation of the esophagus.
vocal fatigue, decrease in vocal range and inten- Intraoperatively, abrupt loss of ETCO2 can rep-
sity, and increased risk of aspiration pneumonia. resent accidental extubation or disconnection of
Seventy percent of unilateral cases involve the left the ventilatory circuit [73]. In open airway cases,
cord [85]. Bilateral paralysis can produce acute loss of ETCO2 can signal loss of airway patency
airway obstruction due to unopposed vocal cord due to laryngospasm or upper/lower airway
adduction [86]. Damage to the recurrent laryn- obstruction [87]. Subtle changes in the amount
geal nerve is believed to occur when the anterior of exhaled carbon dioxide can also provide valu-
branch of the nerve is compressed between the able information. Increases in ETCO2 are seen
endotracheal tube cuff and the thyroid cartilage. in hypoventilation, malignant hyperthermia,
Therefore, to prevent paralysis, it is recommended sepsis, or rebreathing. Decreasing ETCO2 can
that the cuff is kept below the cricoid cartilage and signal hyperventilation, low cardiac output, or
cuff pressure be kept to a minimum. Fortunately, pulmonary embolism [73].
the majority of vocal cord paralysis cases run a When using capnography in open airway
benign course and resolve spontaneously. Possible anesthesia, where carbon dioxide sampling
interventions, if needed, include voice therapy, occurs via a nasal cannula, one must be aware
medialization of the cords via injection laryngo- of inherent limitation in this system. If ETCO2
plasty, and medialization thyroplasty [85]. sampling is combined with supplemental oxygen
administration within the nasal hood, the oxygen
can dilute the exhaled carbon dioxide and yield
5.6 Prevention of Complications lower ETCO2 readings. Nasal cannulas are also
subject to dislodgement, which can inadvertently
The previous section of this chapter discussed affect ETCO2 values. Additionally, patients that
many of the most common complications encoun- are experiencing nasal congestion or are obligate
tered during shared airway anesthesia and steps mouth breathers may yield artificially absent
ETCO2 readings [87]. All these scenarios must be

kept in mind when interpreting ETCO2 values in
an open airway system.
5.6.2 Pre-tracheal Auscultation
Another tool used to monitor a patient’s ventila-

tory status is intraoperative pre-tracheal ausculta-
tion. This technique involves the use of a weighted
5 chest piece that is placed on the airway above the
patient’s sternal notch. The chest piece is then
connected to an earpiece worn by the physician
via plastic tubing or electronically via Bluetooth .. Fig. 5.4 Suturing of armored tube to chin
transmission [88]. The anesthetist is thus able to
listen to real-time sounds as air moves through
the airway [87]. This provides qualitative input on
the status of the patient’s airway and allows early 5.6.4 Suturing the Endotracheal
detection of impending complications. Audible Tube
snoring can signal soft tissue obstruction of the
airway. Bronchospasm would be accompanied by In shared airway anesthesia, due to the proxim-
wheezing. A complete absence of breath sounds ity of the surgeon to the endotracheal tube, the
could alert the anesthetist to a complete airway risk of tube dislodgement and accidental extuba-
obstruction, such as a laryngospasm [88]. The tion is always present. This complication can be
combination of capnography and pre-tracheal prevented by suturing the endotracheal tube in
auscultation can provide optimal monitoring of a place. Reinforced tubes must be used with this
patient’s ventilatory status and help forestall pos- technique to prevent occlusion of the tube. The
sible complications [87]. reinforced tube can be placed and then secured
to the patient with 2-0 silk suture. When a patient
is orally intubated, as the endotracheal tubes
5.6.3 Throat Pack exits the mouth, it can be secured to the chin
(. Fig. 5.4). During head and neck oncologic or

As discussed, throat packs are commonly placed free flap reconstruction cases, a standard trache-
by surgeons working in the oral cavity. They are otomy can be performed and a reinforced tube
placed to prevent aspiration of blood, oral secre- placed instead of a tracheotomy tube. The rein-
tions, surgical debris, and instrumentation [89, forced endotracheal tube can then be secured
90]. Additionally, a moistened throat pack can to the chest with multiple 2-0 silk sutures. This
prevent the passage of flammable gas into the sur- secures the tube and prevents migration or dis-
gical field [80, 81]. Despite these perceived ben- lodgment from the airway.
efits in preventing certain complications, throat
packs have also been shown to be a source of com-
plication themselves. Literature has revealed that 5.7 Review Questions
throat packs are a significant source of postopera-
tive throat discomfort and pain. Also, numerous ?? 1. What technique does the ASA’s Practice
reports have been published describing failure to Guidelines for Moderate Procedural Sedation
remove throat packs prior to extubation leading to and Analgesia recommend for continuous
increased risk of airway aspiration and intestinal monitoring of patient’s ventilatory status
obstruction [89, 90]. There is no doubt that throat during a moderate sedation?
packs play an important role in shared airway A. Pre-tracheal auscultation
anesthesia; however, one must be cognizant of B. Capnography
the fact that if not properly handled, throat packs C. Respiratory rate
themselves can cause serious complications. D. Direct observation
79 5
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83 6
Dental Injury: Anatomy,

Pathogenesis,
and Anesthesia
Considerations
and Implications
G. E. Ghali, Andrew T. Meram, and Blake C. Garrett
6.2 Etiology – 85
6.3 Risk Factors – 86
6.4 Prevention – 86
6.4.1 Preoperative Exam – 86
6.4.2 Dental Anatomy – 87
6.4.3 Dental Pathology – 88
6.4.4 Dental Restorations – 89
6.4.5 Damage to Restorations – 90
6.4.6 Proper Technique – 90
6.5 Dental Injury – 91
6.6 Treatment – 91
6.7 Medical Legal Implications – 92
6.8 Summary – 92
6.10 Answers – 93
References – 93

https://doi.org/10.1007/978-3-319-96125-5_6
84 G. E. Ghali et al.
Key Points 55 The preoperative assessment should

55 Dental injury is the most common include a full history and thorough clini-
complication of airway management for cal dental exam.
general anesthesia and is the most cited 55 The categories of dental injury include
claim in malpractice suits filed against fracture, luxation, and avulsion.
anesthesia providers. 55 In the event of an injury, consultation
55 Mechanical trauma associated with diffi- with the providing dental service is
culty during direct laryngoscopy remains always recommended.
the most common cause of perioperative 55 Communication with the patient during
dental injury. the preoperative exam, while discussing
55 The two most important risk factors are dental injury to obtain an informed con-
preexisting dental disease and a present, and postoperatively in the event of
6 dicted difficulty with intubation. an injury, is essential.
Case
A 51-year-old male with a past exam the resident can see part of and transported to the OR where
medical history significant for the patient’s uvula and documents he has minor difficulty moving
osteoarthritis, class 1 obesity, a Mallampati 2. He notes a large to the table due to the sedative’s
GERD, and obstructive sleep apnea tongue and a moderate maxillary effects. Before preoxygenation,
presents to day surgery at a teach- “overbite.” There is no obvious his pulse oximeter reads 93%. The
ing hospital for arthroplasty of his dental disease, but his maxillary patient is induced with standard
left knee by the orthopedic sur- central incisors, left maxillary weight-based doses of fentanyl,
gery department. He is evaluated lateral incisor, and left maxillary lidocaine, and propofol. An RSI
by a first year anesthesia resident canine all have fixed dental pros- dose of rocuronium is given, and
in the preoperative holding room. theses. Nothing appears loose or after 60 s, the resident attempts
His preoperative evaluation noted fractured. direct laryngoscopy but has great
a BMI of 33.5 kg/m but otherwise As a possible difficult intuba- difficulty. He sees only part of the
unremarkable vitals. He reports tion, thought is given to utilizing epiglottis and none of the aryte-
having been put to sleep approxi- a Glidescope, but both devices noids. He attempts to improve his
mately 15 years ago to fix a man- are currently being used in the view by applying more force and
dible fracture. He is unaware of any Labor and Delivery Unit upstairs, unintentionally cranes the blade
complications from the anesthesia, and the orthopedic surgeon has back onto the patient’s anterior
but he remembers waking up politely requested that the case maxillary incisors, and a harsh
with a sore throat that lasted a get started as soon as possible sound is heard. The attending
few days. The preoperative dental as he has clinic in the afternoon. takes over and successfully intu-
exam documents “no loose teeth” The resident suggests a modified bates and ventilates the patient.
but “multiple dental restorations.” rapid sequence induction, given After confirming placement and
The patient confirms that he has the patient’s history of GERD, then securing the tube, the resi-
a bridge on his “top front teeth,” a and the anesthesia attending dent notices that both the right
few “caps on the back teeth,” and a gives the resident clearance to and left central incisors (teeth #8
few “fillings.” He denies any exist- proceed to the operating room. and #9) have fractured along their
ing loose teeth or fractures. On The patient is given midazolam IV incisal edges.
6.1 Introduction providers would associate “catastrophic” with

complications that could lead to permanent and
With the multitude of serious complications pos- debilitating injuries such as stroke or loss of an
sible from surgery and anesthesia, most health- extremity. While dental injuries sustained in the
care providers may not intuitively include dental perioperative period are not fatal, these injuries
injury as one of the catastrophic complications are extremely prevalent, and complications may be
of the perioperative period. It is likely that most exacerbated by the hospital provider’s inadequate
Dental Injury: Anatomy, Pathogenesis, and Anesthesia Considerations and Implications
85 6
dental knowledge. The burden of dental injury a patient with emergence delirium, or due to a
on providers is the direct result of the large and fall during transfer [3]. Trauma to the dentition
perhaps unexpected impact these injuries have in the perioperative period is almost exclusively
on patients emotionally and economically. Many the result of mechanical trauma from a medical
patients will suffer emotional distress when an instrument [1]. Far and away the most common
anterior maxillary incisor was chipped or worse perioperative procedure causing dental injury
avulsed [10]. The need for restorative dental work is damage to the dentition via traumatic contact
can also elicit an emotional response with 80% with the laryngoscope [5]. Most studies on this
of Americans reporting some dental anxiety and topic are limited by small sample size, as well as
5–14% reporting intense dental anxiety [11, 12]. inadequate dental examination and charting. It
Dental injuries are very common throughout was not until researchers from the Mayo Institute
the perioperative period, but the vast majority of published a study which included 600,000 anes-
these injuries occur during direct laryngoscopy thetic cases performed over a 10-year period
[1, 13]. Dental injuries are also the most common that a reliable incidence could be established [3].
claim in malpractice suits against anesthesia pro- Their results showed that the incidence of dental
viders [1, 13]. Even more significant is the finding injury for general anesthesia was 1:2913. Among
that those malpractice claims account for 33% of the patients who received general anesthesia and
all confirmed claims [1]. Despite perioperative with an endotracheal tube, the incidence of dental
dental injury being well established as the most injury was 1:2805. Patients who received general
common complication of general anesthesia, the anesthetics without endotracheal intubation had
incidence reported in the literature varies from a dental injury incidence of 1:7390. The combined
0.04% up to 12.08% [3]. All providers involved incidence of perioperative dental injury during
in perioperative care should receive training and general anesthesia cases was 1:4537 [20, 3]. The
education focused specifically on dental injury important take-home point was that the incidence
as it remains the most common complication of of dental injury increases from 1:7390 to 1:2875
anesthesia and the most common complaint in when a patient is intubated [20, 3]. Approximately
medical malpractice suits against anesthesia pro- half of all perioperative dental injuries will occur
viders. The topics necessary to educate providers during direct laryngoscopy and tracheal intuba-
about perioperative dental injury include a review tion. Another 23% of dental injuries occur during
of the etiology and classification of the damage. the general anesthetic, but after intubation [3].
Identifying risk factors allows the most accurate Dental injury during the intraoperative period
prediction of injury risk. Additionally, a thorough may be due to an oropharyngeal airway, mouth
understanding of dental anatomy and its associ- prop, surgical retractors, fiber-optic scopes, or
ated pathology can prove vital in the prevention any number of medical devices used to facilitate
of this common complication. As medicolegal oropharyngeal surgery. Only 8% of dental injuries
implications continue to become apparent, the tend to occur during tracheal extubation [5].
need for a strong dialogue and discussion between Perioperative dental injury will most com-
anesthesia and dental colleagues alike is impor- monly cause damage to a single tooth, but 13% of
tant to help best identify preventative strategies cases involve injury to multiple teeth [3]. The teeth
and, in the event these complications occur, the most frequently damaged from dental injury are
different treatment options necessary to minimize the maxillary central incisors, most commonly
morbidity. the left maxillary central incisor. Other common
sites of dental injury include the mandibular
anterior incisors followed by the lower posterior
6.2 Etiology teeth [14]. The type of damage sustained from a
perioperative dental injury will vary based upon
Perioperative dental injury can occur during the preoperative dental health status, as well as the
direct laryngoscopy, placement of oropharyn- amount of traumatic force and location of impact.
geal airway devices and mouth openers or props, Being able to correctly identify and diagnose, a
iatrogenic surgical damage during oropharyn- dental injury is essential for selecting the most
geal procedures, excessive masticatory forces in appropriate treatment.
6.3 Risk Factors 6.4 Prevention
One of the most significant risk factors for Despite the amount of effort by perioperative
perioperative dental injury are teeth that have healthcare providers, there is not a way to com-
preexisting pathology [4]. It is intuitive that pletely eliminate dental injury as a possible peri-
teeth with decay from dental caries or that have operative complication [3]. This makes it very
become loose from periodontal disease would important that the perioperative provider under-
be more prone to traumatic injury than healthy stand the constant risk and ensure that every-
teeth. Patients with preexisting dental pathology thing is done to identify and minimize the risk of
are five times more likely to incur perioperative dental injury. Below is a discussion of the most
dental injury [6]. In addition to dental pathology, important elements for a perioperative provider
the anatomic factors increasing the risk of peri- to understand to prevent their patients from suf-
operative dental injury include a small mouth fering perioperative dental injury.
6 opening, large maxillary incisors, or anterior
dental crowding [4]. A preoperative dental exam
is, therefore, essential in identifying patients with 6.4.1 Preoperative Exam
the highest risk.
Dental injury most frequently occurs during The preoperative assessment is arguably the most
a difficult laryngoscopy when the provider ful- crucial portion of the perioperative period to
crums on a patient’s teeth in an attempt to gain a identify and then minimize the risks of dental
better view (. Fig. 6.1).

injury [3]. The preoperative assessment should be
Therefore, all the factors that are used to started by obtaining a thorough medical, dental,
predict difficult intubations can also be used surgical, and social history. The history provided
to predict the risk of dental injury [4]. These by the patient should be guided by the provider
factors would include limited cervical range of to include any information that may increase the
motion, previous head and neck surgery, cra- difficulty of intubation or indicate poor dental
niofacial abnormalities, and a history of diffi- health. Important medical history may include
cult intubation [3]. congenital diseases or abnormalities of the head
or neck, musculoskeletal conditions limiting
neck mobility, or a history of cancer. The social
history becomes important as smoking and chew-
ing tobacco predispose to a number of dental and
periodontal diseases. The dental history would
include preexisting dental injuries or trauma, cur-
rent dental or periodontal disease, usage of dental
prostheses, and limitation in mouth opening [1,
3]. The surgical history should include any surger-
ies of the head and neck, any difficult intubations,
and any prior perioperative dental injuries. The
previous anesthesia records should be obtained
for any patient who admits to previous difficult
intubation or perioperative dental injury.
Once a thorough history has been obtained,
the next step in preoperative evaluation is the clin-
ical exam. The clinical evaluation must include a
full dental exam and also establish the potential
for difficult intubation. Most healthcare providers
are already adept at performing a clinical exam
.. Fig. 6.1 Correct angulation of laryngoscope to that assesses the findings associated with difficult
prevent damage to dentition intubation. Providers with a purely medical back-
87 6
ground, however, may have difficulty completing 8 9
an adequate dental exam as they often have had 7 10
little training or experience with the basic princi-
6 11
ples of dentistry. It is, therefore, essential that den-
tal anatomy, dental disease, and the fundamentals 5 12
of dental restoration are discussed.
4 13
3 14
6.4.2 Dental Anatomy
2 15
Primary teeth, or baby teeth, begin to develop
during the embryo phase of pregnancy and erupt 1 16
around 6 months of age. A normal primary denti-
tion consists of 20 teeth with 10 teeth on the max-
illary arch and 10 teeth on the mandibular arch 32 17
[15]. The permanent dentition begins to erupt at
6 years of age and ends with the eruption (unless 31 18
impacted) of the third molars between the ages
of 17 and 23 years [15]. The permanent dentition 30 19
consists of 32 total teeth which include 12 molars,
8 premolars, 4 canines, 4 lateral incisors, and 4 29 20
central incisors [15]. The most common method
28 21
for identifying individual teeth is the Universal
Numbering System. This system assigns each per- 22
27
manent tooth a number (1–32) and each primary 23
26 24
tooth a letter (A-T) [16]. The numbering system is 25
designed to mimic a clinical view to facilitate docu-
.. Fig. 6.2 Odontogram demonstrating dental numbering
mentation into an odontogram (. Fig. 6.2) [16].

system
All teeth are divided into two anatomic seg-
ments: the crown and the root. The anatomical
crown is the portion of the tooth visible on a pulp chamber, which extends via canals through
clinical exam. In a healthy dentition, the gum line each root. These root canals house terminal nerve
divides the crown from the root [17]. The shape branches from the inferior and superior alveo-
and number of roots vary by the type of tooth. lar nerves and blood vessels which supply each
The anterior teeth (incisors and canines) typically tooth. The root surface is comprised of the third
have a single cylindrical root that tapers in an api- hard tissue known as cementum. Cementum is
cal direction. The posterior teeth (premolars and softer than both enamel and dentin and made
molars) may have multiple roots with a surprising up of both proteoglycans and collagen allowing
variability in shape, size, and internal anatomy attachment to the surrounding structures [18].
[17]. Each tooth is made up of four unique tis- The tissues which stabilize a support each tooth
sues which form easily discernible anatomic lay- are collectively known as the periodontium. The
ers [18]. The most superficial layer covering the outermost layer of the periodontium visible on
entire anatomical crown is the enamel. Enamel a clinical exam is the gingiva [17]. The gingival
is a very hard and extremely mineralized tissue tissue is prone to injury in the form of laceration
composed mostly of crystallized calcium phos- and periodontal disease in the form of gingivitis.
phate. The layer underneath the enamel is called Attached to the root cementum is the periodon-
dentin and is only exposed with pathology [18]. tal ligament that is then anchored to the alveolar
Within the dentin layer are tubules which allow bone. The alveolar bone is an anatomic designa-
transmission of sensation to the nerves found tion for the tooth-bearing portions of the maxilla
in the pulp chamber. Deep to the dentin lies the and the mandible [17].
6.4.3 Dental Pathology Dental caries causes progressive decay and

structural breakdown of all dental tissues [4]. The
With a confident understanding of dental and decay is a result of demineralization due to acid
periodontal anatomy, the provider must then produced by bacteria [22]. The most common spe-
become familiar with dental disease. Any disease cies of cariogenic bacteria are Streptococcus mutans
or injury that affects the teeth, gingiva, periodon- and Lactobacilli. These bacteria ferment dietary
tal ligament, or alveolar bone increases the risk of fructose, glucose, and sucrose into lactic acid. S.
perioperative dental injury [4]. There are two very mutans also has the ability to convert sucrose to
common diseases found in the mouth, dental car- the polysaccharide dextran which allows adhesion
ies and periodontal disease, both of which have sig- to the tooth surface as well as protection with the
nificant relevance and impact on a patient’s risk of development of a biofilm [23]. Dental caries are
sustaining perioperative dental injury (. Fig. 6.3).

typically not difficult to locate and the severity cor-
The disease most commonly affecting the den- relates very well with their progression throughout
6 tition is dental caries, also known as tooth decay the crown. Early caries will appear as a soft dis-
or dental cavities. Caries is extremely prevalent coloration within the enamel. This breakdown will
with the most recent data indicating an incidence continue deeper within the tooth until the eventual
of 36% of the worldwide population (2.43 billion exposure of dentin followed by the pulp chamber.
people) [19]. Even more impressive was a recent The second most important disease related to
report published by the US Office of Disease dental injury is periodontal disease which may
Prevention and Health Promotion which con- affect the gingiva, ligaments, and alveolar bone.
cluded that within the pediatric population, caries Periodontal disease begins as a bacterial infection of
is five times more common than asthma, making the gingiva caused by the presence of bacteria laden
caries the most common chronic disease of child- dental plaque/calculus [4]. The tissue’s response
hood [21]. The incidence of caries is also increas- to the bacterial infection results in a painless and
ing in both the pediatric and adult populations. slow spreading inflammatory process causing the
.. Fig. 6.3 Clinical schematic of dental caries and periodontal disease

89 6
dissolution of the gingiva, periodontal ligament, fillings, are easy to identify visually and will only
and alveolar bone surrounding the tooth [4, 24]. be placed in a posterior tooth. Composite fillings
The earliest clinical signs of periodontal disease have an impressive variety of shades and opacities
include inflamed, erythematous, and friable gin- allowing the creation of nearly invisible restora-
giva and are termed gingivitis [24]. Gingivitis will tions. These restorations can also be placed any-
continue to worsen and spread which can be clini- where on the dentition making identification very
cally identified as gingival recession causing root difficult [26].
surface exposure. When the inflammatory process
causes destruction of the periodontal ligament and 6.4.4.2 Removable Prosthesis
then alveolar bone socket, it is termed periodonti- The single most important characteristic of a den-
tis [24]. As damage to the periodontal ligament and tal prosthesis for the purposes of identification and
alveolar bone increases, the associated tooth will documentation is whether or not it can be inten-
lose stability causing significant dental mobility. tionally removed and replaced by the patient. A
Caries and periodontal disease share com- removable dental prosthesis fabricated to replace
mon elements including bacterial involvement missing teeth is termed a denture. A denture,
and destruction of tissues causing loss of stabil- sometimes called a plate, may provide partial or
ity or loss of structure, and of course, both greatly full replacement of teeth in the maxillary or man-
increase a patient’s risk of perioperative dental dibular arch. Partial dentures are typically made
injury. These diseases differ in that they predis- of acrylic or resin and are retained by metallic
pose a tooth to distance types of dental injury. clasps which attach to adjacent healthy teeth. A
Periodontal disease causes dental mobility which partial denture is typically easy to identify by the
increases the likelihood of luxation or avul- examiner and easily removed by the patient. A
sion with dental injury. Caries causes loss of the full denture is made of acrylic and ceramic and is
enamel and dentin which increases the likelihood stabilized by either mechanical retention, denture
of crown fracture with dental injury. adhesive pastes, or by attachment to surgically
placed dental implants. Full dentures are also typ-
ically easy to identify and remove. It is important
6.4.4 Dental Restorations to note that the surgically placed dental implants
are osseointegrated into the patient’s jaw, while
The rapid advancement of clinical technology the denture can be removed [26].
including computer-assisted design and in-office
3D printing has enabled dentists to place a greater 6.4.4.3 Fixed Single-Tooth
variety of prostheses at a much faster pace [25]. The Restorations and Fixed
perioperative provider performing a preoperative Multiunit Restorations
dental exam must maintain a working knowledge Large dental defects involving a majority of the
of the most common types of dental restorations anatomical crown may no longer be possible to
and prostheses in a constantly changing field. A adequately restore with a dental filling. Such large
tooth with a restoration will always be more prone defects are replaced with a wide variety of tech-
to dental injury than a healthy tooth [4]. A famil- niques and materials but are alike in that they
iarity with dental restorations and prostheses will are permanently affixed to the remaining healthy
allow the provider to properly take a dental his- dentition. The fixed prostheses which restore a
tory, identify and correctly document restorations partial defect include inlays, onlays, and veneers
and prosthetics in the chart, and assess the level of [29]. Veneers are uniquely important for periop-
damage in the event of dental injury causing dam- erative providers given their hazardous placement
age to a restoration or prosthesis. on the facial and incisal surface of the anterior
teeth. When the fixed prosthesis provides full
6.4.4.1 Amalgam and Resin-Based coverage, it is termed a crown or colloquially, a
Composite Fillings cap. Partial and full coverage fixed prostheses are
Localized defects of the anatomical crown caused nearly all retained via dental cement. Fixed den-
by trauma or carious decay are typically restored tal prostheses can also be used to replace missing
with an amalgam or resin-based composite fill- teeth with an artificial tooth connected to the
ing. Amalgam fillings, sometimes called silver adjacent teeth and may be referred to as bridges
[29]. These prostheses involve the placement of a cement, underlying decay, or mechanical trauma.
pontic (or false tooth) which sits above the gin- Dental prostheses of any size pose a great risk for
giva of an edentulous space and is suspended by aspiration if displaced and require immediate
its rigid attachment to an anterior and posterior attention. Damage to a simple restoration, such as
full coverage crown. These multiunit fixed resto- an amalgam or composite filling, will likely lead
rations can be used to replace very large edentu- to material fracture or deterioration with the pos-
lous gaps caused by the loss of multiple teeth. sibility of tooth fracture.
Fixed restorations which were once nearly all
fabricated using gold, later transitioned to porce-
lain, ceramic, and leucite. Gold restorations are 6.4.6 Proper Technique
easy to locate and properly document. The ceram-
ics have become increasingly esthetic and may Intraoperatively there are a number of strate-
be difficult to identify without asking a patient’s gies to reduce the risk of dental injury. The use
6 dental history. These restorations are particularly of a protective dental guard, or occlusal gutter,
relevant due to the likely chance of full displace- can help to reduce forces acting directly on the
ment, the significant aspiration risk, and high maxillary incisors during laryngoscopy [4, 27].
cost of replacement. Due to all these factors, fixed These gutters are most effective when they are
dental restorations require special attention both custom made preoperatively by the patient’s den-
during documentation and in the perioperative tist. These gutters may be most appropriate for
period [26]. patients with costly fixed dental prostheses of the
anterior maxillary incisors. These gutters should
6.4.4.4 Dental Implants be cautiously used in patients with a predicted dif-
A dental implant is a threaded titanium medical ficult intubation as they limit mouth opening and
device which is surgically drilled into the max- may decrease visualization, thereby worsening
illa or mandible providing excellent stability for the conditions for intubation [4, 27].
a number of dental restorations [30]. The dental Proper technique also involves ideal posi-
implant is drilled to a depth that allows little to no tioning of the patient’s head and neck through
protrusion of the implant beyond the height of the the utilization of blankets, positioning devices,
alveolar bone. The implant is then covered by gin- or adjustment of the operating table. Correct
gival tissue concealing it from clinical view. During positioning will increase the distance between
this time the implant osseointegrates into the bone, anatomical obstacles, including the teeth, and
and after a surgeon-dependent period of time, is decrease the difficulty of laryngoscopy and intu-
uncovered to allow attachment of a prosthesis. The bation [3, 4]. An experienced provider should
dental implant can be used to support single tooth become immediately aware of dental contact
replacements, multiunit prostheses, and, as afore- during laryngoscopy and immediately consider
mentioned, removable partial and full dentures. change in technique including optimizing patient
It is important for the perioperative provider to position [32, 4].
recognize that the surgically placed dental implant During laryngoscopy it is essential that the
is a separate component from possible dental pros- blade be held in the provider’s left hand close to
thetics it can support. Since there are a variety of the junction of handle and blade. The provider’s
implant-supported restorations, it is necessary right hand is used to carefully scissors open the
to determine if the patient’s restorations are fixed patient’s mouth with pressure on the most stable
or removable and to subsequently determine the and posterior teeth to allow safe maximum mouth
number of dental implants and their relative loca- opening. The blade is then introduced slowly into
tion and if they show signs of disease or failure [26]. the right side of the patient’s mouth while the
provider is careful to adjust the geometry of entry
based upon constant visualization of the patient’s
6.4.5 Damage to Restorations lips, gingiva, and teeth [7]. The blade and tongue
are swept to the left and then advanced toward the
Damage sustained to a prosthesis typically results larynx as the provider continues to avoid contact
in loosening or displacement. Displacement with the dentition. Once an adequate depth and
of these prostheses results from failing dental position (based upon the type of blade selected)
91 6
has been achieved, the provider’s left wrist is held with periodontal disease are more prone to dam-
rigid resulting in a lifting force along the axis of age from biting an oropharyngeal airway, endo-
the handle that will displace soft tissue and allow tracheal tube, or supraglottic device [4, 8].
visualization of the vocal cords [7]. The force
applied should be in an anterior and superior
vector sometimes described as a pulling force 6.6 Treatment
toward the junction of the operating room’s far
wall and ceiling. While lifting there should be no The most common dental injury of the periop-
rotation of the wrist causing contact with gingiva erative period is enamel fracture to the maxillary
or dentition. Trainees are apt to pull the laryn- central incisors [3–5]. These injuries are typically
goscope in a superior and cephalad direction small without major immediate risk allowing the
unintentionally using the maxillary incisors as a airway to be secured and the patient stabilized. The
fulcrum. A novice is also more likely to use exces- site of fracture should be evaluated to ensure that
sive forces combined with prolonged time of intu- the remaining dental structure is stable and poses
bation greatly increasing the risk of dental injury. no risk of aspiration. A large fractured segment of
tooth or dental prosthetic or an entirely avulsed
tooth needs to be found. A thorough examination
6.5 Dental Injury of the oral cavity, oropharynx, and hypopharynx
may be warranted. If the displaced segment is not
In healthy dentition, dental injury most com- found, then radiographs of the head, neck, chest,
monly causes enamel fracture of the crown. A and abdomen should be obtained to ensure that
more severe fracture can penetrate to the layer of the fractured segment was not aspirated into the
dentin and may cause exposure the pulp chamber lungs or lodged in the esophagus or stomach [7].
[31]. These fractures are most severe when they If the fragment is visible in the mouth or orophar-
involve preexisting dental cracks undiscovered ynx, a concerted effort should be made to maintain
during the preoperative exam [4]. An injury caus- visualization as these fragments are very easily dis-
ing fracture of the tooth root is less likely than a placed necessitating a time-consuming and difficult
fracture of the crown due to increased structural search. The patient should be kept sedated so as to
strength and protection from the alveolar bone. prevent displacement of the tooth from the patient
The root is also less likely to be weakened by den- swallowing, coughing, or bucking in response
tal caries [31]. Root fractures do still occur and to laryngeal stimulation. When attempting to
can be diagnosed with either detachment or sig- retrieve the dental fragment, the patient should be
nificant mobility of the entire crown. optimally positioned to reduce the risk of poste-
Injury that causes traumatic movement of a rior displacement down the pharynx. If possible,
tooth is termed luxation [2]. These injuries rep- a piece of gauze should be opened to its maximum
resent damage to the ligament or socket which size and placed posterior to the fragment to act as
act to stabilize the tooth. The mildest form of an oropharyngeal screen. The displaced segment
the injury is termed subluxation and represents should be grasped using a Magill forceps or similar
a nondisplaced tooth with minor mobility and surgical instrument. A frantic hand attempting to
bleeding [31]. The more severe form of the injury secure a small fragment located in the back of the
leads to visible displacement of the tooth in a throat will often lead to accidental displacement.
lateral, intrusive, or extrusive direction. When If dental injury causes luxation of a tooth or
dental injury causes a tooth to be completely dis- dental prosthetic, the mobile segment should
placed from the socket, it is termed an avulsion. quickly be stabilized to avoid damage to nearby
This is the most severe form of dental injury, and structures or the complete avulsion of the tooth.
in addition to a poor restorative prognosis, it has A non-dental provider should avoid removing the
the extra risk of displacement into the airway or mobilized segment until dental consultation is
esophagus. The risk of traumatic movement from obtained. The exceptions to this guideline would
dental injury is greatly increased with periodontal be a situation where the mobile segment poses an
disease. Whereas difficult intubation remains the emergent threat to the patient’s health or in a situ-
most common cause of dental injury to maxillary ation where a dental provider will not be available
teeth with periodontal disease, mandibular teeth before emergence or discharge.
All dental injuries sustained in the periop- event of dental injury, immediate consultation by
erative period warrant consultation to the on- the hospital’s dental service is always advised from
call dental service. For minor dental injuries, it a legal standpoint. Dental consultation reduces
is acceptable for the evaluation of the patient to the risk of further injury and will help minimize
be performed in the PACU or even outpatient as the chance of a patient feeling abandoned or
determined by the consultant [7]. Dental injuries interpreting the provider’s actions as negligent.
causing luxation should prompt consultation to As with all medical legal issues, thorough docu-
the dental team and evaluation of the patient in mentation and open communication will always
the OR before emergence. When a tooth is fully improve legal protection.
avulsed, the dental team should urgently present
to the OR for possible replantation of the tooth.
Consultation not only allows evaluation and 6.8 Summary
treatment of the injury by specialists but it may
6 also provide legal protection in the not uncom- Dental injury is a significant perioperative compli-
mon event of future litigation. cation due to its overwhelming frequency, finan-
cial burden, and stressful impact on both provider
and patient. With an ever-increasing amount of
6.7 Medical Legal Implications operative procedures coupled with more frequent
placement of costly dental restorations, this com-
Perioperative dental injuries are both the most plication will only become more significant in
frequently cited complaint in medical malprac- time. It is crucial that providers, including those
tice against anesthesiologists and the most com- without formal dental education, understand the
mon forensics claim related to all of anesthesia elements involved in perioperative dental injury
[4]. The financial burden is especially significant to best prevent these complications. The most
with estimates of most claims averaging $2000 common perioperative dental injury involves
[1]. While only a third of perioperative dental direct laryngoscopy causing dental fracture to the
injuries result in filed complaints, the overall fre- maxillary central incisors. The most relevant risks
quency maintains a very high impact. At the pre- include preexisting dental disease and the factors
operative appointment the findings on the dental predicting difficult intubation. These risks must
exam should be verified and corroborated with be assessed during the preoperative evaluation by
the patient. Involving the patient not only allows obtaining a thorough history and detailed dental
more accurate identification of well-concealed exam. The findings and risks must be well com-
dental restorations but will also notify the patient municated to the patient to allow a valid informed
of the existence of any undiagnosed existing den- consent and then accurately documented by the
tal disease [1]. Many institutions have benefitted provider. The provider should make every attempt
from the use of a structured preoperative den- to prevent trauma but also must be adept at the
tal assessment which facilitates the provision of indicated treatment both in the acute and post-
information to patients, improves clinical docu- operative phases of injury. In the event of peri-
mentation, and reduces overall liability [1]. It is operative dental injury, the provider is expected
then important to specifically discuss the patient’s to be able to quickly diagnose the injury, take
individual risk of dental injury and the possible immediate action to prevent further injury, and
outcomes stemming from an injury. This infor- then determine the appropriate urgency of con-
mation should also be included in the anesthesia sultation. Even with dental consultation, the peri-
and relevant surgical informed consent [4]. operative provider should continue to provide
For patients at particular risk of dental injury care for the patient and remain actively involved
or in whom dental injury may be particularly until its resolution. It is impossible to predict with
costly, the preoperative involvement of the certainty when a complication will lead to legal
patient’s dentist may allow corrective or preven- action, but providers who are meticulous about
tive measures to reduce risk of dental injury and documentation, prevention, and patient commu-
may minimize the chance of legal action in the nication will undoubtedly afford themselves the
event of subsequent dental injury [28]. In the highest level of legal protection.
93 6
6.9 Review Questions the oral cavity, oropharynx, and hypophar-
ynx. If the displaced segment is not found,
?? 1. What is the most common perioperative then radiographs of the head, neck, chest,
dental injury during direct laryngoscopy? and abdomen should be obtained to
A. Subluxation of mandibular central ensure that the fractured segment was not
incisors aspirated into the lungs or lodged in the
B. Enamel fracture to the maxillary central esophagus or stomach. If the fragment is
incisors visible in the mouth or oropharynx, effort
C. Intrusion of maxillary molars should be made to maintain visualization.
D. Laceration of gingiva The patient should be kept sedated so as
to prevent displacement of the tooth from
?? 2. Name three anatomic risk factors associ- the patient swallowing, coughing, or buck-
ated with possible dental injury during ing in response to laryngeal stimulation.
anesthesia? When attempting to retrieve the dental
A. The presence of dental pathology fragment, the patient should be optimally
B. A small mouth opening positioned to reduce the risk of posterior
C. Large maxillary incisors displacement down the pharynx. If possi-
D. All of the above ble, a piece of gauze should be opened to
E. A and C only its maximum size and placed posterior to
the fragment to act as an oropharyngeal
?? 3. What should be done in the event of a den- screen. The displaced segment should be
tal fracture or avulsion during anesthesia? grasped using a Magill forceps or similar
A. A thorough examination of the oral surgical instrument. An immediate consult
cavity, oropharynx, and hypopharynx. to the dental service should be obtained
B. Keep the patient sedated to prevent for further evaluation.
displacement of tooth from swallow-
ing, coughing, or bucking.
C. Use of gauze along posterior orophar- References
ynx to act as screen.
D. All of the above. 1. Givol N, Gershtansky Y, Halamish-Shani T, Taicher S,
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of incident reports. J Clin Anesth. 2004;16(3):173–6.
https://doi.org/10.1016/j.jclinane.2003.06.004.
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6.10 Answers
anaesthesia. Br Dent J. 1996;180(7):255–8.
3. Warner ME, Benenfeld S, Warner MA, Schroeder

vv 1. B – The most common perioperative dental D, Maxson P. Perianesthetic dental injuries: fre-
injury during direct laryngoscopy is enamel quency, outcomes and risk factors. Anesthesiology.
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vv 2. D – Anatomic risk factors associated with insurance-related impact over 4 years in Rouen
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95 7
Complications of General
Anesthesia
Jeffrey P. Cardinale, Nigel Gillespie, and Liane Germond
7.2 Death – 96
7.3 Respiratory Complications – 97
7.4 Awareness – 98
7.5 Stroke – 100
7.6 Cardiac Complications – 100
References – 102

https://doi.org/10.1007/978-3-319-96125-5_7
96 J. P. Cardinale et al.
7.1 Introduction in EKG waveforms, pulse oximeter saturations,

blood pressure readings, end-tidal carbon dioxide
The need of general anesthesia for conduct- (ETCO2) values, or any of the other monitor-
ing surgical procedures is without question. ing devices in use can lend hints to what may be
Complications from general anesthesia can occurring and provide insight into whether the
range from benign (i.e., sore throat) and com- interventions chosen are driving improvement in
mon (i.e., postoperative nausea and vomiting) the patient’s condition.
to debilitating but rare (i.e., stroke or death), as Many factors can be suggestive of potential
well as everything in between. Due to their rar- anesthetic complications: family history, periop-
ity, tracking many of these occurrences is difficult erative comorbidities, and type of surgical pro-
and often the product of multi-year, single-center cedure, among others, and it takes the dedicated
retrospective analyses, a small group of surgical and diligent anesthesia provider to tease out these
center reports, monitoring via closed claims proj- subtleties to provide the safest anesthetic possi-
ects, or based on more dated studies. Predicting ble. However, even the most detailed preoperative
the individuals susceptible to complications of review cannot account for some unexpected out-
7 general anesthesia and having an adequate peri- comes such as unknown muscular dystrophies or
operative anesthetic plan have improved, but it mitochondrial disorders, an undetected coronary
is the unpredictable complication that concerns artery stenosis or first time malignant hyperther-
practitioners. Patients are also concerned about mia event. The relative risk of complications from
such unpredictable complications. The prospect general anesthesia is very complex to interpret.
of undergoing general anesthesia is frightening to One must consider inpatient versus outpatient
roughly 33% of surgical patients [1]. These fears surgery, type of procedure, length of procedure,
primarily manifest themselves distinctly from ASA score, as well as the way the data was col-
the operative procedure and include awareness lected. Even when basing data on the well-known
under anesthesia, not waking from anesthesia or ASA scoring system, there is some variation in
sensing pain and discomfort from the procedure how anesthesiologists score the same patient
and being unable to communicate this concern. A and making its use as a fixed variable question-
more empathetic preoperative visit and acknowl- able [4]. Regardless, studies do bear out that the
edgment of these issues can go a long way in higher the ASA score, the higher the incidence of
assuaging these concerns and even improve post- death, which becomes even more profound when
operative pain and hospital length of stay [1, 2]. factoring in age [5, 6]. To overcome these limita-
This chapter aims to provide an overview of some tions, standardization practices of data collection
of the complications arising from general anes- and follow-up were established, including the
thesia and the direction providers can potentially ASA closed claims project (ASA-CCP), Cochrane
expect in the future. reviews, and the guidelines established by the
The modern anesthesiologist has an ever- National Surgical Quality Improvement Program
improving number of monitoring tools at their (NSQIP), a large surgical registry where out-
disposal. This stands as the cornerstone to good comes are collected for 30 days postoperatively
anesthetic practice, so much so that the American for a wide range of surgical procedures. With
Society of Anesthesiologists (ASA) continually the increasing use of electronic medical records
evaluates and updates their Standard of Practice (EMRs) nationwide, data mining and more pre-
Parameters on standard and nonstandard anes- cise assessment of anesthetic complications and
thetic monitoring guidelines [3]. The basics of this even predictive factors will become more easily
include Standard I, qualified anesthesia person- accessible.
nel, and Standard II, monitoring of oxygenation,
ventilation, circulation and temperature, and fre-
quency of monitoring and alarm requirements. A 7.2 Death
detailed description of the utility and validity of
these monitors is beyond the scope of this chapter, Death from anesthesia was initially common, 1 in
but the value of these tools should not be under- 2680 (0.03%) cases in 1954. By the mid-1980s,
estimated in reducing the morbidity and mortal- estimates from the landmark CEPOD study
ity of complications of anesthesia. Alterations showed risk of death ranging from 1 in 13,000 to
Complications of General Anesthesia
97 7
1 in 185,000 [7, 8]. More recently, studies show 0.1–37% rate of observed respiratory depression.
11–16 deaths per 100,000 persons from anes- The large distribution depended upon the type
thesia alone (0.01–0.016%) [9, 10]. This varied and route of opioid administration and variations
greatly with the ASA physical status of the patient in defining and detecting respiratory depression
undergoing the surgical procedure [5, 6, 11]. [19]. A review of the ASA-CCP, however, showed
Researchers still grapple with defining and mea- that the majority of respiratory depression events
suring death solely from anesthesia versus other occurred within 24 h of surgery (88%) and that
complicating factors. Furthermore, while the 97% were deemed preventable, an unfortunate
practice of anesthesia and the tools are improv- amount of which resulted in death or severe brain
ing, patient acuity is also increasing, allowing damage [20]. Interestingly, patient-controlled
for the relatively stagnant levels of risk of death analgesia (PCA, 53%) and neuraxial anesthesia
from anesthesia from the 1980s till present. It is (39%) were the most cited modes of pain manage-
important to note, however, that the risk of death ment techniques noted in the claims. Recognition
from anesthesia is on par with death as a result of of patient factors (i.e., history of obstructive sleep
pregnancy and that even seemingly benign proce- apnea, age, and debility), reduction in total opioid
dures (i.e., cholecystectomy) carry a higher risk of administration, ETCO2 monitoring, and more
mortality as compared to general anesthesia alone frequent nursing checks, especially within the
[12–15]. Thus, although death from anesthesia is first 2–3 h, are possible approaches to preventing
a known complication, it is less common than the these potentially devastating events.
majority of procedures in which the requirement Similar to respiratory depression, esophageal
for anesthesia is warranted. intubation was a major source of patient injury
in the 1980s [17]. Counting for roughly 6% of
all anesthesia-related closed malpractice claims
7.3 Respiratory Complications and nearly 18% of those specifically associated
with adverse respiratory events since the ASA-
One of the central tenants of anesthetic practice CCP monitoring began, esophageal intubation
is airway and ventilatory management. Therefore, remains a serious concern [17]. This is espe-
it should come as little surprise that significant cially important as nearly 98% of those claims
morbidity and mortality are associated with com- resulted in severe brain damage or death. Prior
plications of the respiratory system. In studying to 1991 and the introduction of ETCO2 as well
the causative factors involved in perioperative as its subsequent adoption by ASA as a standard
morbidity and mortality, several etiologies have monitoring practice, 3–8% of claims per year
been examined. Using the ASA-CCP, review- were made for esophageal intubation. Despite a
ers noted that the largest class of injury (~34%) marked improvement to 1–2% per year following
was respiratory events, with death or significant that landmark discovery, the persistence of these
brain injury occurring roughly 85% of the time. occurrences is primarily secondary to human
Inadequate ventilation, esophageal intubation, error, including fixation error, confirmation bias,
and difficult tracheal intubation were the leading and overconfidence [3, 21, 22]. It’s important to
causes of reported respiratory events with major- note that a portion of these claims included intu-
ity of these deemed preventable [16, 17]. There are bation complications during resuscitative efforts
similar results when comparing general anesthe- outside the OR where ETCO2 detection devices
sia with monitored anesthesia care (MAC), but in and monitoring may not be available; however,
regard to causative etiologies during MAC cases, use of good communication and an open mind
overdose of sedative or opioid medications are the to multiple potential causes of ventilatory dif-
primary cause [18]. ficulties can lead to a decrease in such adverse
Inadequate ventilation was typically associ- events.
ated with MAC cases, but also postoperatively fol- Difficult tracheal intubation is more com-
lowing general anesthesia cases. While it’s difficult plex to study due to the relative ambiguity of the
to quantify total numbers of observed respiratory definition for a difficult airway [23–25]. Some
depression and inadequate ventilation complica- have described it as vaguely as that in which an
tions among all anesthetic cases, a meta-analysis expert anesthesiologist or anesthetic provider
review of roughly 20,000 patients demonstrated a struggles to ventilate or intubate, whereas others
use more specific definitions such as three or to identify UAGA is the Brice interview [33].
more attempts or taking longer than 10 min to Several studies have used this questionnaire or
establish an airway [26]. Regardless, the reported variations of it to identify UAGA in conjunction
incidence of difficult airways is 1.1–3.8% [24, with operative records when available. The opera-
27]. From the Mallampati airway grading scale to tive records are evaluated for consistency between
the entirety of the standard airway exam (mouth patient-reported and practitioner-documented
opening, neck extension, thyromental distance, events and the presence of descriptors that objec-
etc.), many have examined predictive factors tively imply particular levels of consciousness.
associated with difficult intubation [28, 29]. Accounting for the previous considerations, the
Alone, many diagnostic exams are only moder- incidence of UAGA ranges from 0.005% to 0.2%
ately sensitive, yet fairly specific; but in combina- [34–36]. Factors that independently increase the
tion, especially the use of the Mallampati score chances of intraoperative awareness are use of
and thyromental distance, accuracy of predict- neuromuscular blocking agents (NMBs), female
ing difficult intubations improves without much sex, emergency procedures, obstetric and car-
loss in specificity [24, 30]. The ASA routinely diothoracic surgery, obesity, age, and increased
7 updates practice guidelines and difficult airway operative time [33]. UAGA most frequently
algorithms to address such issues [26]. As an occurs during the induction and emergence
entity of respiratory complications, closed claims phases of anesthesia. The occurrence of UAGA
analysis noted that over half of difficult intuba- during maintenance is most often associated with
tions resulted in death or brain damage, though a light plane of anesthesia and is correlated in
the incidence has noted a downward trend, likely some studies with low end-tidal anesthetic gas
owing to improved equipment and training [31]. and MAC. UAGA is not always unpleasant for
Nevertheless, anesthesia providers should famil- patients but the majority report anxiety, fear, and
iarize themselves with both the difficult airway discomfort. The most frequent elements of recall
algorithm (. Fig. 7.1) and the on-site equipment
are auditory events [35]. Patients who report
available for airway emergencies. In conjunction UAGA should have their concerns acknowledged
with a good history and physical exam assess- and questions answered at the time of report-
ment, appropriate airway management planning ing, and further discussion should be centered
will provide a safer avenue for patients undergo- on the patient’s experience. A retrospective
ing general anesthesia. patient-centered report of UAGA found patient
dissatisfaction primarily arose from lack of dia-
log with anesthetic caregivers and conversations
7.4 Awareness that appeared to shift blame to the patient for
their experience [34]. Preoperative discussion of
Unintended awareness during a general anes- the possibility of UAGA in instances where there
thetic (UAGA) is the presence of consciousness are numerous patient and operative risk factors
and explicit recall while receiving treatment can potentially mitigate some concerns should
modalities that should eliminate both [32]. These UAGA occur. Judicious use of NMBs and efforts
criteria are most useful when the anesthetic pro- to maintain adequate anesthetic depth based on
vider observes objective patient demonstrations MAC when available, and multimodal approaches
of meaningful interaction with their environ- when not, should minimize controllable risk fac-
ment or can corroborate the specific events the tors. Use of proprietary algorithmic neuro-mon-
patient recalls. It becomes difficult to assess when itors that interpret EEG, EMG, or AEP signals as
UAGA has occurred if the provider of record can- surrogates for anesthetic depth (BIS, M-Entropy,
not verify the recollections or conscious behavior. aepEX) should be used on a case-by-case basis.
Additionally, intraoperative dreaming, in which There is evidence to suggest that in patients at
the subconscious manifests reasonable scenarios high risk for UAGA, use of these monitors can
that occur during surgery, can be difficult to dis- reduce its incidence. However, in cases where
tinguish from explicit recall. These factors make end-tidal anesthetic gas is available and main-
the identification and study of UAGA challeng- tained >0.7 MAC and compared to BIS, there is
ing. An established standardized questionnaire no difference in the incidence of UAGA [33].
99 7
DIFFICULT AIRWAY ALGORITHM

1. Assess the likelihood and clinical impact of basic management problems:
• Difficulty with patient cooperation or consent
• Difficult mask ventilation
• Difficult supraglottic airway placement
• Difficult laryngoscopy
• Difficult intubation
• Difficult surgical airway access
2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult
airway management.
3. Consider the relative merits and feasibility of basic management choices:
• Awake intubation vs. intubation after induction of general anesthesia
• Non-invasive technique vs. invasive techniques for the initial approach to intubation
• Video-assisted laryngoscopy as an initial approach to intubation
• Preservation vs. ablation of spontaneous ventilation
4. Develop primary and alternative strategies:
AWAKE INTUBATION INTUBATION AFTER
INDUCTION OF GENERAL ANESTHESIA
Airway approached by Invasive Airway
Noninvasive intubation Access(b)* Initial intubation Initial intubation
attempts Attempts UNSUCCESSFUL
successful* FROM THIS POINT ONWARDS
Succeed* FAIL CONSIDER:
1. Calling for help.
2. Returning to
Cancel Consider feasibility Invasive spontaneous ventilation.
Case of other options(a) airway access(b)* 3. Awakening the patient.
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE
CONSIDER/ATTEMPT SGA
SGA ADEQUATE* SGA NOT ADEQUATE

OR NOT FEASIBLE
NONEMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful EMERGENCY PATHWAY
Ventilation not adequate, intubation unsuccessful
IF BOTH
Alternative approaches FACE MASK Call for help
to intubation(c) AND SGA
VENTILATION
BECOME Emergency noninvasive airway ventilation(e)
INADEQUATE
Successful FAIL after
Intubation* multiple attempts Successful ventilation* FAIL
Emergency
Invasive Consider feasibility Awaken invasive airway
airway access(b)* of other options(a) patient(d) access(b)*
.. Fig. 7.1 Difficulty airway algorithm. (From Apfelbaum et al. [26])

7.5 Stroke of PS for general anesthetics [44]. Arterial and

venous catheterization pose the risk of introduc-
Stroke can be defined as end-organ damage to ing emboli by dislodging existing arterial plaques,
a CNS component resulting from a vascular instigating thrombus formation that can later
event. The primary mechanism of stroke in the dislodge, or causing the introduction of air. Most
perioperative setting is ischemic, most often the studies assessing PS demonstrate its occurrence in
result of embolism, rather than hemorrhagic the postoperative period after PACU recovery. In
[37]. The increased risk of perioperative stroke one study, only 10% of PS was identified on emer-
(PS) for patients undergoing cardiac and vascu- gence from anesthesia with the majority being
lar surgery has been well established [38]. While detected on postoperative day 0 or 1 [45]. Patients
the incidence of PS is lower in those receiving at higher risk of PS should receive a thorough
nonvascular, non-cardiac surgery, it continues neurologic examination immediately post-op as
to carry significant patient morbidity and mor- part of their PACU assessment.
tality [39, 40]. Inherent risks exist both due to
patient population and the performed surgical
7 procedure. The most significant patient risks for 7.6 Cardiac Complications
PS are age >70, history of previous stroke, ESRD
requiring dialysis, and atrial fibrillation. MI is Cardiac events surrounding the perioperative
a significant risk factor within 6 months of the period for non-cardiac procedures have been well
event, and the risk of perioperative cardiovascular studied and are known to be a major cause of mor-
events should be weighed against the necessity bidity and mortality [46]. The revised cardiac risk
and benefit of procedure. Generally nonvascular, index (RCRI) is the most widely used tool to iden-
non-cardiac surgeries carry a risk of PS risk of tify patients at increased risk of a major adverse
0.08–0.9%. Head and neck dissection for tumors cardiac event (MACE) defined as myocardial
are the exception and carry PS risk of about 4.8% infarction, cardiac arrest, ventricular fibrillation
[39]. Preoperative assessment of patients at high (VF), complete heart block (CHB), or cardiogenic
risk for PS should focus on optimizing the medi- pulmonary edema [47]. Omitted from the defi-
cal management of comorbid conditions prior to nition of MACE and not included in the predis-
surgery. The incidence of an intraoperative cere- posed risks to MACE are dysrhythmias. Evidence
brovascular accident is difficult to assess under at the time of the RCRI creation suggested patients
general anesthesia due to the inability to perform with controlled atrial fibrillation or asymptomatic
an interactive neurologic examination with the dysrhythmias, including ventricular ones, did not
patient. The POISE trial demonstrated that initia- confer a larger risk of MACE compared to nor-
tion of metoprolol in beta-blocker naïve patients mal patients [48]. However, newer studies have
with significant cardiovascular risk factors led demonstrated that a patient with atrial fibrillation
to an increased incidence of PS [41]. While the may have an increased risk of MACE, possibly
trial included pre- and daily postoperative doses, greater than those with coronary artery disease
many practitioners avoid the use of metoprolol for (CAD) [49]. There may also be an increased risk
intraoperative heart rate control in naïve patients. of MACE in patients who develop frequent pre-
Intraoperative and postoperative predictors of PS mature ventricular contractions (PVCs) or runs
that were clinically significant are hypotension, of non-sustained ventricular tachycardia.
hemorrhage, and new-onset atrial fibrillation. Both tachycardic and bradycardic dysrhyth-
Intraoperative hypotension may be less important mias are commonly seen in the perioperative
than postoperative as an etiologic factor, although period. Patients with a known history of dys-
30% decreases in MAP from baseline have been rhythmias are more likely to experience them in
demonstrated to be associated with postoperative the perioperative period [50]. PVCs or episodes
PS but not causative. Additionally, very few docu- of non-sustained ventricular tachycardia predis-
mented cases of PS are watershed and primarily pose patients to developing sustained periop-
embolic [42, 43]. There are no proven ventilation erative dysrhythmias but have not been shown to
strategies or specific volatile or intravenous anes- increase MACE. Patients with a history of abnor-
thetic agent regimens proven to reduce the risk mal cardiac conduction, such as prolonged QTc
101 7
or Wolff-Parkinson-White (WPW) syndrome, history of MI, chronic stable angina, CAD, isch-
are predisposed to dysrhythmias in the presence emic EKG changes preoperatively, and severe
of medications or abnormal serum chemistry aortic stenosis are at greater risk of PMI for non-
values. The nature of the surgical procedure also cardiac procedures than other patients [54].
contributes to this risk. Thoracotomies carry risk Management of patients with significant
specifically for atrial fibrillation; ophthalmic sur- risks for PMI or recent PMI can be challenging.
geries can precipitate the oculo-cardiac reflex; and Preoperatively, those with known CAD or valvular
pneumoperitoneum and vagal manipulation can disease and history of cardiac dysfunction should
precipitate a multitude of dysrhythmias. There are have a recent evaluation with echocardiography.
many other risk factors that can contribute to the Those with severe dysfunction may need further
development of perioperative dysrhythmia. stress testing, cardiac surgery, or even revascu-
The identification of specific dysrhythmias larization prior to their elective non-cardiac pro-
and their management are complex subjects that cedures to minimize their risk. These patients
will not be discussed in this chapter but being should also be medically optimized. For nonelec-
able to do so is essential for perioperative man- tive procedures, the risk of MACE in the setting
agement of patients. Preoperatively, the goals of of PMI should be less than the risk of morbidity/
management should be medical optimization of mortality of forgoing the procedure before pro-
any existing conduction abnormalities or electro- ceeding [55]. The intraoperative management of
lyte derangements. Intraoperatively, maintenance PMI is supportive care. Intra- and postoperatively,
of adequate hemodynamics is most important. avoidance of events like prolonged hypotension,
Treatment of dysrhythmias may involve phar- persistent tachycardia, uncontrolled hypertension,
macologic intervention, electrical cardioversion, severe anemia, and hypoxemia are all strategies
transvenous or transcutaneous pacing, or sim- that reduce the risk of PMI in susceptible patients.
ply pausing the current surgical manipulation.
Postoperative management is similar to pre- and
intraoperative management strategies with plans 7.7 Conclusion
for long-term patient follow-up.
Perioperative MI (PMI) can be a devastating Complications of general anesthesia are broad
complication. It can be defined as any periop- and potentially devastating. Description of the
erative ischemic myocardial event causing tissue myriad of potential issues is beyond the scope of
necrosis with or without a reduction in cardiac a single chapter. However, while the risks are real
function and with or without clinical symptoms and patient concerns of these complications are
of ischemia [51]. Of patients at increased risk valid and should be addressed, anesthesia remains
for MACE based on the RCRI, the incidence of one of the safest forms of medical practice. With
PMI is estimated to be between 1.1 and 3.3% [52]. the advancement of technology and practice man-
Without clinical symptoms and obvious changes agement techniques, along with the introduction
to patient hemodynamics, it can be difficult to of safer and broader pharmacological options, the
identify PMI and many will go unnoticed. PMI risk related to anesthesia has decreased dramati-
can be divided into two mechanisms: Type I which cally over the last several decades. Death, stroke,
represents a thrombotic/embolic event causing MI, and other commonly feared complications
myocardial ischemia and necrosis and Type II are rare, and the field continues to work toward
which represents hypoperfusion of coronary cir- further reduction in the morbidity and mortal-
culation causing ischemia and necrosis. Type II is ity associated with general anesthesia. The role
far more common than Type I in the perioperative of anesthesia providers to adequately assess and
setting [53]. The use of troponin testing postop- manage patients is essential throughout the entire
eratively to help identify PMI in patients without perioperative period. Effecting change at a sys-
symptoms or hemodynamic changes is currently tems level, and in conjunction with their surgical
debated. European guidelines suggest their rou- and ancillary counterparts, improving both long-
tine use postoperatively for patients at higher risk and short-term care for surgical patients will con-
of PMI, but the current American guidelines do tinue to be the central tenant of anesthesiologists
not suggest routine utilization. Patients with a and anesthetic providers.
References evidence from published data. Br J Anaesth.

2004;93(2):212–23.
20. Lee LA, et al. Postoperative opioid-induced respiratory
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105 8
Pain Management
Michael Franklin, J. Arthur Saus, Yury Rapoport,
and Nicholas Darensburg
8.2 Preoperative Pain – 106
8.3 Getting Informed Consent – 109
8.4 Intraoperative Pain – 110
8.5 Postoperative Pain – 115
8.6 Opioids – 115
8.7 Non-opioid Analgesia – 116
References – 117

https://doi.org/10.1007/978-3-319-96125-5_8
106 M. Franklin et al.
8.1 Introduction and chronic pain development, as well as other

implications of inadequate perioperative pain
Pain control represents an important and often dif- control.
ficult aspect of the perioperative management of
surgical patients. Postoperative pain is associated
with increased morbidity, longer hospital stays, 8.2 Preoperative Pain
and higher costs, whereas, conversely, better pain
control is associated with earlier mobilization, Many patients presenting for surgery do so because
faster discharge, and faster patient recovery. Opioid of some kind of pain experience and trust that the
analgesic agents are commonly used to treat peri- surgical procedure will provide some degree of
operative pain, and while they are effective, their pain relief and/or functional improvement. Adult
use is associated with many side effects, includ- patients, and even more mature pediatric patients
ing postoperative nausea and vomiting, sedation, usually understand that some pain associated
respiratory depression, decreased gastrointestinal with the surgery itself should be expected but also
motility, and other complications, all of which can expect this to be of a relatively short duration and
ironically lead to longer hospital stays, partially or hopefully rather minor in its intensity. They also
completely offseting the potential benefits of effec- generally expect this surgery-related pain can be
8 tive perioperative pain control [1–4]. managed with medications administered dur-
ing the first few days of their post-op experience,
For the anesthesiologist, pain control is a
significant part of delivering a safe and balanced regardless of whether this is in an inpatient or
anesthetic [5]. Even under general anesthesia, outpatient setting. Surgically induced neuropathic
the pain response can manifest as light anesthe- pain (SNPP) is a significant clinical problem, with
sia, resulting in labile hemodynamics, or patient persistent pain estimated to occur in 10–50% of
movement during surgery, which can create tech- individuals after common operations [9].
nically difficult or even dangerous conditions for Failure to achieve the expected pain relief may
the procedure and can carry over into difficulty be experienced by the patient as a catastrophic
with postoperative pain control [6, 7]. surgical or perioperative event, even though in
In an effort to minimize the use of opi- the traditional sense, this may not be considered
oids for the treatment of perioperative pain, by healthcare personnel as anything that is “cata-
some anesthesiologists are using a multimodal strophic.” Guidelines from the American Society
approach to pain management. This can include of Anesthesiologists state “adverse outcomes
the use of nonsteroidal anti-inflammatory drugs that may result from the undertreatment of peri-
(NSAIDs), acetaminophen, ketamine, and anti- operative pain include (but are not limited to)
convulsants such as gabapentin [8]. The use of thromboembolic and pulmonary complications,
regional and neuraxial blockades has also shown additional time spent in an intensive care unit or
to be useful in some cases, and recently, local hospital, hospital readmission for further pain
infiltration with liposomal bupivacaine in the management, needless suffering, impairment of
surgical field has become popular for some pro- health-related quality of life, and development of
cedures as well [1, 4]. chronic pain. Adverse outcomes associated with
In this chapter, we will discuss the implications the management of perioperative pain include
of perioperative pain, not only in the postopera- (but are not limited to) respiratory depression,
tive period but also preoperatively and intraoper- brain or other neurologic injury, sedation, cir-
atively, as well as the effects of various inhalational culatory depression, nausea, vomiting, pruritus,
and intravenous anesthetics on the pain response. urinary retention, impairment of bowel function,
We will discuss the subjective attempts to evalu- and sleep disruption” [10].
ate pain, both qualitatively and quantitatively, and Pain, first of all, must be recognized as a sub-
some of the difficulties associated with this. We jective experience. Despite attempts to describe
will also discuss how the choice of pain control the experience of pain and to communicate to oth-
modality may have both short- and long-term ers the nature and magnitude of this experience,
implications for the patient in terms of length of there exists no adequate means to communicate
hospital stay, recovery, and central sensitization the entire nature of this experience to others. Also,
Pain Management
107 8
currently there is no objective means of assessing Another system devised to communicate the
an individual patient’s pain experience, so we are magnitude of the pain experience was the Wong-
left with just asking the individual patient to com- Baker Faces Pain Rating Scale [11]. This was ini-
municate his or her subjective experience to us. tially intended for use with children who could
Even then, language often fails us in pain assess- not understand a number system, but who could
ment, as it is difficult to find words to adequately recognize a picture of a face exhibiting pain, and
describe the unpleasant experience. We select match the pictured expression to the sensation of
words like “cutting,” “burning,” “stinging,” “ach- pain experienced by the child. Again though, like
ing,” etc. in an attempt to communicate the nature the limitations of the numeric rating scale, this
of the pain, without being able to truly commu- does not adequately convey the subjective experi-
nicate the entire experience. We also use a scale ence of the pain (. Fig. 8.1).

(typically linear of 1–10) to describe the inten- Yet another system, the McGill Pain
sity of the experience. These limitations interfere Questionnaire (also known as the McGill Pain
with our ability as “healthcare providers” to truly Index) was developed at McGill University by
understand the individual patient’s experience Melzack and Torgerson in 1971. This attempted
and limit our ability to provide the most effective to group words to allow individuals to give their
management of this problem. It is recommended, physicians a good description of the quality and
in part due to these limitations, that anesthesiolo- intensity of their pain experience by picking
gists and other healthcare providers should use words from groups of words to establish seven
standardized, validated instruments to facilitate words that were most descriptive of the patient’s
the regular evaluation and documentation of pain experience.
pain intensity, the effects of pain therapy, and side One of the limitations in all these pain scales
effects caused by the therapy. is that the patient must be able to communicate
There have been various scales devised, such effectively. The Abbey Pain Scale was developed as
as a linear numeric rating scale, usually gradu- an instrument to assist in the assessment of pain
ated in 0–10, with greater magnitude of pain in patients who are unable to clearly articulate
being communicated with higher numbers. their needs [12]. This assesses vocalization sug-
These scales are usually used with adults and gesting pain such as whimpering, groaning, or
children greater than 10 years old. Unfortunately, crying, facial expressions, changes in body lan-
patients with severe pain frequently will select guage, and changes in behavior, physiology, and
numbers that are beyond the magnitude of num- physical changes such as skin tears, contractures,
bers offered on the scale. How often have any of etc. Although more useful for the noncommu-
us working with pain patients heard one of them nicative patient, the problem with this system is
describe their pain as something like 16 when the that it relies totally on an observer’s thoughts and
scale only goes to 10? opinions rather than obtaining direct information
.. Fig. 8.1 Numeric pain

rating scale
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain possible
pain
Wong-Baker faces pain rating scale
0 2 4 6 8 10
No hurt Hurts Hurts Hurts Hurts Hurts
little bit little more even more whole lot worst
from a patient who may or may not be experienc- unconsciousness can be produced by these agents.
ing pain. Additionally, it does not differentiate “Indirect evidence suggests that inhaled anesthet-
between distress and pain, which may be totally ics have limited analgesic properties at anesthe-
separate concerns in these patients. tizing concentrations. At 0.2 MAC, enflurane,
Despite the utility and specific applications of halothane, and sevoflurane do not influence pain
these various systems, we are still left with inad- perception in healthy volunteers.”[13] “Nitrous
equate means of truly communicating the totality Oxide does raise the pain threshold, at least in
of the pain experience to others. experimental animals, and it is assumed to do the
Often, when trying to assess pain, especially same in humans. In rats, an antianalgesic effect is
chronic pain, and its effects on an individual, we are produced by 0.1 MAC isoflurane or nitrous oxide.”
left with trying to determine not only the subjective [14] When considering non-opioid analgesics
nature, quality, and intensity of the pain but also how such as diclofenac, acetyl salicylic acid, dipyrone,
it impacts the person’s life. Does the pain limit activ- acetaminophen, and the COX-2 inhibitors, it has
ities of some kind? We may ask what the individual also been recognized that there is limited evi-
can no longer do because of the pain and seek some dence to suggest the combined use of two non-
desired improvement in this activity as an indica- opioid analgesics provides any additive analgesic
tion of some degree of pain relief. In other words, we effect [15]. If a prolonged sensory loss at a painful
may settle for getting the patient to describe some area is desired following the surgical procedure,
8 activity this individual can now accomplish after use of a regional anesthetic which covers the area
pain therapy, that they were not able to accomplish of the body where the surgical procedure is to
prior to therapy, and use this surrogate as an indi- be performed may provide an additional benefit
cation of success. Pain may be of short duration, as that is beyond the intended primary benefit of the
expected with an injury, that resolves as the injury anesthesia, by at least temporarily relieving the
heals. But pain may also be a chronic, lasting experi- perception of pain originating from that area.
ence of long duration, even many years, that has no Extremes of age may also influence the risks
obvious injury associated with it. and perioperative complications of anesthesia.
So, when a patient presents for a surgical pro- The emotional component of pain is particularly
cedure, or following a surgical procedure, with strong in infants and children. Absence of parents,
complaints of pain, how should we proceed? What security objects, and familiar surroundings may
should we tell the patient about current pain and cause as much suffering as the surgical incision.
future pain? Physical preparation for the patient Children’s fear of injections makes intramuscular
primarily entails getting the patient ready for the or other invasive routes of drug delivery aversive.
administration of anesthesia. If a regional anes- Even the valuable technique of topical analgesia
thetic is appropriate for the surgical procedure, and before injections may not lessen this fear. Likewise,
the patient’s complaint of pain originates from the elderly patients exhibit changes in distribution and
area of the body to be anesthetized via a regional metabolism of analgesic drugs and local anesthet-
block, the administration of the regional block ics. This makes it more likely that they may experi-
may eliminate the pain, at least temporarily, for the ence symptoms consistent with drug “overdose” or
duration of the surgical procedure and for some excessive somnolence when a drug is administered
amount of time afterward. By interfering with in what would otherwise be a “normal” dose [10].
transmission of neural impulses from a painful In patients undergoing total hip arthro-
extremity, we may be able to provide not only anal- plasty or total knee arthroplasty, well-performed
gesia and anesthesia for the surgical procedure, but regional anesthetic blocks, with a long duration
may also reduce or eliminate pain originating from of action, resulted in patients being able to dem-
that area as well. In other words, one significant onstrate greater joint range of motion, and their
advantage of regional anesthesia over general anes- postoperative hospital length of stay was shorter.
thesia is that the analgesia provided by the regional But at the same time, care must be exercised
anesthesia may provide a sensory loss that exceeds when administering these or other “nerve blocks.”
the duration of the surgical procedure itself. Often, the regional anesthetic agent of choice
It has long been recognized that inhala- is bupivacaine, since it provides a more long-
tional anesthesia does not provide analgesia, lasting regional anesthetic effect than most other
even though a state of general anesthesia and regional anesthetic agents. During the injection,
Pain Management
109 8
care must be taken to assure this medication is depression that accompanies opioid administra-
not injected intravascularly, since if injected there, tion is a much greater threat to the life and contin-
it can also provide a long-lasting blockade of the ued well-being of the patient than the pain itself.
heart’s conduction system, frequently leading to Although the opioid drugs help reduce pain and
cardiovascular collapse that is resistant to resus- provide a generally reduced feeling of psychologi-
citation measures. It has been discovered that a cal distress in an injured patient, it is generally felt
bolus of 1.5 mg/kg (lean body mass) of a 20% lipid that the best psychological preparation is the pres-
emulsion (Intralipid), administered over 1 min ence of another caring human, preferably with the
via IV as soon as possible after recognizing that necessary training and skills to manage medical
an intravascular injection of a local anesthetic has problems, that the patient can trust.
occurred, reduces many of the symptoms from the
unintended intravascular injection. This should
be followed by a continuous infusion of 0.25 ml/ 8.3 Getting Informed Consent
kg/min, with an increase to 0.5 ml/kg/min if the
blood pressure remains low. This infusion should For the injured patient, obtaining informed con-
be continued for at least 10 min after obtaining sent may present some challenges. A fundamental
circulatory stability. Additionally, the initial bolus concept of the legal basis of obtaining informed
can be repeated once or twice for persistent car- consent is that the patient has the capacity
diovascular collapse [16]. to grant or withhold consent. A competent
However, even properly administered “nerve patient has virtually an absolute right to consent
blocks” may have side effects that may be consid- to, or to refuse, any proposed procedure or treat-
ered “complications” of the procedure. It is well ment. When treating minor children or adults
recognized that epidural morphine, while improv- who have been legally judged to be incompetent,
ing pain relief, also results in a higher frequency a physician must obtain consent from the par-
of pruritus and urinary retention when compared ent of the minor or the incompetent person’s
with intramuscular or intravenous injection [9]. legal guardian. The injured patient may or may
Additionally, the motor weakness that accom- not remain competent to provide this informed
panies “nerve blocks” often becomes an adverse consent. In an emergency situation, defined
effect. This problem is most notable when motor as any problem posing imminent danger to life or
weakness of the lower extremities interferes with limb in an apparently incompetent person (e.g.,
a patient’s ability to ambulate soon after a surgical an unconscious person, a patient with delirium
procedure, since lack of ambulation is associated tremens, or senile patients with gangrenous limbs
with a greater likelihood of development of deep who do not have a guardian), informed consent is
vein thrombosis, which in turn can lead to pul- assumed to have been granted.
monary embolism. In anesthesia practice, it has been well rec-
In patients with burns or other injuries, there ognized traditionally that administration of
is frequently a strong component of apprehension anesthesia poses some risks. There are particular
in addition to the pain. Drugs such as morphine, areas that present significant risks, such as the
meperidine, fentanyl, and most other opioids use of invasive monitoring, the decision to initi-
are effective drugs to relieve both the pain and ate a transfusion, and risks relating to the use of
the associated fear and anxiety. But the dose of specific anesthetic agents or techniques. Many
morphine, meperidine, fentanyl, or other opioids of these may differ from patient to patient, from
should be carefully titrated, and the patient should operation to operation, and surgeon to surgeon.
be continually monitored since some extent of Although many would assume that a surgeon’s
respiratory and cardiovascular depression accom- consent for surgery would imply a consent for
panies the administration of this class of medica- administration of anesthesia to accomplish the
tions. The careful administration of small repeated surgical procedure, current legal thought demon-
amounts via intravenous injection, along with con- strates that a separate consent for administration
tinuing monitoring of the patient, accomplishes of anesthesia should be obtained. While attempt-
the desired pain relief while reducing the poten- ing to disclose all possible complications related
tially catastrophic risks of respiratory and cardio- to anesthesia administration is probably not pos-
vascular depression. The unrecognized respiratory sible, in purely elective cases, a very complete
disclosure of risks related to administration of 8.4 Intraoperative Pain

anesthesia should be made.
One set of risks that should be disclosed in Adequate pain control in an anesthetized patient
each case of general anesthesia relates to potential undergoing surgical procedures is an essen-
complications due to the necessary instrumenta- tial aspect of anesthetic care as it helps to avoid
tion around the mouth. As an example, patients intraoperative stress, hemodynamic disturbances,
who have one or more porcelain crowns on inci- perturbations with tissue oxygenation, and to
sor teeth should be cautioned about the potential decrease the risk of intraoperative awareness.
for damage to these crowns or to the underly- It allows for comfortable environment for the
ing tooth from instrumentation required for the patient and surgeon, faster return of function,
intubation process. The planned use of invasive and prevention and early resolution of ileus, helps
monitoring also presents special problems with to reduce significant discomfort, and decreases
obtaining informed consent. Significant risks exist opioid requirements postoperatively. Poor pain
with placement of arterial lines, central venous control during surgery may lead to lingering
catheters, and pulmonary artery (Swan- Ganz) and difficult to control pain in the postoperative
catheters. Multiple reports of complications with period. Awareness under general anesthesia which
each of these devices can be found in a literature results from inadequate depth of anesthesia is a
search, even though most of the time, when used
8 skillfully by well-trained professionals, there are
rare but frightful intraoperative complication that
is frequently accompanied by moderate to severe
no complications. Discussion of risks with place- pain sensation that patients describe afterward.
ment of any of these devices should be considered Altogether these factors may precipitate physio-
very important, especially in the elective case, but logic and emotional distress and result in develop-
a truly emergent case may not provide the oppor- ment of post-traumatic stress disorder [18]. Tissue
tunity for this preoperative discussion. injury causes acute inflammation and release of
However, the recommendation to discuss risks pro-inflammatory mediators and neurotrans-
related to anesthesia, and the recommendation mitters that activate nociceptive signaling. If left
to obtain an informed consent, does not include untreated, additional input from dorsal horns
a discussion of risks that would be expected to ensues, leading to amplified nociceptive response,
occur in only due to negligence. There is no need central sensitization, and development of hyperal-
to discuss risks that would occur only if the anes- gesia or chronic pain in the long-term perspective.
thesiologist or nurse anesthetist was negligent, Unfortunately, there is no direct way to rec-
since courts have long held that a healthcare pro- ognize pain evoked reactions in anesthetized
vider cannot employ a consent form to insulate patient, which poses unique challenges to the
oneself from liability due to negligence. clinicians and makes them rely solely on indirect
As suggested already, elderly patients may signs. Hemodynamic changes have been tradi-
present special problems in trying to properly tionally thought to be associated with intraopera-
assess and treat pain. While some elderly patients tive stress; however this may not be a consistent
remain totally lucid, others may have compro- trend in certain groups of patients. Hypovolemia,
mised mental capabilities which interfere with preoperative beta-blocker therapy, and heart dys-
their ability to communicate pain issues effec- rhythmias may all distort hemodynamics, making
tively. Disease processes that cause hearing dif- these variations inaccurate predictors of insuffi-
ficulties or mental decline in the elderly may cient pain control. Along similar lines, anesthetic
further exacerbate this problem. Also, due to a drugs themselves, especially in high doses, alter
decline in mental processing capabilities in some vascular and cardiac responses. Several studies
elderly patients, unique difficulties in trying to evaluated various subjective indicators of poor
obtain a proper informed consent for any medi- pain control. Skin- and eye-associated manifes-
cal therapy may be present. In this situation, it tations of pain including moisture, stickiness,
is important to have a properly designated sur- changes in skin temperature, pupil reaction, and
rogate, preferably a close family member or legal lacrimation are all considered proper but inex-
guardian, who can understand the discussion of act indicators of stress [19]. Several standard-
risks and can make informed consent decisions ized scales were created to help with provision of
for the elderly patient [17]. effective pain control in the anesthetized patients.
Pain Management
111 8
A specifically designed Anesthetized Patient Pain device. The Surgical Pleth Index is calculated
Scale (APPS) was validated by multiple authors based on waveform finger plethysmography data
and was demonstrated to correlate well with which is then processed by proprietary algorithm.
decreased postoperative pain levels [20, 21]. This Results were compared to routine physiologic
scale determines hemodynamic, physiologic, and changes (pupillary dilation, hemodynamic altera-
behavioral responses (blood pressure, heart rate, tions) and also information obtained from bispec-
respiratory rate, facial expression, muscle tension, tral index analysis [22]. Both indices and pupillary
body movement) then after the appropriate num- dilation monitoring appeared to accurately predict
ber of points (1–3) is assigned for each parameter, changes in pain levels after tetanic stimulation in a
the resultant score is then calculated. Score of >15 well-correlated manner, and demonstrated supe-
correlates with poor pain control. rior results to hemodynamic changes alone. The
Use of muscle relaxants and high doses of vol- study also postulated that bispectral index did not
atile anesthetics limit monitoring options as mus- show it was either sensitive to nociceptive stimuli,
cle contractions and movement are abolished and nor to analgesic administration, and thus should
autonomic responses are inhibited making the not be considered as a reliable indicator of intra-
visual assessment impractical. Several attempts operative pain control. These techniques are less
have been made to create an automated apparatus accurate in the setting of complex combination of
that could predict pain level in a more objective baseline analgesic use and preexisting comorbidi-
fashion. The latest study compared the validity of ties, altering pain perception.
several newly developed devices which generate The concept of preemptive analgesia was
scales identified as “Analgesia Nociception Index” introduced in attempt to avoid formation of
and “Surgical Pleth Index”. The Analgesia Noci- central sensitization and pain amplification [23]
ception Index issues a numerical index from 0 to (. Fig. 8.2). It warrants administration of anti-

100 resulting from the patient’s heart-rate variabil- nociceptive medications prior to surgical stimu-
ity which is captured and processed by a special lation. While there is a body of basic science
Increased awareness of noxious events
Increased spinal cord

activity
Altered central processing
at brain and spinal level
Increased peripheral
input
Secondary hyperalgesia
Allodynia
.. Fig. 8.2 Central sensitization pathway. (Adapted from 7 wiley-vch.e -bookshelf.de)

research supporting this phenomenon, there is no opioids are notorious for causing a range of adverse
direct clinical evidence that pre-incisional analge- effects including respiratory depression, delayed
sia adds significant benefit in terms of less chronic emergence, prolonged sedation and recovery
pain development. Thus, a broader and more from anesthesia, and an increased risk of post-
appropriate concept for avoiding pain centraliza- operative nausea and vomiting. Immediate nega-
tion known as preventive anesthesia has emerged. tive postoperative effects include development
It is not time constrained and encompasses a mul- of opioid-induced hyperalgesia (OIH) and acute
titude of efforts to reduce postoperative pain and tolerance which contributes to morbidity, patient
opioid consumption by administering treatment dissatisfaction, and increased hospital costs. There
throughout the perioperative period. is empirical evidence that even transitory expo-
Intraoperatively, administration of opioid sure to opioids may increase the risk of opioid-
medications remains the cornerstone of pain induced hypotension (OIH) [25]. Furthermore,
control in the anesthesiologist’s armamentarium. potent- and short-acting opioids (remifentanil)
They are known to be exceedingly effective in were demonstrated to have a propensity to cause
attenuating hemodynamic marks of stress while rapid OIH even after brief infusion [26]. One of
remaining virtually devoid of cardiac depres- the suggested mechanisms for this phenomenon
sion properties. Short-acting synthetic opioids is activation of NMDA receptors, as a result of
including fentanyl, sufentanil, and fentanyl are alternative nociceptive signal propagation [27].
8 given in bolus doses or infused for immediate Chronic pain patients receiving preoperative
analgesia in the operating room. When general opioids usually present additional challenges
anesthesia is employed and transient hemody- to the anesthesiologist, as opioid requirements
namic instability is not acceptable, the typical intraoperatively are a lot higher and unpredict-
regimen involves a large opioid induction dose to able. In a recent retrospective study, it was shown
facilitate endotracheal intubation; often, further that patients on chronic methadone therapy
boluses throughout the case are administered as who underwent liver transplantation required
needed. Continuous IV infusions may be utilized significantly higher doses of fentanyl compared
for procedures associated with high level of surgi- to opioid naïve group (3175 μg vs 1324 μg). In
cal stress and severe pain (spine fusion). Fentanyl a nutshell, a patient’s baseline opioid regimen
or sufentanil provides excellent level of analgesia. should be maintained perioperatively including
Remifentanil is an ultrashort-acting agent that is any transdermal patches. While one may antici-
known for its fixed, brief, context-sensitive half- pate increased opioid requirements (50–300%),
life regardless of the duration of the infusion, and patients should be judiciously monitored for signs
is an excellent choice for surgical opioid infu- of overmedications, and spontaneous ventilation
sions. Long-acting opioids such as morphine, should be achieved early (as allowed by the nature
hydromorphone, or meperidine can also be used of the procedure). Adjunctive medications includ-
intraoperatively. However, these commonly used ing NMDA inhibitors may be extremely beneficial
compounds are less popular in the intraoperative under these circumstances.
setting due to slow onset, increased postoperative There are several analgesic adjuncts that can
nausea and vomiting, and concern for prolonged be administered in addition to opioids and help
emergence, especially when given during rela- achieve stable surgical course, smooth emergence,
tively short procedures. Nonetheless, postopera- and decreased postoperative pain and opioid
tive pain scores were reported higher in patients requirements. Multimodal anesthesia involves
who received only fentanyl in the study that use of two or more medications with distinctive
compared intraoperative pain control with mor- mechanisms of action and designed to maximize
phine to fentanyl. Also the fentanyl group showed efficacy of multiple drugs while abolishing poten-
longer opioid requirement period in the post tial opioid-associated side effects.
discharge stage [24]. Agonist-antagonist opioid Ketamine is an N-methyl-D-aspartate
compounds may be advantageous due to limited (NMDA) receptor antagonist, potent analgesic
effect on respiratory depression, which is particu- known to be particularly effective in treatment of
larly valued when spontaneous ventilation must neuropathic pain. Low-dose ketamine infusion
be preserved, though a ceiling effect limits their has been successfully employed by clinicians for
analgesic potential. Despite apparent advantages the long period to enhance opioid-based analgesia
Pain Management
113 8
and helps to decrease the frequency of OIH and incidence of postoperative delirium, likely sec-
reduce postoperative opioid requirement. It is ondary to decreased pain and reduction of potent
hypothesized to counteract central sensitiza- parenteral anesthetic use [31]. This fact is espe-
tion effect and so-called windup phenomena, cially advantageous in elderly patients, even when
which is experienced after repetitive nociceptive general anesthesia is employed as primary mode.
stimuli. Effectiveness of this combination was Local anesthetic may be injected directly near the
revealed by multiple studies. For instance, it was surgical site. It may help to reduce the somatic
reported that addition of subanesthetic doses of component of the pain; however the visceral ele-
ketamine infusion to sevoflurane-remifentanil ment is left unaffected; thus it only should serve as
maintenance anesthesia resulted in decreased an adjunct to multimodal analgesia regimen.
postoperative pain levels and opioid requirements Intravenous (IV) acetaminophen is a unique
after laparoscopic gynecologic procedures [28]. part of multimodal anesthesia, as it is the only
Nefopam is a relatively novel centrally acting, available non-opioid IV analgesic that has no
non-opioid analgesic with potential for opioid boxed warning on the label and can be safely
reduction effect. The mechanism of action is not indicated for pediatric patients. There is ample
yet well understood; however, it was suggested evidence suggesting that direct antinociceptive
that inhibition of serotonin, dopamine, and nor- effect of the IV formulation is not superior to
epinephrine reuptake may play a role along with oral form; however there are few differences in
NMDA antagonism. The drug acts at spinal and the overall clinical effect [32]. While there is an
supraspinal sites. A placebo-controlled prospec- ongoing debate if IV acetaminophen has a role
tive study that compared effectiveness of low-dose treating postoperative pain in patients who can
intraoperative ketamine infusion to nefopam co- tolerate oral intake, it was postulated that when
administration to standard remifentanil-based administered parenterally, it may reach higher
anesthetic regimen revealed a more profound concentration in the cerebrospinal fluid [33]. IV
morphine-sparing effect of the latter in the imme- route of administration offers possible benefit in
diate postoperative period [29]. Both drugs dem- terms of preventive effect as while given intraop-
onstrated significantly reduced pain scores and erative prior or immediately after incision. One
opioid requirements compared to placebo. The study demonstrated decrease in “rescue” opioid
drug is not currently approved for use in the USA. requirements, increased time to first requested
Local and regional anesthesia are known to analgesic, and lower incidence of postoperative
dramatically improve intraoperative and postop- nausea and vomiting (PONV) following chole-
erative pain control. Central neuraxial approaches cystectomy after preemptive administration of
are excellent techniques administered as primary 1 g of IV acetaminophen [34]. More research is
anesthetic mode or as adjuncts to general anes- needed to provide further recommendation.
thesia. A review of epidural anesthesia in surgical Ketorolac is one of the few available IV non-
practice concluded that this modality is associ- steroidal anti-inflammatory drugs (NSAIDs) that
ated with a significant decrease in incidence and has a role in the intraoperative pain management.
degree of intraoperative physiologic perturba- Administration of the drug prior to emergence
tions, and facilitating hemodynamic stability [30]. from general anesthesia results in synergistic
Single-shot spinal, continuous epidural/spinal, or antinociceptive effects in conjunction with opioid
a combination of these techniques are all possible and other non-opioid medications. One study
treatments, and preference should be made based which looked at patients undergoing gynecologic
on the specific patient’s procedural characteristics. laparoscopic procedures concluded that ketorolac
Contraindications and potential side effects should given at the end of the surgery lead to reduced
also be weighed against the benefits and deci- incidence of pain on awaking and need for rescue
sion made on an individual basis. Utilizations of opioid use. Furthermore, it was associated with
a variety of peripheral nerve blocks for upper and less severe pain and vomiting and faster discharge
lower limb surgery provide a handful of positive from PACU. Historically, there has been concern
intraoperative and postoperative effects includ- for the drug to increase hemorrhage risk, impede
ing less opioid consumption and better hemody- bone healing, and increase incidence in acute kid-
namic profile. Moreover, a recent study that use ney injury especially in patients with decreased
of peripheral nerve block results in reduction of kidney function or dehydration. While there is a
clear theoretical risk of the abovementioned com- intraoperatively exerts opioid sparing [39, 40]. No
plications, several studies failed to confirm these major side effects were reported including wound
statements [35–37]. It is prudent though to dis- infection or healing impairment. However, this
cuss the possible use of the drug with the surgical fact needs further evaluation as not enough data
team and ensure patient is well hydrated prior to was generated during open surgical procedures
administration. to make that statement universal. While preop-
Anticonvulsants, including gabapentin and erative administration of the drug provides even
pregabalin, are often added to the multimodal more marked pain relief, it is somewhat limited
analgesia. Gabapentin is known to be effective due to the well-known side effect of extreme
in treating neuropathic pain. Although it is an perineal pain (50–70%), when drug is given fast
analog of gamma-aminobutyric acid (GABA), in low volumes. While the precise pain-relieving
it is not active at GABAA or GABAB receptors, mechanism of dexamethasone is yet unclear,
so the precise mechanism of action remains it appears that it has to do with inhibition of
unknown. There is a theory that gabapentin acts peripheral phospholipase pathway which results
on voltage-gated calcium channels in the spinal in reduction of cyclooxygenase and lipoxygenase
cord inhibiting release of neuromediators. These production [41].
drugs are thought to interfere with the hyper- The addition of Beta-blockers to opioids, has
excitability of spinal cord dorsal horns, thus recently been investigated in the light of synergis-
8 preventing central sensitization. Gabapentin is tic analgesic effect. Multiple studies showed that
typically administered preemptively and prior to an intraoperative esmolol infusion provides bet-
induction of anesthesia. Pregabalin has a more ter hemodynamic stability, lowers stress, reduces
favorable pharmacokinetics and improved bio- the risk of adverse cardiac events, and also sig-
availability compared to gabapentin. A study nificantly reduces postoperative pain and narcotic
evaluating effectiveness of gabapentin for lumbar intake [42]. There are multiple theories as to how
laminectomy given pre- or postoperatively dem- esmolol exerts its analgesic effect. Peripheral anti-
onstrated decrease in morphine requirements, inflammatory action along with intrinsic potential
vasodilator-stimulated phosphoprotein scores, to abide noxious stimuli and decrease in catechol-
and opioid-associated side effects [38]. Of note, amine surge are to name a few. It has also been
authors stated that patients who received prega- proposed that it is β-blockade-associated reduc-
balin reached discharge criteria 14 h earlier than tion in cardiac output and hepatic blood flow that
their counterparts. Moreover, as single dose was slows metabolism of opioids [43]. Furthermore, it
compared to multiple dosing regimen throughout was proposed that intraoperative administration
the perioperative period, there was no clinically of esmolol may alter the permeability of fentanyl
significant benefit with repeated dosing. Among to blood-brain barrier and thus decreases fentanyl
possible side effects, sedation, dizziness, and requirement [44].
visual disturbances were the most common and A recent meta-analysis suggested that there is
occurred within the first 24 h. Further studies are positive effect in reduction of postoperative pain
needed to verify the target patient population and with intraoperative systemic magnesium adminis-
surgical procedures that would benefit the most tration [45]. Opioid consumption was shown to be
from addition of pregabalin to multimodal anes- markedly decreased as well, and no complications
thesia regimen. associated with magnesium infusion were reported.
Steroids are known for their multitude of Proposed mechanism derived from animal studies
effects with anti-inflammatory action being most includes antagonism of NMDA receptors which
clinically valued. In the scope of anesthesiologist alters duration and perception of pain [46].
practice, dexamethasone has been routinely used Intraoperative pain management is a part of
for postoperative nausea and vomiting preven- continuous process, and thus all phases of peri-
tion. Its potential antinociceptive effects were operative pain management should be consecu-
less researched until lately. Recent meta-analysis tive and coordinated. Preventive and multimodal
presented substantial data on the effect of intra- concepts are effective tools to provide comfort-
operative dexamethasone administration in the able intraoperative care and smooth transition to
context of its possible antinociceptive properties. postoperative stage. Multiple protocols have been
It was revealed that dexamethasone administered suggested for use by many high-tier academic
Pain Management
115 8
institutions tailored to specific surgical proce- medications postoperatively, even though pain
dures. However, there is no one-fits-all model, scores were not decreased. Preoperative epidurals
and intraoperative pain management should showed a decrease in both the use of analgesics
be based on individual patient’s characteristics. and pain scores postoperatively [48].
Central sensitization is the principal cause of
uncontrolled postoperative pain and can result in
significant distress and morbidity; hence efforts 8.6 Opioids
should be made to reduce its occurrence.
Although many methods of pain management
exist, opioids remain the most used analgesics in
8.5 Postoperative Pain the postoperative period. Opioids bind to recep-
tors in the central nervous system and peripheral
Care of patients during the immediate postop- tissues to block the transmission of pain signals.
erative period is one of the many responsibilities They produce analgesia via mu (μ) opioid recep-
of the anesthesia provider. During this period, tor agonist activity in the brain.
patients may present with a variety of complaints. Opioids can be administered in a variety of
One of the most common complaints is acute, ways including orally, transdermally, parenter-
postoperative pain. Over 80% of individuals that ally, neuraxially, and rectally. The most com-
undergo a surgical procedure experience postop- monly used intravenous opioids are morphine,
erative pain [47]. Inadequately controlled pain hydromorphone, and fentanyl (. Table 8.1).

may lead to decreased quality of life, prolonged Although opioids are the most commonly used
recovery times, and increased incidence of post- analgesics postoperatively, they are not with-
surgical complications [9]. out side effects, the most significant of which
Postoperative pain management begins is respiratory depression. Other common side
before the operation. During the preoperative effects include nausea, vomiting, and reduced
period, a thorough history and physical should bowel motility. Patients receiving chronic opi-
be performed to properly assess the patient and oid therapy tend to become tolerant to many of
plan for the management of postsurgical pain. It the side effects over time. However, constipation
is important to address medical or drug history and postoperative ileus caused by the decrease
that may cause a deviation from a standard plan in bowel motility are complications that are still
of care. Extensive recreational or analgesic drug consistently seen in patients with a predomi-
usage can have a significant impact on the plan for nately opioid pain control regimen following
pain management after surgery. For example, in a surgery [49]. This has resulted in the develop-
patient with history of opioid addiction currently ment of peripheral opioid antagonists such as
in remission, the use of opioids in the treatment methylnaltrexone and alvimopan. These drugs
of postsurgical pain may trigger a relapse. If pos- selectively antagonize the peripheral opioid
sible, the anesthesia provider should try to avoid receptors, promoting a return of bowel function,
opioids in this patient population. while ignoring the central opioid receptors that
The management of a patient’s postoperative are being acted upon for pain relief.
pain does not have to begin after the procedure. Opioids may be administered using a stan-
In reality, it is becoming increasingly common dard dosage every set number of hours or using
for pain management to begin even before the a PCA (patient-controlled analgesic) pump.
surgery is started. Management can be started PCA pumps work by allowing the patient to self-
utilizing a variety of medications and methods administer a set dose of analgesic. The provider
such as NSAIDs, peripheral nerve blocks, and sets a maximum amount of analgesic that can be
epidurals. When analgesics are used prior to administered over a period of time. The pump
surgery, the goal is to block pain receptor activa- can then be monitored and modified based
tion or hinder the production and/or activation upon how often the patient is self-administering
of pain neurotransmitters. In a meta-analysis medication. Studies show that PCA (patient-
of acute postoperative pain management, it was controlled analgesia) is valid as an alternative to
shown that people receiving local anesthetics and conventional opioid administration in the post-
NSAIDs prior to surgery had less usage of pain operative period. Certain patient populations
.. Table 8.1 Graph showing common opioids used postsurgically, dosages, and facts
Opioid Route Dose Miscellaneous
Morphine IM 0.05–0.2 mg/kg Excreted through the kidneys. May cause

histamine release
IV 0.03–0.15 mg/kg
Hydromorphone IM 0.02/0.04 mg/kg No active metabolites. No histamine

(Dilaudid) release
IV 0.01–0.02 mg/kg
Fentanyl IV (Intraoperatively) 2–50 mcg/kg 100 times more potent than morphine
IV (Postoperatively) 0.5–1.5 mcg/kg
Sufentanil IV (Intraoperatively) 0.25–20 mcg/kg 10 times more potent than fentanyl
Alfentanil Intraoperatively: Fastest onset of all opioids
Loading 8–100 mcg/kg
Maintenance 0.5–3 mcg/kg/min

8 Remifentanil Intraoperatively: Unique among the opioids in that it is
metabolized by plasma esterases.
Loading 1.0 mcg/kg Commonly used in patients with hepatic
Maintenance 0.5–20 mcg/kg/min or kidney failure
Postoperatively 0.05–0.3 mcg/kg/min
need to be treated carefully when administer- and ultimately provide the patient with satisfac-
ing opioids, particularly obese and chronic tory pain control. Studies show that these drugs
pain patients. Because of their susceptibility to used with PCA morphine lead to a decrease in
obstructive sleep apnea and possibility for an morphine usage and less chance of the deleterious
exacerbation of respiratory depression, providers effects of morphine usage in colorectal and obstet-
are encouraged to limit the usage of opioids in ric operations [50, 51]. Ketorolac, an NSAID, has
obese patients. For these patients, a multimodal been shown by meta-analysis to decrease early
approach to analgesia starting before the surgical pain at rest and overall opioid consumption when
procedure is optimal. Placing an epidural prior used as a single, 60 mg intramuscular dose dur-
to or soon after the surgery leads to a decrease ing the perioperative period. Also, in a double-
in the need for opioids and thus gives the patient blinded, randomized trial of ketorolac vs placebo,
less of a chance of having complication that may it was shown that ketorolac is beneficial in reduc-
be caused by some of the negative side effects of ing postoperative pain and narcotic usage after
opioids, such as postoperative ileus [49]. cesarean section.
Many nonsteroidal anti-inflammatory medi-
cations are cyclooxygenase (COX) inhibitors.
8.7 Non-opioid Analgesia Inhibition of COX hinders the key step in prosta-
glandin synthesis. Prostaglandins play a key role
Although opioids are the most commonly used in the inflammatory process of the body. COX-1
drugs postoperatively, a variety of other drugs receptors are widely distributed throughout the
exist to treat postoperative pain. Drugs such as body (most importantly in the stomach and on
paracetamol, nonsteroidal anti-inflammatory platelets). COX-2 receptors are primarily pro-
drugs (NSAIDs), and local anesthetics work duced in response to inflammation. Aspirin is an
through different mechanisms and have different NSAID that irreversibly inhibits COX-1 through
side effect profiles from opioids. This gives the acetylation. Acetaminophen is an NSAID that
provider the ability to adapt to specific situations is relatively selective for COX-2. There is a
Pain Management
117 8
significant risk of bleeding when giving patients 8.8 Conclusion
increased doses of nonselective COX inhibitors
due to inhibitory effects on prostaglandins that Delivery of a surgical anesthetic can be performed
protect the stomach and promote blood clotting. in a variety of ways, including general anesthesia,
These drugs should be avoided in patients with a regional anesthesia, neuraxial anesthesia, local
history of stomach ulcers. Highly selective COX-2 anesthesia, or a combination of these techniques,
inhibitors such as celecoxib have been developed depending on the suitability of the patient and
to curtail these side effects. However, the gen- the nature of the procedure [8]. As no single drug
eral consensus is that COX-1 inhibitors are still can be used as a “complete anesthetic,” a balanced
preferred given the cardiovascular toxicity of the anesthetic technique, involving a variety of dif-
selective COX-2 inhibitors [52]. ferent techniques, is favored for these procedures
Other modalities exist as well for the treat- [53]. As part of these balanced anesthetic tech-
ment of postoperative pain such as epidural anes- niques, one or more agents with analgesic proper-
thesia, spinal anesthesia, peripheral nerve blocks, ties will typically be utilized.
and local infiltration. Epidural and spinal anes- In this chapter, we have discussed the evalu-
thesia are frequently used in thoracic, abdominal, ation and treatment of pain in the preoperative,
and pelvic surgery. During an epidural, a catheter intraoperative, and postoperative period. We
is inserted into the epidural space, through which discussed the use of a variety of different agents
local anesthetics and/or opioids are administered. that have been used for pain control, or as part
Epidural anesthesia may be performed in the cer- of a multimodal pain control regimen. Regional
vical, lumbar, or sacral region and can range from and neuraxial techniques, local infiltration,
a single-shot technique to the insertion of a cath- opioids, acetaminophen, NSAIDs, ketamine,
eter in which intermittent boluses or continuous gabapentin, and other common anesthetic medi-
infusions are administered. Spinal (intrathecal) cations are often used effectively for pain control,
administration of local anesthetic results in good either by themselves for pain control or as part
postoperative analgesia for up to 24 h. Epidural of a balanced anesthetic. We also discussed the
and spinal anesthesia involve the same time com- effect that adequate pain control can result in
mitment, but with spinal anesthesia skilled post- decreased use of hospital resources, faster recov-
operative care is not required for maintenance of ery, and in some cases, decreased development
the catheter. of chronic pain.
A transversus abdominis plane (TAP) block Overall, analgesia is a cornerstone of an effec-
is a peripheral nerve block that can be used as tive anesthetic, and the choice of analgesic agents
an alternative to an epidural in patients that are can have both short- and long-term implications
having operation on the abdominal wall. A single for the patient [1, 2, 6, 53].
shot of local anesthetic is administered into the
plane between the internal oblique and transab-
dominal muscles. This plane encompasses an ana-
tomical space that includes nerves that innervate References
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121 9
Regional Anesthesia/MAC
Treniece Eubanks, Yury Rapoport, Leslie Robichaux,
Farees S. Hyatali, and Tomasina Parker-Actlis
9.2 Monitored Anesthesia Care – 122
9.3 Patient Selection and Monitoring – 123
9.4 Systemic Sedatives and Analgesics – 125

9.4.1 Propofol – 125
9.4.2 Midazolam – 125
9.4.3 Ketamine – 126
9.4.4 Dexmedetomidine – 126
9.4.5 Opioids – 126
9.4.6 The Adjuncts – 126
9.5 MAC Procedures – 127

9.5.1 Ophthalmologic Procedures – 127
9.5.2 Otolaryngologic Procedures – 127
9.5.3 Inguinal Herniorrhaphy – 127
9.5.4 Cardiovascular Procedures – 128
9.5.5 Interventional Pain – 128
9.5.6 Ambulatory Procedures – 128
9.5.7 Neurosurgical Procedures – 129
9.5.8 Pediatric Procedures – 129
9.6 Summary – 130
9.8 Answers – 131
References – 131

https://doi.org/10.1007/978-3-319-96125-5_9
122 T. Eubanks et al.
9.1 Introduction oversedated from standard doses of medications.

Patients with certain comorbidities such as pul-
As regional anesthesia, noninvasive surgeries, and monary disease or obstructive sleep apnea also
short procedures with quick turnovers and faster require special consideration as development
recoveries become more popular, the use of moni- of respiratory depression in this patient popula-
tored anesthesia care (MAC) increases. MAC tion can be detrimental. The airway exam is also
generally provides increased patient satisfaction very important as gauging the ease at which the
due to fewer adverse side effects than general airway can be obtained may help to determine
anesthesia, and a pain-free, rapid surgical recov- whether a provider will choose to perform a case
ery when regional anesthesia is utilized along under MAC. Once a MAC technique is chosen,
with it. These attributes make it perfect for ambu- all standard ASA monitoring must be used, and
latory surgery centers, as patients are discharged the provider must be able to convert to general
home the same day. Ideally, MAC safely provides anesthesia immediately and secure the patient’s
amnesia and analgesia while allowing the patient airway. The provider also needs to be aware of
to spontaneously breathe and protect his airway the type of procedure being performed and what
during short simple procedures or longer cases complications can arise when doing that proce-
done under regional anesthesia. Although amne- dure in conjunction with a MAC technique. This
sia and analgesia are achieved in most instances, chapter will serve as a guide to anesthesia provid-
there are instances where it is not due to compli- ers by defining MAC more broadly, discussing the
cations associated with MAC anesthesia. Because agents most commonly used and their side effects,
9 the technique does not provide a specific level of and discussing the most common procedures and
sedation and can range from minimal sedation complications to be aware of when using MAC.
to deep sedation depending on what agents are
used, oversedation can happen, which can lead to
many adverse complications. These complications 9.2 Monitored Anesthesia Care
include but are not limited to hypotension, tachy-
cardia, airway obstruction, and cardiorespiratory MAC is a type of anesthesia that consists of many
depression and/or failure. There are also second- of the same components as general anesthesia
ary complications that are not necessarily due to including amnesia, analgesia, sedation, and anx-
the MAC anesthetic but are from the type and iolysis. MAC is administered by a qualified anes-
length of the procedure being done. Examples of thesia provider and consists of pre- procedure,
these include local anesthetic systemic toxicity intraprocedure, and post-procedure anesthesia
(LAST) due to a large amount of local anesthetic care. MAC is not a specific level of sedation but
absorbed or injected into a blood vessel while it allows the anesthesiologist to change the level
is being used to obtain regional anesthesia and of sedation based on the patient’s clinical and
an airway fire that may happen when electrocau- physiologic changes that occur during surgery.
tery is used in the face while a patient is receiving Sedation levels can vary from minimal, moderate,
supplemental oxygen. and deep sedation with deep sedation being the
Due to the delicate nature of MAC, it should most common level during MAC. The provider
only be utilized by experienced anesthesia pro- must be able to convert to general anesthesia at
viders who are trained in airway management. any point during the surgical procedure if medi-
The provider needs to be aware of what types of cally indicated. Analgesia is usually provided with
patients will do well with MAC and what types local anesthetic. According to the ASA during
will be more likely to have adverse complica- monitored anesthesia care, the anesthesiologist
tions. Choosing the correct patients for the tech- provides:
nique is critical; therefore, a detailed history and
physical exam for every patient is necessary. In »» 1. Diagnosis and treatment of clinical prob-
general, ASA I and II patients with good airways lems that occur during the procedure
are ideal candidates for MAC anesthesia. Extra 2. Support of vital functions
consideration should be given to patients in the 3. Administration of sedatives, analgesics,
pediatric, geriatric, and morbidly obese popula- hypnotics, anesthetic agents or other
tions as these patients are more likely to become medications necessary for patient safety
123 9
4. Psychological support and physical anesthesia care, these respiratory events were
comfort and provision of other medical most likely due to inadequate oxygenation or
services as needed to complete the pro- ventilation. Cardiovascular events were also a
cedure safely [1] significant portion of complications under MAC
accounting for 14% of the injuries. These closed
MAC is often used interchangeably with con- claims analysis concluded that “oversedation
scious sedation, but the two are distinct. Accord- leading to respiratory depression” caused the
ing to the American Society of Anesthesiologists highest incidence of injury in patients undergo-
(ASA), conscious sedation involves a physician ing monitored anesthesia care. The anesthesia
supervising a medical provider or personally provider should use appropriate interoperative
administering sedatives and analgesics to induce monitoring of patient’s vitals and level of con-
moderate sedation. The physician in this case sciousness to prevent oversedation leading to
must only possess the skills necessary to detect respiratory depression. The closed claims analy-
when moderate sedation converts to deep seda- sis also concluded that “on-the-patient fires”
tion and be able to reverse the deep sedation. The was another leading complication in patient’s
provider does not need to be trained in airway undergoing MAC. Seventeen percent of injuries
management. MAC on the other hand requires were due to cautery fires. The anesthesia pro-
the provider to not only be trained in airway vider should also be aware and avoid “the fire
management but to also be able to utilize general triad (oxidizer, fuel, and ignition source)” while
anesthesia if need be. As a result, the anesthesia administering MAC [3].
provider may use deeper sedation when required.
Monitored anesthesia care is becoming
increasingly popular as it allows a quicker recov- 9.3 Patient Selection
ery from anesthesia compared with general anes- and Monitoring
thesia and is associated with decreased incidence
of postoperative nausea and vomiting. MAC also Because converting to general anesthesia from
causes less physiologic disturbances compared deep sedation may occur due to the patient’s
with general anesthesia and recent studies have inability to protect his airway or to adequately
shown increased patient satisfaction with MAC ventilate spontaneously, it is imperative that due
versus general anesthesia. With increasing con- diligence is done when choosing a patient as
cerns for OR efficiency and decreased hospitaliza- a candidate for MAC. One must make sure to
tion stays the quick recovery from anesthesia that communicate with surgical colleagues about the
is associated with MAC provides a safe and effi- type of procedure and what is expected from the
cient alternative to general anesthesia. According patient. One must also take into the account the
to recent data MAC is the first choice in “10–30% projected level of sedation based on the procedure
of all surgical procedures” [2]. type and ensure that easy airway access would
While monitored anesthesia care provides a be always feasible. It cannot be stressed enough
quicker recovery from anesthesia, decreased post- how important a thorough preoperative assess-
operative nausea and vomiting, and less physi- ment including an anesthesia-directed history
ologic changes than seen with general anesthesia, and physical exam is for the safety of the patient.
MAC still has serious complications. A closed As a matter of fact, it should be the same as it is
claims analysis was performed in 2006 and exam- in preparation for general anesthesia. There are
ined the ASA closed claims database to compare several other unique features of MAC that should
closed malpractice claims associated with general be addressed in the preoperative setting. Since
anesthesia with claims associated with moni- patient cooperation is of paramount importance,
tored anesthesia care and regional anesthesia. mental status and ability to follow verbal com-
The amount of monitored anesthesia claims was mands should be preserved. Dementia, cogni-
significantly less than general and even regional tive impairment, language barrier, agitation, and
anesthesia, but the complications were similar. intoxication may compromise the patient’s ability
Analysis [3]. The most common mechanism to communicate and require deeper level of seda-
of injury in both MAC and general anesthesia tion to allay anxiety and minimize movements,
was due to a respiratory event. Under monitored posing additional risks for airway compromise or
aspiration. Furthermore, though MAC may be a from oversedation and subsequent respiratory
practical alternative to general anesthesia in high- depression leading to permanent brain damage
risk patients with significant disease burden and or death [5]. Although every patient undergoing
decreased functional status, it is prudent to con- any type of anesthetic should have standard ASA
firm that patient can tolerate prolonged supine or monitors, pulse oximetry and capnography are
dependent position and remain immobile for the instrumental in helping to detect hypoxemia. The
duration of the surgery. In patients with persis- precordial esophageal stethoscope is an optional
tent cough, tremor, and marked orthopnea, MAC modality that allows verification of adequate
may not be ideal approach, especially if intricate ventilation [6]. As for the level of sedation, sev-
microsurgical technique is involved and preci- eral clinically relevant scales had been devel-
sion of surgical movements is imperative. The oped. Electroencephalography-based devices are
presence of certain underlying pathologies may available to supplement the subjective practitio-
have direct implications on the anesthetic choice ner’s judgment. The most widely known – the
and dosages to reduce the likelihood of conversa- Observer’s Assessment of Alertness/Sedation
tion to general anesthesia. For instance, sedative (OAA/S) Scale – was developed in the 1990s to
drugs should be used judiciously in the elderly evaluate the depth of sedation using midazolam.
population or in patient with sleep apnea as the It, however, can be applied to other agents as well
risks of respiratory and cardiovascular instabil- [7] (. Fig. 9.1). Nonetheless, clinical validity of

ity are higher [4]. Comprehensive airway evalu- the scale has been recently questioned, and it is
ation should be routinely carried out as need for now mostly used for research purposes. Objective
9 endotracheal intubation may arise, and if difficult monitoring can be executed using electroen-
airway is predicted, additional pertinent equip- cephalographic (EEG) or bispectral index (BIS)
ment should be readily available during the case. methods; however, a lot of controversy exists. In
Recommendations regarding fasting guidelines the early era of BIS use, several authors expressed
and lab workup are no different from that for gen- significant interest in its implementation for MAC
eral anesthesia. cases, and some studies showed relative effective-
Application of MAC warrants not only vigi- ness of BIS particularly during propofol-based
lant cardiovascular and respiratory monitoring sedation [9]. On the contrary, there is dearth of
but also requires constant supervision of sedation reliable evidence on other commonly used anes-
level. As previously discussed, analysis of closed thetics. More recent studies argued its benefits,
claimed files demonstrated the vast majority of presenting conflicting data that indicated that,
adverse outcomes associated with MAC resulted even with propofol, it is sometimes not possible
Level of responsiveness Speech Facial expression Eyes Score

Responds readily to name Normal Normal Clear, No ptosis 5
spoken in normal tone
Lethargic responses to name Mild slowing or Mild relaxation Glazed or mild ptosis 4
spoken in normal tone thickening (less than half the eye)
Responds only after name is Slurring or Marked relaxation Glazed and marked ptosis 3
called loudly and/or repeatedly prominent slowing (slack jaw) (half the eye or more)
Responds only after mild Few recognizable 2
prodding or shaking words
Does not respond to mild 1
prodding or shaking
.. Fig. 9.1 Observer’s Assessment of Alertness/Sedation Non-Commercial License (7 http://creativecommons.org/

(OAA/S) Scale [8]. (Copyright the Korean Society of Anes- licenses/by-nc/4.0/), which permits unrestricted noncom-
thesiologists, 2018. This is an open-access article distrib- mercial use, distribution, and reproduction in any medium,
uted under the terms of the Creative Commons Attribution provided the original work is properly cited)
125 9
to discriminate changes between light and deep maintenance. On the contrary, various drug deliv-
sedation [10]. Another study revealed that audi- ery systems, namely, target-controlled infusion,
tory evoked potential index (AAI) is superior to patient-controlled infusion, and variable rate
BIS and can help differentiate slight fluctuations infusion, provide a more reliable steady state of
in consciousness [11]. Despite promising initial sedation and analgesia without peaks and drops.
results, this approach requires additional hard- The latter helps to increase patient satisfaction
ware application and trained personnel that may level while abating potential side effects [12].
significantly prolong OR time and increase cost, Various medications and their combinations
which contradicts the MAC concept. Up to date, have been extensively studied in the context of
no modality, other than close surveillance along monitored anesthetic care. Satisfaction levels
with standard respiratory and cardiovascular (physicians’ and patients’) along with incidence
monitoring, has shown proven clinical benefits of side effects including respiratory depression are
and thus is not routinely recommended. In accor- the major determinants of effectiveness and safety.
dance with ASA guidelines, level of sedation is Despite advantages of certain drugs over the oth-
determined by patient’s response to verbal, tactile, ers in the clinical context, there is paucity of sub-
or painful stimuli. If patient is only responsive to stantial data to advocate for one-fits-all regimen.
painful stimuli, deep sedation ventilation may not
be adequate and vigilant assessment is necessary.
Anybody who is not responding to painful stim- 9.4.1 Propofol
uli is considered under general anesthesia and
requires definitive securing of the airways. Propofol by itself or in combination with opioids
has historically been the mainstay of monitored
anesthesia care. It gained wide acceptance for
9.4 Systemic Sedatives predictable sedation level and short duration, fast
and Analgesics onset and offset, significant antiemetic action, and
satisfactory side effects profile. Propofol acts via
A variety of systemic analgesics and sedatives GABA receptors potentiating inhibitory effects
have a role in providing patient comfort under of the transmitter. It produces dose-dependent
MAC. An ideal agent should have a fast onset, a respiratory depression, myocardial depression,
wide therapeutic range, easy titratability, a short and vasodilation. At anesthetic doses, it yields
elimination half-life, and a favorable side effects sedation and consistent amnesia. Fast and clear
profile. Particularly, it should be able to preserve cognitive recovery occurs shortly after discon-
spontaneous ventilation and maintain cardiovas- tinuation of the drug. It should be noted that no
cular stability. A positive effect on postoperative reliable amnesia can be achieved with low doses.
nausea and vomiting (PONV) is also valued. Propofol is devoid of analgesic effects and there-
Apart from pharmacological properties, it is fore must be supplemented with analgesics if pain
essential that in the era of increasing healthcare relief is needed.
expenses, efforts are made to maintain the bal-
ance of cost-effectiveness and patient safety.
Thus, most clinically appropriate drug combina- 9.4.2 Midazolam
tions should be advocated. In compliance with
these principles, the patient’s age, sex, underly- Midazolam is a short-acting benzodiazepine act-
ing pathology, type and duration of anticipated ing via GABA receptor. It has anxiolytic and seda-
procedure, and potential interactions between tive properties, hence providing good comfort
medications should be well thought out. Variety level implementing positive changes on percep-
of drug delivery techniques are available allow- tion of pain. Yet administration of midazolam may
ing for optimal titratability. Bolus dosing is the lead to unwanted prolonged psychomotor impair-
easiest and fastest way of induction and facilitates ment. Additionally, synergism occurs in combina-
sedation quickly with most of the currently used tion with opioids, enhancing the hypnotic effect
anesthetics. Blood and effect-site concentrations and aggravating respiratory depression potential.
are however unpredictable, and the sedation lev- A study revealed that a combination of mid-
els might be fluctuant if bolus dosing is used for azolam and fentanyl (0.05 mg/ kg of midazolam
along with 2 μg/kg of fentanyl) put healthy volun- 9.4.5 Opioids

teers at significant risk for apnea and hypoxemia
[13]. One of the benefits of the combination and Opioids are commonly used during procedures
the reason why benzodiazepine/opioid regimen is under MAC and provide general analgesia if local
supported by many clinicians is due to a fact that analgesia is not sufficient alone. Fast-onset and
specific antagonists are available for both medica- short-acting drugs are preferred. Fentanyl is most
tions and the effects can be reversed. commonly used. Other agents that are frequently
utilized during MAC are afentanyl and remifent-
anil. Afentanyl may be given in frequent boluses
9.4.3 Ketamine and has a very fast onset. Remifentanil is suitable
for continuous infusion due to its short context-
Ketamine is an arylcyclohexylamine derivative sensitive half-life – especially when a continuous
and NMDA receptor antagonist. It provides good state of analgesia is required. However, remifent-
analgesia, amnesia, and cognitive disruption anil is notorious for causing respiratory depression
which is also referred to as dissociative anesthesia. even at low doses, so careful monitoring is critical.
It also preserves hemodynamic stability (except for
the situations when patient is profoundly depleted
of catecholamines) and spontaneous respirations. 9.4.6 The Adjuncts
For these properties, ketamine is specifically valu-
able in MAC. Ketamine can be combined with There are a few other adjuncts that have been
9 propofol or midazolam to counteract their respi- reportedly used as supplements to mainstay MAC
ratory side effects and decreases the dose of both regimen. Phenergan (promethazine) is currently
medications. Moreover, supplementing ketamine used mostly for its anti-nausea properties; how-
with midazolam reduces the likelihood of emer- ever it is also known for its mild sedative and
gence delirium, specifically hallucinations, agita- hypnotic effects. It serves as an alternative to
tion, and postoperative dysphoria. benzodiazepines for preoperative anxiolysis. A
recent study compared the effectiveness of adding
Phenergan to Fortwin (pentazocine) and mid-
9.4.4 Dexmedetomidine azolam combination. This mixture was found to
be superior compared to ketamine + midazolam
Dexmedetomidine is an alpha-2 adrenergic ago- regimen in terms of hemodynamic stability, com-
nist that recently gained wide acceptance due to fort, and surgeons’ and patients’ satisfaction [16].
a constellation of positive effects, most impor- Ketorolac is a nonsteroidal anti-inflammatory
tantly good hypnotic and mild analgesic proper- drug that has weak analgesic properties and
ties along with minimal respiratory depression can be considered as an alternative to opioids.
effects. Due to its propensity to cause hypotension The main advantage compared to opioids is the
and bradycardia, it may not be the ideal choice absence of respiratory side effects, pruritus and
in elderly patients or for patients with struc- PONV; however oftentimes analgesic effect is
tural heart pathology, rhythm disturbances, and not sufficient. Intravenous acetaminophen may
hemodynamic instability [14]. Also, the onset/ potentially be added to the analgesic regimen and
offset of the drug is prolonged compared to fast- help provide pain-free experience for the patient.
acting GABA agonists, accounting for slow induc- It has been extensively studied in regard to post-
tion and delayed recovery. Hence, it may not be operative pain control and proven to decrease
advantageous for quick ambulatory procedures opioid consumption in the postoperative period;
when used as a sole anesthetic. Combination of however more research is needed to describe its
dexmedetomidine with ketamine was proven to intraoperative effects.
be a valuable tool in the pediatric population, pre- The choice of sedatives and analgesics should
cisely for magnetic resonance imaging cases [15]. be primarily driven by the required level of seda-
It creates steady sedation and good analgesia with tion, type of the procedure, and specific patient’s
minimal risk of respiratory depression, which is characteristics. Knowledge of potential drug
critically important when immediate and direct interaction and subsequent effects on respiration
access to the airways is not feasible. and hemodynamics is crucial, and emergency
127 9
equipment should always be available regardless done with dexmedetomidine, there were higher
of the case location in or outside of the operating patient-surgeon satisfaction rates compared
room. to use of midazolam-fentanyl combination.
Dexmedetomidine decreases sympathetic outflow
via the α2 agonist effect and continuous cardio-
9.5 MAC Procedures vascular monitoring throughout the procedure
is paramount. Additionally, due to decreased
9.5.1 Ophthalmologic Procedures sympathetic outflow, there is reduced blood loss,
resulting in improved visualization of the surgical
Monitored anesthetic care (MAC) has become field. The midazolam-fentanyl combination has
increasingly popular for vitreoretinal and cata- been associated with increased risk of respira-
ract surgery compared to other anesthetic tech- tory suppression and intraoperative hypotension,
niques. Topical anesthesia (TA) generally does and continuous intraoperative cardiopulmonary
not produce adequate analgesia for these proce- monitoring is needed.
dures, whereas solely regional anesthesia (RA) Complications are generally related to airway
poses serious albeit uncommon risks such as and pharmacologic adverse effects. Local anes-
retrobulbar hemorrhage, globe rupture, and
thetic toxicity with these procedures is a possibil-
optic nerve injury. Consequently, MAC sedation ity and is seen more commonly in the pediatric
is commonly used and has also been associated population. Care must be taken to ensure no acci-
with increased patient-surgeon satisfaction with dental intravascular injection occurs as this can
cataract surgery compared to other anesthetic lead to neurologic and cardiovascular collapse.
techniques. Furthermore, patients undergo- Airway complications may occur, and there may
ing cataract surgery with only TA have showed be a need to convert the procedure from a MAC
to have increased anxiety and discomfort when to GA.
compared to MAC or TA combined with MAC. Anesthesia providers must also be extremely
Two common complications associated with vigilant when doing MAC cases for head and neck
ophthalmologic procedures are snoring and surgeries due to the risk of on-patient fires. Most
sneezing. Snoring has been proven to be a risk patients are given supplemental oxygen during
factor associated with head movement during MAC cases, and when combined with electro-
vitreoretinal cases under MAC. It is increased cautery, this supplemental oxygen can act as an
by intraoperative propofol infusion. Avoidance oxidizer, while the electrocautery is the ignition
of the use of propofol during the procedure can source. The fuel can be represented by sponges,
reduce the risk of head movement by reducing towels, or anything else in the surgical field. These
the level of sedation and thus the airway obstruc- three things, an oxidizer, fuel, and ignition source,
tion. Intraoperative sneezing is also associated represent the fire triad. Providers must communi-
with propofol usage for intravenous sedation cate with the surgical team to minimize all com-
combined with periocular local anesthesia. Risk ponents of the fire triad, i.e., lowering the FIO2
factors for sneezing include male gender, history when cautery is needed.
of photic sneezing, bilateral or upper eyelid infil-
tration, deep sedation, and concurrent adminis-
tration of midazolam. The use of adjunct opioids, 9.5.3 Inguinal Herniorrhaphy
especially alfentanil, has found to be protective
and has reduced the risk of sneezing. Additionally, Inguinal herniorrhaphy (IH) can be performed
avoidance of the use of midazolam as well as RA under MAC with regional anesthesia. A tradi-
are protective. tional transversus abdominis plane (TAP) block
or an iliohypogastric nerve block along with
MAC has been shown to produce less postopera-
9.5.2 Otolaryngologic Procedures tive pain, faster recovery times, and greater 24-h
post-procedure satisfaction. This approach is also
Tympanoplasty and percutaneous dilational more cost-effective compared to GA and spinal
tracheostomy are two otolaryngologic pro- anesthesia (SA), and it is ideal in an outpatient
cedures that can be done under MAC. When setting. In a small subset of patients, there exists
a need to convert to general anesthesia due to function. Communication is necessary in this

inadequate anesthesia. This may be due to an inef- field as surgeons require feedback from patients
fective regional anesthetic technique or patient to prevent potential nerve damage. Epidural
anxiety. Because preoperative education has been injection is an example of the type of proce-
shown to decrease anxiety, all attempts should be dure that may cause nerve damage if there is no
made to educate and calm the patient prior to the communication. Epidural spinal steroid injec-
surgery. tions have increased risk of spinal cord damage.
Needle contact with the cord is likely to elicit a
strong paresthesia which can be impaired with
9.5.4 Cardiovascular Procedures the use of moderate or deep sedation which can
alter the patient’s perception of a needle-induced
Endovascular aortic aneurysm repair (EVAAR), paresthesia. This then increases the likelihood of
transcatheter aortic valve implantation (TAVI), accidental injection of material directly into the
and peripheral vascular procedures have all cord which can produce a substantial neurologic
been performed under MAC, general anesthe- injury. Needle penetration of the cord is not likely
sia, and regional anesthesia as well. Patients who to produce widespread injury unless significant
have undergone major vascular procedures with bleeding occurs. The risk is increased in patients
MAC compared to GA had adequate intraopera- with severe cervical spinal stenosis when epidural
tive anesthesia, less postoperative pain, shorter pressure is increased.
postoperative hospital stay, and reduced risk of In fully conscious individuals, injection of
9 respiratory complications. Due to the increased small volumes of drug may produce significant
risk of cardiovascular complications that can discomfort or paresthesia, prompting the phy-
occur with GA, MAC cases provide a greater sician to limit the volume used. If sedation and
safety profile than GA. Additionally, arteriove- analgesics blunt these sensations, larger volumes
nous fistula under MAC with axillary block has may be injected thus increasing the chance for
shown to have increased 3-month patency rates injury. Electrical stimulation can be employed to
for fistulae. minimize the chances of injury to adjacent nerves
Major complications are related to the and stimulation and will produce both sensory
comorbidities of the patient and the anesthetic and motor effects on nerve roots if the needle
administered. Most patients undergoing vascular position is incorrect. While motor effects of stim-
procedures have evidence of vascular pathol- ulation are preserved, the sensory effects may be
ogy and are at increased risk for perioperative lost during moderate to deep sedation which can
myocardial ischemia and stroke. These patients lead to neurological damage.
should be risk stratified and fully optimized
preoperatively to prevent these complications.
Additionally, side effects of local anesthetic 9.5.6 Ambulatory Procedures
administration such as neurotoxicity and cardio-
vascular collapse must be considered preopera- Ambulatory practices have incorporated the use
tively as well. The use of local anesthetic agents of MAC in outpatient gastroenterology and pul-
that have a greater safety profile, such as ropiva- monology suites. ERCP and colonoscopy have
caine, would be more appropriate for regional been increasingly performed under MAC due to
anesthesia than bupivacaine. decreased patient awareness, increased patient
satisfaction, and reduced length of recovery.
Bronchoscopy should allow the patient spontane-
9.5.5 Interventional Pain ous ventilation while having the ability to protect
their airway as well as blunt sympathetic response.
MAC is wide spread in the field of interventional The use of dexmedetomidine, although it
pain. It is particularly useful in vertebroplasty has a slow onset and offset, has been associated
and epidural steroid injections. MAC allows with lower incidence of oxygen desaturation
intraprocedural patient-surgeon communica- and reduced incidence of oral suctioning due to
tion while simultaneously allowing adequate preservation of respiratory drive. Ketamine has
analgesia and preservation of cardiopulmonary also been used as it allows preservation of airway
129 9
patency and respiratory function however can Continuous cardiopulmonary monitoring and
prove to increase difficulty of procedure as ket- diligent observation are required to identify
amine has been known to increase airway secre- and minimize the effects of respiratory depres-
tions. Use of glycopyrrolate may help in reducing sion. Conversion to general anesthesia may
such secretions. be necessary, and the provider should always
Complications seen in the ambulatory set- be prepared to do so. Providers should also
ting include hypotension, hypertension, hyper- be aware of the possibility of reduced MEPs.
capnia, and arrhythmias. These complications Dexmedetomidine has been used in more
can be detrimental in patients who have a his- modern times as an adjunct to propofol-/
tory of cardiopulmonary comorbidities as it can remifentanil- based TIVA for neurosurgical
increase the risk of perioperative myocardial procedures. This has remained a controversial
infarction, stroke, and postoperative respiratory topic as some studies have shown a decrease in
failure. Control of blood pressure to within 20% amplitude of the motor-evoked potential moni-
of baseline can reduce these risks. Intraprocedural toring, if plasma levels of dexmedetomidine are
hypercapnia due to inadequate ventilation is greater than 0.4 ng/ml. However, other studies
also a concern. Due to their pulmonary pathol- have shown no effect on MEP with dexmedeto-
ogy in patients undergoing bronchoscopy, these midine. Careful monitoring of the administered
patients have an increased risk of respiratory dose of dexmedetomidine with adjustment if
compromise. Hypercapnia is common with MEP is depressed should be done. Lastly, post-
moderate amounts of hypercapnia not linked to operative opioid hyperalgesia can be associated
worse outcomes; however severe hypercapnia with prolonged use of intraoperative remifent-
(PaCO2 > 100 mmHg) predisposes patients to anil. This along with opioid tolerance can pre-
increased risk of postoperative cardiac failure and dispose patients to respiratory compromise and
increased extubation times and intraoperative increased analgesic requirements in the imme-
stay. Intraprocedural blood gases can determine diate postoperative period. Continued monitor-
the presence of hypercapnia and the underlying ing postoperatively while treating postop pain
cause to be corrected. is necessary to prevent additional postop com-
plications.
9.5.7 Neurosurgical Procedures

9.5.8 Pediatric Procedures
MAC has been commonly used for awake cra-
niotomies as it allows patient and surgical team MAC sedation in combination with caudal blocks
communication. It also allows for the mainte- has become an increasing popular anesthetic
nance of adequate cardiorespiratory function technique particularly in pediatric urologic
while also allowing intraoperative neuromonitor- and general surgical cases. There is evidence to
ing. Commonly used combinations of drugs in show that MAC procedures involving the use
these procedures are a combination of intrave- of regional anesthesia reduced the risk of early
nous anesthetic and ultrashort-acting opioid such postoperative apnea in premature neonates when
as propofol-remifentanil or sufentanil combina- compared to GA. MAC anesthesia using propofol
tions. Recently, there has been an increased use or dexmedetomidine has been shown to decrease
of dexmedetomidine as it preserves respiratory the incidence of postoperative delirium and
function, reduces anesthetic requirements, and allows smoother emergence in this patient popu-
has neuroprotective properties. lation compared to sevoflurane-based GA which
Complications seen when using MAC for is associated with 10–80% of emergence agitation.
neurosurgical procedures include respiratory Administration of a caudal block generally targets
depression, reduced motor-evoked potentials the sacrococcygeal ligament in these patients.
(MEPs), and postoperative opioid hyperal- There exists a small risk of local anesthetic toxicity
gesia. Respiratory depression can be seen via accidental intravascular injection, leading to
when both propofol and an opioid infusion neurological deficits and cardiovascular collapse.
are used. The combination has been proven Use of the appropriate anesthetic with a lower risk
to increase the risk for this complication. of toxicity should be considered.
9.6 Summary Because regional anesthesia often accom-

panies MAC procedures, large amounts of local
Monitored anesthetic care procedures are fre- anesthetics are frequently used. Providers should
quently used among anesthesia providers due to be familiar with local anesthetic systemic toxicity
the enhancement of minimally invasive proce- and how to treat it. LAST can occur when local
dures. It provides amnesia, analgesia, sedation, anesthetic is accidentally injected into a blood ves-
and anxiolysis. These are the same components sel or too much local anesthetic is absorbed into
as general anesthesia but with a faster recovery, a the vascular system. Symptoms can range from
reduction in postoperative nausea and vomiting, tinnitus and perioral numbness to tonic-clonic
intraprocedural patient-surgeon communication, seizures and apnea and then eventually ventricu-
and less physiological changes. MAC procedures, lar dysrhythmias and cardiac arrest. Treatments
along with supplementation of local anesthetics, include airway support, low-dose epinephrine
have gained popularity and are more favorable (10 mcg boluses), and lipid emulsion therapy. The
with patient satisfaction. In the pediatric popula- intralipid emulsion should consist of 20% lipids
tion, MAC reduces the risk of postoperative apnea and 1.5 ml/kg should be bolused followed by an
in the premature neonates and decreases the inci- infusion at a rate of 0.25 ml/kg/min. Airway sup-
dence of postoperative delirium allowing smoother portive methods can range from a forward chin
emergence in the older children. Although the use thrust with a nasal cannula to placement of a
of MAC procedures has its benefits, it also has its laryngeal mask airway or endotracheal tube.
list of complications such as but not limited to In conclusion, although the MAC technique
9 deep sedation transitioning to general anesthesia has its benefits, it can also present with grave
where a protected airway is needed, hypoxemia complications if providers do not plan properly
from inadequate oxygenation or ventilation lead- for their specific patient. Futhermore, it is imper-
ing to respiratory compromise, side effects of the ative to understand the ramifications of the spe-
sedating drug used such as hypotension, local cific procedure taking place, and to monitor and
anesthetic systemic toxicity (LAST), and compli- diligently observe their patient throughout the
cations of the procedure such as cautery fires. procedure so that they may intervene promptly if
When choosing the best anesthetic sedative and necessary.
analgesic combination, a thorough preanesthetic
evaluation is needed, and the type of surgical proce-
dure and level of sedation required, a knowledgeable 9.7 Review Questions
anesthetic provider, and emergency equipment are
prudent to yield a safe and uneventful case. The ?? 1. What is known as the fire triad?
American Board of Anesthesiology (ASA) guide- A. Oxidizer, fuel, ignition source
lines mandate a standard level of care with the use B. Oxidizer, fuel, heat
of intraoperative assessment of the patient’s oxy- C. Fuel, heat, laser
genation, ventilation, circulation, and temperature. D. Ignition source, laser, O2
Poor oxygenation and ventilation will lead to hyper-
carbia, hypoxemia, and ultimately cardiovascular ?? 2. Which of the following is not a specific
collapse. The anesthetic drugs such as dexmedeto- indication for choosing MAC over con-
midine, ketamine, propofol, and promethazine used scious sedation?
for sedation have multiple side effects. Examples are A. Morbid obesity (BMI > 40)
hypotension, hypertension, and tachycardia, and B. h/o sleep apnea or stridor
if these are not treated promptly, cardiovascular C. Acutely agitated
collapse can take place. Vigilant monitoring is the D. ASA P2 or greater
key to minimizing complications. As instructed by
the ASA guidelines, level of sedation is determined ?? 3. Which drug is an alpha-2 adrenergic
by a patient’s response to verbal, tactile, or pain- agonist?
ful stimuli. If the sedation is deep as to where the A. Ketamine
patient cannot respond to painful stimulation, this B. Dexmedetomidine
level of sedation is considered general anesthesia C. Midazolam
and requires a protected airway. D. Phenergan
131 9
9.8 Answers care. Anesth Analg. 2004. 379–382. https://doi.
org/10.1213/01.ANE.0000131964.67524.E7.
7. Chernik DA, Gillings D, Laine H, Hendler J, Silver JM,
vv 1. A – The fire triad is known as the oxidizer, Davidson AB, Schwam EM, Siegel JL, de Louw AJ. Valid-
fuel, and ignition source (Analysis, A.C.C. ity and reliability of the Observer’s Assessment of
[3], Injury and Liability Associated with Alertness/Sedation Scale: study with intravenous mid-
Monitored Anesthesia). azolam. J Clin Psychopharmacol. 1990;10(4):244–51.
8. Sohn H, Ryu J-H. Monitored anesthesia care in and
outside the operating room. Korean J Anesthe-
vv 2. D – Include ASA P3 or greater, morbid siol. 2016;69(4):319–26. https://doi.org/10.4097/
obesity (BMI > 40), severe sleep apnea, kjae.2016.69.4.319.
inability to follow simple commands, 9. Liu J, Singh H, White PF. Electroencephalographic
spasticity/movement disorders, antici- bispectral index correlates with intraoperative recall
and depth of propofol-induced sedation. Anesth Analg.
pated intolerance to standard sedatives,
1997;84(1):185–9. https://doi.org/10.1213/00000539-
patients <12 years old and > 70 years old, 199701000-00033.
pregnancy, h/o sleep apnea or stridor, oral/ 10. Chisholm CJ, Zurica J, Mironov D, Sciacca RR, Orn-
neck/jaw/facial abnormalities, and acutely stein E, Heyer EJ. Comparison of electrophysiologic
agitated, uncooperative patients (Policy, monitors with clinical assessment of level of seda-
tion. Mayo Clin Proc. 2006;81(1):46–52. https://doi.
M. C. [17]. Monitored Anesthesia Care).
org/10.4065/81.1.46.
11. Nishiyama T. Auditory evoked potentials index versus
vv 3. B – Dexmedetomidine is an alpha-2 adren- bispectral index during propofol sedation in spinal
ergic agonist. anesthesia. J Anesth. 2009;23(1):26–30. https://doi.
org/10.1007/s00540-008-0678-3.
12. Rodrigo MRC, Irwin MG, Tong CKA, Yan SY. A ran-
domised crossover comparison of patient-controlled
References sedation and patient-maintained sedation using
propofol. Anaesthesia. 2003;58(4):333–8. https://doi.
1. ASA. Position on monitored anesthesia care, commit- org/10.1046/j.1365-2044.2003.03081.x.
tee of origin: Economics, economics, (Approved by 13. Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA,
the House of Delegates on October 25, 2005, and last Stanley TH. Frequent hypoxemia and apnea after
amended on October 16, 2013). sedation with midazolam and fentanyl. Anesthesiol-
2. Ghosh DS. Monitored anesthesia care : an overview. ogy. 1990;73:826. https://doi.org/10.1097/00000542-
J Anaesthesiol Clin Pharmacol. 2015. https://doi. 199011000-00005.
org/10.4103/0970-9185.150525. 14. Shukry M, Miller JA. Update on dexmedetomidine: use
3. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee in nonintubated patients requiring sedation for surgi-
LA, Domino KB. Injury and liability associated with cal procedures. Ther Clin Risk Manag. 2010. https://doi.
monitored anesthesia care: a closed claims analysis. J org/10.2147/TCRM.S5374.
Am Soc Anesthesiol. 2006;104(2):228–34. 15. Luscri N, Tobias JD. Monitored anesthesia care with
4. Höhener D, Blumenthal S, Borgeat A. Sedation and a combination of ketamine and dexmedetomidine
regional anaesthesia in the adult patient. Br J Anaesth. during magnetic resonance imaging in three children
2008;100:8. https://doi.org/10.1093/bja/aem342. with trisomy 21 and obstructive sleep apnea. Paediatr
5. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee Anaesth. 2006;16(7):782–6. https://doi.org/10.1111/
LA, Domino KB. Injury and liability associated with j.1460-9592.2006.01857.x.
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rately detects apnea during monitored anesthesia
133 10
Massive Perioperative
Hemorrhage:
Considerations
in Clinical Management
Usama Iqbal, Jaime Sanders, Longqiu Yang, Mingqiang Li,
10.2 Etiology of Massive Perioperative Bleeding – 134

10.2.1 Trauma – 134
10.3 Clinical Manifestations – 137

10.3.1 Vital Signs Changes – 137
10.3.2 Vital Organ Perfusion-Related Presentations – 138
10.4 Evaluation and Diagnostic Checklist – 138

10.4.1 Prothrombin Time and Activated Partial
Thromboplastin Time – 138
10.4.2 Electrolytes Alterations – 139
10.4.3 Point-of-Care Testing – 139
10.5 Anesthetic Management of Massive Perioperative

Hemorrhage – 140
10.5.1 Non-pharmacologic Management – 140
10.5.2 Massive Blood Transfusion Protocol – 142
10.5.3 Pharmacologic Management – 144
10.6 Conclusions – 145
10.8 Answers – 146
References – 146

https://doi.org/10.1007/978-3-319-96125-5_10
134 U. Iqbal et al.
10.1 Introduction in patients surviving to hospital admission with

the highest incidence in 1–3 h after admission [4].
There is no universally accepted definition of Etiology of major trauma includes motor vehicle
massive hemorrhage. The British Committee for accidents, bullet injuries, blunt trauma injuries,
Standards in Haematology has consensus but arbi- fall from certain heights, glass injuries, blast inju-
trary definition, “Bleeding which leads to a heart rate ries, etc. These traumatic injuries are potentially
of more than 110 beats/min and/or systolic blood associated with major vascular laceration(s) or
pressure less than 90 mmHg” [1]. Massive transfu- organ rupture (spleen injury) leading to extensive
sion in an adult has commonly been defined as ten blood loss. Most of the patients expire on their
or more units of packed red blood cells (PRBC) in way to hospital because of massive hemorrhage.
a 24-h period, which almost replaces one blood So, hemorrhage/hemorrhagic shock is still the
volume based on the total blood volume of a 70-kg leading cause of death in all major traumatic inju-
male [2]. Massive transfusion can also be defined if ries worldwide [4].
one of the following conditions is satisfied: blood
loss exceeding circulating blood volume within a 10.2.1.1 Surgical Procedures
24-h period, blood loss of 50% of circulating blood 1. Liver transplantation: In 1963, Starzl and col-
volume within a 3-h period, blood loss exceeding leagues performed the first liver transplanta-
150 ml/min, and blood loss that necessitates plasma tion procedure in human beings. The first five
and platelet transfusion [3]. Hemorrhage is the patients all died of bleeding complications.
main cause of death in major trauma patients sur- Liver transplantation has usually been associ-
viving to the hospital admission [4]. In this review, ated with massive hemorrhage and requires
we will discuss the risk factors for massive periop- considerable amount of blood transfusion.
10 erative hemorrhage, clinical manifestations and The etiologies of liver transplantation-associ-
evaluations, and various management strategies. ated bleeding can be multifactorial including
preoperative (liver failure, cirrhosis, cholesta-
sis, and splenomegaly), intraoperative (tran-
10.2 Etiology of Massive section of the fragile collateral vessels, release
Perioperative Bleeding of heparin-like factors from the allograft,
coagulopathy), and postoperative (leaks at
Perioperative massive hemorrhage can be caused vascular suture lines, graft-versus-host dis-
by various etiologies, as illustrated in . Table 10.1.
ease, thrombocytopenia, coagulopathy, etc.)
[5]. Intraoperative management-related issues
such as massive volume load and subsequent
10.2.1 Trauma hypothermia and hypocalcemia secondary to
citrate toxicity can also significantly worsen
Major trauma is one of the leading causes of peri- the preoperative coagulopathy, thus further
operative massive hemorrhage, and hemorrhage increasing the perioperative hemorrhage
is the main cause of death following major trauma [6]. Excessive blood loss and large quantity
.. Table 10.1 Etiologies of massive perioperative bleeding
Major trauma Surgical procedures Coagulation abnormalities Obstetric diseases
Major trauma Liver transplantation Acute traumatic coagulopathy Placenta previa/accreta
Cardiac/major Clotting factor deficiencies Embryonic emboli-

vascular surgery associated DIC
Major cancer surgery Drug-induced acquired factor deficiency
An undiagnosed inherited bleeding

disorder
Dilutional coagulopathy
Massive Perioperative Hemorrhage: Considerations in Clinical Management
135 10
of blood transfusion during orthotopic liver important role in exacerbating intraoperative
transplantation are unfortunately associated blood loss like sevoflurane results in signifi-
with significantly decreased graft survival cantly greater intraoperative blood loss than
and dramatically increased episodes of sepsis propofol [11]. Certain cancer surgeries also
and therefore prolonged ICU stay [6]. In cause massive perioperative bleeding due to
principle, the degree of hemorrhage can be extensive intra-tumor blood vessel networks
estimated based on the severity of preopera- that lead to unpredictable internal bleeding
tive liver disease and coagulation function, during surgery. A case study is presented on
quality of the donor liver, recipient’s overall metastatic prostate adenocarcinoma in which
clinical status, and surgical skills and experi- patient develops hyper-fibrinolysis leading
ence of the transplantation team [7]. There is to widespread ecchymosis and disseminated
a strong correlation between MELD score and intravascular coagulation (DIC). Any surgi-
transfusion requirements in patients under- cal attempt to resect this type of cancer can
going orthotopic liver transplantation. Higher potentially lead to massive perioperative
MELD scores (>30) was found to be signifi- hemorrhage and other complications [12].
cantly associated with increased bleeding and 3. Cardiac/major vascular surgery: In cardiac or
transfusion requirements when compared to major vascular surgeries, surgeons deal with
patients with lower MELD scores (<30) [8]. main blood vessels like the aorta, coronar-
Massive bleeding can have multiple clinical ies, and femoral, tibial, brachial, or vertebral
consequences, as illustrated by 7 Box 10.1.
arteries. So, there are higher chances of
2. Major cancer and spine surgery: Recon- intraoperative and postoperative hemorrhage
structive and multilevel procedures like leading to severe consequences.
spine surgery and spine fusion procedures
are potentially complicated by significant 10.2.1.2 Coagulation Abnormalities
intraoperative blood loss and the need for 1. Acute traumatic coagulopathy: It could
allogeneic blood transfusion. The unique mainly be an iatrogenic or secondary coagu-
prone position (knee-chest) for spine surgery lopathy, a condition in which various ele-
likely leads to increased intra-abdominal ments are thought to play a role, including
pressure which increases epidural venous consumption of clotting factors, hemodilu-
pressure and consequently exacerbates tion from large quantity of crystalloid infu-
intraoperative surgical bleeding. Raised intra- sion, acidosis, and hypothermia. The exact
abdominal pressure is measured via a urinary mechanism of coagulopathy is still unknown.
bladder catheter [9]. The total blood loss is One theory believes that actual injury causes
proportionate with the intra-abdominal pres- release of certain tissue factors that lead to
sure, also proportionate with patient’s body thrombin and fibrin generation and utiliza-
mass index (BMI) [9]. In another study, the tion leading to DIC [13]. Another theory
effects of prone versus jack-knife position on describes that trauma-induced hypoperfu-
intra-abdominal pressure and intraopera- sion and ischemia lead to release of activated
tive bleeding during lumbar disc herniation protein C, which leads to consumption of
surgery were conducted, and intra-abdominal plasminogen activator inhibitor, inhibition
pressure came out to be significantly higher of the clotting cascade, systemic anticoagu-
in prone position [10]. Certain anesthetic lation, and hyper-fibrinolysis [14]. A high
agents in spine and cancer surgeries play an fresh frozen plasma to RBCs ratio is the cur-
rent treatment of choice for acute traumatic
coagulopathy [15].
Clotting factors deficiencies: Clotting
Box 10.1 Consequences of Liver Disease factors deficiencies may be congenital or
on Coagulation acquired. Congenital deficiency includes
55 Thrombocytopenia
55 Accelerated or decreased fibrinolysis
factor VIII deficiency called hemophilia A
55 Qualitative defects in platelets function disease and deficiency of factor IX called
55 Predisposition to fibrinolysis hemophilia B. Another congenital bleeding
disorder is von Willebrand’s disease caused
136 U. Iqbal et al.
by deficiency of von Willebrand factor prothrombin complex concentrate are the

(vWF). Acquired clotting factors deficiency first line of management.
also develops in selective individuals because 2. Drug-induced acquired factor deficiency:
of the autoantibodies affecting the activity or Warfarin, an oral vitamin K antagonist, is
accelerating the clearance of clotting factors used to prevent arterial and venous throm-
[16]. Such antibodies are usually directed boembolism in variety of clinical conditions.
against factor VIII and vWF. These acquired It is one of the leading drugs causing emer-
antibodies are basically IgG4 type targeting gency room visits for adverse drug reactions.
several epitopes of clotting factors [17]. Annually the frequency of bleeding complica-
An undiagnosed inherited bleeding dis- tions associated with over-anticoagulation
order: Some individuals have congenital defi- is 15% to 20%, with fatal bleeds accounting
ciency of coagulation factors like factor VIII for as high as 1% to 3% [19]. Assessment of
and vWF. These patients do not have bleeding warfarin-induced anticoagulation is typically
symptoms initially. If such patients are never done using the international normalized ratio
being diagnosed with congenital coagulation (INR). The INR levels and their management
factors deficiency and yet they present for are summarized in . Table 10.2. The authors

any elective surgery or emergency trauma recommend the use of 3-factor prothrombin
surgery, then bleeding is profuse and unpre- complex concentrate (PCC) with vitamin
dictable [18]. Diagnosis is difficult in these K and a judicious amount of rVIIa as the
patients unless some family members with treatment of choice for over-anticoagulation,
some type of bleeding disorder or in some although the risk of thromboembolism
cases these patients are found to have large is still there. Selective serotonin receptor
10 multimers of vWF [16]. Common bleeding inhibitor (SSRI) is a group of antidepressant
sites are the skin, mucosa, and muscles. Hem- drugs most commonly used for depression
arthrosis is rare. Recombinant factor VII and all over the United States. Studies show that
.. Table 10.2 Guidelines for the reversal of anticoagulation therapy [22]
INR Clinical scenario Management
<4.5 No bleeding Hold warfarin until INR in therapeutic range
Rapid reversal required Hold warfarin

Consider vitamin K 2.5 mg oral
4.5–10 No bleeding Hold warfarin until INR in therapeutic range

Consider vitamin K 2.5 mg oral

Give vitamin K 2.5 mg oral or 1 mg IV infusion
>10 No bleeding Hold warfarin until INR in therapeutic range

Give vitamin K 2.5 mg oral or 1–2 mg IV infusion over 30 min, and
repeat q24h as needed

Give vitamin K 1–2 mg IV infusion over 30 min, and repeat q6–24 h as
needed
Any INR Serious or life- Hold warfarin

threatening bleeding Give vitamin K 10 mg IV infusion over 30 min
Give 4 units FFP/plasma
Consider 4-factor PCC (Kcentra) (preferred for life-threatening bleeding)
INR 1.5–3.9: 25 units/kg (maximum 2500 units)
INR 4.0–6.0: 35 units/kg (maximum 3500 units)
INR >6.0: 50 units/kg (maximum 5000 units)
137 10
there is a risk of postoperative hemorrhage DIC. In parturient, fibrinogen levels are
with SSRI use only when used along with 4–6 g/L, almost twice the level when com-
NSAIDs or warfarin [20]. Cessation of SSRIs pared to nonpregnant females. And the con-
before surgery is still under investigation current drop in protein C and S promotes
because cessation of SSRI before surgery may prothrombotic state resulting in shorter PT
potentially precipitate a discontinuation syn- and aPTT values. So, the combined results
drome, which may exacerbate depression and may come out normal in massive hemor-
increase sensitivity to postoperative pain [21]. rhage [28]. A retrospective study shows that
So, the internists, surgeons, and anesthesiolo- there is no association between the method
gists should be aware of potential periopera- of placenta removal and postpartum blood
tive SSRI-associated bleeding risks. loss in cesarean section deliveries. Placenta
3. Dilutional coagulopathy: Dilutional coagu- removal can occur spontaneously by mas-
lopathy is defined as a coagulation abnormal- saging on the uterine fundus and applying
ity due to “loss, consumption, or dilution of gentle traction on the umbilical cord, or it
coagulation factors that occurs when blood can be removed manually by placing sur-
is replaced with fluids that do not contain geon’s dominant hand in the uterine cavity
adequate coagulation factors” [23]. This and removing the placenta by detaching it
hemostatic disturbance is further deterio- from the uterine wall [29].
rated by continuous fluid administration, 2. Embryonic embolic event-associated DIC:
acidosis, fibrinolysis, and hypothermia. It is Amniotic fluid embolism leading to DIC
a multifactorial change that affects thrombin usually occurs at term or immediate post-
generation, clot firmness, and fibrinolysis. partum. Amniotic fluid contains surfactant
Acquired fibrinogen deficiency is considered and various pro- and anti-anticoagulants.
the leading cause of dilutional coagulopathy Surfactant, a lipoprotein produced by fetal
[24]. High molecular weight dextrans are lungs and present in increasing amounts in
also linked to severe disturbances of clot amniotic fluid with increasing gestational age,
formation [25]. This impact on clot forma- is structurally like tissue thromboplastin and
tion was significantly reduced by introduc- possesses significant thromboplastic activity.
ing new low molecular weight starches, but It also contains cysteine protease that directly
depending on the amount of fluid given, a activates factor X, and it directly inhibits the
marked impairment of hemostasis can still platelets too [29]. Newborns may develop
be observed. Rotation thromboelastometry tachypnea and cyanosis. Patient shows signs
is the test of choice to evaluate perioperative of hypotension, brief generalized seizures,
coagulation status. FFP transfusion 30 ml/ and profuse vaginal bleeding followed by
kg is the treatment of choice for dilutional unconsciousness. PT, aPTT, and bleeding
coagulopathy and in massive transfusion time all are prolonged, and fibrinogen level
scenarios [26]. falls drastically. Treatment strategy comprises
of blood component replacement, including
10.2.1.3 Obstetric Diseases PRBC, FFP, platelets, cryoprecipitate, and
1. Placental anomalies: Definition of mas- possibly fibrinogen concentrate. Recombinant
sive obstetric hemorrhage include a fall in factor VIIa use is associated with increased
hemoglobin concentration of >40 g/L or mortality as compared to the patients who do
blood loss of >2500 mL or transfusion of > not receive rFVIIa.
four units of RBCs [27]. Postpartum hem-
orrhage (PPH) means more than 500 mL
blood loss from the genital tract within 10.3 Clinical Manifestations
24 h of birth. PPH is subdivided into minor
(500–1000 mL), moderate (1000–2000 mL), 10.3.1 Vital Signs Changes
and severe (>2000 mL) [2]. Common etiolo-
gies include uterine atony, placenta previa, Perioperative massive bleeding is categorized
placenta accreta, abruptio placenta, uterine as compensated, mild, moderate, and severe, as
rupture, or embryonic emboli associated shown in . Table 10.3.

138 U. Iqbal et al.
.. Table 10.3 Vital sign changes in various severity of hemorrhage [30]
Stage I (compensated) II (mild) III (moderate) IV (severe)
Blood <15% 15–<30% 30–<40% >40%

loss 750–1000 ml 1000–1500 ml 1500–2000 ml 2000 ml or more
Blood Normal Orthostatic changes in Markedly decreased Profoundly

pressure Vasoconstriction BP SBP <90 mmHg decreased
redistributes Vasoconstriction vasoconstriction SBP <80 mmHg
blood flow, slight intensifies in noncritical decreases perfusion to decreased perfusion
rise in diastolic BP organs (skin, muscles, vital organs like the liver, affects the brain and
seen and gut) spleen, and kidneys heart
Respira- Normal Rate mildly increased Moderate tachypnea Marked tachypnea,

tion respiratory collapse
Heart Normal Tachypnea Tachycardia Tachycardia

rate (<100 bpm) (>100 bpm) (120 bpm) (140 bpm)
Urinary >30 ml 20–30 ml/h <20 ml/h Anuria

output
Capillary Normal >2 s >3 s >3 s

refill <2 s Clammy skin Cool, pale skin Cold mottled skin
Mental Normal or slightly Mildly anxious or Confused and agitated Obtunded

status anxious irritated
10
10.3.2 Vital Organ Perfusion-Related
.. Table 10.4 Perfusion monitoring parameters
Presentations
Organs Perfusion monitoring parameters
All ASA members and consultants strongly
agree to the monitoring of vital organ’s perfu- Heart Blood pressure, heart rate, oxygen
saturation, EKG, and echocardiography
sion using standard ASA monitors (. Table 10.4)
(. Fig. 10.1).
Brain Cerebral oximetry and NIRS
Kidneys Urine output and arterial blood gas analysis
10.4 Evaluation and Diagnostic

Checklist [31]. The limitations of PT and aPTT are sum-
marized in 7 Box 10.2.
10.4.1 Prothrombin Time

and Activated Partial Thromboelastography (TEG) and Thrombo ela

Thromboplastin Time stometry (ROTEM) Since PT/aPTT tests are usu-
ally performed in central/core laboratories of the
PT is used to test factor VII (extrinsic factor hospital, there is substantial time delay in getting
pathway). aPTT measures the integrity of intrin- the results. So TEG/ROTEM can be performed as
sic system (factor VIII, IX, XI, XII). Using the a point-of-care hemostasis monitoring test. Both
cutoff value of international normalized ratio of tests evaluate the speed and strength of clot for-
more than 1.5 times normal, PT demonstrates mation as well as clot stability; both help to evalu-
a sensitivity of 88% and a specificity of 88% in ate hemophilia, fibrinogen deficiency, factor XIII
detecting at least one non-hemostatic coagula- deficiency, and fibrinolytic state [33]. Reference
tion factor level after trauma, whereas aPTT ranges can vary from institution to institution.
(more than 1.5 times normal) demonstrates a Clinical results of both tests can be similar, but the
sensitivity of only 50% and a specificity of 100% two results are not interchangeable [34]. Systemic
because factor VIII is often increased as an acute fibrinolysis is suspected when clot breakdown is
phase reactant in trauma and surgical patients observed within 1 hour [35].
139 10
a b
.. Fig. 10.1 a The excised specimen was grossly 9cm in microscopically showed normal splenic tissue with a firm
diameter, had a giant hematoma surrounded by gray hrad capsule [60]
parenchyma witha smooth capsule. b The specimen
.. Table 10.5 Advantages/disadvantages of POC

Box 10.2 Limitations of PT/aPTT [32]
testing [39]
55 PT and aPTT do not provide any clue about
in vivo interaction of platelets with coagu-
Advantages of POC Disadvantages of POC
lation factors.
testing testing
55 PT and aPTT remain prolonged even if
thrombin generation is improved because
Only a small volume No single POC coagulation
of antithrombin or protein C deficiency.
(1–5 ml) of blood is test covers the functioning
55 PT/aPTT does not tell about the overall
needed for testing of the entire hemostatic
stability of a hemostatic thrombus because
system
both tests are terminated at very low throm-
bin levels and before fibrin is polymerized. Rapid availability of Hypo- and hyperthermia
results affect the results
Lab transportation Total cost of POC exceeds

of blood sample is that of conventional
10.4.2 Electrolytes Alterations no longer necessary coagulation testing
Can be carried out Pre-existing coagulopa-

Serum calcium: Since massive hemorrhage is without specialized thies can alter the results
accompanied with massive blood and blood prod- training
ucts replacement, electrolyte alterations are com-
mon consequences particularly serum calcium
levels as it plays an important role in coagulation
cascade and has an inotropic effect on cardiac 10.4.3 Point-of-Care Testing
myocytes. RBCs are stored in citrate, a calcium-
chelating agent. So, massive transfusion leads to It includes basic electrolytes, serum glucose level,
potentially severe hypocalcemia [36]. lactate measurement, arterial blood gas analysis,
Serum magnesium: Citrate also binds magne- and Hb/Hct ratio. Timely measurement of these
sium like calcium, so patient may develop hypo- parameters facilitates assessment of occurrence
magnesemia resulting into certain fatal cardiac and severity of any disturbance and helps its man-
manifestations as well. agement accordingly. Currently POC testing is
Serum potassium: Hypokalemia or hyperka- usually suggested in most of trauma patients who
lemia may also occur because of release of stress have significant injuries but not enough to acti-
hormones or reentry of potassium ions into trans- vate a massive transfusion protocol (MTP) [38].
fused RBCs or higher potassium concentration in The advantages and disadvantages of POC are
stored RBCs [37]. summarized in . Table 10.5.

140 U. Iqbal et al.
10.5 Anesthetic Management Packed Red Blood Cells (RBCs)

of Massive Perioperative For many decades, the decision to transfuse RBCs
Hemorrhage has been based upon the “10/30 rule” that means
transfusion was used to maintain a blood hemo-
Anesthetic management strategies of massive globin concentration above 10 g/dl (100 g/L)
perioperative hemorrhage are summarized in and a hematocrit above 30% [41]. These guide-
. Table 10.6.

lines were revised by the National Institutes of
Health Consensus Conference in 1988 and many
times afterward. Basically, there is no universally
10.5.1 Non-pharmacologic accepted single criterion for RBC transfusion. It
Management varies with patient’s clinical status and oxygen
delivery needs and from institution to institution.
10.5.1.1 Transfusion Oxygen delivery = cardiac output × arterial
oxygen content
Blood products transfusion is generally consid-
In healthy subjects, oxygen delivery is
ered for massive perioperative hemorrhage [40],
increased by increasing cardiac output, but in crit-
except in those patients with unique religious
ically ill patients, oxygen delivery becomes more
believe such as Jehovah’s Witness which prohibits
dependent on arterial oxygen content [42]. So, the
any blood product infusion (7 Box 10.3).
higher hematocrit, the more oxygen will be deliv-

ered to tissues. Following is the blood transfusion

guidelines for hemodynamically stable patients
.. Table 10.6 Management strategies of massive without active bleeding (. Table 10.7).

10 perioperative bleeding For patients with massive bleeding or hemo-

dynamically unstable, blood transfusion should
Management of massive perioperative hemor
be guided by the ability to achieve hemostasis and
rhage
the rate of bleeding, rather than by the hemoglobin
Non-pharmacologic Pharmacologic level alone. Therefore, the decision of transfusion
Transfusion Desmopressin
Temperature management Tranexamic acid

.. Table 10.7 Blood transfusion guidelines [41]
Patient positioning Aminocaproic
acid Hemoglo Comments
bin Level
Acid-base balance Aprotinin
<6 g/dl Transfusion recommended except in
Damage control resuscitation Vasopressors
exceptional circumstances
Other non-pharmacologic
6–7 g/dl Transfusion generally likely to be
measures
indicated
7–8 g/dl Transfusion may be appropriate in

patients undergoing orthopedic
surgery or cardiac surgery
8–10 g/dl Transfusion generally not indicated

Box 10.3 Currently Available Blood Prod
but should be considered for some
ucts for Massive Perioperative Hemorrhage populations such as those with
Therapeutic agents generally considered for symptomatic anemia, ongoing
massive perioperative hemorrhage: bleeding, acute coronary syndrome
55 RBCs with ischemia, and hematology/
55 Fibrinogen oncology patients with severe
55 Fresh frozen plasma (FFP) thrombocytopenia who are at risk of
55 Cryoprecipitate bleeding
55 Albumin
55 Prothrombin complex concentrates >10 g/dl Transfusion generally not indicated
55 Recombinant factor VII except in exceptional circumstances
141 10
in acutely hemorrhaging patients cannot rely on Plasma
thresholds. Another concern is whether admin- Plasma is extensively transfused in surgical and
istration of fresher blood improves clinical trauma patients, but research shows there is no ben-
outcome or not. One study demonstrated that efit for most of the clinical conditions except trauma
fresher blood did not improve clinical outcomes [47]. Some studies showed that the risks of excessive
as compared to stored standard-issue blood [43]. plasma transfusion might outweigh the benefits,
Without any doubt, RBC transfusion during sur- hence proving to be harmful [48]. Plasma has three
gical hemorrhage can potentially improve out- different preparations as illustrated in 7 Box 10.4.

come and even be lifesaving in bleeding patients. FFP contains all the components in donor
However, it is challenging we may not be able to plasma, including albumin and immunoglobulins
completely delineate the relative contributions of and procoagulant, anticoagulant, and antifibri-
hemodynamic instability, systemic inflammatory nolytic factors. If thawed, FFP is kept at 1–6 °C
reaction, and the transfusion-related side effects for 5 days, and such plasma can be used in acute
to the adverse clinical outcomes associated with emergencies for massive transfusion. There are
surgical blood loss [44]. some safety concerns as well with this FFP use:
first being the transfer of viral infection that can
Fibrinogen be reduced in the future with use of viral-free
Fibrinogen provides a matrix and mesh network plasma products [49] and second being fluid
essential for clot strength, thus an important overload and multiple organ failures because a
therapeutic product for bleeding control in peri- large volume of FFP is required to meet required
operative settings. Following massive hemorrhage, serum coagulation factors level [50]. It should be
hypofibrinogenemia occurs because of hemodilu- kept in mind that these plasma preparations are
tion from volume replacement and consumption never a good source of fibrinogen as fibrinogen
by clotformation. So, the clot strength is evaluated concentration can vary 1–3 g/l. A large volume of
by thromboelastography, and fibrinogen is admin- plasma is required to replenish required fibrino-
istered along with other clotting factors to control gen level that can lead to volume overload instead
perioperative bleeding [45]. Four fibrinogen pre- [51]. The ideal choice for fibrinogen replacement
cipitates are currently available and used all over. It is fibrinogen precipitate or cryoprecipitate.
is important to note that high fibrinogen levels can
lead to high thrombin generation and ultimately Cryoprecipitate
thromboembolic events. Also of note, fibrino- Cryoprecipitate contains factor VIII, fibrinogen,
gen concentrate must be reconstituted by adding fibronectin, von Willebrand factor (vWF), and fac-
water and agitating for several minutes and has tor XIII used widely for congenital and acquired
a somewhat limited shelf-life. To raise the serum coagulopathies. In 2007, the first version of the
fibrinogen level by of 1 g/L, 60 mg/kg of fibrinogen European guidelines on the management of bleed-
administration is required [46] (. Table 10.8).
ing after major trauma recommended treatment
with fibrinogen concentrate or cryoprecipitate if
significant bleeding is accompanied by a plasma
.. Table 10.8 Suggested bleeding management fibrinogen level <1 g/L; updates to these guidelines
with focus on fibrinogen repletion strategy [46] were in 2010 [52]. Generally, 1 unit of cryopre-
cipitate per 10 kg of body weight will increase the
Suggested bleeding management with focus on
fibrinogen repletion strategy
fibrinogen level by about 0.5 g/L. The target thresh-
old of 1.0 g/L has been pushed up to 1.5 g/L in many
1 Fibrinogen level is Fibrinogen concen-
<1.5–2 g/l trates 25–50 mg/l
Cryoprecipitate
8–10 units Box 10.4 Types of Plasma Preparations
2 Platelets are Platelet concentrate Different plasma preparations
<100,000/mm 8–10 units 55 Fresh frozen plasma (FFP)
55 Plasma frozen within 24 h of collection
3 INR >1.7 OR FFP 20–30 ml/kg 55 Thawed plasma (used within 5 days of
hypovolemia initial thaw)
142 U. Iqbal et al.
institutions (2.5 g/L in obstetric hemorrhage) [53]. of vitamin K in patients requiring urgent surgery,
The following are indicationsfor three recommen- i.e., within 6 h. Generally, it is not recommended
dations of cryoprecipitate use: congenital fibrinogen for massive transfusion and coagulopathy associ-
deficiency, bleeding patients with von Willebrand’s ated with liver dysfunction. Patients with heparin-
disease, and the correction of microvascular bleed- induced thrombocytopenia (HIT) are the absolute
ing in massively transfused patients with fibrinogen contraindication [62]. FDA has approved PCC use
concentrations less than 80–100 mg/dl [54, 55]. only in warfarin-related bleeding because only vita-
In a randomized controlled trial, efficacy of FFP min K-dependent factors are affected in it, while
infusion was compared with cryoprecipitate sup- perioperative coagulopathy involves deficiency of
plement; the result suggested FFP were more effi- multiple coagulation defects like thrombocytope-
cacious, and FFP produced a significantly greater nia, hypofibrinogenemia, and hyper-fibrinolysis
improvement in INR and activated partial throm- [63]. There is a risk of thromboembolic events with
boplastin time (aPPT) and resulted in less exposure use of these PCC as well, first reported many years
to blood products than cryoprecipitate [56]. ago. In 1990s many activated factors were removed
from PCC to improve its safety. In today’s PCC,
Albumin factor II called prothrombin is identified as the
During surgery, circulation is usually supported main culprit causing thrombogenicity. That’s why
by crystalloids or colloid as a temporizing mea- it is recommended that PCC should be labelled
sure when there is an impending need for blood according to prothrombin content as compare to
transfusion. Colloids such as albumin and hydro- Factor IX [63]. Three retrospective clinical studies
xylethyl starch (HES) are advantageous since they have shown that although PCC alone can attenuate
may remain in the intravascular compartment bleeding, it is more effective when used combined
10 longer than crystalloid [57]. A meta-analysis found with FFP [45, 64]. In another study in a rabbit
increased perioperative bleeding and need for trans- model of hemostasis, four-factor prothrombin
fusion with the use of albumin compared to admin- complex concentrate administration significantly
istration of hydroxyethyl starch. Albumin may decreased edoxaban (oral anticoagulant)-associ-
reduce the platelets activation and release of inflam- ated hemorrhage, and edoxaban-induced factor
matory mediators. Another randomized controlled Xa inhibition and a nticoagulant effect have been
trial compared the effect of albumin administration shown to be similar in rabbits and humans [64].
and Ringers’ lactate (LR) during a major surgery
and found similar blood loss in the two groups of Recombinant Factor VIIa
patients yet increased need for transfusion of blood Recombinant activated factor VIIa is approved in
in the albumin-treated group [58]. A randomized Europe for the management of hemophilia A or
clinical trial studied the impact of albumin on B with inhibitors, acquired hemophilia, inherited
coagulation competence and hemorrhage during factor VII deficiency, and Glanzmann thrombas-
a major surgery. Resultsshowed that the periopera- thenia with antibodies to glycoprotein IIb/IIIa
tive use of 5% albumin compared to LR to support and/or human leucocyte antigens and refrac-
the circulation during cystectomy reduces the post- toriness to platelet transfusion. It is also recom-
operative volume surplus but affects coagulation mended in massive perioperative hemorrhage in
competence and has no impact on postoperative those patients who do not have already existing
complications or hospital stay [59]. coagulopathy. It is effective in reversing the coag-
ulopathy but is associated with widespread arte-
Prothrombin Complex rial thrombosis too. So, recombinantfactor VIIa is
Concentrates (PCC) not the priority until the last option [64].
Prothrombin complex concentrate (PCC) is a term
to describe pharmacological products that con-
tain lyophilized, human plasma-derived vitamin 10.5.2 Massive Blood Transfusion
K-dependent factors II, II, X, and X and various Protocol
amounts of proteins C and S. PCC is administered
at bedside irrespective of blood group and usually While most institutions have developed their
given to patients using oral anticoagulants [61]. It own massive transfusion protocol (MTP) involv-
is also effective for warfarin reversal or deficiency ing multidisciplinary committee, the common
143 10
theme of all such protocols is determining spe- MTP can lead to some complications such as
cific triggers for activation of MTP, transfusion acid-base disturbances, electrolyte abnormalities,
end targets, and the logistics of blood product and and hypothermia, in addition to acute trauma
adjunct availability [65]. A sample MTP is shown coagulopathy, which are reviewed in the table
in 7 Box 10.5.
below.
Generally, MTP is activated after replacement
of total blood volume in 24 h needing ≥10 units of 10.5.2.1 Temperature
packed RBCs, replacement of >4 units of packed Hypothermia is associated with significant coagu-
RBCs in 1 h with the anticipation of continuous lopathy. Hypothermia is defined as 35 °C or below
need for blood products, or replacement of 50% since enzyme denaturalization occurs at this
of the total blood volume within 3 h and blood temperature [70]. The following are the effects
loss of up to 1.5 ml/kg/min for more than 20 min. of low temperature on coagulation, as shown in
In children, this is activated after transfusion of 7 Box 10.6.

4–10 units [68]. MTPs may have a predefined

ratio of RBCs, FFP/cryoprecipitate, and platelet 10.5.2.2 Patient Positioning
units in each pack (e.g., 1:1:1 or 2:1:1 ratio) for Performing a straight leg raise or exaggerated
transfusion [69]. It is recommended to use the fol- lithotomy position has been shown to increase
lowing MTP checklist. cardiac output and to increase coronary and cere-
bral perfusion pressure, respectively, for between
5 and 10 min. In case of sudden severe blood loss
Box 10.5 Sample Massive Transfusion Proto when leg raising or exaggerated lithotomy position
col from the National Blood Authority [66, 67] is not possible, then 5 degrees of Trendelenburg
Massive transfusion protocol (MTP) checklist: position or keeping the patient in a level position
55 Is raising the patient’s legs possible? (Avoid
head-up position.)
is recommended [71].
55 Inform transfusion medicine doctor “on call”
that the MTP has been activated. 10.5.2.3 Acid-Base Balance
55 Call for help (e.g., anesthesia clinical assis- Maintenance of acid-base balance is critical in
tant [ACA] or second anesthesiologist), or massive perioperative hemorrhage. In trauma
assign a nurse or ACA to check blood prod-
ucts and do charting.
patients, acidosis is usually induced by tissue
55 Start arterial catheter after large-bore hypoperfusion leading to anaerobic respiration
intravenous access has been established at and lactic acid production. This metabolic aci-
two sites (14–16G peripheral intravenous dosis impairs almost all components of coagula-
lines preferred; consider large-bore sheath tion. At pH <7.4, platelets change their shape and
introducer or dialysis-type catheter).
55 Is cell salvaging an option? Call the perfu-
structure. Impaired thrombin generation due to
sionist “on call.” reduced activity of coagulation factor complexes
55 Send baseline blood work (type and screen, on the cell surface is a major cause of coagu-
CBC, INR, fibrinogen, electrolytes/biochemistry). lopathic bleeding. Furthermore, acidosis leads
55 Has systemic anticoagulation been to increased degradation of fibrinogen which
reversed?
55 Is salvage surgery (i.e., packing and revisit-
further aggravates the coagulopathy. Therefore,
ing later) an option? maintaining a delicate acid-base balance in a mas-
55 Ask the surgeon: “Should we call a vascular sive perioperative hemorrhage is mandatory for
surgeon or other assistance for you?” the anesthesiologists.
55 Fluid/blood warmer (rapid infuser set up?).
55 Forced air heater or other warming device
(if <37 °C).
55 Should calcium administration be consid- Box 10.6 Effects of Hypothermia on Coag
ered? ulation [66]
55 Consider intravenous tranexamic acid 55 Increase in fibrinolysis
(15–30 mg·kg-1). 55 Reduced synthesis of coagulation factors
55 Consider NaHCO3 or THAM for a pH <7.2. 55 Activation of clotting cascade is slowed
55 Change blood filter every four transfusions down
if possible (and change the 3-L reservoir 55 Direct inhibition of platelets through
every 4 h). sequestration
144 U. Iqbal et al.
10.5.2.4 Damage Control of leukocyte-depleting filters removes nearly

Resuscitation all cancer cells. Randomized trials suggest
This concept was first proposed in the mid-2000s that the use of intraoperative cell salvage
as an alternative approach to manage the hemor- (ICS) with LDFs results in no difference in
rhagic shock. Damage control resuscitation com- long-term survival or tumor recurrence.
ponents are shown in 7 Box 10.7 [72, 73].

Nevertheless, the use of cell salvage tech-
niques in cancer surgery remains controver-
10.5.2.5 Other Non-pharmacologic sial [76].
Management 4. Intraoperative normovolemic hemodilution:
Other non-pharmacologic measures are outlined In this technique, whole blood is withdrawn
in 7 Box 10.8.

from a patient by venesection and is replaced
1. Piggyback technique: Instead of two by other isotonic fluids. This blood is then
end-to-end anastomoses in the classic re-transfused intraoperatively and postopera-
technique, piggyback involves anastomos- tively as required. This preserves the integrity
ing the donor retrohepatic vena cava of RBCs and clotting factors [74].
directly to the recipient inferior vena cava
to help patient better tolerate the hypovole-
mic state [74]. 10.5.3 Pharmacologic Management
2. Low CVP level: A CVP of less than 5 mmHg
is required to reduce intraoperative bleeding. 1. Desmopressin: Desmopressin enhances
However, there are the risks associated with platelet activation and thrombus formation
maintaining a low CVP including cardiovas- and thus restores hemostasis perioperatively.
10 cular instability and air embolism [75]. It does not change whole blood thrombo-
3. Intraoperative blood salvage technique: elasticity and coagulation times. Adverse
Autologous blood transfusion and intraop- effects may include transient hypotension
erative blood salvage are useful techniques or tachycardia due to endothelial release of
for the special patient population like nitric oxide potentially induced by desmo-
Jehovah’s Witnesses and patients with rare pressin [77].
blood types, undergoing surgery with high 2. Tranexamic acid: The use of tranexamic acid
risk of intraoperative blood loss and transfu- in massive postpartum hemorrhage seems
sion. Cell salvage may be used in obstetric, to be promising. A randomized, multicenter
cardiac, vascular, orthopedic, pediatric, and clinical trial enrolled 20,000 obstetric
oncologic surgeries. Cell salvage with the use patients and showed that tranexamic acid
reduces death due to bleeding in women
with postpartum hemorrhage with no
adverse effects. Tranexamic acid should be
Box 10.7 Components of Damage Control
given as soon as the onset of bleeding to
Resuscitation
55 Rapid control of surgical bleeding
achieve the maximal benefits. Patients in
55 Early and increased use of red blood cells, tranexamic acid group were administered
plasma, and platelets in a 1:1:1 ratio 1 g tranexamic acid intravenously, while
55 Hypotensive resuscitation strategies patients in control group received normal
55 Prevention and treatment of hypothermia, saline [78]. Another study was conducted
hypocalcemia, and acidosis
55 Limitation of excessive crystalloid use
in pediatric patients undergoing scoliosis
surgery in 2005. The benefits of tranexamic
acid in controlling perioperative bleeding
were investigated. Intraoperative blood
loss was 41% lower in patients receiv-
Box 10.8 Other Non-pharmacologic Measures ing tranexamic acid (1230 +/− 535 ml)
55 Piggyback technique
55 Low central venous pressure
compared with the placebo group (2085
55 Intraoperative cell salvage +/−1188 ml, P < 0.01) [79]. Tranexamic acid
55 Intraoperative normovolemic hemodilution has also been documented to safely reduce
the need for blood transfusion in surgery
145 10
and improve important health and eco- blood loss when compared with control
nomic implications in high-, middle-, and group in a retrospective nonrandomized
low-income countries [80]. study of 110 patients85.
3. ε-Aminocaproic acid: Meta-analysis of
placebo-controlled randomized clinical tri-
als indicate that ε-aminocaproic acid admin- 10.6 Conclusions
istered before and/or during a procedure
is effective in reducing total blood loss and This chapter highlights a very important topic
the total number of patients transfused in in the field of anesthesia practice. Managing the
major orthopedic, cardiac, or liver surgery. massive perioperative bleeding is a very challeng-
Aminocaproic acid administration also lowing task, both for surgeons and anesthesiologists.
ers the requirement of blood transfusion We discussed the possible etiologies of massive
perioperatively as demonstrated by ran- perioperative hemorrhage including trauma,
domized clinical trials in knee replacement major cardiothoracic, spine surgery, liver trans-
surgery [81]. The 2015 American Society of plantation, obstetric complications, and several
Anesthesiologists’ (ASA) guidelines on peri- congenital coagulation anomalies. Incidence and
operative blood loss management suggest mortality of perioperative hemorrhage varies with
the intraoperative antifibrinolytic therapy in different causes. The most common cause is major
the perioperative setting to decrease blood trauma. The clinical presentation of massive hem-
loss and blood product transfusions in orrhage depends upon the severity and rate of
major cardiac, liver, and orthopedic surgery blood loss. Amniotic fluid embolism- induced
[82]. The dosing of ε-aminocaproic acid var- disseminated intravascular coagulation has a
ies considerably in the literature; commonly very high mortality rate that should be addressed
reported is a loading dose ranging from 25 very seriously by both obstetricians and anesthe-
to 150 mg/kg followed by a maintenance siologists. Prothrombin time, activated partial
dose of 12.5 mg–30 mg/kg/h [83]. Side prothrombin time, and international normalized
effects include seizures and renal dysfunc- ratio were the traditional laboratory tests used for
tion. Being a structural analogue of neu- diagnostic purposes for many decades, while TEG
rotransmitter: GABA, ε-aminocaproic acid and ROTEX revolutionized the diagnostic tech-
has lower seizure complications as compared niques for hemostasis by providing results quickly
to tranexamic acid [84]. and accurately, which helps clinical management
4. Aprotinin: It is a small peptide extracted from of patient in massive hemorrhage tremendously.
bovine tissues which belongs to the SERPINS Serum electrolytes also provide very useful infor-
family. It can neutralize a variety of peptides mation which helps in management decisions.
like trypsin, plasmin, and tissue and plasma Treatment strategies can be non-pharmacological
kallikrein. Due to its antiplasmin activity measures including massive blood and blood
obtained at low concentrations, aprotinin is product transfusion, surgical hemostasis, and
often used as an antifibrinolytic agent periop- maintenance of normothermia and electrolyte
eratively. Aprotinin also inhibits thrombin- and acid-base balance. And pharmacologic man-
induced platelet activation by unknown agement includes desmopressin, antifibrinolytic
mechanisms. Aprotinin was discontinued due agents, and some vasopressors.
to potential increase in long-term mortality
in coronary artery bypass surgery patients.
There are ongoing investigations attempting 10.7 Review Questions
to bring it back to clinical utilization in selec-
tive groups of patients. ?? 1. What point-of-care techniques can you
5. Vasopressors: Certain vasopressors are of use to measure fibrinogen in the surgical
clinical benefits in reducing hemorrhage bleeding patient?
associated with liver transplantation. The
use of low-dose vasopressin (0.04 U/min) ?? 2. What are the sensitive electrolyte altera-
infusion during the dissection phase of liver tions in massive perioperative hemor-
transplantation was associated with reduced rhage in trauma?
146 U. Iqbal et al.
?? 3. What is the ideal transfusion option for Br J Haematol. 2015;170(6):788–803. https://doi.

patients already using oral anticoagulants? org/10.1111/bjh.13580.
2. Cleland S, Corredor C, Ye JJ, Srinivas C, Mccluskey
SA. Massive haemorrhage in liver transplantation:
?? 4. What is the treatment of choice for dilu- consequences, prediction and management. World J
tional coagulopathy? Transpl. 2016;6(2):291–305. https://doi.org/10.5500/
wjt.v6.i2.291.
?? 5. What is the relationship between MELD 3. Haubelt H. Indications for plasma in massive. Transfu-
sion. 2002;107(Suppl 1):S19–22. PMID: 12379288.
score and blood transfusion in a patient of
4. Holcomb JB. The prospective, observational, mul-
liver transplantation? ticenter, major trauma transfusion (PROMMTT)
study. JAMA Surg. 2013;148(2):127–36. https://doi.
?? 6. What is piggyback technique? org/10.1001/2013.jamasurg.387.
5. Donohue CI, Mallett SV. Reducing transfusion require-
ments in liver transplantation. World J Transplant.
2015;5(4):165–82. https://doi.org/10.5500/wjt.
10.8 Answers v5.i4.165.
6. Pandey CK, Singh A, Kajal K, et al. Intraoperative blood
vv 1. Thromboelastometry (ROTEM; TEM Interna- loss in orthotopic liver transplantation: the predictive
tional, Munich, Germany) and thromboelas- factors. World J Gastrointest Surg. 2015;7(6):86–93.
https://doi.org/10.4240/wjgs.v7.i6.86.
tography (TEG; Haemonetics Corp., Braintree,
7. Feltracco P, Brezzi ML, Barbieri S, et al. Blood loss,
MA) are increasingly used as point-of-care predictors of bleeding, transfusion practice and strat-
devices in perioperative settings. egies of blood cell salvaging during liver transplan-
tation. World J Hepatol. 2013;5(1):1–15. https://doi.
vv 2. Hypocalcemia and hypokalemia are two org/10.4254/wjh.v5.i1.1.
8. Perkins JD. Are we reporting the same thing?: com-
10 sensitive electrolytes disturbances seen in
ments. Liver Transplant. 2007;13(3):465–6. 10.1002/
massive perioperative hemorrhage due to lt. https://iths.pure.elsevier.com/en/publications/are-
trauma. we-reporting-the-same-thing-comments.
9. Han IH, Son DW, Nam KH, Choi BK, Song GS. The effect
vv 3. Prothrombin complex concentrate (PCC) of body mass index on intra-abdominal pressure and
blood loss in lumbar spine surgery. J Korean Neuro-
is the ideal transfusion option for patients
surg Soc. 2012;51(2):81–5. https://doi.org/10.3340/
already on warfarin therapy. jkns.2012.51.2.81.
10. Akinci IO, Tunali U, Kyzy AA, et al. Effects of prone
vv 4. FFP transfusion 30 ml/kg is the treatment and jackknife positioning on lumbar disc herniation
of choice for dilutional coagulopathy and surgery. J Neurosurg Anesthesiol. 2011;23(4):318–22.
https://doi.org/10.1097/ANA.0b013e31822b4f17.
in massive transfusion scenarios.
11. Willner D, Spennati V, Stohl S, Tosti G, Aloisio S, Bilotta
F. Spine surgery and blood loss: systematic review of
vv 5. High MELD scores (>30) was found to be clinical evidence. Anesth Analg. 2016;123(5):1307–15.
significantly associated with increased https://doi.org/10.1213/ANE.0000000000001485.
bleeding and transfusion requirements 12. Anselmo MP, Jesus GN, De, Lopes JM, Victorino RMM,
Santos JM. Massive bleeding as the first clinical mani-
compared to patients with low MELD
festation of metastatic prostate cancer due to dis-
scores (<30). seminated intravascular coagulation with enhanced
fibrinolysis. Case Rep Hematol. 2016;2016(January
vv 6. Piggyback technique involves anastomos- 2017):3–5. https://doi.org/10.1155/2016/7217915.
ing the donor retrohepatic vena cava 13.
Gando S. Disseminated intravascular coagula-
tion in trauma patients. Semin Thromb Hemost.
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2001;27(6):585–92. https://doi.org/10.1055/s-2001-
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151 11
Cardiovascular System
Damaging Events
J. Arthur Saus, Harish Siddaiah, and Farees S. Hyatali
11.1 Complications, Cardiac Arrest, and Local

Anesthetic Toxicity – 152
11.2 Hypertension – 152
11.2.1 Preoperative Hypertension – 152
11.2.2 Intraoperative Hypertension – 153
11.2.3 Postoperative Hypertension – 153
11.3 Hypotension – 153
11.3.1 Preoperative Assessment – 153
11.3.2 History and Physical Examination – 153
11.3.3 Intraoperative Hypotension – 154
11.3.4 Postoperative Hypotension – 154
11.4 Sinus Tachycardia – 155
11.5 Chest Pain (Angina, MI) – 156
11.6 Cardiac Arrest – 156
11.7 Local Anesthesia, Cardiotoxicity, and Other

Comorbidities – 156
References – 158

https://doi.org/10.1007/978-3-319-96125-5_11
11.1 Complications, Cardiac Arrest, A pre-procedure review of the patient’s medica-

and Local Anesthetic Toxicity tion regimen is vital since chronically, hyperten-
sive patients generally tend to be on a strict
All surgical procedures performed with the use of regimen of medications. It is imperative that the
anesthesia carry a certain amount of risk, regard- clinician be aware of the medications which need
less of the anesthetic technique used. Of course, it to be continued in the perioperative period. Most
must also be recognized that an attempt to per- antihypertensive medications are continued in
form almost any surgical procedure without prior the preoperative period except angiotensin-
administration of anesthesia would carry even converting enzyme inhibitors (ACEI). These
greater risks, and very few (if any) humans would medications need to be held pre-procedurally on
agree to have a surgical procedure performed the morning of the surgery, as their use is associ-
upon themselves without administration of anes- ated with intraoperative hypotension [4].
thesia. In particular, the risks of major cardiac Beta-blockers (β-blockers) are commonly a
events occurring in the perioperative period are mainstay of therapies for patients with a history of
quite common; however these risks can be miti- congestive heart failure and myocardial infarc-
gated or even prevented if appropriate periopera- tion. The 2008 POISE study of 8351 patients from
tive care is performed. 190 hospitals across 23 countries “with, or at risk
Prior to any surgical procedure requiring of, atherosclerotic disease” examined a composite
administration of anesthetic agents, a thorough of cardiovascular death, nonfatal myocardial
preoperative history and physical are necessary to infarction, and nonfatal cardiac arrest in patients
evaluate risk of adverse cardiac (or other) events newly started on extended-release metoprolol
and to obtain medically indicated tests prior to succinate in the immediate perioperative period.
the procedure. This evaluation of the patient’s his- Of note however, patients were excluded from the
tory and review of indicated laboratory or other POISE study if they had already been receiving
beta-blocker therapy or had a prior adverse reac-
11 preoperative tests are done to reduce, or elimi-
tion to therapy with beta-blocking drugs or had
nate, the patient’s risks. This applies especially
when the patient comes to surgery with a consid- any other contraindication to their use. This study
eration of baseline cardiac risks. Considering that included only patients started on metoprolol
patient safety is of paramount importance, a within 2–4 h prior to the surgical procedure or
detailed anesthetic plan may then be formulated within 6 h after completion of the surgical proce-
so as to reduce the chances of an untoward event dure. While this study found greater than 80% of
occurring in the perioperative period. patients in both the study and control groups had
This chapter deals with the identification and atherosclerotic cardiovascular disease, fewer
management of the major types of adverse car- patients in the study group experienced nonfatal
diac events that may occur in the perioperative myocardial infarctions, and this difference
period and includes strategies to reduce the became obvious within a few days following sur-
chance for them to occur. It is intended to also gery. This study found both risks and benefits
provide the reader with information that pertains associated with perioperative initiation of beta-
to an anesthetic plan which reduces the risk of blocker therapy. While the metoprolol group had
such events. fewer nonfatal myocardial infarctions, there were
actually more cardiovascular and non-
cardiovascular deaths, nonfatal cardiac arrests,
11.2 Hypertension fatal and nonfatal strokes, congestive heart failure,
clinically significant hypotension, and clinically
11.2.1 Preoperative Hypertension significant bradycardia in the group of surgical
patients newly treated with metoprolol in the
Preoperative evaluation of patients begins with a perioperative period for this study [3].
detailed history and physical. The patient should A report from the American College of
be questioned about whether or not the underly- Cardiology/American Heart Association Task
ing medical conditions are well controlled, the Force on Practice Guidelines, published in 2014 in
patient’s current medication regimen, and the Circulation, further examined this study and oth-
patient’s compliance to the medication regimen. ers, then came to the conclusion that periopera-
Cardiovascular System Damaging Events
153 11
tive beta blockade started within 1 day or less response to pain can be treated with intraoperative
before non-cardiac surgery prevents nonfatal MI opioids as well as antihypertensive medications
but increases the risk of stroke, death, hypoten- such as beta-blockers, nitrates, calcium channel
sion, and bradycardia. This report also stated that blockers, and rapid-acting Angiotensin Converting
there was insufficient data to determine risks or Enzyme Inhibitors (ACEI) [5]. Nitroglycerin, nitro-
benefits if beta-blocker therapy was started 2 or prusside, and milrinone can be used to control IH
more days prior to surgery. This seemed to high- during cardiac surgery. Heart rate should also be
light the benefit of continuing beta-blockers in the considered when treating IH as an increased heart
perioperative period in those patients who have rate may increase myocardial oxygen demand in
chronically used beta-blockers, as their use was these patients and predispose to ischemia [5].
shown to reduce the incidence of perioperative
MI and stroke [8]. Conversely, it discouraged ini-
tiation of beta-blocker treatment in the periopera- 11.2.3 Postoperative Hypertension
tive period as this appears to increase the risk for
perioperative hypotension, MI, and stroke [3, 8] Common causes of postoperative hypertension are
There is also a need to determine whether pain, hypercarbia, hypoxemia, and emergence from
hypertension associated with tachycardia is due to general anesthesia. Patients should be monitored in
a secondary cause such as anemia or renal failure. the PACU to ensure all vital signs return to within
This is important because it may warrant obtain- normal limits [5]. Postoperative Hypertension can
ing tests such as a complete blood count and a be treated with beta-blockers, α2-agonists and also
complete metabolic panel to determine the sever- clevidipine; the ideal regimen should be rapid act-
ity of disease as well as to determine the baseline ing, inexpensive, safe, and convenient [5].
function of the patient [2]. If treatment of reversible causes of hyperten-
Social history of the patient also contributes to sion, as well as antihypertensive administration, do
preoperative evaluation concerns, as smoking, not lower the blood pressure to an acceptable blood
obesity, lack of exercise, and/or history of drug pressure, the patient should be admitted to inpa-
use are modifiable causes of hypertension. tient unit or ICU ward for further monitoring [5].
Controlling these factors preoperatively may also
help in optimization of the patient [2].
Causes of elevated BP that should be ruled out 11.3 Hypotension
in the perioperative setting include:
55 Pain 11.3.1 Preoperative Assessment
55 Anxiety
55 Hypoxemia Since many factors contribute to baseline blood
55 Hypervolemia pressure for any individual, positional changes,
medical comorbidities, and potentially a host of
Patients with preoperative blood pressures of other factors influence an individual’s blood pres-
≤180/110 mmHg may proceed with surgery sure. Changes from baseline should lead one to
(unless there is evidence of end-organ damage). assess the patient for causes of hypotension. As
Evidence of end-organ damage in patients with mentioned before, ACEI should be discontinued
such blood pressures is defined as hypertensive prior to the procedure to prevent intraoperative
emergency which mandates the need for medical hypotension.
management to prevent worsening of sequelae [2].
11.3.2 History and Physical

11.2.2 Intraoperative Hypertension Examination
Intraoperative hypertension (IH) can be caused by A thorough history and physical exam prior to
increased sympathetic stimulation from tracheal any procedure is key. Prior to the procedure, the
intubation as well as response to pain. IH from patients may not have had any fluid intake for
tracheal intubation can be treated with lidocaine, approximately 8 h; this predisposes the patient to
fentanyl, and esmolol [5]. Increased sympathetic intravascular volume depletion [2]. This is felt to
be a common cause of preoperative hypotension myocardial infarction following non-cardiac

and exacerbation of hypotension at the moment surgery [1, 5]. Studies have shown an association
of anesthesia induction. Although currently there between short episodes of IOH (MAP < 55 mmHg)
is no clinically useful method to reliably and accu- and perioperative myocardial infarction, acute
rately determine a patient’s intravascular volume, kidney injury (AKI), and cerebrovascular acci-
a reliable method to make this determination is dent (CVA) as well as a higher mortality rate in
needed. Currently the best estimate of preopera- both cardiac and non-cardiac surgery [1, 6–8].
tive intravascular fluid depletion is achieved by
considering the fluid deficit from duration of 11.3.3.2 Treatment
NPO status, based on the patient’s body mass, Hypotension may be due to hypovolemia due to
added to recognized sensible losses related to blood loss or inadequate fluid resuscitation and
acute preoperative blood loss, emesis, diuresis, can be treated with a fluid bolus as well as com-
and diarrhea [2]. mon intraoperative vasopressors such as phenyl-
ephrine and ephedrine. The clinician must be
wary of pneumothorax especially in patients
11.3.3 Intraoperative Hypotension undergoing laparoscopy as intraoperative pneu-
mothorax can produce a sudden hypotension
11.3.3.1 Etiology with asystole or pulseless electrical activity [2].
Intraoperative hypotension (IOH) appears to be a
common phenomenon, but an exact definition of
specific parameters to diagnose intraoperative 11.3.4 Postoperative Hypotension
hypotension is somewhat elusive. Rather than a
specific systolic, mean, or diastolic blood pressure 11.3.4.1 Etiology
value as a clear definition of intraoperative hypo- Mild postoperative hypotension is commonly
11 tension, general consensus is that a decrease in
systolic blood pressure greater than 20% below
observed in the post-anesthesia care unit (PACU)
but usually does not require intensive treatment.
the individual patient’s baseline value is often cho- Significant hypotension is often defined as a
sen to define perioperative hypotension. Although decrease of SBP of at least 20% below the indi-
the incidence of postoperative stroke appears to vidual patient’s baseline and usually requires
be uncommon and is felt to be primarily due to an treatment [2]. Causes of significant postoperative
embolic phenomenon, there is some evidence hypotension are generally hypovolemia, left ven-
that the duration of hypotension during a surgical tricular dysfunction, and arterial vasodilation
procedure influences the risk of a postoperative (which is usually related to prolonged infusion of
finding of an ischemic stroke [1]. In a case- anesthetic agents); hypovolemia is by far the most
controlled study within a retrospective cohort of common cause of hypotension in the post-
48,241 patients undergoing general anesthesia, anesthesia care unit [2, 5].
Bijker et al. found evidence suggesting that the
duration of intraoperative hypotension, defined 11.3.4.2 Hypovolemia
as changes up to a 30% reduction in a patient’s Hypovolemia can be divided into absolute hypo-
mean arterial blood pressure from baseline val- volemia or relative hypovolemia. Absolute hypo-
ues, correlated with increasingly greater risks of volemia may be due to fluid sequestration by
postoperative stroke within the first 24 h up till tissues, wound drainage, or hemorrhage. Relative
10 days later in patients undergoing non- hypovolemia may occur due to vasodilatory
cardiovascular, non-neurologic surgery [1]. effects from local anesthetics, venodilators, and
Procedures of longer duration may lead to alpha-adrenergic blockade. Hypotension may
increased fluid losses resulting in IOH unless also occur from sepsis or from anaphylactic reac-
appropriate fluid resuscitation is performed. If tions to medications. In these situations, a combi-
IOH persists, it can disturb organ perfusion and nation of vasodilation and hypovolemia secondary
lead to ischemic damage to end organs. Even to fluid loss is generally present [2].
short episodes of intraoperative hypotension with Hypotension which occurs due to a tension
mean arterial pressure <55 mmHg are associated pneumothorax or cardiac tamponade generally
with increased risk of acute kidney injury and results from impairment of blood return to the
155 11
right heart. A new onset of left ventricular placement, even before radiographic confirma-
dysfunction in a previously healthy patient under- tion. Severe hemodynamic compromise is likely
going a surgical procedure is a less common cause to follow rapidly if a tension pneumothorax is left
of postoperative hypotension. When it does occur, untreated while attempting to obtain confirma-
it is generally seen in patients with underlying coro- tory studies [2].
nary artery disease, valvular heart disease, or con- Previously, rapidly obtaining a chest X-ray to
gestive heart failure. This etiology of left ventricular confirm or rule out pneumothorax was consid-
dysfunction can be precipitated by fluid overload, ered an important step in the management of this
myocardial ischemia, increases in afterload, and diagnosis. Currently, a rapid ultrasound exam of
arrhythmias. Venous pooling of blood in peripheral the thorax searching for the “lung sliding sign” is
tissues is a more likely etiology of a sudden onset of now recommended and can often be performed
hypotension and reduced cardiac output [2]. more quickly in the immediate postoperative set-
ting. If found to be present, tension pneumotho-
11.3.4.3 Treatment rax needs to be treated.
Mild hypotension is a common side effect follow- Another consideration for the hypotensive
ing anesthesia administration, as many anesthetic post-op patient is to search for Beck’s triad (muf-
agents produce vasodilation. Significant hypoten- fled heart sounds, increased jugular venous dis-
sion, defined as 20–30% reduction of blood pres- tention, and hypotension with increased pulse
sure below the patient’s baseline level, usually pressure) which suggests cardiac tamponade,
requires correction, and the treatment is based on especially in patients following chest trauma or
the ability to assess intravascular volume [2]. A those who are immediately post cardiothoracic
fluid bolus of 250–500 cc of crystalloid or a 100– procedure [2].
250 cc bolus of a colloid may be used in most situ-
ations as a test of a hypovolemic etiology and also
acts as a therapeutic maneuver concurrently. An 11.4 Sinus Tachycardia
increased blood pressure in response to this fluid
administration generally confirms hypovolemia During the preoperative period, sinus tachycardia
as the etiology. With severe hypotension, a vaso- might result from anxiety, pain, hypovolemia, or
pressor or inotrope may be necessary to increase withdrawal of beta-blockers. Intraoperatively
arterial blood pressure until the intravascular vol- sinus tachycardia may be due to pain from surgi-
ume deficit is corrected [2]. cal stimulation, light anesthesia, hypovolemia,
One must monitor for signs of cardiac dys- hypotension, or administration of sympathomi-
function in patients with a history of heart dis- metic agents. In the postoperative period, post-
ease or cardiac risk factors [2]. Failure of a patient surgical pain or hypovolemia may cause sinus
to respond to initial measures attempting to cor- tachycardia [9, 11].
rect hypovolemia should prompt evaluation of Depending on the cause, administration of
cardiac function via echocardiography or inva- opioids, crystalloids, or anesthetic agents might
sive monitoring. Manipulation of preload, cardiac help relieve sinus tachycardia. If tachycardia is
contractility, and afterload may be necessary to still persistent after the above measures, then
correct the apparent hypovolemia in these administration of short-acting beta blocker like
patients [2]. esmolol might help to reduce heart rate [10, 12].
When examination of the hypotensive post- Sinus tachycardia in patients with co-existing
operative patient also reveals unilateral breath coronary artery disease might be detrimental
sounds and tachycardia, the diagnosis of tension since it will increase the oxygen demand/supply
pneumothorax should be high on the list of dif- ratio within cardiac muscle. Hence it is crucial to
ferential diagnoses. Deviation of the trachea, maintain heart rate within normal limits in such
away from the side of the tension pneumothorax, patients.
helps confirm the presence of a severe tension If the tachycardia remains persistent, then a
pneumothorax. If symptoms suggesting a tension cardiologist should be consulted to evaluate the
pneumothorax are found, this should be treated patient, especially to rule out underlying
rapidly and aggressively with immediate decom- tachyarrhythmia that might progress to fatal
pression via pleural aspiration and chest tube arrhythmias.
11.5 Chest Pain (Angina, MI) tion may also be a cause for myocardial dysfunc-
tion. Acidosis may occur secondary to sepsis,
Patients with significant coronary heart disease bowel infarction, or other etiologies.
may demonstrate ischemia of cardiac muscula- Tension pneumothorax may result from a
ture which manifests clinically as chest pain or spontaneous rupture of emphysematous bullae or
angina. Unless it is considered that the patient from an iatrogenic etiology during placement of a
with symptoms consistent with angina or chest subclavian vein catheter. The risk of a vascular air
pain must go to surgery emergently, any patient embolus, resulting in sudden, otherwise unex-
with these symptoms should be first evaluated via plained, cardiac collapse, is also present while
a left heart catheterization by a cardiologist to placing a central venous catheter.
check the extent of coronary lesions. Embolic phenomena may also be the etiology
If it is an emergency surgery and the patient of sudden cardiac arrest. Pulmonary emboli may
exhibits symptoms of ongoing angina, then result from a pre-existing deep vein thrombosis.
administration of sublingual nitroglycerine is rec- Coronary thrombosis may result from a sudden
ommended to relieve the symptoms. During the dislodgement of an atherosclerotic plaque.
surgical procedure, myocardial oxygen supply Standard CPR guidelines should be followed
and demand ratio should be kept normal as pos- while resuscitating a patient with cardiac arrest.
sible. This may be achieved by keeping the heart Any reversible causes such as hypoxia, hypother-
rate and blood pressure as close to patient’s preop- mia, hyperkalemia, hypotension, acidosis, tension
erative baseline. During the intraoperative period, pneumothorax, or cardiac tamponade should be
a continuous infusion of nitroglycerin may be corrected immediately in the operating room.
started to decrease the preload as well as dilate the Treatment of pulmonary emboli includes embo-
coronary vessels. lectomy, fibrinolytic therapy, or anticoagulant
Intraoperatively, transesophageal echocar- therapy. Treatment of coronary thrombus includes
diography is useful to monitor cardiac wall angioplasty, stent placement, or emergency coro-
11 motion abnormalities. If needed, infusions of ino- nary bypass surgery [11, 13].
tropic agents and vasopressors such as epineph-
rine, norepinephrine, dobutamine, milrinone, etc.
may be initiated to support cardiac function. 11.7 Local Anesthesia,
Placement of a central line is often useful to Cardiotoxicity, and
deliver these inotropic agents and vasopressors. Other Comorbidities
Placement of a pulmonary artery catheter might
also be necessary to monitor pulmonary artery Some degree of temporary cardiovascular depres-
pressures. sion and some mild decrease in blood pressure
Postoperatively the patient should be admit- are expected to occur each day, as the heart rate
ted to a cardiac ICU for recovery [9, 10]. slows when a person goes into the state of natural
sleep. Likewise, in anesthesia practice, some
degree of cardiac depression is expected to occur
11.6 Cardiac Arrest from the use of anesthetic agents which provide
progressively deeper states of sedation and gen-
Cardiac arrest during the perioperative period eral anesthesia. Additionally, some degree of car-
may result from various causes. Hypoxia, hypovo- diac depression may be pre-existing in a patient
lemia, hypothermia, hypokalemia, hyperkalemia, who presents for a surgical procedure due to car-
acidosis, tension pneumothorax, cardiac tampon- diotoxicity from medications the patient is using
ade, pulmonary thrombosis, or coronary throm- prior to administration of any anesthetic agent.
bosis are often the etiology. The greatest concern of severe cardiac depres-
An absolute or relative hypovolemia may sion and cardiac toxicity from administration of
result from acute surgical blood loss, but may also an anesthetic agent (instead of just a mild sleep-
occur during induction with anesthetic agents related cardiovascular depression) is due to the
due to the sudden onset of vasodilation effects inadvertent intravascular administration or
upon administration of these medications. absorption of bupivacaine. With proper adminis-
Hyperkalemia from succinylcholine administra- tration, bupivacaine provides a long-lasting block
157 11
of sensory and motor nerves, as well as potentially in nerve cell membranes. Their time to onset, dura-
blocking autonomic nerves in the area covered by tion of action, and adverse effects are all drug-specific,
the block when used in regional anesthesia. An though they share similar characteristics [14, 15].
inadvertent intravascular administration of bupi- With the chance discovery that intravenous
vacaine usually results in severe, life-threatening lipid emulsion administration may improve the
cardiovascular complications and severe depres- chance of successful resuscitation, recommenda-
sion of the central nervous system which is often tions now include assuring that lipid emulsion
accompanied with transient seizure activity. is immediately available in every location where
Cardiovascular collapse from accidental intravas- regional anesthetic administration occurs. Initially,
cular injection of a regional anesthetic is a rare recommendations were to have 500 cc of 20% lipid
but often catastrophic complication. Why does emulsion available whenever an injection was
this happen? How is it that anesthetics adminis- done for a regional anesthetic block. There have
tered around a nerve or bundle of nerves provide also been reports of successful initial resuscitation,
desirable results, but if too much of the otherwise but with the cardiac dysfunction returning within
proper dose is administered intravascularly, tox- the following 60 min. More recent recommenda-
icity rapidly occurs, and reversal of those effects is tions are that 1000 cc of this 20% lipid emulsion
traditionally felt to be exceedingly difficult? should be readily available, so that a repeated rapid
Administration of toxic doses of local anes- administration may be done if needed.
thetics increases disruptions of cellular mecha- As suggested at the beginning of this discus-
nisms, thus interfering with inotropic function, sion, a patient presenting for surgery may already
pathways that regulate Na+, K+, and Cl− ion flow, have some degree of cardiovascular depression as
modulation of the autonomic nervous system, and a “pre-existing condition” from other medical
enzymatic processes for adenosine triphosphate conditions such as a tumor either compressing
formation. This mechanism is the desirable result vascular structures or secreting vasoactive com-
when the drug is administered around a nerve pounds. Alternatively, that “pre-existing condi-
bundle but undesirable when it affects the cardio- tion” may be from cardiovascular effects from
vascular system. Standard, prolonged resuscita- other medications and treatments used in the
tion efforts are not always successful in the event management of those problems. Plans for anes-
of local anesthetic cardiotoxicity. Traditionally, thesia management in this situation include con-
the cardiovascular collapse associated with an sideration of the direct effects of the tumor, toxic
intravascular injection of bupivacaine was felt to effects of the chemotherapy and radiation therapy,
be lethal in most cases, unless a large dose of hep- drug-drug interactions with chemotherapeutic
arin could be immediately administered for anti- agents, specifics of the surgical procedure, pain
coagulation and the patient could be connected to syndromes, and psychological status of the
a cardiac bypass circuit and pump for a few hours patient, especially if the patient is a child.
to allow the intravascularly injected bupivacaine Cancer therapy agents, such as chemothera-
to be metabolized and eliminated from the body. pies and cytotoxic drugs, may present uncommon
Although different amounts of bupivacaine, but significant complications of cancer treatment.
levobupivacaine, and ropivacaine can be adminis- Radiation (X-ray) therapy to the chest may cause
tered intravascularly before cardiovascular toxicity direct cardiac damage. This is found at a higher
results, all are potentially lethal with accidental rate in children, especially when the child is
overdose. Likewise, even “safer” local anesthetics younger at the time of diagnosis. The use of higher
with a shorter duration of action, such as lidocaine cumulative radiation doses, female gender, tri-
or procaine, also may affect the cardiac conduction somy 21, and black race have all been associated
system if administered in large enough intravenous with greater cardiac damage from radiation ther-
doses, especially if rapidly administered. In fact, apy in the child [16, 17].
these short-acting local anesthetics are intention- Some of the most widely used and most suc-
ally administered intravascularly in some situa- cessful anticancer drugs are doxorubicin and
tions, such as to assist in management of other anthracyclines. But it is well recognized that
arrhythmias. Local anesthetic agents all f unction by use of these drugs is associated with a cumula-
preventing the conduction of nerve impulses pri- tive, dose-dependent cardiotoxicity which may
marily by inhibition of voltage-gated Na+ channels be expected to occur in >20% of patients treated
with them. Unfortunately, the pathogenesis is not References

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Jakobsen CJ, Yusef S. Effects of extended- release DB. Perioperative myocardial necrosis in patients at
metoprolol succinate in patients undergoing non-car- high cardiovascular risk undergoing elective non-
diac surgery (POISE trial): a randomised controlled cardiac surgery. Heart. 2012;98(10):792–8. https://doi.
trial. Lancet. 2008;371:1839–47. org/10.1136/heartjnl-2011-301577.
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Gemert AW, van Poorten F, Bax JJ, Thompson IR, Pol- Thomassen O, Brandner B, et al. Ketamine: use in anes-
dermans D. Bisoprolol and fluvastatin for the reduc- thesia. CNS Neurosci Ther. 2013;19(6):381–9. https://
tion of perioperative cardiac mortality and myocardial doi.org/10.1111/cns.12072.
infarction in intermediate-risk patients undergoing 19. Widimsky P, Mot’ovska Z, Havluj L, Ondrakova M, Bar-
noncardiovascular surgery: a randomized controlled toska R, Bittner L, Dusek L, Dzupa V, Knot J, Krbec M,
trial (DECREASE-IV). Ann Surg. 2009;249:921–6. Mencl L, Pachl J, Grill R, Haninec P, Waldauf P, Gurlich
14. Kapoor AS, Kanji H, Buckingham J, Devereaux PJ, R. Perioperative cardiovascular complications versus
McAlister FA. Strength of evidence for perioperative perioperative bleeding in consecutive patients with
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2008.01.005. org/10.1053/j.jvca.2012.06.031.
161 12
Airway and Respiratory
System Damaging Events
Evangelyn Okereke, Shilpadevi Patil, and Gregory Allred
12.2 Airway Complications in PACU – 162
12.3 Children – 163
12.4 Legal Issues – 164
12.6 Obesity – 167
12.6.1 Airway Changes with Obesity – 167
12.6.2 Respiratory Changes with Obesity – 167
12.7 Airway Fires – 169
12.8 Components – 169
12.9 Predisposing Risk Factors for Airway Fire – 170
12.10 Preventive Measures – 170
12.11 Management – 171
12.12 Airway Trauma – 171
12.13 Types of Airway Injuries – 172
12.15 Prevention – 172
12.16 Management – 173
12.19 Answers – 174
References – 174

https://doi.org/10.1007/978-3-319-96125-5_12
162 E. Okereke et al.
12.1 Introduction and pharmacologic rescue (reversal for

neuromuscular blockade and opioid/benzodiaz-
Over the years, the practice of anesthesia contin- epine antagonism) [3].
ues to improve in both safety, efficacy, and qual- Hypoxemia in the PACU can present as altered
ity; but there are certain airway and respiratory mental status, tachypnea, dyspnea, and tachycar-
events that could lead to serious complications dia. It may easily be confused as emergence delir-
in the perioperative period. These complications ium, agitation, “sundowning” seen mainly in the
can translate into excess healthcare costs in the elderly, or even new-onset psychosis [4]. With pro-
form of patient morbidity and mortality, longed hypoxemic duration and worsening respi-
extended or unplanned hospitalizations, medi- ratory distress, the patient’s primary and secondary
cation administration, etc. The goal of this chap- respiratory muscles fatigue. Due to the imbalance
ter is to help the providers gain a better of myocardial oxygen consumption and demand,
understanding of the airway and respiratory ischemia occurs, followed by arrhythmias and
issues that can occur in the perioperative period eventual respiratory and cardiac arrest [5].
so that the provider can identify the patients On induction of general anesthesia, atelectasis
and/or procedures that are most at risk. Secondly, develops rapidly in the majority of adult patients
this chapter serves to highlight these airway and from pulmonary shunt [6], alveolar hypoventila-
respiratory issues that can occur so that the pro- tion [7], and V/Q inequalities [8, 9]. Relaxation of
vider may be more prepared to treat and in some the diaphragm allows abdominal pressures to be
cases prevent such complications from occur- transferred into the thoracic cavity resulting in
ring. Airway and respiratory complications lead- compression of the lung [10]. Alveolar hypoventila-
ing to litigation are a small proportion of all tion results in hypercapnia from insufficient venti-
claims against anesthetists but are associated lation as a result of opioids, hypnotics, residual
with notably high rates of death and brain dam- neuromuscular blockade, or metabolic distur-
age, high rates of “less than appropriate care,” bances [11]. V/Q mismatch results from changes in
and high costs [1]. Postoperative pulmonary the thoracic rib cage dynamics [12] and rostral dia-
complications are a major part of any surgery, phragmatic movements [13, 14]. While these com-
12 and when compared to cardiac complications, pile the majority of hypoxemic events in the PACU,
there have been similar rates of morbidity and it is, however, important to regard the nature of the
mortality and prolonged hospital stays [2]. surgery and its impact on ventilatory mechanics,
Preoperative preparation should aim to prevent vascular compression, and persistent action of
morbidity associated with these events, and anesthetic drugs [15]. Despite having received
intraoperative strategies could help lessen asso- seemingly appropriate neuromuscular blockade
ciated morbidity and mortality. Even though reversal, patients may continue to exhibit persistent
there is not a clear consensus on what constitutes residual paralysis from short- and intermediate-
a pulmonary complication, these adverse effects acting neuromuscular blockade in the PACU [16].
can hopefully be mitigated. Key to the management of PACU patients is a
keen awareness of the surgical type. The largest
known patient and/or procedure factor that con-
12.2 Airway Complications in PACU tributes to respiratory complications postopera-
tively parallels the proximity of the surgery to the
The anesthesia recovery unit can be riddled with diaphragm [17]. The more approximate the inci-
ventilatory issues and respiratory complications sion site is in the diaphragm, the higher the risk of
that include, but are not limited to, hypoxemia respiratory complications (see . Table 12.1).

(hemoglobin oxygen concentrations less than Treating hypoxemia in the PACU is generally
90%), hypoventilation (respiratory rate <8 done by providing supplemental oxygen. The goal
breaths per minute or a partial pressure of of O2 therapy is to maintain partial pressure of
CO2 > 50 mmHg), and airway obstruction (stri- oxygen (PaO2) of ≥60 mmHg which correlates to
dor, laryngospasm, bronchospasm). Providers an oxygen saturation (SaO2) of 90% [18]. By
may be required to intervene with noninvasive titrating in careful quantities of FiO2, you can
(BiPAP, oral and nasal airway) and invasive air- improve alveolar hypoventilation; however, if
ways (endotracheal tube or supraglottic airway) FiO2 gets too high, it may knock out hypoxic
Airway and Respiratory System Damaging Events
163 12
.. Table 12.1 Risk factors for respiratory complication and level of evidence
Level of Patient related Procedure related Lab tests

evidence
Good ASA class >/= 2 Thoracic surgery Albumin level < 35 g/L
Cardiac failure Abdominal surgery
Advanced age Upper abdominal surgery
Functional dependence Head neck surgery
COPD General anesthesia
Aortic aneurysm repair
Neurosurgery
Prolonged surgery
Vascular surgery
Emergency surgery
Fair Impaired sensorium Perioperative transfusion Chest radiography BUN > 7.5 mmol/L
(>20mg/dL)
Cigarette use
ETOH use
Weight loss
Abnormal findings on CXR
ulmonary vasoconstriction and hypoxic ventila-

p nasal or facial mask from head or neck surgeries
tory drive needed in patients that require an ele- [20]. Ultimately, careful consideration of hypoxic
vated partial pressure of CO2 (COPD) [18] and causes and oxygen delivery mechanisms needs to
will increase dead space. While supplemental be weighed prior to providing appropriate oxygen
oxygen will ameliorate diffusion impairments and therapy and titration in the PACU for hypoxemic
provide increased oxygen extraction, with V/Q patients.
mismatch, an elevation in the partial pressure of
O2 (PaO2) can wash out alveolar nitrogen and
can shift a lung area of low V/Q mismatch into a 12.3 Children
true shunt secondary to alveolar collapse [4].
Treatment for improving V/Q mismatch includes The highest incidence of morbidity and mortality
bronchodilators for COPD and asthma and PEEP has been proven to be the extremes of age [21, 22],
for acute lung injury and pulmonary edema [4]. and this section will focus on the lower extremes
The application of noninvasive ventilation (NIV), of age. In comparison to older children, it has also
like CPAP, can be used to recruit more alveoli been agreed that incidence of adverse events is
from in those with hypoxemia from atelectasis. By higher in infants [15, 21, 23–26]. Respiratory
providing positive pressure, the work of breathing events occur with higher frequency in younger
decreases, and pulmonary compliance can children particularly those involved with ENT
improve [4]. However, NIV may be inappropriate surgery versus other surgical sites [27, 28]. The
for some patients, particularly those that are sta- higher incidence is said to be from narrow infant
tus post gastric or esophageal surgery [19]. airway anatomy and higher incidence of respira-
Relative contraindications to NIV are those at tory tract infections [29, 30] in younger children.
high risk for aspiration, altered mental status, Of the adverse events, the most common are
refractory hypoxemia, hemodynamic instability, incidents related to the respiratory tract [23, 27,
and arrhythmias and those who cannot have a 31, 32]. Airway management in children can vary
greatly and include, but is not limited to, nasal

cannula, mask ventilation, supraglottic airways, Box 12.1 Cuffed Endotracheal Tube Bene-
and endotracheal intubation. The risk of respira- fits [44]
tory complications increases with intubation [27], 55 Reliable, sealed airway requiring less tube
exchanges
particularly in those with new onset or recent
55 Avoids repeat oral-airway manipulation by
upper respiratory tract infections [33]. laryngoscopy
Interestingly, the risk of perioperative respiratory 55 Decreases fresh gas flows
events is lower when endotracheal intubation is 55 Constant minute ventilation
done with neuromuscular relaxants; furthermore, 55 Precise respiratory and capnography
monitoring
this risk decreases 8% with each increasing year of
55 Prevention of aspiration
age [28]. In recent years, muscle relaxants have 55 Decreases OR pollution with volatile
been shied away due to the frequency of allergic anesthetics and N20
reactions observed under general anesthesia [34]. 55 At cuffed pressure less than or equal to
Adverse events or respiratory complications 20 cm H20, there is no increased incidence
of postextubation stridor vs uncuffed ETT
include laryngospasm, which is total airway
obstruction and usually unresponsive to maneu-
vers for soft tissue obstruction. Airway obstruc-
tion is thought to be associated with redundant, relieved by providing jaw thrust, positive pressure,
soft airway tissue where partial airway obstruction or oral airway. Bronchospasm is when the bron-
occurs (snoring) (. Table 12.2). This can be

chial smooth muscle contracts erratically causing
expiratory wheezing, hypercapnia, and oxygen
desaturation. Often the capnography reading will
.. Table 12.2 Factors identified as being
predictive of respiratory complications/adverse
have steeper slope, and there will be elevated peak
events airway pressures. Oxygen desaturation can be
seen when the SpO2 dips below <95% [28].
Good evidence Not supported Alarming postmortem studies showed 45% of
intubated children who had died showed at least
12 Age of child (<6 years old) Asthmaa
some degree of airway trauma [37]. The most
Respiratory infections Bronchial common cause of laryngotracheal injury associ-
hyperreactivityb ated with intubation is using an endotracheal tube
ENT surgery Allergies that is too large [38]. While the debate of cuffed
versus uncuffed endotracheal tubes remains con-
Tracheal intubation w
ithout Induction
muscle relaxant technique (IV vs
troversial, if a child is intubated for surgery, the
inhalation) literature shows that cuffed endotracheal tubes can
and should be considered [39–43] (7 Box 12.1).

Passive smoke exposure Provider experi-

ence in intubating
LMA (more mechanical Patient’s sex 12.4 Legal Issues

failure)
Anesthetic care by Type of intubation Despite years of systematic training, quality

non-pediatric-trained (orotracheal or improvement initiatives, checklists, and equip-
anesthesiologist (twice as nasotracheal
ment upgrades and enhancements, the truth is
likely if anesthesiologist is a intubation)
resident) anesthesia and its procedures do not come with-
out risks. While it may be impossible to attribute
Cuffed endotra- the actual numbers of adverse events caused by, or
cheal tube
at least in part by, anesthesia, it is worthwhile to
Duration of surgery consider the implications of what providers do on
a daily basis and how complications negatively
Refs. [28, 35, 36]
aStudy included only children with controlled asthma impact patient lives and even cause irreparable
bStudy included only children with no acute harm. Despite suffering harm from complica-
symptoms of bronchial hyperreactivity tions, it is still a vast minority that point the liti-
gious finger in filing a claim against anesthetic
165 12
providers. The other side of that coin indicates as effective as the provider using them. Larson
that the compensation rates, if those harmed et al. (2009) cautioned that in 28% of their respi-
actively pursued claims, could rise dramatically ratory claims, pulse oximetry and/or capnogra-
[45]. Although a small sample size in Denmark, phy was not applied, observed, or interpreted
Hove et al. showed that from 1996 to 2002, 374 correctly and resulted in catastrophic respiratory
patients were awarded in total eight million euros events [57].
as financial compensation for harm caused by We are akin to witness advancements in tech-
anesthetic procedures. Their study was remark- nology regarding anesthesia equipment, volatile
able in that only 0.2% of patients receiving anes- anesthetics, enhanced monitoring techniques,
thesia may develop complications that leads to provider training, patient safety education, surgi-
financial compensation [46]. cal techniques, and perioperative risk and optimi-
The most common adverse outcomes are zation assessments. While these may depreciate
related to medication errors [47, 48]; however, the risks with anesthesia, it is undoubtedly up to
since most of errors are negligible and often times the provider to demonstrate constant and consis-
unreported, they are poorly represented in stud- tent vigilance, adherence to standard of care prac-
ies. According to the American Society of tices, and anticipation of issues and potential
Anesthesia Closed Claims Project (ASACCP), problems.
adverse outcomes from respiratory events are the
largest class of injury. In 1990 Caplan et al. deter-
mined that 34% of all claims were related to respi- 12.5 Risk Factors
ratory events and 85% involved in either death or
permanent brain damage as severe outcomes, 76% There are numerous risk factors for airway and
demonstrated substandard care, and 72% were respiratory issues in the perioperative period.
considered preventable with improved monitor- These risk factors can generally be broken down
ing [49]. Additionally, they determined that most into three categories (. Table 12.3). Due to the

(72%) respiratory claims received a median pay- lack of uniform consensus on the definition of
ment of $200,000. Respiratory events were classi- adverse respiratory events, there is not an absolute
fied as inadequate ventilation (38%), esophageal way to determine the frequency of adverse respi-
intubation (18%), and difficult intubation (17%) ratory events in the perioperative period.
[49]. Aspiration made up 3% and occurred mainly Respiratory complications are more frequently
during induction prior to endotracheal intuba- seen in pediatric anesthesia cases. Studies have
tion. Interestingly, half of the aspiration claims shown that children with an upper respiratory
were during emergency surgery [49]. Interestingly, infection are more at risk of respiratory complica-
during 1 study of 222 claims, 35% of the medico- tions including but not limited to laryngospasm
legal claims demonstrated that the providers had and bronchospasm during the procedure. For
previously claims against them [50]. some of these cases, this could lead to the need for
In 1990, the ASA Airway Task Force made prolonged postoperative stay for monitoring,
recommendations, and Peterson et al. (2005) supplemental oxygen, and bronchodilation medi-
indicate a reduction in death and brain damage cations. The choice and airway management has
only upon induction (35% vs 62%) and not at also been shown to have an effect on the incidence
other times [51]. Cheney et al. reported (1975– of respiratory complications during the case.
2000) a drop in respiratory claims and brain dam- Bordet et al. looked at the rate of airway complica-
age; however, the downward trend did not tions in pediatric patients comparing face mask,
delineate a clear causality by improved monitor- laryngeal mask airway (LMA), or tracheal intuba-
ing [52, 53]. Perhaps new training or safety mea- tion with a tube. They found that the incidence of
sures are responsible; however, since the advent of airway issues was highest in those patients receiv-
pulse oximetry and capnography, providers are ing LMA at 10.2% vs 4.7% for face mask and 7.4%
able to detect cyanosis [54–56] earlier and esoph- for a tracheal tube. Airway issues in this study
ageal intubation with reliability. Even though pro- were defined as any laryngospasm, broncho-
viding these additional monitors may provide spasm, laryngeal edema, aspiration, desaturation
some benefit to patient safety, closed claim less than 90%, failure to intubate, air leak or venti-
research [57] grandstands that monitors are only lation problem, breath holding, and others. They
.. Table 12.3 Risk factors for adverse respiratory events in the operating room [59]
Surgical factors Patient factors Anesthesia factors
Emergency procedures Upper respiratory infection within the last Inhalational induction
Abrupt surgical stimulation 2 weeks Premedication with midazolam
ENT procedure Premature infants Use of desflurane for maintenance
Dental procedures Young age of anesthesia
Respiratory procedure Smoking exposure Administration of neuromuscular
Secretions in airway Current asthma and/or recurrent symptoms blocker
Blood in airway Nightly dry cough Less experienced anesthesia
Eczema personnel and postanesthesia care
Sleep apnea recovery staff
Obesity High patient-to-staff ratio in the
Cystic fibrosis PACU
Allergies Mixed population hospital
Respiratory sickness (children and adults)
Airway malformations Topical lidocaine on vocal cords
NPO violation
also revealed three independent risk factors for tion in perioperative pulmonary complications in
airway complications were presence of a respira- high-risk patient that receives epidural with local
tory infection, age less than 6 years old, and the anesthetics, but the lack of consensus on defini-
use of LMA [1]. tion of postoperative pulmonary complications
The type of surgery that patients are having makes it difficult to show any advantage [58].
also plays a role in the development of respiratory General anesthesia generally has various
complications in the perioperative period. Prior effects on the pulmonary system that could cause
studies have shown that the rate of pulmonary a decline in pulmonary function. Premedication
complications in abdominal surgeries can be as with benzodiazepines has not been shown to
12 high as 30% [58]. Patients who undergo abdomi- reduce the occurrence of laryngospasm or bron-
nal and thoracic surgery have been shown to have chospasm, and it is associated with a 1.8-fold
lower vital capacity and forced residual capacity increase in the overall incidence of perioperative
postoperatively. These changes lead to ventilation- respiratory adverse events [59]. Inhaled anesthet-
perfusion mismatches that can eventually result ics decrease the tidal volume with spontaneous
in hypoxemia. Laparoscopic surgeries have also respiration, functional residual capacity decreases,
been shown to reduce lung volumes and forced and atelectasis can form in dependent portions of
residual capacity by up to 50% which can also lead the lung leading to ventilation-perfusion mis-
to ventilation-perfusion deficits that can cause matching. Even small concentrations of volatile
hypoxia. It can take up to 2 weeks for these lung anesthetics can blunt the ventilator response to
changes to return back to normal baseline values. hypoxia and hypercarbia by suppressing periph-
Anesthetic technique can have an impact on eral chemoreceptors; this could potentially lead to
postoperative pulmonary function. There is no postoperative pulmonary complications as well.
clear evidence for the use of one type of anesthetic Neuromuscular blocking agents have been shown
technique over another in reducing the amount of to produce cephalad displacement of the dia-
perioperative pulmonary complications. There are phragm leading to mechanical depression of the
certain effects that each anesthetic produces that dependent parts of the lung causing atelectasis
can affect the pulmonary function of a patient. In [60]. Neuromuscular blocking agents such as
general, regional anesthesia confers the benefit of rocuronium can be used to decrease the incidence
allowing the patient to maintain spontaneous res- of laryngospasm at the time of endotracheal intu-
piration without the need to instrument the air- bation, but the patients still tend to have a higher
way. The sensation of pain can impair a patient’s incidence of laryngospasm in the postoperative
ability to take deep breaths and cough; this type of period [61, 62]. The general take home should be
lung restriction could lead to atelectasis and in that neuromuscular blocking agents should be
turn hypoxia. Studies suggest that there is a reduc- used in cases where muscle relaxation is neces-
167 12
sary. Studies seem to indicate that due to a
.. Table 12.4 Stratification of obesity in adults
decrease in the occurrence of adverse periopera- [67]
tive respiratory events, IV induction may be more
desirable when compared to inhalational induc- Stratification of risks for adults based on body
tion with volatile anesthetics [61, 63, 64]. mass index (BMI)
Patient factors also play a role in the develop- BMI Classification Stratification of
ment of postoperative pulmonary complications. coexisting diseases
The knowledge of these factors beforehand can
help the provider identify patients at high risk and Less Underweight Low
lessen the incidence and effect of postoperative than 18
pulmonary complications. Patient risk factors 18–25 Normal Normal
that have a higher incidence of postoperative pul-
Greater Overweight Moderate to severely
monary complication include cigarette smoking, than 25 increased (increases
underlying chronic respiratory disease, emer- with increasing BMI)
gency surgery, anesthetic time of 180 min or
more, and advanced age [65].
a irway management. There are studies that have

12.6 Obesity shown a significant yet weak correlation between
BMI and the difficulty of a provider to obtain the
The incidence of obesity in the United States and airway. Failure in managing the airway is the most
other developed nations is rapidly growing. important cause of mortality in patients undergo-
Obesity is often defined as condition of abnormal ing general anesthesia. About 50–75% of cardiac
or excessive accumulation of adipose tissue, to the arrests during general anesthesia are because of
extent health may be impaired [66]. Obese indi- difficult intubations [68]. The etiologies of difficult
viduals not only differ in the amount of fat that intubations vary and are related to the distribution
they store, but they also differ in the regional dis- of adipose tissue throughout the body including
tribution of fat within the body. It is the accumu- the airway. In addition to obese individuals seem-
lations of abdominal adipose tissue that is the ing to have a more difficult a irway, obesity also
greatest risk factor for the development of disease seems to be a risk factor for difficult mask ventila-
versus the amount of adipose tissue present [67]. tion. Kheterpal S et al. looked at the attempts of
Body mass index (BMI) is what is generally used mask ventilation of over 22,000 patients and con-
to classify the level of overweight and obesity. The cluded that a BMI of 30 or more was an indepen-
definition of obesity varies somewhat, but it is dent risk factor for the combination of difficult
generally defined as a body mass index greater mask ventilation and difficult intubation [69].
than or equal to 30 mg/kg2. . Table 12.4 is gener-
Neck circumference has also been shown to cor-
ally what is used by the WHO to classify the level relate with BMI for both genders and has been
of overweight and obesity. used recently to classify individuals as overweight
Obesity is increasing worldwide, and the rea- or obese [69]. Neck circumference correlates posi-
sons for the increasing incidence of obesity are tively with changes in the systolic and diastolic
multifold, but obesity presents certain challenges pressure and other components of the metabolic
in the airway and respiratory system for patients syndrome and is considered as an index of upper
undergoing anesthesia. The incidence of obesity is body obesity [70] (. Fig. 12.1) (. Table 12.5).

increasing worldwide necessitating the impor-

tance of recognizing the issues that obesity pres-
ents for the airway and respiratory system. 12.6.2 Respiratory Changes
with Obesity
12.6.1 Airway Changes with Obesity Obesity causes marked changes on the respiratory
system. Obesity affects many respiratory physio-
Although obesity is not a definitive risk factor for logical parameters, including compliance, resis-
a difficult airway, it can present challenges in tance, lung volumes, spirometric measures,
Hard Soft
palate palate Uvula
Pillar
12
Class I Class II Class III Class IV
.. Fig. 12.1 Example of Mallampati class I airway
turn, may affect the work of breathing, ventilatory

.. Table 12.5 Mallampati classification scoring drive, and exercise capacity and lead to sleep-
system
breathing abnormalities [71]. Obesity, particu-
Mallampati Structures visualized larly severe central obesity, affects respiratory
score physiology both at rest and during exercise.
Reductions in expiratory reserve volume, func-
Class I Soft palate, hard palate, tonsillar tional residual capacity, respiratory system com-
pillars, full uvula, fauces
pliance, and impaired respiratory system
Class II Soft palate, hard palate, full uvula, mechanics produce a restrictive ventilatory defect.
fauces The obese patient also has significantly increased
Class III Soft palate, hard palate, base of oxygen consumption (VO2) and CO2 production
uvula (VCO2) and an impaired ventilatory system [72].
After being anesthetized and paralyzed, VO2
Class IV Hard palate
declined by 16% in obese individuals compared
with <1% in lean individuals. Many factors may
contribute to increased WOB in obese individu-
bronchial hyperreactivity, upper airway als, including impaired respiratory mechanics,
mechanical function, neuromuscular strength,
upper airway mechanics, neuromuscular strength,
diffusing capacity, and gas exchange. These, in gas exchange, neurohormonal influences, and
169 12
ventilatory drive [71]. The most common and cation to occur, it does have grave consequences.
consistent pulmonary function test abnormality Prevention of such a rare but fatal complication
seen in obese individuals is a reduction in func- is essential. Hence, a thorough knowledge of the
tional residual capacity (FRC) and expiratory predisposing risk factors, components, preven-
reserve volume [73]. Because breathing occurs at tive measures, and management of airway fire is
low FRC and in the less compliant portion of the crucial for an anesthesia provider. Anesthesia
pressure-volume curve, increased effort is needed providers have direct control over the method of
to overcome respiratory system elasticity. Thus, administration and oxygen concentration.
obese individuals need to do more respiratory Communication between all the members
work to maintain appropriate levels of ventilation involved in patient care is the key to successfully
[72]. Many aspects of respiratory function worsen manage an airway fire [78].
in the supine position and during sleep in obese
subjects, especially during the rapid eye move-
ment stage of sleep [74]. Sleep-disordered breath- 12.8 Components
ing is very common in the obese patient with
obstructive sleep apnea (OSA) and obesity-related The three elements involved in airway fire or
respiratory failure being more common [75]. It what constitutes the fire triad are the fuel, an oxi-
has been estimated that about 50% of patients dizing agent, and the ignition or the heat source.
with a BMI greater than 40 have symptoms of The fuel sources that have the ability to catch fire
obstructive sleep apnea (OSA). Obstructive sleep could be the endotracheal tubes, drapes, alcohol-
apnea is defined as complete or partial closure of based preps, dry sponges and swabs, gauze,
the upper airway which can result in hypercapnia, gowns, foam padding, clothing, mattresses, plas-
oxygen desaturation, and sleep fragmentation tic supplies, body hair, silicone or palliative air-
[76]. OSA is associated with a higher rate of post- way stents, and vaporized adipose tissue. The
operative respiratory failure, cardiac events, and oxidizing agents are oxygen, nitrous oxide, and
ICU admission [77]. air. The sources of heat or ignition may be laser,
cautery, hot light bulb, fiber-optic light or cables,
warming devices, frayed cords, high-speed
12.7 Airway Fires burrs, static electricity, and defibrillators [79]
(. Fig. 12.2).

Patients undergoing surgery are at risk for air-

way fires. In the past it was attributed mainly to
flammable anesthetic agents, but currently air-
way fires are most likely associated with laser
surgery and the use of electrocautery during
head and neck surgeries. The incidence of oper-
ating room and airway fires has declined over
the last century due to decreased use of flamma-
ble anesthetic agents and their replacement
with less or nonflammable anesthetic agents.
Approximately 700 fires are reported each year Fuel
with more than 500 near misses or unreported
cases. Despite the knowledge of risk factors and
how to prevent fire, surgical fires continue to Fire
occur. Each year in US hospitals, about 650 cases
are reported, according to the Food and Drug
Administration with 3 to 4 times near misses
Heat or
and unreported events. In closed claim database, Oxidizer
ignition
the cautery fires causing burns increased from
11% to 44% from 1994 to 2003; majority of them
were attributed to airway and facial plastic
surgeries. Although it is not a common compli- .. Fig. 12.2 Fire triad
12.9 Predisposing Risk Factors ventive measures, they can be easily avoided.
for Airway Fire ASA guidelines for prevention of operating room
fires include proper education of all anesthesia
Some of the predisposing risk factors are the type providers for fire safety specifically for OR fires.
of surgery, surgical site, use of ignition source, Before each surgical case, the OR team should
and need for use of oxidizing agents such oxygen determine if a case is at high risk for surgical
supplementation during surgery. fires. If a high- risk situation exists, the team
The types of surgeries that pose the most risk should decide on a plan and roles for preventing
for airway fires are head and neck surgeries or and managing a fire. Communication between
surgeries above T5 level, ENT procedures such as nursing staff, anesthesiologist, and surgeon is
tonsillectomies, adenoidectomies, tracheosto- critical.
mies, skin or plastic surgeries, cataract or eye sur- Cuffed endotracheal tubes (ETTs) are
geries, burr hole surgeries, rigid bronchoscopies strongly recommended as they are more advan-
with airway stent placement, tracheal dilation and tageous over uncuffed ETTs. The ETT cuff may
granulation tissue removal, and airway debulking serve as a barrier and prevent leaking of oxygen
procedures [78]. from the trachea and accumulating around the
Electrosurgical units or cautery and lasers are operative site. It is very essential to check the
frequently used to coagulate or cut tissue and in integrity of cuff before use. ASA guidelines for
bipolar mode. The cutting mode of electrocautery laser procedures recommend that a laser-resis-
is more hazardous as it generates more heat than tant tracheal tube should be used. The tracheal
the coagulation mode. The bipolar electrocautery cuff of the laser tube should be filled with saline
or argon plasma coagulation used at low voltage and colored with an indicator dye such as methy-
with short burst period has the least risk of causing lene blue.
fire ignition and is recommended as a safer option. When an ignition source is in use such as a
This poses a great risk during airway surgeries in cautery or laser, it is preferred to lower the inspired
an oxygen-rich environment. This kind of oxygen- oxygen concentration below <40% while main-
rich environment may occur when the oxygen can taining patient’s oxygen saturation within normal
12 leak around tracheal cuff or concentrate heavily range. Oxygen with air mixture or oxygen with
under the drapes in an open source of oxygen such helium mixture has been recommended. Red rub-
as nasal cannula or mask especially when higher ber catheters or other materials should not be
concentrations of oxygen are used (>40%). Some used to sheathe the probes. The heat from the
of the ignition tests conducted on polyvinyl chlo- active electrode may ignite the rubber even in the
ride ETT showed that even after moving the ETT air.
away from the cautery still ignited the ETT when- During procedures such as tonsillectomies,
ever oxygen concentration was increased. commercially available electrosurgical electrode
A mixture of oxygen and nitrous oxide is fre- probes that are insulated should be used to pre-
quently used to ventilate and anesthetize patients, vent burns in the oral cavity. Avoid usage of red
respectively. These highly combustible gases rubber catheters as sheath for the probes as it can
require a very low level of heat source to ignite. ignite easily.
Also the oxygen-rich environment may lower the The use of wet gauze or sponges can help
temperatures at which fuel sources such as drapes decrease oxygen concentration in the oropha-
and endotracheal tube can catch fire easily than at ryngeal area by catching leaking oxygen or
room air. Tissue especially fatty tissue when heated nitrous oxide. Also scavenging around the sur-
by an ignition source may turn into gas and burn gical site with separate suction may help reduce
if mixed with high concentration of oxygen [79]. the chances of creating an oxygen-rich envi-
ronment.
In some studies the use of LMA for adenoton-
12.10 Preventive Measures sillectomies has been suggested to reduce airway
fire but is debatable as the risk of aspiration can
As with any potential hazard, awareness is the increase (“Practice Advisory for the Prevention
first step to prevention. Airway fires are signifi- and Management of Operating Room Fires,”
cant risk in the OR, but with awareness and pre- 2008) (7 Box 12.2).

171 12
cautery from the fire site and spray saline and
Box 12.2 Readily Available Operating wash the area. Flooding the area with carbon
Room Fire Equipment That Needs to Be Read- dioxide has also shown to be of help in preventing
ily Available the spread of airway fires induced by cautery.
55 Several sterile saline containers Maintaining oxygenation, ventilation, and sta-
55 A carbon dioxide fire extinguisher
bilization of hemodynamic status should be the
55 Rigid bronchoscope blades and rigid
fiber-optic laryngoscope goals of therapy for smoke inhalation injury. If
55 Replacement endotracheal tube, face necessary, immediate reintubation and ventila-
masks tion with self-ventilating bag at room air may be
55 Replacement breathing circuits used. Inhaled bronchodilators and racemic epi-
55 Replacement sponges and drapes
nephrine help reduce bronchospasm and stridor,
respectively. Anticholinergic drugs may be used
to prevent excessive secretions. Humidification
helps relieve excessive drying of the airway and
12.11 Management mucous plugging. Even though antibiotics and
corticosteroids do not improve morbidity and
Early recognition is the key to successful treat- mortality, they may not be routinely used in
ment. Some of the signs of airway fire are visual- patient with smoke inhalation, but they should be
ization of smoke or spark with a loud pop, and in considered, in case of secondary infection and
some cases gray dust may be seen. Dyspnea and airway edema. These patients may have to be
hypoxemia may develop quickly depending on observed in intensive care units until they are
the severity of the burn and patient’s underlying stable [79].
physical health status. In severe burn injury cases, repeat bronchos-
The sequelae of airway fire are airway edema, copy with protected brushings and washings
inflammation, mucosal necrosis, presence of every 3–5 days may be necessary. Fiber-optic or
soot, and charring in the airways on bronchos- rigid bronchoscopy may need to be performed to
copy exam. Damage of ciliary transport func- remove granulation tissue and exudate in case of
tion and failure to clear casts in the bronchi may extensive burns. Some patients may need trache-
lead to debris or pseudomembrane formation ostomy temporarily to allow for the healing of the
and obstruction of the bronchi. The bronchial burnt tissue. Most patients with mild to moderate
obstruction could further lead to atelectasis and injury make good recovery without complica-
pneumonia. tions. In rare cases of severe burns, if the condi-
In the management of airway fire, the most tion of the patient does not improve in regard to
important thing to do is to eliminate the fire and oxygenation and ventilation, then the patient may
protect the patient. It is necessary to halt the pro- need lung transplantation.
cedure, remove the object on fire, and immedi- In summary, the OR team should determine
ately cut off the oxygen source. high-risk cases and be at high alert during the
Immediate extubation versus maintaining the procedure. Awareness is the key to avoidance of
ETT is debatable. General ASA guideline says fire. The OR team should have a plan and decide
immediate extubation during any airway fire is on the roles in preventing and managing fire. In
appropriate as the thermal injury may continue or successful management of a fire, communication
worsen if the burning ETT is kept in place. The and multidisciplinary approach between the anes-
debate arises in patients with difficult airways thesiologist, a surgeon, and the nursing staff is
where maintaining the ETT may be considered crucial [79].
after assessing the risk vs benefits. The decision to
keep or remove ETT may depend on the case at
hand. 12.12 Airway Trauma
Depending upon the anesthesia provider’s
assessment on control of airway, steps should be Trauma to the airway is a well-recognized compli-
taken to extinguish the airway fire by disconnect- cation of anesthesia. Most airway injuries are
ing the oxygen supply immediately with or associated with difficult intubation and are a
without extubation. Next step is to remove the significant source of morbidity and mortality

among patients and a source of liability for anes- t racheotomies were performed for the purpose of
thesiologists. The frequent sites of airway injury emergency airway management associated with
were the larynx (33%), pharynx (19%), and difficult intubation. The other indications for tra-
esophagus (18%) according to the closed claims. cheostomy were development of subglottic or tra-
Approximately 6% of closed claim database were cheal stenosis as a consequence of tracheal
due to airway injury coming only after other com- intubation. Patients with tracheal perforation
plications such as death (32%), spinal cord or developed subcutaneous emphysema, pneumo-
peripheral nerve damage (16%), and brain dam- thorax, and pneumomediastinum. Chest X-ray
age (12%) [80]. helped in making the diagnosis when clinical
signs were not obvious.
Temporomandibular joint (TMJ) injuries such
12.13 Types of Airway Injuries as pain and dislocation were associated with rou-
tine tracheal intubation and accounted for about
Damage to the nose, temporomandibular joint 10% of airway trauma claims. Preexisting TMJ
(TMJ), larynx, trachea, pharynx, or esophagus disease is a risk factor.
constitutes airway injury. Coming to laryngeal
injuries, most of them were mostly associated
with non-difficult intubations. Arytenoid dislo- 12.14 Risk Factors
cation, vocal cord paralysis, hematoma, and
granuloma formation were some of the laryn- Most of the abovementioned airway traumas are
geal injuries that were noticed. Hoarseness was due to difficult airway encounters. Difficult air-
one of the common symptoms of laryngeal way could be due to many factors including but
injury. not limited to obesity and cervical arthritis to
Unlike most laryngeal injuries, pharyngeal mention a few. With the presence of preexisting
injuries were associated with difficult intubation. conditions such as poor dentition, TMJ disease
Laceration and contusion, localized infection, and increases the incidence of dental and TMJ inju-
perforation were most common pharyngeal injuries, respectively. Females less than 60 years of
12 ries. Sore throat was a frequent symptom. age, prolonged intubation, excessive inflation of
Pharyngeal injuries could be severe enough lead- the endotracheal cuff, excessive movement of
ing to mediastinitis and death. the ETT, procedures such as emergency surgical
Among esophageal injuries perforation of the tracheostomies, emergent nonoperating room
esophagus was common. Similar to pharyngeal intubations, improper head positioning, poor
injuries as mentioned above, these were associ- muscle relaxation, application of a high cricoid
ated with difficult intubation as well. Female gen- pressure, long-term indwelling naso- or orogas-
der and age greater than 60 years were the other tric tube, transesophageal echocardiogram
risk factors for this type of injury. Patients with (TEE) probes, airway tools such as oral and
esophageal perforation have poor outcome as it is nasal airways, endotracheal tubes, laryngeal
a serious complication. mask airways, laryngoscope blades, bougies, a
Another type of injury associated with diffi- rigid or flexible stylet with or without exposure
cult intubation, female gender, and age greater of the tip, and the rigid bevel of an endotracheal
than 60 years is pharyngoesophageal injuries. tube are some of the risk factors for trauma to
These patients developed subcutaneous emphy- the airway.
sema and pneumothorax in the immediate
postoperative period. Delay in diagnosis was
associated significantly with the development of 12.15 Prevention
the late infectious sequelae such as mediastini-
tis or mediastinal abscess, retropharyngeal A good history, physical exam, anticipation, and
abscess, or pneumonia in two thirds of the thorough preparation with backup plan are vital
patients. for prevention. It is important to do a good preop-
Tracheal injuries occurred due to tracheal per- erative assessment and know about previous anes-
foration, surgical tracheostomy, and infection. thetic or difficult intubation history and previous
The chances of injury were high when the head and neck surgeries. A thorough airway exam
173 12
including the dental exam is essential with proper vigilance as they are directly in continued patient
documentation. Anesthesia consent should care postoperatively. In cases where there is a
include all the injuries that are possible in the oral delay in diagnosis, late infectious sequelae such
cavity such as dental, laryngeal, pharyngeal, and as deep cervical or retropharyngeal abscess,
esophageal injuries. The airway management and mediastinitis, or pneumonia may occur and
need for reintubation, or tracheostomy especially increase the risk of morbidity and mortality.
in suspected difficult airway cases, should be dis- These patients may present with symptoms of
cussed with the patient. Next, communication fever, dysphagia, and dyspnea. Overall mortality
with the surgical team about airway management after esophageal perforation is reported to be as
is also very crucial. In patients with history or high as 25%, even with rapid diagnosis and treat-
anticipated difficult airway undergoing elective ment. The treatment consists of limitation of oral
procedure, it is important to have a discussion intake, antibiotic administration, surgical closure,
with the surgical team about the airway manage- and drainage.
ment plan and if necessary to schedule a case A high index of suspicion by the anesthesiolo-
when there is help such as on a weekday or regular gist and the surgeon may reduce the risk of severe
work hours for patient’s safety. It is important to complications [80].
have the necessary airway equipment readily
available such as different-sized laryngoscope
blades, ETTs, oral/nasal airways, video-assisted 12.17 Conclusions
laryngoscope, fiber-optic scopes, bougie, and
laryngeal mask airway. The knowledge of ASA The incidence of airway and respiratory compli-
difficult airway algorithm and proper way to use cations will never be nil. The use of pulse oxim-
the airway equipment is also as crucial as having etry and capnography has reduced a large
them. number of airway complications perioperatively.
Even with utmost care by the anesthesiologists
and use of advanced monitors, they continue to
12.16 Management happen.
The causes are multifactorial and depend on
Anticipation, rapid detection, and treatment are various factors including but not limited to
the key to successful management of a complica- patient’s physical health status, technical errors,
tion. Most of the airway complications are minor type of procedure, anesthetic type, obesity, age of
and are temporary or self-limiting as most the patient, misjudgments, lack of adequate expe-
patients recover completely without permanent rience in infrequent complications, and use of
disability. If difficult airway was encountered, high-risk fire-causing equipment as mentioned in
having a high index of suspicion for a complica- this chapter. Most complications are minor and
tion is important. These patients must be observed recover completely. Unfortunately some compli-
and watched for development of signs and symp- cations are severe and fatal, leading to patient
toms of potential airway complications. Survival morbidity and mortality. They also increase the
after major complications has been reported to be cost and may have legal implications. It is hence
improved by early diagnosis and initiation of important to have adequate knowledge of the
treatment. perioperative airway complications that could
Prompt diagnosis of pharyngoesophageal per- occur, their prevention, and management. Prior
foration may be difficult as early symptoms of discussions, plans, and communication among all
perforation are absent or relatively nonspecific the OR personnel are the key to avoidance and
and include sore throat, deep cervical pain, chest management of a complication if it were to hap-
pain, and cough. If it progresses to subcutaneous pen. Having protocols in place for rare, but seri-
emphysema, pneumomediastinum, or a pneumo- ous complications such as airway fires or
thorax, then hypoxia, cyanosis, or change in vital operating room fires is very helpful. Conducting
signs occurs. fire drills helps better understand and manage the
After a difficult intubation, surgeons should situation. Multidisciplinary approach is the best
be notified and alerted about the possibility of a approach for a successful management of a com-
complication. This warns them to be under high plication.
12.18 Review Questions 4. (“The Anesthesia Patient Safety Foundation

(APSF) announces the availability of the
?? 1. Which of the following respiratory param- 18-minute educational Video: Prevention and
eters increases in obese individuals com- Management of Operating Room Fires -
pared to lean individuals? Anesthesia Patient Safety Foundation,” n.d.)
A. Tidal volume 5. (Akhtar et al., 2016)
B. Functional residual volume 6. (Karen B. Domino, M.D., M.P.H.; Karen
C. Oxygen consumption L. Posner, Ph.D.; Robert A. Caplan, M.D.;
D. Upper airway respiratory tone Frederick W. Cheney, n.d.)
7. (American Society of Anesthesiologists.,
?? 2. Which of the following anesthetics has the Posner, Caplan, & Cheney, 1999)
least risk of perioperative adverse events?
A. General anesthesia without the use of
paralytics for cerebral aneurysm clip-
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2010;376(9743):773–83. outcome. Br J Anaesth. 2012;109(6):897–906.
62. Devys JM, et al. Intubating conditions and adverse 78. Akhtar N, Ansar F, Baig MS, Abbas A. Airway fires dur-
events during sevoflurane induction in infants. BJA Br ing surgery: management and prevention. J
J Anaesth. 2011;106(2):225–9. Anaesthesiol Clin Pharmacol. 2016;32(1):109–11.
63. Oberer C, von Ungern-Sternberg BS, Frei FJ, Erb
https://doi.org/10.4103/0970-9185.175710.
TO. Respiratory reflex responses of the larynx differ 79. Lee J-Y, Park CB, Cho E-J, Kim CJ, Chea JS, Lee BH, Kim
between sevoflurane and propofol in pediatric patients. JO, Chung MY. Airway fire injury during rigid bron-
Anesthesiol J Am Soc Anesthesiol. 2005;103(6):1142–8. choscopy in a patient with a silicon stent -a case
64. Burgoyne LL, Anghelescu DL. Intervention steps for report. Korean J Anesthesiol. 2012;62(2):184–7.
treating laryngospasm in pediatric patients. Pediatr https://doi.org/10.4097/kjae.2012.62.2.184.
Anesth. 2008;18(4):297–302. 80. Domino KB, Posner KL, Caplan RA, Cheney FW. Airway
65. Pedersen T, Viby-Mogensen J, Ringsted C. Anaesthetic injury during anesthesia : a closed claims analysis.
practice and postoperative pulmonary complications. ASA. 1999;91:1703–11.
Acta Anaesthesiol Scand. 1992;36(8):812–8.
177 13
Burns in the Operating
Room
Kraig S. de Lanzac and Joseph R. Koveleskie
13.2 Fire – 179
13.2.1 The Fire Triad – 179
13.3 Prevention of Fire – 180

13.3.1 Fuel – 180
13.3.2 Oxidizer – 182
13.3.3 Heat and Ignition – 182
13.4 Operating Room Preparation – 183

13.4.1 Personnel, Process, and Teamwork – 183
13.4.2 Flammable Solutions – 183
13.4.3 Anatomic Location – 183
13.4.4 Oxygen and Nitrous Oxide – 184
13.4.5 Electrosurgical Units, Lasers, and Fiber Optics – 184
13.4.6 Fire Contributors – 184
13.4.7 Silverstein Fire Risk Assessment Tool – 185
13.5 Management of Operating Room Fires – 185

13.5.1 General Action Plan – 185
13.5.2 Specific Next Actions to Take – 187
13.6 Airway Fires – 187

13.6.1 Preparation – 189
13.6.2 Prevention – 189
13.6.3 Treatment – 190
13.7 Intracavitary Fires – 190
13.8 Thermal Injury – 190

13.8.1 Maintenance of Normothermia – 191
13.8.2 Thermal Injury from Other Sources – 191

https://doi.org/10.1007/978-3-319-96125-5_13
13.9 Chemical Burns – 192
13.10 Electrical Burns – 193

13.10.1 Electrosurgery Units: ESU – 193
13.10.2 Electrocautery – 194
13.10.3 Electrical Faults – 194
13.11 Magnetic Resonance Imaging – 194
References – 195
Burns in the Operating Room
179 13
13.1 Introduction 13.2.1 The Fire Triad
In 2017 the World Health Organization [1] stated, There are three elements required for a fire to
“A burn is an injury to the skin or other organic occur often called the “fire triad.” The fire triad
tissue primarily caused by heat or due to radia- consists of fuel, an oxidizing agent, and an ignition
tion, radioactivity, electricity, friction or contact source. All three of these elements are commonly
with chemicals.” The operating room has many of present in a typical operating room, although they
these sources commonly present. Burn injury may not be easily recognized as potential dangers.
occurs from fire or other thermal sources, stray Fire prevention requires us to remove at least one
electrical current from monitors and equipment, of the triad elements. Cooperation and constant
and contact with chemicals. This chapter will look vigilance of the entire operative team is needed so
at these four common sources of burn injury in that the elements of the fire triad are not being
the operating or procedure room and consider brought together.
risk assessment and prevention. Friction from
positioning and movement during surgery is yet 13.2.1.1 Fuel
another cause of burns not covered. There are multiple sources for fuel present during
most surgical procedures (. Table 13.1). A com-

monly available fuel is the alcohol in alcohol-

13.2 Fire based surgical skin preparation solutions. Surgical
drapes, towels and sponges, patient clothing and
The ECRI Institute (formerly the Emergency Care sheets and blankets, hair, ointment, and dressings
Research Institute) is a not-for-profit organization can also all serve as fuel. Every plastic part of the
that researches approaches to improve patient
safety. In 2009 ECRI [2] estimated that 550–650
surgical fires occur each year in the United States. .. Table 13.1 Fuel sources
Operating room fires can occur inside the body,
on the skin, or in the environment around the Organic solvent solutions NIBP cuff
patient in the operating room. The result of an
Alcohol-based prep Anesthesia mask
operating room fire ranges from no injury to solutions
minor or major burns and even to patient death
although that is extremely rare. Operating room Surgical drapes and towels Breathing circuit
fires are dramatic events that can produce cata- Surgical gauze and Endotracheal tube
strophic injury, but with persistent, effective dressings
teamwork, they are also preventable. The first step Surgical gloves, gowns, Laryngeal mask
to take in the prevention of operating room fires is mask, cap, shoe covers airway
to recognize that there is a risk. The next step is to
Oxygen tubing,
take consistent and definitive action to mitigate mask, cannula
the risk factors to prevent a fire. Finally if a fire
does occur, appropriate steps must be followed to Petroleum-based ointment Oral and nasal
airways
minimize injury. Every member of the operating
room team is responsible for patient safety and Adhesive NG tube
thus the prevention and response to operating Patient gown and clothing IV tubing
room fires.
Sheets and blankets Tape
»» Operating room fires are dramatic events that Hair Paperwork
can produce catastrophic injury, but with
persistent, effective teamwork they are also GI tract gas Packaging materials
preventable.
180 K. S. de Lanzac and J. R. Koveleskie
anesthesia circuit, the endotracheal tube, and 13.3 Prevention of Fire

oxygen cannulas, masks, and tubing can be a fuel
source as well as paperwork, charts, and books. The easiest way to avoid an operating room fire
Just about everything in the operating room would be to eliminate all items in one of the three
except the tile walls and the metal door knob will arms of the fire triad. Unfortunately, that is not
ultimately burn. very feasible. All of the examples mentioned
above have crucial specific jobs in the care of the
13.2.1.2 Oxidizer surgical patient and are not easily eliminated.
The second element of the fire triad is an oxidiz- However, operating room teams can work to
ing agent. In the operating room, oxidizers avoid bringing items from the three triad ele-
include room air, oxygen, and nitrous oxide. ments together at the same time and same place
Higher oxygen concentrations increase the chance which is what creates the conditions for a fire to
of ignition and burning. Nitrous oxide by itself is start. This is a recurring, multi-step process that
not flammable, but when it is heated in an existing the team must perform for each and every surgi-
fire, it will release additional oxygen and so sup- cal procedure to prevent a problem that may seem
ports combustion even more readily than just remote and unlikely and one that many of us have
oxygen. never seen. Many organizations such as the
American Society of Anesthesiologists (ASA), the
»» Nitrous oxide by itself is not flammable, but Anesthesia Patient Safety Foundation (APSF), the
Association of periOperative Registered Nurses
when it is heated in an existing fire it will
release additional oxygen and so supports
(AORN), the ECRI Institute, and the Food and
combustion even more readily than just
Drug Administration (FDA) have all made efforts
oxygen.
to produce educational materials to assist organi-
zations in developing an environment of safety
when it comes to operating room fires and have
13.2.1.3 Ignition developed checklists and practice parameters to
The most common sources of ignition in the assist in fire prevention. We will address the rec-
operating room are the many different styles of ommendations as they relate to the three elements
electrosurgery units (ESU) used to cut and coagu- of the surgical fire triad.
13 late tissue. Other ignition sources include electro-
cautery, lasers, defibrillator pads, fiber-optic lights
and sources, surgical power drills, burs and saws, 13.3.1 Fuel
electrical arcs from a fault, and static electricity
(. Table 13.2).

The variety of items that can serve as fuel in a fire
in the operating room are so plentiful that it is hard
to imagine completely eliminating fuel to solve the
problem. Instead the entire operating room team
needs to be educated to recognize the fuels for
.. Table 13.2 Ignition sources what they are and to limit the risk to the patient.
Electrosurgical units Surgical drills, burs, and 13.3.1.1 Alcohol Prep Solutions
(ESU) saws
The American Society of Anesthesiologists (ASA)
Electrocautery units Defibrillator pads Operating Room Fires Closed Claims Analysis [3]
(ECU) cited alcohol prep solutions as the fuel in 12% of
Lasers Static electricity all cases resulting in claims. Alcohol-containing
prep solutions are inexpensive and highly effective
Fiber-optic lights Electrical faults
for decreasing surgical site infection, so they cur-
Operating room lights rently play an extremely valuable role in the care
of our patients and not likely to go away anytime
181 13
soon. But liquid alcohol creates vapors that can be
the fuel for a fire and so is potentially very danger- Box 13.1 Safety Recommendations for Prep
ous. After the liquid alcohol has fully dried and Solutions
the vapors have dispersed, there is no fuel avail- 55 Use controlled dose applicators
55 Follow manufacturer instructions for
able from alcohol to support a fire. Thus, allowing
application
alcohol to fully dry before draping is just one step 55 Use sterile towels to catch runoff and
in a process for safely using alcohol-based skin remove when finished
preps while keeping the risk of fire low. The appro- 55 Avoid pooling of prep
priate timing may be variable depending on the 55 Do not allow prep to soak hair, sheets, or
clothing
type or amount of solution used and the charac-
55 Ensure prep is dry before drapes are applied
teristics of the patient and the location of the prep. 55 Allow vapor to disperse
Although 3 min is the amount of time that is com-
monly used, visual inspection of the area should
be performed prior to draping the operating field
confirming that there is no residual liquid. such as with the use of a standardized time-out
The FDA became involved in surgical fire and checklist. All operating room sites should
prevention in 2015 because they regulate skin adhere to these precautions, create documented
prep solutions [4] and several of these substances policies and procedures to ensure adherence to
can serve as fuel for a fire. In 2007, recognizing the precautions, and then document the use of the
the risk of alcohol-based skin prep and OR fires, safety measures in the patient’s record. In sum-
the Centers for Medicare and Medicaid Services mary, one can limit the risk of alcohol becoming a
(CMS) issued a memorandum [5] that required fuel in a fire in the operating room by using appro-
implementation of fire risk measures whenever priate technique and application, limiting pooling
alcohol-containing skin preparations are used. of alcohol, and allowing adequate drying time.
One step to decreasing the fire risk of alcohol-
containing skin prep solutions is to control the 13.3.1.2 Surgical Drapes and Gowns
amount of alcohol used in the skin prepping pro- Surgical drapes are also a common fuel source.
cess. Both the FDA and CMS recommend the use From 1990 to 2006, 81% of operating room surgi-
of the applicator provided by the manufacturer cal fires were fueled by surgical drapes [6]. Culp
rather than open use of the solution out of a bot- et al. [7] reviewed the Consumer Product Safety
tle. The applicators can still lead to pooling of the Commission’s (CPSC) flammability of garment
solution on the patient and on the surgical bed, testing protocol known as the Standard for
or the solution can soak linens, patient clothing, Flammability of Clothing Textiles (SFCT), which
or even hair. This should be avoided as the pooled measures the burn time of material samples [7].
alcohol or alcohol-soaked material will evaporate They modified the testing to include various con-
and the vapor can then ignite. The use of towels centrations of oxygen as might be present near a
around the prepped area to absorb excess solu- patient receiving supplemental oxygen. Currently
tion that are then safely discarded prior to final only surgical gowns are required to undergo flam-
sterile draping is a safe practice that can reduce mability testing. Not surprisingly, they concluded
the risk of fire by removing one source of fuel. that in oxygen-enriched environments, the time
CMS now requires that hospitals and surgery to ignition of surgical drapes and sponges was
centers that utilize alcohol-based skin prep estab- decreased and that as the oxygen concentration
lish policies and procedures to reduce the risk of increased, the risk of a surface flash fire also
fire. In the 2007 memorandum, CMS made sev- increased. They demonstrated that in 50–100%
eral recommendations for the proper handling of oxygen environments, surgical drapes, sponges,
alcohol-containing prep solutions which are sum- and gowns would all be considered Class III fab-
marized in 7 Box 13.1. All members of the operat-
ric, which means they would be unacceptably
ing room team should be cognizant of the risk and flammable as consumer wear. They concluded
participate in making sure prep solutions are dry that physician anesthesiologists and other operat-
before surgical drapes are applied. CMS requires ing team members should make informed deci-
that verification of the above precautions takes sions on the material choices to decrease the
place prior to initiating the surgical procedure likelihood of surgical fires.
13.3.1.3 Other Fuels or laryngeal mask a irway to minimize increased

There are other fuels present in the operating ambient oxygen concentration. Fires during
room [8]. Just about anything made of plastic can MAC cases increased from 6% of MAC claims
serve as a fuel including nasal and oral airways, during 1985–1989 to 31% of MAC claims from
anesthesia masks, endotracheal tubes, laryngeal 2000 to 2009 [3].
mask airways, nasal cannulas, and face masks. In
addition to surgical drapes, gowns, and sponges
»» To decrease the risk of fire, delivery of
supplemental oxygen by open systems such
being potential fuel, bed linens, patient clothing as nasal cannula or face mask should be
and gowns, gauze, towels, and dressings can simi- avoided.
larly serve as a fuel source especially if saturated
with flammable liquids. Ointments, makeup, and
hair are other potential fuel sources. Petroleum-
based ointment can readily burn. 13.3.3 Heat and Ignition
»» Ointments, makeup, and hair are other 13.3.3.1 Electrosurgery
potential fuel sources.
Electrosurgery units (ESU) are by far the most
commonly reported ignition source for surgical
fires (e.g., “Bovie™,” Bovie Medical Corporation,
13.3.2 Oxidizer Purchase, NY, and others). Diathermy is the gen-
eral process of creating heat in tissue with high-
While a fire can start in the presence of the 21% frequency electrical current, essentially radio
oxygen in room air, increasing oxygen concentra- waves. The terms electrosurgery and electrocau-
tion increases the risk of ignition and combus- tery are often incorrectly interchanged. An elec-
tion. Also, the time for ignition of a fire decreases trosurgical unit uses AC electricity at high
with increasing oxygen concentration [7, 9]. The frequency from an active electrode (e.g., the
seemingly innocuous MAC procedure with sup- handpiece of a “Bovie™”) to deliver the energy to
plemental oxygen delivered via an open system the tissue for cutting, coagulating, and destroy-
such as a nasal cannula can be particularly dan- ing. There are numerous brands with proprietary
gerous because vigilance regarding fire may be methods to accomplish similar goals. A true
13 very low. Nasal cannula oxygen at high flow rates electrocautery device uses DC electricity to heat
can produce surprisingly high concentrations, up the tip of the device until it glows red, and
especially if it is allowed to pocket under the then that is applied to the tissue to cause coagu-
drapes [10]. Another particularly dangerous situ- lation. All of these devices can be a source of
ation is oxygen channeling through the drapes if ignition in a fire. Current ASA Closed Claims
the edges of the drapes are not tightly adhered to Analysis on Operating Room Fires showed that
the skin. A wrinkle in the edge of the drape can electrosurgery was involved in 90% of fire claims
allow a tunnel to form and allow oxygen to move [3]. ESUs are used in 80% or more of all surgical
or accumulate and cause a fire away from where procedures [11]. According to Mehta et al., and
the oxygen is being delivered. Forced air ventila- ASA closed claims data, claims for ESU-induced
tion or suction scavenging of excess oxygen fires during MAC increased dramatically, repre-
under the drapes may be helpful in decreasing senting almost a third of claims related to MAC
the oxygen concentration available to start a fire. in the 2000s.
Oxygen and nitrous oxide use are almost always
under the direction and control of the anesthesia 13.3.3.2 Surgical Drills, Burs, and Saws
team. To decrease the risk of fire, delivery of sup- During operation surgical power drills, burs, and
plemental oxygen by open systems such as nasal saws may produce enough heat from internal fric-
cannula or face mask should be avoided. If tion or friction of the cutting surface against the
patients require a higher concentration of oxy- tissue to serve as an ignition source. A surgical
gen, especially in procedures above the clavicle, bur is a spinning grinder with metal teeth. During
consideration should be given to inducing gen- an operation it can spit off sparks of hot material
eral anesthesia and utilizing an endotracheal tube that have landed on hair or other fuels and started
183 13
a fire. It may be advisable to drip saline on the cut- 13.4 Operating Room Preparation
ting surfaces and/or the tissue during use to cool
the surfaces as well as to limit activation time of 13.4.1 Personnel, Process,
the device. and Teamwork
13.3.3.3 Lasers Prevention of surgical fires is critical; these events
Medical lasers are another source of ignition in should all be preventable. Knowledge of the risk
the operating room. The ability of a laser to focus of fire by the entire operating room team is para-
a lot of energy on a small area makes them useful mount. Education must take place, but to be truly
in surgery but also potentially dangerous. Lasers effective, fire drills should be conducted on a reg-
focused on dry materials such as the surgical ular basis including operating room and patient
drape, towels, or gauze can cause an ignition. Of fires specifically. Operative teams should be edu-
particular concern is the use of laser devices in the cated, conduct drills, debrief, and correct errors in
airway which puts the high-energy beam in very the process through continued education.
close proximity of both a fuel and oxidizer source, The first step in operating room fire preven-
the endotracheal tube, and any oxygen in and tion is recognition of the risks described in the
around the endotracheal tube, even room air. This previous sections. Every surgical procedure is
will be addressed later in the section on airway preceded by a time-out, and every time-out
fires. 7 Box 13.2 outlines common laser safety

should be accompanied with a surgical fire risk
precautions. assessment.
»» Prevention of surgical fires is critical; these
events should all be preventable.
Box 13.2 Laser Safety Recommendations
55 Appropriate staff education and frequent
updates
55 Establish specific laser safety policies and 13.4.2 Flammable Solutions
procedures
55 Specific laser credentialing of physicians
55 Check equipment and cables for damage AORN has produced a Fire Risk Assessment Tool
55 Have equipment tested frequently with [12] to assist the operating room team in recogni-
documentation tion of the risk of surgical fire and to enhance
55 Only the operator should trigger the device communication in the operating room regarding
55 Minimize active laser time
fire risk and treatment. The risk of surgical fire is
55 Use standby mode when laser is not in use
55 For airway lasers use laser-resistant airway identified in five areas which address the presence
devices of components of the fire triad. The first section
55 Eye protection for staff and patient addresses the use of alcohol-based prep solutions
or other flammable solutions preoperatively. If
they are used, prevention techniques such as
avoiding pooling and adequate drying time
13.3.3.4 iber-Optic Lights, Cables,
F should be adhered to. This should be confirmed
and Light Sources before an ignition source is introduced to the
Fiber-optic light sources are very common in sur- same area.
gery both as headlights and as the source for light-
ing for endoscopic procedures. The heat generated
at the tip of the light source and at any of the metal 13.4.3 Anatomic Location
connectors can cause ignition. As a result, fiber-
optic lights and connectors should never be rested The second question section relates to the ana-
on surgical drapes, towels, or sponges because tomical location of the procedure. In particular, it
they could be hot enough to start a fire or burn the should be ascertained if the procedure will be
patient’s skin. above the xiphoid process or in the oropharynx. If
it is, an adhesive drape should be used and the use, it should be placed in the plastic holder and
hair and skin protected. When supplemental oxy- not laid on the patient or drape, and the active
gen is required, it should be minimized, or it electrode tip of the ESU should always be in view
should be delivered through a closed system such before it is triggered by the user so that there is not
as an endotracheal tube or LMA. Airway fires and inadvertent arcing to an unintended area that
precautions will be discussed later in this chapter might contain enough fuel and oxidizer to start a
as they have some unique dangers and precau- fire. The tip should also remain clean. If coagulated
tions. tissue builds up on the tip of the device, the tissue
itself may burn and flame, and then that may ignite
other materials. ESU and fiber-optic light cords
13.4.4 Oxygen and Nitrous Oxide and cables should be dry and free of coils and
knots. The cables and connectors of a fiber-optic
The third section of the AORN checklist asks light can become very hot and may serve as a
about the use of oxygen and nitrous oxide. If those source of ignition. Cables should be inspected fre-
oxidizers are in use, drapes should be placed in a quently for damage, and the light source should be
manner to allow adequate forced air ventilation to in standby mode when not in use.
disperse high concentrations of oxygen or flam- To reduce the fire risk, a bipolar electrode
mable vapors like evaporating alcohol skin prep. should always be considered as there has never
The lowest possible concentration and flow of been a fire reported related to the use of bipolar
oxygen is always advised. Providers should con- electrosurgical units, possibly due to lower energy
sider using forced air or suction to scavenge excess being used and less chance of an arc occurring [13].
oxygen from under drapes. If the surgical proce-
dure is above the xiphoid, oxygen should be »» If coagulated tissue builds up on the tip of
the device the tissue itself may burn and
turned off for at least a minute and the area venti-
flame and then that may ignite other
lated with room air before the ESU is used. This
materials.
requires good communication between the oper-
ating team and the anesthesia team. The time-out Laser safety is similar in that the cords should
procedure should also allow for recognition of the be free of coils, moisture, and breaks and that only
fire risk and should include a reminder discussion the operator should trigger the laser. The laser
13 on the importance of communication between should be placed in standby mode when not in
team members when an ignition source is used. use, and the working end should be protected by
placing on a moist drape or towel and away from
flammable materials or the patient’s skin.
13.4.5 lectrosurgical Units, Lasers,
E
and Fiber Optics
13.4.6 Fire Contributors
The fourth section is concerned with the correct
use of the ESU and other devices. Ideally, only the The fifth and final section of the AORN checklist
person holding the ESU electrode should trigger covers other fire contributors that may be present
the device via the handheld or the foot pedal to during a procedure. This includes defibrillator
prevent unintentional arcing. The operator of the pads, drill bits, and burs.
ESU should communicate with the anesthesia Defibrillator pads should be appropriately
team when the ESU will be used, especially in sized and applied completely without any wrin-
MAC cases and high-risk procedures. ESU should kles to the patient’s skin. The skin should be dry
not be used to enter the bowel or trachea. Current and free of lotion, and only approved conducting
used should always be the minimum current gel should be used. When defibrillator pads must
required to be effective so that there is not exces- be used to cardiovert or defibrillate a patient, the
sive arcing and possible flame formation at the tip. lowest current acceptable should be used, and the
Whenever the ESU electrode instrument is not in operating room team should always be prepared
185 13
for a spark and ignition. In the operating room, 13.4.7 ilverstein Fire Risk
S
very often these pads are out of the field and under Assessment Tool
the drapes, requiring even more vigilance to dry-
ing the area of prep solutions and minimizing Another simple risk assessment tool is the
oxidizers under the drapes. Silverstein Fire Risk Assessment Tool, developed
by Kenneth Silverstein, M.D., a physician anes-
The five sections of the AORN checklist help the thesiologist and Chief Clinical Officer at
operating team assess the risk for surgical fire and Christiana Care Health System in Delaware [14].
improve communication and recognition of risk This easy-to-use tool consists of these three ques-
among the team. In the simplest terms, the questions, each scored 0 for NO and 1 for YES. Will
tions should be asked and a yes or no answer open oxygen source such as a nasal cannula or
should be given. If “yes” the risks should be dis- mask be used? Will a laser or electrocautery unit
cussed, and prevention preparation should be be used? Is the procedure at or above the level of
made including preparations to respond to a fire. the xiphoid process? A low fire risk procedure is a
Vigilance must be maintained for unusual sounds score of 0 or 1. Intermediate fire risk is a score of
and smells as they may be the first sign of an invis- 2. High fire risk scores 3.
ible ignition. Once a procedure is identified as a
high-risk for fire, appropriate precautions should zz Silverstein Fire Risk Assessment Tool
be followed as outlined in 7 Box 13.3.

Will open oxygen source such as a nasal cannula
»» The five sections of the AORN checklist help or mask be used?
Will a laser or electrocautery unit be used?
the operating team assess the risk for surgical
fire and improve communication and Is the procedure at or above the level of the
recognition of risk amongst the team. xiphoid process?
Low fire risk procedure is a score of 0 or 1.
Intermediate fire risk is a score of 2.
High fire risk scores 3.
Box 13.3 High Fire Risk Procedure The APSF has developed a simple and useful
Precautions algorithm (. Fig. 13.1) that can be followed once

55 Appropriate staff education and frequent a procedure is designated as a high-risk procedure

updates [15].
55 Risk assessment during time-out procedure
and throughout
55 Identify roles of OR team members in a fire
55 Allow prep solutions to dry 13.5 Management of Operating
55 Do not allow pockets or channels to form in Room Fires
drapes that would allow oxygen to
accumulate 13.5.1 General Action Plan
55 Minimize oxygen supplementation or
consider closed system
55 Turn off oxygen and allow oxygen Despite excellent planning, training, and proper
concentration to decrease prior to ESU preventative measures, you and your patient
activation may be faced with a fire. The fire may be in or on
55 Communicate prior to ESU activation the patient, or it may be nearby in the same
55 Minimize current and ESU activation time;
consider bipolar
room or down the hall. Well-established institu-
55 Keep gauze and sponges moist tional policies and procedures should be in
55 Have designated saline or water readily place and followed to prevent patient injury.
available on the field Typically this would include very general mem-
55 Frequent open communication among the orizable action plans like R.A.C.E. for Rescue,
OR team
55 Constant vigilance and preparedness to act
Alert, Contain, Extinguish or Evacuate and fire
55 Follow all standard institutional and OR fire extinguisher usage P.A.S.S. for Pull the pin, Aim
precautions low, Squeeze the handle, Sweep the discharge
nozzle.
Fire Prevention Algorithm*

www.apsf.org
Is patient at risk for surgical fire? NO Proceed but reassess for

(Procedures involving the head, neck and upper changes in fire risk frequently.
chest/above T5 and use of an ignition source in
proximity to an oxidizer.)
Nurses and surgeons avoid pooling of alcohol based

YES skin preparations and allow adequate drying time.
Communication between surgeon and anesthesia
professional prior to initial use of electrocautery.
NO
Does patient require oxygen supplementation? Room air sedation.
YES
NO
Is >30% oxygen concentration required to maintain
oxygen saturation?
YES
Use delivery device such as
Secure airway with endotracheal tube or blender or common gas outlet
supraglottic device.† to maintain oxygen below 30%.
† Although securing the airway is preferred, for cases where using a device is undesirable or not feasible,
oxygen accumulation may be minimized by air insufflation over the face and open draping to provide
wide exposure of the surgical site to the atmosphere.
*The following organizations have indicated their support for APSF’s efforts to increase awareness of the
potential for surgical fires in at-risk patients: American Society of Anesthesiologists, American Association
13 of Nurse Anesthetists, American Academy of Anesthesiologist Assistants, American College of Surgeons,
American Society of Anesthesia Technologists and Technicians, American Society of PeriAnesthesia Nurses,
Association of periOperative Registered Nurses, ECRI Institute, Food and Drug Administration Safe Use
Initiative, National Patient Safety Foundation, The Joint Commission
PROVIDED AS AN EDUCATIONAL RESOURCE BY THE

©Anesthesia Patient Safety Foundation 3/10/2013
Anesthesia Patient Safety Foundation
.. Fig. 13.1 APSF fire prevention algorithm, used with permission from APSF
zz Fire Action Plan be extinguishing the flames using approved

R: Rescue methods appropriate for the type of fire. The
A: Alarm or alert facility should again have a well-defined pro-
C: Contain or confine cedure for this, which should be known to all
E: Extinguish or evacuate staff throughout the facility and drilled fre-
quently.
There should be a system to alert others of the
fire such as “code reds” or activating a fire zz Fire Extinguisher Use
alarm pull station. Fire should be contained by P: Pull the pin
closing off doors as appropriate, shutting off A: Aim low
fresh gas flow, and removing potential fuel and S: Squeeze the lever
oxidizers from the area. The next step would S: Sweep the fire
187 13
13.5.2 Specific Next Actions to Take Standard fire drills and precautions do not cover
the unique nature of operating room fires. Specific
The ASA has produced an effective algorithm for education, drills, and simulations for OR fires
operating room fires depicted in . Fig. 13.2 [8]. If

should be focused on fire risk assessment, preven-
any signs of fire like smells, sounds, or visual cues tion, and management. Fire drills should be con-
present themselves, then it is better to speak up ducted with all members of the operating room
and act. The first step is to halt the procedure and team at specific time intervals to assure awareness
alert the rest of the operating room team. If no fire of the risk and management. A simple drill can eas-
is present, the procedure may be continued if ily imprint on the providers important information
investigation of the cause is completed and fire is regarding the location of extinguishers, fresh gas
not present. shutoff valves, and emergency exits in the operating
If a fire is present, stop the flow of airway room suites. These locations may not always be
gases. Any burning materials should be immedi- obvious, and searching for them in a time of disas-
ately removed from the patient and extinguished ter is not conducive to a good outcome. Drills can
using saline or water. If the fire is in the airway, also help the facility to recognize potentially dan-
stop the flow of gases and remove the endotra- gerous situations or lack of safety equipment in a
cheal tube immediately. In an airway or intracavi- safe, controlled setting rather than during an actual
tary fire, flood the site with saline or water. If fire catastrophe. Operating room fire drills should be
persists a carbon dioxide fire extinguisher can be complementary to facility fire drills and procedures.
used on the materials and the patient. Recently After a fire, there should be an open discus-
ignited materials should be isolated until com- sion with the patient and the family with the risk
pletely extinguished so that the fire is not fed. management team of the facility if available. The
If after these first actions the fire continues, events should be discussed without assessing
the general fire alarm should be sounded, and blame. The status of the patient and the plans for
standard hospital protocols should be followed. care should be discussed. Speculation on why the
This includes rescuing the patient from the fire event happened should be avoided in the early
area, containing the fire by shutting off gas supply stages. The time for that discussion can come
to the room and shutting the door, and evacuating later. The incident should be reported to the qual-
as needed. Continued efforts to contain or man- ity assurance personnel, and a root cause analysis
age the fire should be undertaken by those mem- should be undertaken. This will allow the team to
bers of the team separate from those charged with evaluate the predisposing factors and what could
caring for the patient. have been done differently and hopefully decrease
After the fire is extinguished, the patient the chance of a similar event. Equipment should
should be examined thoroughly for any injury. be quarantined and disposables saved if possible
Treatment should begin with assessment of patient to assist in the investigation of causes.
injuries, which may not be readily apparent
immediately, especially in the airway. Inhalational
injury secondary to smoke and fumes as well as 13.6 Airway Fires
exposure to burning products in an airway fire
may occur. Fire and smoke injuries may take some Airway fire prevention and treatment require spe-
time to evolve in the airway. Burned skin should cial reinforcement and consideration. Airway
be treated immediately to limit injury and to pre- procedures are the perfect storm bringing an
vent infection. Depending on the extent of injury, oxygen-enriched environment in the respiratory
consideration should be given to transferring a tree in close proximity to the ignition source of
patient to a burn center after stabilization. Great the ESU or laser with the endotracheal tube serv-
care should be taken in removing burning items ing as the fuel. These rare but potentially cata-
so that a secondary fire does not occur in the strophic events can be prevented with appropriate
operating room around the patient. There should caution and preparation. If an airway fire does
be a call for help to obtain additional caregivers occur, the treatment must be rapid and appropri-
and members of the team as necessary to contain ate to minimize patient injury. 7 Box 13.4 outlines

and extinguish the fire allowing other members of the precautions that should be taken in cases that
the team to care for the patient. may result in an airway fire.
OPERATING ROOM FIRES ALGORITHM

Fire • Avoid using ignition sources1 in proximity to an oxidizer-enriched atmosphere2
Prevention: • Configure surgical drapes to minimize the accumulation of oxidizers
• Allow sufficient drying time for flammable skin prepping solutions
• Moisten sponges and gauze when used in proximity to ignition sources
YES Is this a High-Risk Procedure? No

An ignition source will be used in proximity to an
oxidizer-enriched atmosphere
• Agree upon a team plan and team roles for preventing and managing a fire
• Notify the surgeon of the presence of, or an increase in, an oxidizer-enriched atmosphere
• Use cuffed tracheal tubes for surgery in the airway; appropriately prepare laser-resistant tracheal tubes
• Consider a tracheal tube or laryngeal mask for monitored anesthesia care (MAC) with moderate to deep
sedation and/or oxygen-dependent patients who undergo surgery of the head, neck, or face.
• Before an ignition source is activated:
Announce the intent to use an ignition source
Reduce the oxygen concentration to the minimum required to avoid hypoxia3
Stop the use of nitrous oxide4
Fire Management:
Early Warning Signs of Fire5
Fire is not present; HALT PROCEDURE

Continue procedure Call for Evaluation
FIRE IS PRESENT
AIRWAY 6 FIRE: NON-AIRWAY FIRE:

IMMEDIATELY, without waiting IMMEDIATELY, without waiting
• Remove tracheal tube • Stop the flow of all airway gases
• Stop the flow of all airway gases • Remove drapes and all burning and
• Remove sponges and any other flammable flammable materials
material from airway • Extinguish burning materials by pouring
• Pour saline into airway saline or other means
13 If Fire is Not Extinguished on First Attempt

Use a CO2 fire extinguisher 7
Fire out If FIRE PERSISTS: activate fire alarm, evacuate patient, Fire out
close OR door, and turn off gas supply to room
• Re-establish ventilation • Maintain ventilation

• Avoid oxidizer-enriched atmosphere if • Assess for inhalation injury if the patient is
clinically appropriate not intubated
• Examine tracheal tube to see if fragments may
be left behind in airway
• Consider bronchoscopy
Assess patient status and devise plan for management

1
Ignition sources include but are not limited to electrosurgery or electrocautery units and lasers.
2
An oxidizer-enriched atmosphere occurs when there is any increase in oxygen concentration above
room air level, and/or the presence of any concentration of nitrous oxide.
3
After minimizing delivered oxygen, wait a period of time (e.g., 1-3 min) before using an ignition
source. For oxygen dependent patients, reduce supplemental oxygen delivery to the minimum
required to avoid hypoxia. Monitor oxygenation with pulse oximetry, and if feasible, inspired,
exhaled, and/or delivered oxygen concentration.
4
After stopping the delivery of nitrous oxide, wait a period of time (e.g., 1-3 min) before using an
ignition source.
5
Unexpected flash, flame, smoke or heat, unusual sounds (e.g., a “POP,” snap or “foomp”) or odors,
unexpected movement of drapes, discoloration of drapes or breathing circuit, unexpected patient
movement or compint.
6
In this algorithm, airway fire refers to a fire in the airway or breathing circuit.
7
A CO2 fire extinguisher may be used on the patient if necessary.
.. Fig. 13.2 ASA operating room fire algorithm, used with permission
189 13
strike on the cuff. Alternatively the endotracheal
Box 13.4 Airway Fire Precautions tube may be repeatedly placed and removed by
55 Recognition of risk the surgeon performing using the laser during
55 Follow standard fire precautions with
periods of apnea.
recognition of high risk
55 Minimize oxygen concentration
55 Communicate before activation of ESU or
»» Airway procedures are the perfect storm
bringing an oxygen enriched environment in
laser
55 Never use ESU to enter the airway the respiratory tree in close proximity to the
55 Use laser-resistant endotracheal tubes ignition source of the ESU or laser with the
when applicable endotracheal tube serving as the fuel.
55 Fill endotracheal tube cuff with tinted
saline for laser cases
55 Be prepared to emergently turn off fresh
gases and remove the endotracheal tube 13.6.2 Prevention
55 Additional airway equipment available
55 Saline or water available and designated on
the field or table Tracheostomy and tonsillectomy are two typi-
55 Vigilance and a rehearsed plan of action if a cal airway procedures. If the cuffed endotra-
fire occurs cheal tube works perfectly, oxygen should not
escape during a tonsillectomy. But during a
tracheostomy, the risk of fire goes up even more
because the surgeon intentionally enters the
13.6.1 Preparation potentially oxygen-enriched tracheal lumen.
Even small holes in the airway can produce a jet
Preparation for a case that could lead to an airway of oxygen- enriched gas igniting a fire. ESU
fire includes all of the previously mentioned gen- should not be used to enter the trachea to limit
eral fire prevention education, skills, strategies, the chance of ignition within the trachea.
communication, equipment, and practiced team- Decrease the FiO2 to 21% but at least less than
work plus some additional items which should be 30% if possible, and realize that it may take sev-
immediately available: eral minutes for the FiO2 in the trachea to
55 Saline or water in a basin with soaked gauze decrease adequately. Good communication
sponges on the field to extinguish a fire with the surgeon is necessary.
55 Backup airway equipment such as endotra- Lasering vocal cord lesions is definitely a high
cheal tubes and an anesthesia mask if a fire risk case. Jet ventilation has been advocated
burned airway device must be removed to reduce the fire risk by reducing the fuel of the
55 An anesthesia machine that can deliver air to endotracheal tube in the airway. Unfortunately,
deliver a lower FiO2 anesthetic airway fires can still occur with jet ventilation.
55 Even greater attention to the sparing and “fire Wegrzynowicz et al. [16] published a case report
safe” use of the ESU where jet ventilation was used for a patient hav-
ing a vocal cord papillomata removed [16]. All
Adding a laser to an airway procedure brings an fire precautions were taken including having the
even higher energy ignition source than an entirety of the patient’s head covered in saline-
ESU. Typical PVC endotracheal tubes readily saturated OR towels to prevent laser injury and
ignite producing thick black toxic smoke and are fire. An inadvertent laser strike caused second-
generally avoided. Laser “safe” tubes made of degree burns as two fingers of a surgeon’s glove
alternate materials or covered with metal foil or flamed bright blue and orange. A muffled roar
other coatings to reduce flammability can be eas- was heard as this flaming gas was entrained by
ily purchased. Purpose-made metal foil tape can the Venturi effect into the oxygen-enriched tra-
be wrapped around a regular endotracheal tube to chea as the jet ventilator was activated. The flam-
lessen the vulnerability of the tube to a laser’s heat. ing gas then was exhaled out of the mouth but
Flexible metal endotracheal tubes are available. also the nose under the wet towels, setting the
The cuff(s) of all of these tubes should be filled patient’s moustache ablaze and causing second-
with saline, often tinted with methylene blue for degree burns of his lip. It all happened in an
easier leak detection, to reduce the risk of a laser instant!
13.6.3 Treatment equipment should be removed, extinguished, and

safely discarded. The patient should be examined
The plan to treat an airway fire should be well for burns externally as well as within the airway.
rehearsed mentally and ideally also in simulation.
If an airway fire is suspected, either due to visual-
ization of flames, unusual smells, or even auditory 13.7 Intracavitary Fires
cues such as a “whoosh” or a “pop,” then fire
should be assumed and treatment begun immedi- Intracavitary fires in the abdomen, pelvis, chest,
ately. Treatment can always be stopped if fire is and sinuses are all possible when ignition devices
not present, but waiting to initiate treatment can such as fiber-optic light, lasers, and ESUs are used
have devastating consequences. 7 Box 13.5
in the presence of fuels like bowel gas or plastics
outlines the steps that should be taken if an airway and the oxidizer oxygen. One of the reasons car-
fire is suspected. At the first sign of a problem, the bon dioxide is used for insufflation is that it is
procedure should be halted. The laser and electro- noncombustible. But this is not a foolproof tech-
cautery unit should be stopped and placed away nique. An intra-abdominal fire occurred during
from the field in standby mode. The field should an elective laparoscopic cholecystectomy in the
be flooded with saline. At the same time, fresh gas insufflated abdomen after the use of the ESU [17].
flows should be stopped, and the endotracheal During investigation of the cause of the fire, it was
tube should be removed simultaneously. The found that one of the carbon dioxide tanks used
quickest way to stop fresh gas flows is to discon- for insufflation of pure CO2 instead contained
nect the circuit at the elbow and remove the endo- 86% oxygen, but the pin index pattern was that
tracheal tube. Surgical drapes and towels should same as for pure CO2, allowing the tank to be
be immediately removed. Once the fire is extin- mounted to the insufflation machine. In this case
guished on its own or with saline or wet towels, after the fire was recognized, the abdomen was
ventilation can be reinitiated as needed. A thor- opened and flooded with saline. The procedure
ough inspection of the area should take place to continued and that patient survived.
ensure that fire does not persist or that burning
debris is not present. The patient should be rein-
tubated, and the trachea should be bronchoscopi- 13.8 Thermal Injury
13 cally examined for signs of damage. Consultation
with an ENT physician should occur, and rigid Fire is not the only cause of heat injury to patients
bronchoscopy may be considered. Oxygen should in the operating room. Any warm or hot device or
be provided as needed. The procedure should be substance that can come in contact with the
aborted, and attention should be turned to patient patient can cause a burn injury resulting in tissue
rescue and treatment. If the airway fire has caused damage. Potential sources of thermal injury are
ignition of equipment and drapes, the drapes and listed in 7 Box 13.6 and described below.

Box 13.5 Management of Airway Fire

55 Stop the procedure Box 13.6 Causes of Operating Room
55 Remove the endotracheal tube Thermal Injury
55 Stop fresh gas flow 55 Forced air warmers
55 Remove burning materials from the airway 55 Heated fluid bags or bottles
55 Flood site with saline or water 55 Warming mattresses or blankets
55 Once extinguished, resume ventilation with 55 Recently sterilized instruments not allowed
minimal oxygen to cool
55 Examine the oropharynx, hypopharynx, and 55 Unintended ESU activation or hot tip after
airway activation
55 Reintubate if necessary 55 Lasers
55 Consider bronchoscopy and ENT consulta- 55 Fiber-optic light sources, cables, and
tion connectors
55 Perform patient assessment and begin 55 Exothermic reaction of cement
necessary treatment 55 Surgical drills, burs, and saws
191 13
13.8.1 Maintenance be used, and all equipment should be inspected
of Normothermia for damage and faults. Alarms from warming
devices should be heeded, and the cause for the
Warming devices are frequently used to maintain alarm should be aggressively investigated.
normothermia and can be very safe if used prop- Devices should never be customized or used
erly but can also be linked to thermal injury if not inappropriately. All manufacturer instructions
applied appropriately. and recommended use for safety should be
strictly adhered to. Even when appropriate warm-
13.8.1.1 Forced Air Warming ers are used in the indicated fashion, the device
Forced air warming devices are routinely used in and its application to the patient should be moni-
the intraoperative and postoperative period. These tored frequently during use and the area assessed
devices consist of a heating mechanism for warm- after use.
ing air and blowing it through tubing into a
two-layer blanket that inflates like an air mattress. 13.8.1.3 Heated Materials
One layer has small holes that allow a gentle dif- Materials such as water bottles and IV fluid bags
fuse amount of heated air to be applied evenly to have been heated in microwaves or blanket
the patient’s skin over a large area. These warming cabinets and then used for mainte-
double-layer blankets must be applied appropri- nance of temperature as well as for positioning
ately and the hoses attached as indicated accord- of patients. This practice has been linked to
ing to manufacturer’s instructions. The use of a patient burns because the materials were not
forced air warmer hose shoved under a regular designed to be used on anesthetized patients in
bed blanket, a practice known as “hosing” on an this manner or for long periods of time that are
anesthetized patient, can easily lead to the air typical during an operation. In the 1994 ASA
blowing on just one small part of the body causing closed claims analysis on burns from warming
overheating and a skin burn. A review of ASA devices, 64% of the burns reported were from
closed claims data [18] showed that 87% of burn warmed intravenous fluid bags or plastic bottles
injuries from forced air warming were attributed [19]. All of these were preventable. Do not use
to the use of the hose without the appropriate anything that is not intended and manufactured
double-layer blanket. Another possible mechanism for patient warming.
of burn injury is applying the air blanket to poorly
perfused extremities such as in a case where there
is arterial occlusion to the lower extremities. The 13.8.2 hermal Injury from Other
T
limb will get warmer and warmer but due to lack Sources
of circulation won’t carry the heat back to the rest
of the body, resulting in burn injury to the skin 13.8.2.1 Sterilized Instruments
and perhaps deeper tissue. Thermal injury resulting in patient burns may
also result from recently sterilized instruments. In
13.8.1.2 Warming Mattresses particular the flash sterilization process, now
and Blankets known as immediate-use steam sterilization, can
In addition to forced air warmers, fluid-filled result in very warm instruments being delivered
warming mattresses and electrical blankets have to the operating room without an appropriate
been used in the operating room. As with most cooling time. The use of these instruments on
thermal injuries, tissue damage is a function of patients or resting the instruments on a patient’s
the temperature and the duration of exposure. exposed skin may result in a burn and blistering.
Burns from electrically powered warming equip- These instruments will be hot to touch if they are
ment represent only 29% of total burns from handled by the surgeon, but some items may not
warming devices, but more than half are water be handled before application to the patient. The
mattresses [19]. temperature of these instruments should be
When using warming devices, the minimum verified as safe before they are rested on a patient’s
temperature to maintain normothermia should skin or used in the procedure.
13.8.2.2 Electrosurgical Units cal instruments such as retractors. Light is

ESUs and electrocautery can cause a surgically transmitted from a light source through fibers in
precise thermal reaction on tissue at the intended a cable to the device and ultimately to the illumi-
site, but the active electrode tip may remain hot nated end. The light source, damaged fiber-optic
after use in the surgical field. If the hot electrode cables, metal connectors along the cable, and the
tip is rested on the patient’s skin, a burn can occur. illuminated end can all heat up and cause thermal
The electrode should always be returned to the injury if allowed contact with the patient [20].
approved plastic holster. 7 Box 13.7 outlines rec-
Attention should also be given to the light source
ommendations for safe use of electrosurgical units. generator which may unknowingly come in con-
tact with one of the patient’s extremities if it is
13.8.2.3 Fiber Optics allowed to be pulled too close to the operating
Thermal injury and burns may occur with the use table.
of fiber-optic equipment in the operating room.
Fiber-optic devices are used in endoscopic proce- 13.8.2.4 Lasers
dures, in headlamps, and in other types of surgi- In addition to serving as a source of ignition,
especially in airway fires, lasers can also induce
unintended thermal burns. In addition to skin
Box 13.7 Steps to Prevent ESU Injury and mucosal injury, direct or indirect laser light
55 Routine inspection of the device by a exposure can cause serious and potentially irre-
biomechanical engineer versible corneal and retinal injury. The anesthe-
55 Appropriate education of surgeon and tized patient’s eyes should be protected from
operating room team
laser light by taping the eyes closed and also use
55 Follow all manufacturer’s instructions and
precautions of saline-soaked eye pads and perhaps laser-
55 Inspection of the unit and cables daily resistant goggles depending on the type of laser
before use being used. Remember that reflected and scat-
55 Test safety alarms and never silence alarms tered laser light can cause eye and skin thermal
55 Document serial number of device on each
injury.
case
55 Do not place devices on or around ESU that
may create interference 13.8.2.5 Bone Cement
13 55 Appropriate placement of dispersion pad Bone cements such as polymethyl methacrylate
55 Reusable equipment should be clean and in
working order
undergo an exothermic free-radical polymeriza-
55 Never reuse disposables tion process, which causes the cement to heat up
55 Never use ESU in the area of flammables considerably. This polymerization can reach tem-
55 Alert team when ESU will be used in peratures of 82–86 °C in the body [21].
high-risk procedures Temperatures in this range on the skin and sensi-
55 Limit current and activation time
55 Recognize the presence of implanted
tive tissue such as nerves can cause thermal injury.
cardiac devices There has also been a case report of a thermal
55 Report any malfunctions and take unit out burn from bone cement used in a total hip arthro-
of use plasty [22].
55 Follow all institutional policies and
procedures
55 Only the operating physician should
activate the device 13.9 Chemical Burns
55 The active end of the electrode should be
in sight before activation Chemical burns in the operating room can result
55 Do not allow debris to build up on active from the use of common skin preparation solu-
electrode tip
55 Always holster device when not in use
tions as well as accidental exposure to caustic
55 Recognize that the tip may remain warm materials. Chemical burns and skin irritation
after activation from skin prep solutions are more likely to occur
when the solutions are not allowed to dry and
193 13
when they remain in contact with the skin for 13.10 Electrical Burns
long periods of time [23]. Povidone-iodine can be
irritating to the skin. When this wet solution gets 13.10.1 Electrosurgery Units: ESU
under the patient’s body or under the tourniquet
cuff, irritation, maceration, friction, and pressure Currents greater than 50 Hz are more likely to cre-
can compound each other and lead to skin burn ate burns rather than electric shock. ESUs utilize
or ulceration [24]. Somewhat similar to the rec- this high-frequency (500 kHz) AC current to cre-
ommended procedure with alcohol skin prep ate heat, which can cut and coagulate tissue. This is
solutions, iodine solutions should be prevented known as diathermy. The electrical current passed
from pooling and soaking the linens in contact into the patient from the tip of the ESU instrument
with patient skin, especially in dependent areas, is allowed to safely return to the ESU generator
and it should be allowed to dry before applying unit by way of a dispersion pad placed away from
tourniquets or draping. An impervious drape the incision site. Dispersion pad surface areas are
around tourniquets can help prevent prep s olution large enough to allow current dispersion and to
contact with the skin. Replace the tourniquet or minimize heating and damage under the pad, if it
dispersion pad if prep solution runs under it. is properly applied. Recommendations for the safe
Chlorhexidine gluconate (CHG) has been use of dispersion pads are listed in 7 Box 13.8.

associated with a risk of chemical burns in neo- Modern isolated electrosurgery units will com-
nates and children. Forty-four cases of chemical pletely stop delivering energy if the dispersion pad
burns were found in preterm infants after the is not on the patient at all, but if the pad is applied
application of chlorhexidine [25]. These infants poorly with wrinkles and is partially lifted or has
were 26 weeks or younger or were infants that dried out nonconductive areas, this may not be
weighed less than 1000 grams. In five of the cases,
the injury resolved but left scarring, discoloration,
or keloids. Death was reported in five cases with
most attributed to comorbidities attributed to Box 13.8 Recommendations for Dispersion
prematurity, but the chemical burns were consid- Pad Safety
ered a possible contributory factor. Due to the risk 55 Only approved pads should be used
55 Do not reuse disposables
of chemical burns, CHG should not be used in 55 Pads should be applied close to the surgical
neonates. site
Quaternary compounds used to clean the sur- 55 Apply pad to a clean and dry site
gical table and stretchers for transport can also 55 Use appropriately sized pads for the patient
cause skin burns. These substances may also be 55 Confirm that pad is securely adhered to the
skin
used in the cleaning of surgical tools. These burn 55 Never reposition a pad using the same pad
injuries are rare if standard precautions of ade- 55 Place pad over a well-perfused area with
quate drying time and avoidance of contact with large muscle mass
patient skin are followed. 55 Do not place over implanted hardware
Accidental chemical burns may also occur due 55 Do not place pad over scar tissue
55 Consider clipping hair before placement or
to mislabeled solutions in the operating room. In avoid hairy areas
2013, according to the Institute for Safe Medication 55 Avoid pad placement over joints or bony
Practices (ISMP), which operates the National protrusions
Medication Errors Reporting Program, several 55 Place pad after patient has been positioned
cases of chemical burns have been reported from 55 Document site and skin condition before
and after pad placement and removal
accidental use of glacial acetic acid (99.5%), a 55 Adhere to safety alarms and recheck pad as
highly concentrated form of acetic acid, instead of necessary
a 4–5% solution [26]. 55 Avoid placing a pad distal to a tourniquet
The application and removal of adhesive tape, 55 Avoid placing pad near implanted cardiac
electrocardiogram pads, and surgical drape adhe- devices
55 Avoid placing pad over tattoos as certain
sive may cause chemical burns or physically inks may contain metal
denude the skin which may scar as much as a burn.
sensed properly by the machine, and then the cur- should be undertaken when sedation is utilized.
rent may still flow across a smaller skin area and Patients should be screened for metallic objects,
cause a burn. Also if the dispersion pad is too close and they should always change into a hospital
to the incision or is placed over metal implants, a gown. When patients are placed on the table, skin-
burn can occur. to-skin contact should be avoided to prevent cur-
rent loops [27]. Only manufacturer-approved
padding should be used to insulate patients.
13.10.2 Electrocautery Monitoring cable and other lines should be routed
in a straight line out of the MRI tube and not
Electrocautery uses DC electrical current to heat coiled. Coiling can allow induction of current
a metal wire until glowing, which is applied to tis- leading to burns. Trained technicians should oper-
sue to burn or coagulate a specific area of tissue. ate the MRI machine, and standard operating pro-
Current does not pass through the patient typi- cedures should be followed. Patients should always
cally, but heat is passed to the tissue from the wire. be observed while in the MRI unit, and institu-
This is typically used by dermatologists, ophthal- tional fire safety precautions should be followed.
mologists, and plastic surgeons. ECUs are smaller
and may be battery operated.
13.12 Conclusion
13.10.3 Electrical Faults Patients expect that they will be safe from danger
when undergoing surgery and protection from
Electrical faults from equipment or wiring can burns is no exception. Burns of any type in the
lead to electric shock in the operating room. operating room are an unexpected event, but they
Electrical shock often leads to burns that present should not be completely unanticipated.
with only a small surface lesion on the skin but We have outlined various types of burns that
much more significant tissue damage underneath. can occur. The risks of burns in the operating
A very high index of suspicion is needed when room should be recognized by the members of the
examining and caring for these patients. anesthesia care team, and methods for prevention
should be considered and undertaken. This
13 includes education of all members of the operat-
13.11 Magnetic Resonance Imaging ing room team on risk assessment and methods
that can be used to minimize the potential for
There are several mechanisms for burns to occur burns.
in the magnetic resonance imaging (MRI) unit In the unfortunate event that a burn occurs,
including electromagnetic induction heating, whether a significant injury due to fire, or a minor
antenna effects, and closed-loop current induc- skin burn from adhesive, the operating room
tion [27]. team should recognize the injury, report and doc-
Monitor cables, external objects, and implants ument the injury, and as a quality measure assess
can be heated during MRI resulting in burns. system policies and procedures to see if they were
Manufacturer guidelines and facility protocols followed or if they need to be improved. Patients
should be followed when patients are undergoing and family members should be informed of the
MRI. Only monitors and cables approved for MRI potential risk of burns and if a burn were to occur
use should be used in the MRI unit. appropriate treatment delivered as needed.
There are a few simple safety precautions that Surgical fires and other burn injuries are rare but
can be followed to minimize the chance of burns are almost always preventable, and with appropri-
during an MRI procedure. Sedated patients will ate training, education, and attention to risk fac-
not necessarily be able to alert of a warming sensa- tors, operating room teams can protect patients
tion or a burn. Therefore heightened precautions from these potentially catastrophic events.
195 13
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ating room fires. Anesthesiology. 2013;118(5):1133–9.
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dominal fire during laparoscopic cholecystec-
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197 14
Eye Injury
Chizoba N. Mosieri and Mary E. Arthur

14.2 Mechanisms of Eye Injury – 198
14.3 Corneal Abrasions and Mechanisms
of Occurrence – 199
14.4 Function of the Cornea – 200
14.5 Injuries Due to Patient Movement – 204
14.6 Injuries Due to Prone Position – 204
14.7 Postoperative Visual Loss and Other
Ophthalmic Injuries Associated with
the Prone Position – 205
14.8 Ischemic Optic Neuropathy and Orbital
Compartment Syndrome (OCS) – 205
14.9 Central Retinal Artery Occlusion (CRAO) – 205
14.10 Cortical Blindness (CB) – 205
14.11 Acute Angle-Closure Glaucoma – 205
14.12 Preparation for Eye Surgeries – 207
14.13 Consent for Anesthesia: What Should
Be Discussed in Patients at Risk for
Perioperative Visual Loss? – 207
14.14 Monitoring During Eye Surgery – 208
14.15 Positioning During Eye Surgery – 208
14.16 Prevention of Eye Injury – 208
14.16.1 Closed Case Claims – 209
14.16.2 Conclusion – 209
References – 210

https://doi.org/10.1007/978-3-319-96125-5_14
198 C. N. Mosieri and M. E. Arthur
14.1 Introduction .. Table 14.1 Incidence and amount of payment

in eye injury cases [6]
Some studies show that ocular injury occurs dur-
ing 0.1–0.5% of general anesthetics and is mostly Type of claim Number of Median
corneal in nature in patients whose eyes are taped claims with payment
payment (× $1000)
shut during the case [1, 2]. When the eyes are left
untaped during general anesthesia, the incidence All movement 16 (76%) 90*
of ocular injury has been reported to be as high as claims (n = 21)
44% [2, 3].
During general 14 (88%) 108
General anesthesia reduces the tonic con- anesthesia
traction of the orbicularis oculi muscle, causing (n = 16)
lagophthalmos, a condition in which the eyelids
During MAC 2 (40%) 35
do not close completely, in 59% of patients [1]. (n = 5)
Additionally, general anesthesia reduces natural
tear production and tear-film stability. This Non-movement 34 (68%) 9
(n = 50)
results in the drying of the corneal epithelium
leading to reduced lysosomal protection. The All corneal 16 (64) 3†
protection afforded by Bell’s phenomenon (in abrasions
(n = 25)
which the eyeball turns upward during sleep,
protecting the cornea) is also lost during general Non-abrasion 34 (74%) 83
anesthesia [4]. (n = 46)
Intraoperative eye injuries have been men- All other claims 18 (72%) 75
tioned in insurance claims across the globe. They (n = 25)
account for 2% of medicolegal claims in Australia
Adapted from Gild et al. [6], with permission
and the United Kingdom [1, 5] and 3% in the
Note: Claims with no payment are excluded
United States. Claims against anesthesiologists for *P ≤ 0.01 between median payment for eye injuries
eye injuries analyzed as part of the ASA Closed caused by movement and other eye injury claims
Claims Project accounted for 3% of all claims in †P ≤ 0.01 between median payments for corneal
the database (71 of 2046). While the payment fre- abrasions and other eye injuries
quency for eye injury claims was higher than that
for non-eye injury claims (70% vs. 56%; P ≤ 0.05),
the median cost of eye injury claims were less
14 than for other claims ($24,000 vs. $95,000; percent of these cases (16 of 21) occurred during
P ≤ 0.01). There was a low median payment general anesthesia, and the remaining 24% [5]
($3000) for claims for corneal abrasion, while the occurred during monitored anesthesia care
median payment for claims involving movement (MAC) [6].
was ten times greater than for non-movement Corneal abrasions are the most prevalent ocu-
claims ($90,000 vs. $9000; P ≤ 0.01) [6]. lar injuries in the perioperative period. Anesthesia
(. Table 14.1).
and analgesia inherently mask the natural
response to pain, preventing the patient from
sensing and reacting to the noxious stimulus of
14.2 Mechanisms of Eye Injury ongoing corneal exposure. Reviewers in the
closed claims analysis were able to identify a
In the ASA closed claim analysis, two distinct mechanism of injury in only 20% of claims for
subsets of eye injury associated with anesthesia corneal abrasion.
were identified. The first, 25 of 71 claims (35%), Prolonged surgical procedures (>7 h) associ-
was characterized by corneal abrasion and a low ated with acute blood loss, hypotension, and
incidence of permanent injury (16%) during gen- hypoxia leading to posterior ischemic optic neu-
eral anesthesia. Patient movement characterized ropathies as well as direct pressure to the perior-
the second subset of eye injury during ophthalmic bital region of the eye from positioning leading to
surgery (21 of 71; 30%). Blindness was the out- increased intraocular pressure have also been
come in all cases in the second subset. Seventy-six implicated in eye injuries [7].
Eye Injury
199 14
14.3 Corneal Abrasions 55 Long surgical procedures, (odds ratio, 1.16
and Mechanisms of Occurrence per hour of anesthetic care; CI, 1.1–1.3)
55 Lateral positioning during surgery (odds
In non-ocular surgery, eye injuries are rela- ratio, 4.7; CI, 2–11)
tively uncommon. There may be pain, discom- 55 Operation on the head or neck (odds ratio,
fort, and occasionally visual loss when they 4.4; CI, 2.2–9.0)
occur. As mentioned earlier, corneal abrasions 55 General anesthesia (odds ratio, 3.0; CI,
are the most frequent ocular complications 2.2–38)
reported in the literature following general 55 Surgery on a Monday (odds ratio, 2.7; CI,
anesthesia [8–11]. 1.4–5.3)
They are a very painful postoperative burden
to the patient. The 1992 ASA closed claim analysis A specific cause of injury could only be identified
showed that of the 3% of all claims in the database in 21% of these cases [10]. These corneal abrasions
attributable to eye injury, 35% of these claims rep- with their multiple etiologies can lead to sight-
resented corneal abrasions with a 16% incidence threatening keratitis and permanent scarring. In a
of permanent eye injury [6]. Corneal abrasions report in the 1970s, patients whose eyes were nat-
occurred during general anesthesia, MAC, and urally closed or covered by adhesive tape during
regional anesthesia. general anesthesia did not develop exposure kera-
Corneal injury can occur secondary to various titis and showed negative fluorescein staining in
mechanisms. These can be due to mechanical the immediate postoperative period. The develop-
injury, chemical injury, exposure keratopathy, and ment and deployment of the handheld slit lamp
tear film destruction. There are several causative has made eye examination easier, more conve-
factors under mechanical injury, ranging from nient, and precise. The detection of tiny corneal
direct corneal trauma from facemasks, stetho- injuries can now be achieved with the use of the
scopes, identity badges, and other foreign objects slit lamp in fluorescein-stained eyes which other-
and surgical drapes which come in contact with the wise could have been missed or gone undetected
patient’s eyes accidentally. These injuries may occur under direct light observation.
secondary to loss of pain perception, inadequate In the study using a handheld slit lamp [11],
closure of eyelids, decreased corneal reflexes, or a corneal injuries were detected in a few patients
decrease in basal tear production. It is necessary to with adhesive tape protection or hydrogel patch
have in place prophylactic strategies that can pre- with higher incidence than was reported in other
vent corneal exposure and maintain tear film. studies [8, 9], hence greater accuracy of detection.
The reported incidence varies depending on Having studied the use of hydrogel and adhesive
the methodology of detection. The incidence has tape protection, this group started advocating for
been reported as high as 44% in a small prospec- the use of the convenient handheld slit lamp
tive study of general surgical patients, where fluo- immediately postsurgery to check for postsurgical
rescein staining of the corneal epithelium was eye injuries, which would provide instructions for
used [9]. In a large prospective study (n = 4652) of the use of protective eye drops or ointment after
patients undergoing neurosurgical procedures, an surgery to avoid eye discomfort and even perma-
incidence of 0.17% of corneal abrasions was nent ocular sequelae [11]. Therefore, the hand-
reported based on symptoms and confirmed by held slit lamp is more accurate and represents a
fluorescein staining [8]. In a review of 60,965 better way of evaluating corneal injury during
patients by a group in North America, an inci- general anesthesia.
dence of 0.056% was reported as sustaining eye This study of 76 patients also showed that
injuries (n = 34). Corneal abrasions were the most there was less ocular damage in the hydrogel
common [n = 21, (0.036%)] or 60% of all eye inju- group than the adhesive tape group (p < 0.01).
ries reported in this study [10]. Other injuries Twelve eyes (15.8%) in the hydrogel patch group
were conjunctivitis, blurred vision, red eye, chem- and 30 eyes (39.5%) in the adhesive tape group
ical injury, direct trauma, and blindness. showed ocular injury immediately after surgery.
Independent factors associated with a higher rela- All eyes with positive staining recovered sponta-
tive risk of eye injury included: neously within 24 h. At this time, there is no stan-
dard method of protecting the cornea during Anatomy Review The cornea is an avascular
general anesthesia for non-ocular surgery. structure that is comprised of five histologically dis-
Now, since it is considered that direct trauma tinct layers. A pre-corneal tear film that is com-
and destruction of tear film are the major culprits posed of three layers – lipid, aqueous, and
in corneal abrasion, it is imperative that strategies mucin – protects the cornea. The outermost lipid
that reduce both phenomena be employed in the layer prevents evaporation of the aqueous layer and
reduction of same. Currently the practice of peri- acts as a lubricant. The aqueous layer oxygenates
operatively taping the eyelids closed is not with- the corneal epithelium. The main function of the
out its shortcomings. The practice of instilling mucin layer is to create a hydrophilic surface for the
ointment is uncommon. Both practices have corneal epithelium. The pre-corneal tear film
shortcomings, including foreign body sensation regenerates by blinking; therefore, the absence of
and blurred vision. Thus, it may be time to stan- blinking during general anesthesia makes the cor-
dardize eye protection (. Table 14.2).
nea susceptible to injury/damage [12] (. Figs. 14.1,

14.2, and 14.3).

The cornea is highly sensitive to hypoxia, cor-
neal oxygen partial pressures dramatically
.. Table 14.2 Comparative chart of hydrogel eye decreasing even with as little as 30 s of hypoxia
shields with medical adhesive tape to prevent [13]. This leads to corneal edema and the
exposure keratitis
potential for epithelial layer loss. This epithelial
Item Medical Hydrogel eye loss leads to corneal abrasion. Hence any physio-
adhesive tape shields logical factor that leads to a reduction in corneal
blood flow has the potential to predispose
Principle Mechanical Mechanical patients to corneal injury. Malpositioning of the
effect closing and moisture
head, pressure from incorrectly applied face-
closing
environment masks, or any application of mechanical objects,
be it for a brief period, that causes undue pressure
Duration of Longer time in Over 8 h to the eye hence reduction in arterial blood flow
action surgery
or elevated intraocular pressure can predispose
Safety Easy to pull up Good patients to corneal injury.
skin in friable compatibility
patients and
cause irritability
14.4 Function of the Cornea
14 Water No Over 70%
percentage
The cornea has a threefold role: protection, trans-
Protection Weak Strong mission, and refraction.
Adhesiveness Strong Suitable
Protection The cornea is critical in keeping
Convenience Disposable Disposable, intact the fragile intraocular contents, which are
without
dirtying,
needed to maintain the function of the eye. The
convenient corneal epithelium is a tight, protective, strati-
fied squamous epithelium. This comprises five to
Sight dim/ No No
seven layers of cells, which are firmly attached to
irritation
the underlying stroma. Like other epithelia, the
Skin irritation Can cause No corneal epithelium continually sheds cells to the
serious irritation
environment. In this way, it helps impede the
General effect Common Better progress of pathogens into the relatively defi-
cient stromal tissue.
Adapted from the chart comparing Jujiu eye The cornea provides three modes of protec-
shields with other methods used in the prevention
of exposure keratitis but here only showing
tion:
differences between the hydrogel eye shield and 1. Mechanical protection
adhesive tape [11] 2. Transport protection
3. Light protection
Choroid Superior latera
(Mainy blood vessels) Rectus muscle
Eye Injury
Retina Sclera
Ora serrata Sclera
Ciliary Ciliary muscle

Viteous chamber
body Ciliary process
(Vitreous body)
Sideral venous sinus
(Canal of schlemm) Central fovea of
macul lutea
Posterior
Anterior cavity chamber
(Aqueous humor) Anterior Retinal arteries
chamber and veins
Central
retinal vein
Visual
Light
axis Central
retinal artery
Pupil
Cornea
Lens
Iris
Bulbar conjunctiva
Suspensory ligament Optic nerve
of lens
Optic disk
(Blind spot) Dura mater
201

.. Fig. 14.1 The vertical section of the right eye from the nasal side. Illustration by Equiano Mosieri. (Adapted from 7 scienceclarified.com)
14
Choroid
Conjunctiva
Ciliary body
Iris Retina
Lens Macula
Vitreous body
Pupil
Cornea Anterior chamber
Conjunctiva Optic nerve
Sclera
Optic disc
.. Fig. 14.2 Simplified eye diagram. Illustration by Equiano Mosieri. (Adapted from 7 allaboutvision.com)
14

Mechanical protection is achieved by highly damage to stem cell niches presents a very serious
aligned and tough collagenous lamella, which are condition for which there are limited treatment
arranged to withstand biaxial loads and therefore options. The cornea and the lens are thought to
provide significant mechanical protection to the act together as cooperative special filters which
intraocular contents. protect the retina from toxic UV radiation.
Transport protection is provided by the corneal
epithelium. Since it is the leading surface of the Transmission The cornea is able to transmit about
ocular system, it is subject to chemical, mechani- 95% of the incident radiation in the accepted visible
cal, and pathological insult. It handles this diffi- spectrum. The cornea has to be maintained in a
cult environmental insult by generating and relatively dehydrated state. If cornea stroma were
sloughing cells, while it still continuously pre- allowed to absorb fluid to equilibrate internal pres-
serves tight junctional complexes at all times [14]. sure, it would become opaque. So corneal structural
A continuous supply of proliferative basal cells architecture needs to be maintained and protected,
derived from stem cell niches at the limbus hence high vigilance during surgery and anesthesia.
ensures the sturdiness of the endothelial coverage
of the stroma [15]. If stem cell niches are not Refraction The corneal curvature is involved in
compromised, any damage to the epithelium is refraction but exact mechanism of its control and
repaired quickly (within 3–5 days). Any loss or maintenance is not well understood.
Eye Injury
Cornea Lamina cribosa Central retinal v. Optic canal

Iris Circle of zinn-haller Superior ophthalmic v. Pial branches from int. carotid a.
Trabecular meshwork Short posterior Perpendicular branches of pial a.
Lens Ciliary a. Hypophyseal branches of int. carotid a.
Dura
Optic nerve
Optic tract
Optic chiasm
Ophthalmic a Cavernous sinus
Central retinal a. Internal carotid a.
Short posterior ciliary a. Inferior ophthalmic v.
Site of CA Site of AION Site of CRAO Site of PION
.. Fig. 14.3 Diagram showing the sites of occurrence of different eye injuries and the causes. Illustration by Frances Mak. (Adapted from Mendel et al. [17])
14 203
The Neurovasculature of the Eye Branches of the

a
internal carotid artery provide the arterial supply
of the optic nerve and the retina. The central retinal
artery solely supplies the retina. Veins of the retina
empty into the cavernous sinus. The location of
anterior ischemic optic neuropathy (AION) is
anterior to the lamina cribrosa. The cause of AION
is most probably secondary to occlusion of the pos-
terior ciliary artery. Posterior ischemic optic neu-
ropathy (PION) occurs posterior to the laminar
cribrosa. The cause of PION is improper pial vas-
cular supply. Central retinal artery occlusion
(CRAO) can be caused by emboli or any factor that
can cause globe compression that results in loss of b
blood supply of the surface layer of the optic disk.
Corneal abrasions (CA) are due to decreased tear
production and inhibition of the corneal reflex and
any factor that contributes to either.
14.5 Injuries Due to Patient

Movement
In the closed claims analysis, the medium pay-

ment for claims that involved patient movement
was ten times greater than for non-movement
c
claims ($90,000 vs. $9000; p ≤ 0.01) [6].
Anesthesiologist reviewers declared care rendered
in general anesthesia “movement” claims as meet-
ing standards in only 19% of claims [6].
14 14.6 Injuries Due to Prone Position
Significant physiologic changes are associated with

the prone position (. Fig. 14.4). If proper attention

to detail is not paid to properly apply padding and

place supporting bolsters, there will be undue and
significant pressure on the abdomen and thorax. .. Fig. 14.4 a–c Significant physiologic changes are
Increased thoracic pressure leads to raised central associated with the prone position
venous pressure and a reduction in left ventricular
filling. This will in turn lead to reduced ventricular Kwee et al. [16] noted that several studies dis-
volume, stroke volume, and cardiac output and cussed postoperative visual loss, with fewer stud-
eventual reduction in blood pressure. ies addressing other complications which had
Usually surgery in the prone position is a lower levels of evidence. Postoperative visual loss
necessity when access to posteriorly positioned and cardiovascular complications, including
anatomic structures is required. The prone posi- hypovolemia and cardiac arrest, had the most
tion is known to be fraught with many complica- studies and the highest level of evidence. Among
tions, which could be associated with the type of the evidence-based recommendations are careful
surgery and the physiological changes that occur planning for optimal positioning, careful padding
with increased pressure to anterior anatomic of pressure points, timing, and an increased level
structures. In a systematic review of 53 papers, of vigilance when operative prone positioning is
Eye Injury
205 14
required. Most complications are due to inappro- with crystalloids more than colloids, the edema
priate pressures to vital structures and cardiovas- can be aggravated, thereby worsening intraocular
cular and pulmonary changes and can result in pressure. Orbital apex congestion can result in
prolonged hospitalization, permanent disability, orbital compartment syndrome (OCS) and an
or death. Postoperative visual loss can result from ischemic orbit. Decreased perfusion pressure on
inappropriate orbital pressure, and this can also the optic nerve results in ION. Even in the pres-
be a permanently debilitating c ondition. Half the ence of sufficient supportive facial padding, ION
papers addressed postoperative visual loss and OCS are well-established risks.
(POVL) though it had a low incidence rate, and
13 of the papers (25%) discussed cardiovascular
complications (hypovolemia and cardiac arrest). 14.9 entral Retinal Artery
C
Increased thoracic pressure will also lead to Occlusion (CRAO)
respiratory changes that include reduction in lung
compliance and high peak airway pressure which Hypotension, compression, vasospasm, and
will lead to reduced venous return and cardiac emboli can all lead to CRAO. It has been particu-
output and eventual reduction in blood pressure. larly linked to plaque displacement from carotid
Abdominal and pelvic compression will lead arteries which can lead to blockage of the central
to raised intra-abdominal pressure, venous pool- retinal artery. It is almost always irreversible.
ing secondary to inferior vena cava compression,
and eventual reduction in venous return, cardiac
output, and blood pressure (. Table 14.3).
14.10 Cortical Blindness (CB)
Emboli to the posterior cerebral artery territory

14.7 Postoperative Visual Loss or significant hypotension and bilateral watershed
and Other Ophthalmic Injuries infarctions affecting the visual cortex can lead to
Associated with the Prone cortical blindness. There is a possibility of
Position improvement in the succeeding weeks, but com-
plete recovery of sight is unlikely.
The rate of POVL associated with the prone posi-
tion is estimated to be between 0.05% and 1%.
14.11 Acute Angle-Closure
Glaucoma
14.8 I schemic Optic Neuropathy
and Orbital Compartment The prone position can cause a forward shift in
Syndrome (OCS) the lens-iris diaphragm. This impinges on the
drainage angle recess and obstructs the aqueous
Direct orbital pressure can lead to trauma. This humor outflow, thereby increasing intraocular
can lead to pain, conjunctival edema, chemosis, pressure and hence optic nerve injury in those
hemorrhage, and visual loss. patients predisposed to acute angle-closure glau-
Ischemic optic neuropathy (ION) is caused by coma, even in short surgical procedures.
damage to the optic nerve secondary to increased Types of anesthesia used for eye surgery (this
intraocular pressure and orbital venous pressure. section will not include illustrations of the anat-
ION is classified depending on if it occurs anterior omy and nerves that are targeted for blocks):
to the lamina cribrosa, anterior ION, or posterior 55 General
ION. Posterior ION is more common postopera- 55 Local with sedation
tively and is more severe than anterior ION. 55 Monitored anesthesia care
Direct pressure on the orbits causes an 55 Block with or without sedation
increase in intraocular pressure (IOP). This 55A higher incidence of eye surgery injury is
increase in combination with raised intra- associated with eye block coupled with
abdominal pressure reduces venous return in the sedation rather than with sedation alone.
orbit, thereby increasing venous pressure and These injuries are generally associated with
edema. If fluid replacement has been high and the block placement which can result in
14
206
.. Table 14.3 Summary of identified causes of postoperative vision loss (POVL) and malpractice claims
Identified Pathophysiology Clinical presentation Incidence range Post op injury Permanent Median claim
cause of POVL malpractice eye injuries payment
claim incidence (1980–2011) (1980–2011)
(1980–2011)
C. N. Mosieri and M. E. Arthur
Corneal Decreased corneal protection Complaints of blurry vision, 0.17–44% during 31% (1980–1994)
abrasion through inhibition of corneal tearing, redness, photophobia, the perioperative 18% (1995–2011)
reflex and decreased tear foreign body sensation [19] period [19] [20]
production [18]
Ischemic optic Not well understood; proposed AION: painless and progressive 89% of POVL Optic nerve 49% $128,100
neuropathy mechanisms include increased deterioration of vision, optic disk occurring from injuries 1980–1994
intraocular pressure and edema which resolves spine surgery; 5% (1980–1994)
ophthalmic vein congestion [21] spontaneously in 7.9–11.4 weeks
PION: acute painless visual loss Posterior ION 38% (1995–2011) 73% $424,750 [23]
in one or both eyes that can (PION) accounts for [23] 1995–2011
progress to complete blindness 60% of these cases [23]
[22] [25]
Central retinal Emboli and direct pressure on Typically manifests unilaterally 11% of spine
artery the globe [24] with “cattle tracking” of the surgeries [26]
occlusion arterioles with a “cherry-red”
spot visible during fundoscopic
exam [25]
Cortical Ischemia or extreme hypoperfu- Deteriorating vision that results 0.0038% of POVL –
blindness (CB) sion of the occipital lobes [27] in partial or bilateral POVL [27] cases due to CB [26]
Adapted from Mendel et al. [17] Vision loss during non-ocular surgery
Eye Injury
207 14
permanent injury in most cases. Peripheral
nerve blocks however are associated with Box 14.1 Risk Factors Associated with Isch-
temporary injuries. The most major cause emic Optic Neuropathy After Spinal Fusion
for concern is local anesthetic toxicity Surgery: The Postoperative Visual Loss Study
which can result in brain damage and death. Group [29]
55 Obesitya
55 Male gendera
55 Wilson framea
14.12 Preparation for Eye Surgeries 55 Lower % colloid administrationa
55 Longer anesthetic duration
Depending on the type of case and patient comor- 55 Greater estimated blood loss
bidities, both surgeon and anesthesiologist should
discuss and agree on the type of anesthetic, i.e., aSignificantly and independently associated with
general anesthesia, monitored anesthetic care, developing ischemic optic neuropathy after spinal
fusion surgery
local anesthesia with sedation, and block with or
without sedation that will be a safe option for the
patient.
Box 14.2 Advantages of Educational Vid-

14.13 Consent for Anesthesia: What eos in Advocating Best Practice Changes
Should Be Discussed [30]
in Patients at Risk 55 Readily available and free
55 Viewed at learner’s convenience
for Perioperative Visual Loss? 55 Provide a concise and clear message
55 Can be shared by others
In a 2016 APSF Newsletter, Stoelting [28] suc- 55 Enduring but can be updated as needed
cinctly summarized the discussions carried out by 55 Publicly available (accessible to patients)
the APSF Board of Directors Workshop in 2015,
which will be part of the information proposed to
be passed onto these groups of patients and their APSF believes that educational videos provide
responsible carers with full understanding. The advantages compared with traditional written
APSF Board of Directors Workshop on October information or report when addressing anesthesia
2015, in conjunction with the ASA Annual patient safety issues and advocating for “best
Meeting in San Diego, CA, addressed the topic, practices” to reduce the possibility of the adverse
“From APSF Educational Videos to Your Practice: events described in the video in 7 Box 14.2.

How to Make it Happen.” Lorri A. Lee introduced There are also POVL resources at the APSF
the APSF videos that dealt with perioperative website: 7 http://www.apsf.org/resources/povl/

visual loss (POVL) and the companion video that Simulated Informed Consent
presented various scenarios for obtaining Scenarios for Patients at Risk for Perioperative
informed consent for those patients at risk for Visual Loss (POVL) (7 Box 14.3): 7 http://www.

POVL. The importance of recognizing that poste- apsf.org/resources/povl-consent/.

rior ischemic optic neuropathy (PION) following APSF believes that increased awareness and
spine surgery is not caused by pressure on the understanding of risk factors associated with
globe, unlike central retinal artery occlusion POVL is a timely patient safety topic. Peer-review
(CRAO), was stressed. PION seems to be associ- literature and data from the ASA POVL Registry
ated with venous congestion of the head (head are evolving in a way that suggest a patient pro-
down prone position). There is increasing accep- file at risk for POVL and the steps to take in the
tance that the informed consent process should surgical and anesthetic management that might
include the risk of POVL in a select group of reduce the incidence of this devastating compli-
patients. It was acknowledged that the importance cation.
of the informed consent to the patient was also From the APSF data, it seems that the inclu-
dependent on those responsible for the patient’s sion of the risk of POVL in selected patients in the
care being cognizant of the strategies designed to informed consent for surgery and anesthesia is
reduce the risk of POVL (7 Box 14.1).
increasingly being accepted. It is noteworthy that
is key and always required. Since corneal injuries

Box 14.3 APSF Recommendation for Best occur by direct trauma, exposure keratopathy, or
Practices in Patients at Risk for Perioperative chemical injury, the anesthesiologist’s duty is to
Visual Loss (POVL) [28] ensure proper eye closure to prevent exposure
Informed consent should include remote risk of keratopathy. If cleaning materials are inadver-
POVL
tently split into the eye, chemical injury can
55 If the risk of POVL is not part of the surgical
informed consent, it should be part of the occur. The only antiseptic skin preparation that is
anesthesia informed consent. not toxic to the cornea is povidone-iodine 10%
55 The informed consent should include a aqueous solution. This is therefore the agent of
discussion of risk factors and steps to take choice for skin preparation of the face when
to reduce the likelihood of POVL.
required. [31]
55 Controlled hypotension is not recom-
mended. Postoperative visual loss is a much rarer com-
plication in anesthesia. The most frequent cause is
ischemic optic neuropathy [31]. Ocular blood
those responsible for caring for these patients are flow is determined by arterial pressure, ocular
aware of evolving information and strategies venous pressure, and ocular vascular resistance.
designed to reduce the risks of POVL. Thus, arterial hypotension, elevated venous pres-
sure or raised intraocular pressure, increased
resistance to flow, or decreased oxygen delivery
14.14 onitoring During Eye
M (via anemia or hypoxemia) can lead to ischemia
Surgery of the optic nerve.
Blood flow to the retina is under autoregula-
Monitoring during anesthesia should include tory control and maintained at a constant level
ASA standard monitors, as well as strictly moni- until intraocular pressure reaches 40 mmHg.
toring the level of neuromuscular blockade by Blood flow to the optic nerve at the disk stops at
using TOF for patients undergoing general anes- an intraocular pressure of 60 mmHg, though flow
thesia. In monitored anesthesia care cases, moni- is maintained in the choroidal and retinal circula-
toring should also include end tidal CO2 tion [1]. Infarction at this watershed area leads to
monitoring of spontaneous ventilation in anterior ischemic neuropathy and gives rise to a
patients. visual defect, with a pale edematous optic disk
and edema of the optic nerve in the posterior
scleral foramen.
14 14.15 ositioning During Eye
P The posterior part of the optic nerve is sup-
Surgery plied by the pial braches of the ophthalmic artery.
These vessels are not capable of autoregulatory
Patients should be positioned comfortably. There control; hence, the posterior part of the optic
should be a preoperative discussion with the nerve is more susceptible to ischemia in the event
patients about the use of restraints to prevent falls of a drop in perfusion pressure or anemia, leading
and to prevent sudden reaching for their eyes and to posterior ischemic optic neuropathy. There is a
other unplanned sudden movements. This can be slower onset of visual field defect and mild optic
a cause of some of the eye injuries that can occur disk edema.
from patient movement. The patients at higher risk of ischemic optic
neuropathy include those with diabetes, hyper-
tension, smoking, and polycythemia. Other asso-
14.16 Prevention of Eye Injury ciated factors include prone positioning (doubles
intraocular pressure), surgery causing major
Methods to prevent perioperative corneal injuries blood loss and hypotension (e.g., spinal surgery),
include simple measures like simple manual clo- cardiopulmonary bypass, and bilateral neck dis-
sure of the eyelids shut, use of ointment, paraffin section.
gauze, bio-occlusive dressings, and suture tarsor- Postoperative blindness may also be caused by
rhaphy. It is noteworthy that none of the protec- central retinal artery occlusion, by either an
tive strategies are completely effective. Vigilance emboli from carotid or cardiac lesions or from
Eye Injury
209 14
direct pressure on the eye, in conjunction with
perioperative ischemic optic neuropathy. Box 14.4 Practice Advisory for Periopera-
Fundoscopic examination shows a pale retina tive Visual Loss Associated with Spine Sur-
with a “cherry-red spot” [25]. gery: Advisory Statement
American Society of Anesthesiologists Task Force
on Perioperative Visual Loss.
Practice advisory for perioperative visual loss
14.16.1 Closed Case Claims associated with spine surgery (updated report, 2012).
Preoperative preparation:
Of note is that the median payment for claims 55 Inform patients who will undergo
involving movement was ten times greater than prolonged spine surgery in the prone
position with or without substantial blood
that for non-movement claims ($90,000 vs.
loss of the risk of postoperative visual loss.
$9000). Hence the legal burden laid on the anes-
thesiologist’s responsibility to ensure patients’ Intraoperative management:
immobility especially during ophthalmic 55 Monitor blood pressure continually. Aim to
procedures carried out under general anesthesia. maintain MAP within 20–25% of baseline.
Of utmost importance is the emphasis on the use 55 Administer colloids along with crystalloids
to maintain euvolemia for patients who
of intraoperative neuromuscular monitoring of
have substantial blood loss.
this patient subset to ensure a positive and good 55 Monitor hemoglobin or hematocrit
overall outcome for all concerned parties. periodically during cases with substantial
Reviewers were only able to identify a mecha- blood loss.
nism of injury in only 20% of the claims for 55 Position the head at the level of the heart or
higher and in a neutral forward position, i.e.,
corneal abrasion. Anesthesiologist reviewers

without significant neck flexion, extension,
declared the care rendered in the general anesthe- lateral flexion, or rotation when possible.
sia “movement” claims as meeting standards in 55 Avoid direct pressure on the globe to prevent
only 19% of claims [6] (7 Box 14.4).
central retinal artery occlusion. (Perform
Source: American Society of Anesthesiologists frequent eye checks every 15–20 min with a
mirror attachment to the headrest. This
Task Force on Perioperative Visual Loss (2012).
ensures that prolonged inappropriate
Practice advisory for perioperative visual loss external orbital pressure is avoided.)
associated with spine surgery: an updated report 55 Consider staging spine procedures in
by the American Society of Anesthesiologists high-risk patients.
Task Force on Perioperative Visual Loss [32].
Postoperative management:
55 Vision should be assessed when patient
becomes alert after anesthesia.
14.16.2 Conclusion 55 If there is potential visual loss:
– Urgent ophthalmologic consultation
In conclusion, great attention to detail should be should be obtained.
paid during all types of anesthesia. During gen- – Additional management may include
optimizing hemoglobin or hematocrit,
eral anesthesia, simple maneuvers such as care-
hemodynamic status, and arterial
fully taping the eyes shut and using special oxygenation.
eye-shield gels go a long way to reduce the occur- – Consider magnetic resonance to rule out
rence of corneal abrasions. Special precautions intracranial causes of visual loss.
should be taken to ensure that no mechanical
object or undue pressure is applied to the patient’s
eyes and that chemical skin preparation does not patients for POVL and necessary steps to take in
gain access to the patient’s eyes. Early referral to the surgical and anesthetic management that
the ophthalmologists of those patients with eye might reduce the incidence of this devastating
complaint should be encouraged. complication. There also seems to be increasing
APSF believes that increased awareness and acceptance that the informed consent for surgery
understanding of risk factors associated with and anesthesia should include the risk of POVL
POVL is a time safety issue. Data from the ASA in selected patients. Those responsible for patient
POVL Registry and peer-reviewed literature are care should be cognizant of the changes and
evolving and seems to be pointing to at-risk strategies designed to reduce the risk of POVL.
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Eye Injury
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213 15
Severe Peripheral Nerve

Injury
Rayhan Tariq, S. Nini Malayaman, Hong Yan, Usama Iqbal,
Mingqiang Li, Marcus Zebrower, and Henry Liu
15.2 Risk Factors and Causes of Nerve Injury – 214
15.2.1 Patient-Related Factors – 214
15.2.2 Anesthesia-Related Factors – 214
15.2.3 Surgery-Related Factors – 215
15.3 Clinical Manifestations of Nerve Injury – 215

15.3.1 Upper Extremity Peripheral Nerve Injury – 217
15.3.2 Lower Extremity Peripheral Nerve Injury – 218
15.4 Evaluation and Diagnosis – 219

15.4.1 Electromyography – 219
15.4.2 Nerve Conduction Study – 219
15.4.3 Imaging – 219
15.5 Management of Severe Nerve Injury – 219

15.5.1 Endogenous Nerve Healing in Response to Injury – 219
15.5.2 Surgical Treatment – 220
15.5.3 Nonsurgical Methods – 221
15.5.4 Role of Stem Cells to Augment Peripheral Nerve
Repair – 222
15.5.5 Role of Hyperbaric Oxygen – 222
15.5.6 Role of Lithium – 222
15.5.7 Role of Electroacupuncture – 222
15.5.8 Low-Intensity Ultrasound – 222
15.6 Summary – 223
15.8 Answers – 223
References – 223

https://doi.org/10.1007/978-3-319-96125-5_15
214 R. Tariq et al.
15.1 Introduction 3. Vascular injury: Ischemic vascular injuries

may be related to an embolic phenomenon,
In the setting of anesthesiology practice, nerve direct trauma, or vasoconstriction of the
injuries can occur during general anesthesia as a artery of Adamkiewicz that causes anterior
result of patient positioning and/or tourniquet spinal cord artery syndrome (ASAS).
placement. During regional anesthesia, there is Vascular injury may also arise from water-
the potential for direct injury to the nerve. shed infarct related to hypotension or
Perioperative nerve injuries (PNI) are the third vasoconstriction [5].
most common cause of anesthesia-related litiga- 4. Infectious etiology: Postsurgical inflamma-
tions [1]. In the American Society of tory neuropathy is a cause of PNI that can
Anesthesiologists (ASA) closed claims analysis, present as pain and weakness in a focal,
nerve injuries comprise 15–16% of the claims. multifocal, or diffuse pattern including
Etiology of nerve injuries can be multifactorial. epineural perivascular lymphocytic inflam-
The most likely pathologic mechanisms of injury mation, axonal degeneration, and microvas-
include stretch, compression, ischemia, and envi- culitis [6].
ronmental abnormalities [2]. The majority of 5. Chemotherapy: Patients on chemotherapy are
these PNIs are preventable. This chapter classifies more susceptible to peripheral nerve injuries
identifiable risk factors and how they can be when compared to healthy individuals as
evaded. Clinical manifestations of commonly shown in case reports [7, 8].
encountered nerve injuries are described, so the 6. Body habitus extremes: Obesity, bulky
perioperative service providers can quickly recog- musculature, underweight, and malnutrition
nize a peripheral nerve deficit. The diagnosis can are also risk factors for PNIs.
be aided by EMG, nerve stimulation, and certain 7. Tobacco use: Smoking has been identified as
imaging techniques. An overview of surgical and a risk factor for PNI [2].
nonsurgical management techniques is described.
15.2.2 Anesthesia-Related Factors

15.2 isk Factors and Causes
R
of Nerve Injury 1. Mechanical trauma: Injury to the nerve may
occur directly with a regional block needle or
Risk factors are often multifactorial, and it is help- catheter. Direct nerve perforation and injury
ful to classify these into various categories: to the fascicle or perineurium is possible;
patient-related, anesthesia-related, and surgery- nerve edema and hematoma are known
related causes. complications. Peripheral nerve blockade-
15 related PNI is most severe with intrafascicu-
lar injection [9]. Anatomic variance of the
15.2.1 Patient-Related Factors spinal cord can make it more susceptible to
direct trauma during neuraxial techniques;
1. Preexisting neurologic disease: Preexisting this includes low-lying conus, inaccurate
neurologic disease or nerve injury, although determination of vertebral interspace, and
sometimes insufficient alone to cause clinical incomplete midline fusion of the ligamentum
symptoms, limits the neurologic reserve of a flavum [5].
nerve, meaning that it is more susceptible to 2. Local anesthetic use: Local anesthetics
develop clinical deficits from a second injury decrease neural blood flow in a
(the double crush syndrome) [3]. Diabetic concentration-dependent manner. The
patients may develop neuropathy of periph- addition of epinephrine to local anesthetic
eral nerves. These patients are at greater risk solution makes a susceptible nerve more
of a secondary, possibly subclinical, insult that prone to injury, especially in patients with
may result in a permanent nerve injury [4]. microvascular disease [10]. The internal
2. Hypertension: A retrospective analysis of milieu of the nerve fascicle is maintained by
380,680 patients in a 10-year period identi- an intact perineurium and vascular endothe-
fied hypertension as a risk factor for PNI [2]. lium. High concentrations of extrafascicular
Severe Peripheral Nerve Injury
215 15
anesthetics can produce axonal injury 15.2.3 Surgery-Related Factors
independent of edema formation. Injection
of local anesthetic agent within the nerve 1. Compressive dressings and casts: The underly-
fascicle is clearly neurotoxic and may ing cause of all tissue damage is inadequate
damage the perineurium [11]. And other perfusion. Ischemia may be due to occlusion
incidental injection of chemical agent into of major vascular structures or restricted
intrathecal space may cause spinal cord capillary perfusion. Metabolism continues
injury [12]. despite inadequate perfusion, and tissue
3. Improper positioning: In most litigation acidosis ensues, with failure of membrane
claims, patient positioning is considered to pumps. As a result, sodium ions accumulate
be the responsibility of the anesthesiologist intracellularly, water moves into the cells, and
who provided anesthesia service to the intracellular volume increases. Tissue edema
patient. It is important to be mindful and results and contributes to ischemia by
avoid placing patients in positions that will increasing tissue pressures and preventing the
anatomically change the orientation of the movement of fluid and nutrients from the
nerve, causing stretching or compression capillaries into the cells [14].
injuries. It is helpful to perform a check 2. Tourniquet pressure and duration: PNI may
before surgical draping. Positions known result from inadequate blood supply when
to predispose to PNI include arm abduc- tourniquets are placed with high pressures,
tion of more than 90°, shoulder girdle prolonged immobility, or a hematoma
compression, pronation of arms, lateral surrounding a nerve. Pneumatic tourniquet
rotation of the shoulder in combination pressures of more than 400 mmHg are known
with shoulder abduction, contralateral to be associated with postoperative nerve
neck flexion, full elbow extension, com- injury [15]. The minimal effective pressure
pression of ulnar nerve by the table edge should be used for occluding blood flow to
when tucking arms at the sides, and wrist the extremity. General guidelines suggest
extension [13]. . Table 15.1 lists position-

using tourniquet pressures no greater than
ing devices that are placed by surgical staff two times the systolic pressure for the lower
in general; the anesthesiologist should be extremity and 70–90 mmHg greater than the
aware of potential nerve injury that may systolic pressure for the upper extremity.
result. Additionally, because tourniquet time is an
independent risk factor, tourniquet times
should be limited to less than 2 h to decrease
the risk of neural ischemia [16].
.. Table 15.1 Causes of nerve injuries 3. Prolonged bed rest: Postoperative bed rest for
a prolonged period is a recognized risk factor
Positioning Perioperative factors for ulnar neuropathy. It could be implicated
devices
in other PNIs also [17]. The timing and goals
Table straps Coagulopathy or presence of of physical therapy should be discussed.
hematoma near the nerve
Leg holders Infection/presence of abscess

near the nerve 15.3 Clinical Manifestations
of Nerve Injury
Shoulder Hypovolemia and hypotension
braces
Certain peripheral nerves are particularly predis-
Positioning Dehydration posed to mechanical injury because of their ana-
frames
tomical location. The terms entrapment or
Headrests Hypoxia compression neuropathy are used when the nerve
Electrolyte imbalance
is compressed, stretched, or angulated by adjacent
anatomic structures to such an extent that dys-
Hypothermia function occurs. While there are several classifica-
tions of nerve injuries (. Tables 15.2 and 15.3) in

15
216
R. Tariq et al.
.. Table 15.2 Classification of nerve injuries
Lundborg Physiological Myelin Axonal damage Axon + endo damage Axon + endo + peri Axon + endoneurium + perineu-

classification conduction block damage damage rium + epineurium damage
Type A Type B
Sunderland I II III IV V
classification
Seddon Neurapraxia (transient block) Axonotmesis Neurotmesis (division of a nerve)

classification (lesion in
continuity)
Recovery and Recovery in weeks to months. Good Good prognosis Guarded prognosis. Poor prognosis. Surgery Poor prognosis. Early surgical
prognosis prognosis Surgery may be required necessary intervention needed
217 15
clinical practice, nerve injuries are often on a pronated. This is due to involvement of musculo-
spectrum of severity. cutaneous, axillary, and suprascapular nerves. If
Sunderland II and above are considered non- the lower nerve roots C8–T1 are involved, numb-
degenerative. ness in the ulnar nerve distribution and a “claw
In most cases, injuries resolve within hand” can be observed [19].
6–12 weeks. More than half of the patients typi-
cally regain complete sensory and motor function 15.3.1.2 Ulnar Neuropathy
within a year. Ulnar nerve injury is significantly more common
than any other nerve injury. Sensory deficit is
characterized by tingling or numbness along the
15.3.1 pper Extremity Peripheral
U fifth/little finger. Weakness of abduction and/or
Nerve Injury (. Table 15.4)
adduction of the fingers can be present, while
motor involvement is appreciated by an ulnar
15.3.1.1 Brachial Plexus Injury claw hand which entails hyperextension of the
Brachial plexus is innervated via C5–T1 nerve metacarpophalangeal joints and flexion at the dis-
roots. If upper nerve roots are involved (C5, C6), tal and the proximal interphalangeal joints of the
a typical “waiter’s tip” position is seen in which fourth and the fifth fingers [18]. For majority of
the hands are by the side, medially rotated, and patients with ulnar neuropathy, manifestations
began 2–7 days after surgery. Symptoms are most
often mild, confined to sensory deficits, and were
.. Table 15.3 Definitions of closed versus open completely reversible [20].
injury
15.3.1.3 Median Nerve Injury
Closed nerve injury Open nerve injury
The median nerve is supplied by C5–T1 nerve
Nerve injuries in continu- Open injury along roots. Median nerve injury usually results from
ity without disruption in the nerve course invasive procedures around the elbow and direct
continuity of nerve. provoked by knives, injury via regional anesthesia techniques. Early
Spontaneous recovery is propellers, glass, or
symptoms are pain and paresthesia confined to a
possible. Surgery is scalpel. Immediate
indicated only if no surgery is required median nerve distribution in the hand, i.e., involv-
recovery after 3 months in open nerve ing primarily the thumb, index, and middle
injuries fingers as well as the lateral half of the ring finger.
Motor manifestations include weakness of
.. Table 15.4 Specific clinical manifestations of upper extremity nerve injuries [18]
Nerve Sensory deficit Motor deficit
Median nerve Numbness over the index finger Weakness of abduction of the thumb
Ulnar nerve Numbness over the little finger Weakness of abduction and/or adduction of
the fingers
Radial nerve Numbness over anatomical snuffbox Weakness of extension at the distal
interphalangeal joint of the thumb and of the
wrist and finger extensors
Musculocuta- Numbness along lateral aspect arm Weakness of flexion of the elbow
neous nerve
Circumflex – Weakness of abduction of the shoulder

nerve
Brachial Combinations of sensory lesions within the Combinations of motor lesions within the
plexus median, ulnar, radial, musculocutaneous, and median, ulnar, radial, musculocutaneous, and
circumflex nerve territories circumflex nerve territories
218 R. Tariq et al.
.. Table 15.5 Most common nerve injuries as per .. Table 15.6 Specific clinical manifestations of
ASA closed claims analysis [19] lower extremity nerve injuries
1. Ulnar nerve 28% Nerve Sensory Motor deficit

deficit
2. Brachial plexus 20%
Femoral Numbness Weakness of
3. Lumbosacral nerve root 16%
nerve over the flexion of the
anterior thigh hip and knee
and medial extension
abduction and opposition of the thumb (also aspect of the
leg
referred to as “ape hand”), weak wrist flexion, and
the forearm being kept in supination. The muscles Obturator Numbness in Weakness of
of the thenar eminence become wasted, and the nerve the upper adduction of
hand appears flattened [18]. medial ventral the hip
thigh region
15.3.1.4 Radial Nerve Injury Sciatic nerve Numbness Weakness of
The radial nerve may be compressed at the axilla below the ankle
knee dorsiflexion
by pressure against the vertical portion of an anes- and plantar
thesia screen or an arm board positioned at an flexion. Also,
incorrect height. The resulting deficit is primarily weakness of
motor manifested as weakness of extension at the knee flexion, if
distal interphalangeal joint of the thumb and of the lesion is
proximal
the wrist and finger extensors resulting in “wrist
drop” (. Table 15.5).
Common Numbness Weakness of
peroneal along the dorsiflexion of
nerve lateral aspect the ankle and
of the leg toes
15.3.2 ower Extremity Peripheral
L below the
Nerve Injury (. Table 15.6)

knee
Tibial nerve Numbness Weakness of

15.3.2.1 erve Injuries in Lithotomy
N along dorsal plantar flexion
Position aspect leg of the ankle
The most commonly injured lower extremity and toes
nerve in patients undergoing surgery in lithotomy
position is the common peroneal nerve. This
15 nerve is supplied via L4–S2 and is responsible for direct invasive procedures (central line place-
foot dorsiflexion and toe extension. Thus comment, arterial line insertion) in the femoral
mon peroneal nerve injury can lead to “foot drop.” region. Sensory deficit is seen as numbness over
However, similar to upper extremity injuries, sen- the anterior thigh and medial aspect of the leg
sory deficits are more common than motor defi- along the distribution of saphenous nerve. Motor
cits. Sensory manifestations are described along deficit is usually first recognized as a difficulty in
the anterolateral border of the leg and the dorsum climbing stairs due to weakness of flexion of the
of the digits except those supplied by saphenous hip and knee extension.
and sural nerves [18]. The sciatic nerve can be
injured in the lithotomy position as well. Sciatic 15.3.2.3 Pudendal Nerve Injury
nerve injury has also been reported postcoronary The pudendal nerve might be injured during
artery bypass graft, possibly from prolonged orthopedic surgeries and gynecological injuries.
nerve pressure along with low perfusion pressure. In hip arthroscopy, pudendal nerve injury may
occur in as many as 10% of cases. Probable mech-
15.3.2.2 Femoral Nerve Injury anism involves nerve compression. Clinically,
The femoral nerve can be injured with compres- pudendal nerve injury presents as perineal and
sion at the pelvic brim by retractors as seen in groin pain followed by a sensory deficit, which
gynecological procedure, lithotomy position, and may be aggravated by sitting position. Rarely there
219 15
might be sexual dysfunction. Recommendations evoked potentials are studied, reduced amplitude
for prevention or reducing the risk of pudendal in evoked responses indicates axonal loss, and
nerve injury include limiting traction to only increased latency indicates demyelination.
critical portions of the operation and use of good
padding on the footplate and at the perineum by
the use of a large pelvic support. 15.4.2 Nerve Conduction Study
Peripheral nerve injuries can have demoraliz-
ing effects on patients with decreased ability to Nerve conduction study (NCS) is a measurement
perform daily functions and routines. A retro- of the speed of conduction of an electrical impulse
spective database review of 490 patients with through a nerve. NCS can determine nerve dam-
peripheral nerve injuries showed negative psy- age and destruction. It tells us the function of
chosocial effects, which were more pronounced in both motor and sensory nerves. The conduction
case of proximal upper extremity peripheral nerve velocity and the size of muscle response theoreti-
disorders when compared to single site nerve cally estimate the number of axons and muscle
compression neuropathies. The impact on quality fibers activated. NCS evaluates the functional
of life was strongly correlated with pain and integrity and localizes the focal lesion [23].
depression [21].
15.4.3 Imaging
15.4 Evaluation and Diagnosis
MRI and ultrasound are the two advanced modal-
Evaluation and diagnosis of peripheral nerve ities most frequently used to assess upper extrem-
injuries begin with a detailed history to detect any ity nerve entrapment [24]. 3 Tesla MRI can
preexisting nerve deficit and thorough physical provide high-resolution imaging to visualize the
examination to determine the site of lesion. peripheral nerve and confirm the site of lesion. It
Physical exam should be able to show if the nerve can be particularly helpful if used in adjuvant to
deficit is sensory or motor and involves single or EMG/NCS.
multiple nerves. In actuality, nerve injuries are on
a spectrum. The localization of the nerve deficit is
based on the distribution of abnormal findings. 15.5 anagement of Severe Nerve
M
Ideally, the evaluation of perioperative nerve inju- Injury
ries involves a consultation with a neurologist
particularly if there is a motor or mixed deficit. The recovery time of the injured nerve depends on
Electromyography (EMG) and nerve stimulation various external factors including most importantly
studies are also important in determining the early nerve exploration and repair. However, it
extent of injury. These electrophysiology tests can should be known that axonal regeneration rate is as
help distinguish between nerve dysfunction due slow as only 1–2 mm per day and there is almost no
to axonal degeneration (such as with PNI) and treatment to accelerate this process [25]. Irreversible
nerve dysfunction due to demyelination (such as motor unit degeneration starts 12–18 months after
with chronic compressive lesions including carpal denervation of the muscle but may persist for
tunnel syndrome). Certain imaging modalities 26 months [26]. Recovery and regeneration of sen-
might prove helpful as well. sory nerve may take even longer (. Table 15.7).

15.4.1 Electromyography 15.5.1 ndogenous Nerve Healing

E
in Response to Injury
EM may reveal evidence of denervation of the
affected muscles and can be used to determine Acute inflammatory changes at the site of the
whether any motor units remain under voluntary peripheral nerve lesion include an increase
control. EMG can help determine if a deficit was in local leukocytes that, along with the Schwann
present preoperatively, as denervation signs take cells, help to clear the cell body of myelin debris
approximately 3 weeks to develop [22]. When [29, 30]. The concomitant interaction of Schwann
220 R. Tariq et al.
initial injury to provide time for full Wallerian

.. Table 15.7 The effects of neurotrophic factors
in peripheral nerve regeneration [27, 28]
(anterograde) degeneration. Currently, primary
repair is performed within 72 h and up to 7 days
Neurotrophic factors Effect after nerve injury [36]. However, when immediate
repair criteria are not met, delayed repair is
Nerve growth factor Survival signaling, required.
(NGF) neurite outgrowth
Glial cell line-derived Sensory regeneration 15.5.2.2 Direct Repair

neurotrophic factor Direct nerve repair with epineural microsutures is
(GDNF)
the gold standard surgical treatment for severe
Brain-derived Positive modulation of axonotmesis and neurotmesis injuries. Epineural
neurotrophic factor peripheral nerve repair is performed when a tension-free coaptation
(BDNF) myelination
in a well-vascularized bed can be achieved [28].
Neurotrophin-3 (NT-3) Negative modulation of The modality of direct repair is shown as in [37].
peripheral nerve 55 End-to-end repair: The simplest class of
myelination surgical repair from a technical standpoint is
Ciliary neurotrophic Survival of motor the end-to-end repair. In this surgical
factors (CNTF) neurons procedure, the entire nerve trunk is sutured
as a unit by application of sutures placed in
the epineurium or by placement of a single
cells and surrounding environment promotes suture through the axial center of the injured
axonal sprouting, typically at a rate of 1–4 mm per nerve trunk [38]. Correct fascicular position-
day [31, 32]. Electrodiagnostic testing evaluates ing can be confirmed by the continuity of the
the degree of nerve injury and determines whether nerve’s surface structures such as blood
there is an early reinnervation at 6 weeks. If there vessels (vasa nervorum) within the epineu-
is no evidence of reinnervation at the end of rium [39].
3 months, surgical intervention should be consid- 55 Epineural sleeve repair: In this technique, the
ered [33]. epineurium covering the distal stump is
rolled back, and then a 2 mm nerve segment
is resected. The newly created epineural
15.5.2 Surgical Treatment sleeve is pulled over in the proximal nerve
end and is sutured to the epineurium 2 mm
15.5.2.1 Timing of Nerve Repair proximal to the coaptation site with two
Mackinnondemonstrated that early nerve repair sutures. The epineural sleeve provides a
15 results in improved functional outcomes. There is biological chamber for the axoplasmic fluid
an accepted window period of 12–18 months for leakage from transected nerve ends providing
muscle reinnervation to occur to achieve func- a neuropermissive environment for growing
tional recovery before irreversible motor end axons [40].
plate degeneration occurs [34]. It is worth noting 55 End-to-side repair: End-to-side repair offers a
that there is no definite evidence to support this promising technique for repair of peripheral
nerve regeneration as late as 26 months after nerve injuries when the proximal nerve
injury and reconstruction [28]. More proximal stump is unavailable or a significant gap
nerve injuries, such as a brachial plexus injury, between two ends exists. The origin of
involve distances of up to a meter and require reinnervating axons is currently widely
periods of more than 2–3 years for regenerating discussed. Some authors assume that the
axons to reach and reinnervate the hand muscles. nerve fibers invade from the donor nerve
In such cases, it is well recognized clinically that axons that are damaged during nerve
there may be little or no restoration of function preparation for coaptation [41]. Others
[25]. Timing of nerve repair depends on the type provide evidence based on double-labeling
of nerve injury sustained, condition of the wound, studies for collateral (nodal) sprouting from
and vascular supply to nerve bed [35]. Historically the undamaged axons of the donor nerve at
primary nerve repair was performed 3 weeks after the coaptation side [42].
221 15
15.5.2.3 Nerve Grafting to serve as nerve regeneration conduit [49].
55 Nerve autografts: When there are nerve gaps Materials used include non-resorbable
that cannot be approximated and coaptated polymers (silicone and expanded polytetra-
without tension, current gold standard of fluoroethylene) and resorbable conduits
repair is autologous nerve grafting. Nerve (polyglycolic acid polymer, polylactide-
grafts revealed superior results when com- caprolactone polymer, polyglycolic acid
pared with direct repairs that may be per- polymer coated with cross-linkedcollagen,
formed under excessive tension producing and type I collagen [50].
nerve ischemia [43]. The harvested fascicular
graft undergoes Wallerian degeneration [44]
and provides mechanical guidance by creating 15.5.3 Nonsurgical Methods
a supportive structure for the ingrowing
axons. Sensory cutaneous nerves are com- 1. Nerve regeneration by electric stimulation:
monly used as donor nerves for autografting Animal studies demonstrated that as short as
because their harvest results in acceptable 1 h of direct nerve electrical stimulation
morbidity consisting of sensory loss in the immediately after repair of a transected
area supplied by the harvested sensory femoral nerve in the rat promotes a dramatic
branch. Currently used donor nerves include increase in the kinetics of target muscle
sural nerve, lateral antebrachial cutaneous reinnervation [51]. In a clinical pilot study,
nerve, anterior division of the medial ante- 1 h of electrical stimulation was applied after
brachial cutaneous nerve, dorsal cutaneous median nerve decompression at the wrist for
branch of the ulnar nerve, and superficial 21 patients with carpal tunnel syndrome and
sensory branch of the radial nerve [45]. thenar atrophy [52]. The electrical stimula-
55 Nerve allografts: In gaps where the recon- tion group showed evidence of accelerated
struction requires a length of graft exceeding axonal regeneration and target reinnervation
available nerve autografts, the application of through motor unit number estimation and
allograft material from cadaver donors is the sensory and motor nerve conduction studies.
only clinical option currently available. 2. Nonthermal laser amnion wrap: Photochemi-
Allograft nerve provides guidance and viable cal tissue bonding creates a covalently
donor Schwann cells enabling growing host bonded nerve wrap around a nerve coapta-
axons to pass from the proximal to distal tion, using an Nd/YAG laser, photoactive dye,
stump and reinnervate the intended organs. and a nonimmunogenic amnion wrap [53].
Although allogenic nerve tissue has low Collagen fibers in the amnion wrap are
immunogenic potential compared to the skin, covalently bonded to collagen in the epineu-
muscle, or bone, it does require immunosup- rium. This bond adds strength to the repair,
pressive treatment to prevent rejection of the concentrates neurotrophic and neurotropic
graft [46]. factors inside the coaptation where they are
needed, excludes inflammatory mediators
15.5.2.4 Conduit Repair from the extrinsic tissues, and contains
55 Biologic conduits: Biological conduits include regenerating axons, guiding them distally
arteries, veins, mesothelial chambers, toward the motor or sensory target.
pre-degenerated or fresh skeletal muscle, and 3. Thermal laser welding: Thermal laser achieves
epineural sheath [47]. Utilization of vein tissue bonding by denaturation of structural
grafts has been studied most extensively to proteins, which anneal and join when cooled.
promote axonal growth by providing an Tse and Ko reported successful nerve
environment rich in collagen, laminin, and coaptation by laser welding in 1985; however,
Schwann cells encountered in adventitia of this was followed by reports of frequent
vessels [48]. dehiscence of 12–41% [54]. To prevent
55 Artificial conduits: Various materials includ- dehiscence, one or two stay sutures can be
ing synthetic polymers, extracellular matrix placed before laser welding; it is worth noting
components, and supportive therapies that nylon stay sutures will lose their tensile
(cytokines, cells) were used in animal studies strength when irradiated with a CO2 laser.
222 R. Tariq et al.
4. Glue repair: Advantages of an adhesive glue by enhancing or preventing the production of

for nerve repair include ease of use, less growth factors. Yu et al. found that hyperbaric
tissue trauma, maintenance of nerve oxygen reduced the gene expression of GDNF
architecture, better fascicular alignment, and after 1 day of injury, as confirmed by immune-
less scarring compared to microsutures [54]. histochemical staining [60]. Some of the growth
The ideal nerve glue should not cause factors, such as basic fibroblast growth factor,
fibrosis that can lead to nerve compression, are ineffective in stimulating healing under isch-
and, in the case of substance interposition emic conditions even at high doses. But when
between nerves, it should not act as a barrier treated with hyperbaric oxygen, growth factors
to nerve regeneration. The glue should recover their function and become highly effec-
provide adequate mechanical strength to tive again [61]. Hyperbaric oxygen increases the
prevent gapping or rupture at the initial production of bFGF, vascular endothelial growth
repair and during the postoperative period. factor, and TGF-ß1. At cellular level, hyperbaric
A systematic review of fibrin glue for oxygen will maintain the tissue levels of ATP;
peripheral nerve repair revealed 14 animal restore mitochondrial dysfunction; inhibit, pre-
studies, 1 cadaver study, and 1 human study vent, or reduce the ischemic reperfusion injury;
[55]. Most found fibrin glue repair to be and have significant antioxidant and anti-apop-
equal or superior to suture repair. However, totic effects. The treatment window for acute
in clinical practice, concerns remain about peripheral nerve lesions appears to be around
the lack of adequate tensile strength for 6 h [62].
fibrin glue repair alone, so currently fibrin
glue is predominantly used as an adjunct to
microsutures or to coapt nerves where 15.5.6 Role of Lithium
suturing is not possible, for example,
intervertebral foramina. Glycogen synthase kinase 3β inhibitors, especially
the mood stabilizer lithium chloride, are also used
as neuroprotective or anti-inflammatory agents.
15.5.4 ole of Stem Cells to Augment
R Lithium exerts its action in Schwann cells by
Peripheral Nerve Repair increasing the amount of β-catenin and provok-
ing its nuclear localization [63].
Stem cell infusionhas been successful in promot-
ing regeneration and remyelination of the injured
spinal cord and peripheral nerve [56]. To serve as 15.5.7 Role of Electroacupuncture
a realistic therapy, candidate transplant cells
15 should be easily accessible, rapidly expandable in In a model of crushed sciatic nerve in rabbits,
culture, capable of survival and integration in host electroacupuncture promoted nerve regeneration.
tissue, and amenable to stable transfection and Low-frequency pulsed electromagnetic field was
expression of exogenous genes [57]. To find such ineffective on rat sciatic nerve regeneration [62].
a cell, emphasis has shifted toward using stem
cells or progenitor cells as therapy for injury in the
peripheral and central nervous systems. Based on 15.5.8 Low-Intensity Ultrasound
their apparent plasticity and ease of harvest, bone
marrow stromal cells have attracted the attention Low-intensity ultrasound in combination with
of several groups interested in finding a suitable poly(DL-lactic acid-co-glycolic acid) conduits
replacement for host stem cells [58, 59]. was found to have significantly greater number
and area of regenerated axons at the mid-con-
duit of implanted grafts. Low-intensity ultra-
15.5.5 Role of Hyperbaric Oxygen sound stimulation on silicone groups was
found to induce a mass of fibrous tissues that
Hyperbaric oxygen can also exert its beneficial covered the nerve conduits and retarded axon
effect in peripheral nerve repair and r egeneration regeneration [64].
223 15
15.6 Summary ?? 2. What is the gold standard of surgical treat-
ment for severe axonotmesis and neurot-
Peripheral nerve injuries are frequent and mesis injuries?
avoidable complications perioperatively. While
most patients with PNI have complete recovery, ?? 3. What should be the ideal tourniquet appli-
some can have permanent deficit. Identification cation time to prevent the neural ischemia?
of the patient risk factors and surgical risk fac-
tors, along with proper patient positioning and
appropriate intraoperative management, is par- 15.8 Answers
amount in evading PNI which is the third most
common cause of litigation for anesthesiolo- vv 1. Ulnar nerve injury is significantly more
gists. Certain peripheral nerves are particularly common than any other nerve injury. Over
predisposed to mechanical injury because of 90% of ulnar nerve injuries have no known
their anatomical locations. Proper position and cause. They can occur even with ideal
awareness of the anatomical vulnerability can positioning and padding.
decrease the risk of the PNI. Surgical positions
known to have a high risk of nerve injury should vv 2. Direct nerve repair with epineural
be avoided wherever possible. The tourniquet microsutures is the gold standard surgical
pressure and duration must be minimized. treatment.
Factors that predispose a patient to PNI include
coagulopathy or presence of hematoma near the vv 3. It should ideally be less than 2 h to
nerve, infection or presence of an abscess near prevent neural ischemia. A safe time limit
the nerve, hypovolemia, hypotension, dehydra- of 1–3 h has been described. It has been
tion, hypoxia, electrolyte imbalance, and hypo- recommended to assess the operative
thermia. The use of compressive dressings, situation at 2 h, and if the anticipated
casts, and tourniquets are also important risk duration is >2.5 h, then use a 10-min
factors. deflation interval at that point and at
Most nerve injuries are manifested as sensory subsequent 1-h intervals. In pediatric
deficits and have a complete recovery. Nerve patients, inflation time of <75 min has
injury can be recognized by EMG, nerve stimula- been recommended for lower extremities.
tion studies, and MRI. Management options
include surgical and nonsurgical options. Surgical
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227 16
Catastrophic Perioperative
Complications and
Management in the
Trauma Patient
Elyse M. Cornett, Matthew B. Novitch, Julia B. Kendrick,
Jennifer M. Kaiser, Patricia D. Toro-Perez, Alex B. Shulman,
Forrest Ericksen, Christopher Zeman, and Alan David Kaye
16.1 Summary: Aims and Scope – 229
16.2 Acute Management of the Trauma Patient – 229

16.2.1 Preparation for the Arrival of the Trauma Patient – 229
16.2.2 Pre-arrival and Triage – 229
16.2.3 Pre-arrival Room Preparation – 230
16.3 Airway Management – 230

16.3.1 Traumatic Facial Injury – 232
16.3.2 Airway Compression – 232
16.4 Perioperative Management of Cardiovascular

and Chest Injuries – 232
16.4.1 Hemothorax – 232
16.4.2 Blunt Cardiac Injury (BCI) – 233
16.4.3 Penetrating Cardiac Injury (PCI) – 233
16.4.4 Aortic Injury – 234
16.4.5 Tension Pneumothorax – 234
16.4.6 Cardiac Tamponade – 235
16.5 Perioperative Management of Burn Injuries – 236
16.6 Perioperative Management of Gastrointestinal

and Abdominal Injuries – 236
16.6.1 Intro – 236

https://doi.org/10.1007/978-3-319-96125-5_16
16.7 Perioperative Management of Musculoskeletal
Injuries – 238
16.7.1 Major Hemorrhage – 238
16.7.2 Open Fractures – 238
16.7.3 Pelvic Injuries – 239
16.7.4 Compartment Syndrome – 239
16.7.5 Major Joint Dislocation – 239
16.8 Perioperative Management of Neurological

Injuries – 239
16.8.1 Traumatic Brain Injury – 240
16.8.2 Spinal Cord Injury and Trauma – 240
16.9 Perioperative Management of Electrocution

Injuries – 241
References – 242
Catastrophic Perioperative Complications and Management in the Trauma Patient
229 16
16.1 Summary: Aims and Scope ensue to ensure maximum survival potential. The
Advanced Trauma Life Support (ATLS) training
In the last two decades, the care of the surgical program was developed to provide uniformity in
patient has changed dramatically. New equip- the assessment and management of trauma
ment, monitors, and pharmacologic agents have patients [15]. Since then, the program has been
transformed surgical technique and improved adopted nationally by the American College of
outcomes. Patients once deemed “too sick” for the Surgeons Committee on Trauma (ACSCOT) and
operating room are found frequently on operating has provided the latest evidence for the most
room schedules nationwide. effective trauma care. With the proper prepara-
Today, anesthesiology for the healthy patient tion, even catastrophic perioperative complica-
in most developed countries is extremely safe. tions can be dealt with to maximize survival
However, perioperative complications still occur. potential.
These events can be catastrophic for patients and
may have serious implications for residents, surgi-
cal and anesthesiology staff, and nurses. Prompt 16.2.2 Pre-arrival and Triage
recognition and management of these incidents
may reduce or negate complications. This is based Pre-arrival notification is imperative to the suc-
on a fundamental base of knowledge acquired cess of the trauma team. Local EMS systems ought
through several avenues and practiced with other to have a protocol in place to alert the team and
team members to maximize outcomes. provide information with regard to patient status.
Engagement of all caregivers impacts outcomes. Upon notification to the emergency room, many
Many organizations do not have the structural hospitals use an overhead paging mechanism to
components or education to recognize or manage alert staff. This alert should include the level of
these catastrophic events. severity, the location in the hospital, and the time
This chapter will provide educational material of arrival, for example, “Code Yellow-Room
for the many students, as well as nurses, residents, 32-Level 1-15 minutes.” This notification should
or attending physicians who participate in peri- activate a coordinated sequence of events involv-
operative medicine. It will focus on the most seri- ing the trauma surgeon, anesthesiologists, nurs-
ous perioperative complications and include a ing team, technicians, radiologist, and operating
discussion of the pathophysiologic and pharma- room representatives. If time allows, a gathering
cologic implications unique to each. Additionally, of personnel in the room prior to arrival will allow
it will provide medicolegal information pertinent the designation of tasks to ensure that the proper
to those providing care to these patients. All equipment is set up based on the specific needs of
chapters will be written with the most current and the patient. At this meeting, the individual that
relevant information by leading experts in each received EMS report would give a summary
field. including key details that should be known by
everyone on the trauma team. For example,
“Patient is a 26-year-old male involved in a motor
16.2 Acute Management vehicle collision. He is having a hard time breath-
of the Trauma Patient ing and has a possible head injury and a right leg
injury.” The first step in room preparation should
16.2.1 Preparation for the Arrival begin promptly with the appropriate personal
of the Trauma Patient protective equipment for each member of the
team. Mask, gloves, and gowns should be dawned
Inadequate preparation and equipment place- as personal safety is top priority. From this point
ment can negatively influence the outcome of the forward, the room can be tailored to meet the
traumatic patient. It is critically important that needs of the patient with the guidance of the
each individual member of the trauma team trauma surgeon. For example, airway difficulty
knows their role and has the necessary prepara- may prompt the anesthesiology team to set up for
tion and skills for an unpredictable situation. As possible intubation and radiology at bedside for
soon as the patient presents through the doors, an immediate chest X-ray along with a chest tube kit
expedited and highly coordinated process must for easy accessibility [14].
into the correct tier. For example, when a patient

.. Table 16.1 Glasgow coma scale, reported from
3 to 15, with 15 being the best and 3 being the
believed to be involved in a low-speed collision
worst possible score. A score of 8 or below presents in acute respiratory distress with a blood
corresponds to severe brain injury, 9–13 indicates pressure of 80/50, the necessity to quickly upgrade
moderate injury, and 13 or above indicates mild from a level 2 to a level 1 is imminent to ensure the
injury best possible care and greatest availability of
Glasgow coma scale Score
resources for trauma team.
Eye opening
Spontaneous 4
16.2.3 Pre-arrival Room Preparation
To loud voice 3 Meticulous room preparation can heavily impact
To pain 2 the already chaotic parameters of a traumatic
patient. With multiple team members attempting
None 1
to access the patient, it can become highly clus-
Verbal response tered and make it difficult for team members to
Oriented 5 perform their job adequately. Proper placement of
the bed, monitors, cabinets, and tables ensures
Confused, disoriented 4 quality, efficient care. Technicians should arrange
Inappropriate words 3 equipment to allow smooth transition of care
from EMS to the trauma team. Typically, this
Incomprehensible words 2
starts with bed placement in the room. First, zero
None 1 a weighted bed and place a draw sheet to allow
Motor response easy movement of the patient once transferred
from the EMS cart. Slightly angling the cart and
Obeys commands 6
placing a side rail down often indicate for EMS to
Localizes pain 5 transfer the patient on that side upon arrival. This
Withdraws from pain 4 may be important to ensure access to equipment
during the transfer from EMS cart to bed.
Abnormal flexion posturing 3 Following transfer, if space allows, center the bed
Extensor posturing 2 in the room to allow maximum space for all team
members to perform their tasks. . Figure 16.1

None 1
indicates the proper positioning of all team mem-
bers in the trauma room.
Triage of trauma patients will typically classify

16 into a three-tiered system which is indicative of 16.3 Airway Management
the resources that will be necessary for the care of
that patient. For example, a level 1 trauma (highest Airway management in a trauma setting is com-
acuity) will require utilization of more resources plicated by the potential for neurologic injury and
than a level 3 trauma (lowest acuity) (. Table 16.1).
compromised airway anatomy. The risk of spinal
This system is utilized to ensure that all necessary manipulation, and difficulty in establishing a
resources are available to the trauma team. Level 1 usable airway, requires diligent understanding of
activation should trigger the greatest number of the potential harms of airway management and
personnel, while a level 3 activation indicates the the techniques used to avoid them.
need for a routine trauma team consult. Hospitals The LEMON score is an organized and stan-
that have a tiered system of triage and trauma dard way to assess the airway of traumatic
team activation correlate to more efficient resource patients.
utilization and better patient outcomes than hos- 55 L requires the attending provider to Look at
pitals lacking such a system [35]. Additionally, the cervical and facial region and examine for
hospital systems should have a protocol in place to facial or neck trauma, large incisors, presence
upgrade a trauma patient if they are not placed of beard, large tongue, or orofacial soft tissue
231 16
Consider mechanism,
presence of extra-abdominal trauma
Hemodynamically stable?
No Yes
US+/–DPT Alert?
Non-intoxicated?
+ –
No Yes
LAP Signs of
extra-abdominal Management options include: US
hemorrhage?
– Abd CT
(eg, pelvic fracture, – Serial exams +/– admit
long bone fracture, – +
laceration?)
If Abd CT If serial exams, continue

positive, until patient clinically sober
No Yes NOM vs. LAP and no distracting injury
Resuscitation (+/–) Serial exams Abd CT

Stabilize
then Abd CT +/– Abd CT
(eg, angiography,
splint, whipstitch)
– +
– +
Observe NOM
Observe/serial NOM vs. LAP
exams vs. LAP
+/– admit
Discharge
.. Fig. 16.1 Anesthesia for trauma. New evidence and new challenges (must request access)
stiffness. One point is added for each of the obstruction cannot be visualized. One point is
conditions listed if they are present. For assigned to the presence of airway obstruction.
example, if the patient has large incisors and a 55 N stands for Neck mobility. One point is
large tongue, two points are added. assigned to the presence of neck mobility
55 E stands for Evaluate. The 3–3-2 finger rule is caused by any reason, including cervical
used for this section, to specify an interincisor collar.
distance <3 fingers, mentum to hyoid distance
<3 fingers, and floor of the mouth to thyroid With a maximum of 10 points, the LEMON score
notch distance <2 fingers. One point is assigned gives a rough estimation of ease of airway con-
for each abnormal finding. solidation in the traumatic patient [11, 41, 47].
55 M stands for Mallampati score, which is a If oxygen levels and the external ventilation
traditional evaluation of the oral cavity to are viable at time of first response, definitive air-
assess for ease of intubation. Inability to way establishment may be detrimental and not
visualize the uvula suggests a grade 3 or 4 required [24, 46, 48]. Evaluation of the airway is
view during laryngoscopy. One point is key as trauma may not be overt. Full airway exam-
assigned for Mallampati grade 3 and 4 view. ination should be completed; however, due to
55 O stands for Obstruction of any cause, immobilization, injury, and lack of time, extensive
including if signs and symptoms are there and assessment is not always an option. History
should be taken only when practical and is not 16.3.1 Traumatic Facial Injury
essential when treating acute injuries [3].
Initiation of emergent airway consolidation Condylar fractures and mandibular and zygo-
requires routine protocol and procedures of air- matic arch injuries can cause difficulties in open-
way management combined with special knowl- ing the jaw because of mechanical impediment or
edge of several common factors that may alter muscular spasms. Trismus may resolve with neu-
protocol in a traumatic setting [5]. Oxygen should romuscular paralysis, but bony blockages may
be administered, the airway should be cleared, require surgical removal. Nasal intubation is not
and many airway management procedures may recommended due to risks in disturbing the basi-
be utilized including suction, oral airway, and lar skull. Basilar skull fractures due to nasal intu-
bag-mask ventilation and intubation. A manipu- bation increase the risk of intracranial infection
lation of the neck can cause movement of the spi- and meningitis [6].
nal cord leading to neurologic injury [30]. During
all proceedings the maneuvers must maintain
manual in-line immobilization to decrease the 16.3.2 Airway Compression
risk of cervical spine injury [30].
Definitive airway establishment is not essen- Neck trauma significantly increases the dangers of
tial in all patients with airway injury. Indications intubation. Cervical spine injuries can cause
for emergent airway establishment would include hematoma in the retropharyngeal space which
hypoxia, agitation, respiratory distress, shock, can compress the airway and complicate intuba-
cardiac arrest, a score of less than 8 on the Glasgow tion despite no external signs [16]. For this rea-
coma scale, and altered mental status. If a defini- son, it is important to consider the timing of the
tive airway is not established initially, regular injury as movement of the airway may dislodge
reassessment is necessary [30]. Despite the dam- hematoma [16]. RSI may be suitable during spon-
aged anatomy often present in trauma cases, RSI taneous ventilation to prevent eventual closure of
can be successful and is the most frequently used the airway due to hematoma. Surgical airway
maneuver for airway establishment [28, 30]. The should be utilized following failure of RSI.
decision to pursue surgical, RSI, or external air-
way management depends on the stability of the
patient’s condition as well as preference, equip- 16.4 Perioperative Management
ment, available personnel, and the clinical sce- of Cardiovascular and Chest
nario. Video laryngoscopy and fiber-optic Injuries
bronchoscopy are options which may lessen the
amount of cervical movement during intubation; Injuries to the cardiovascular system and chest
however, their use is limited by the presence of wall largely contribute to trauma-related mortal-
debris, blood, and mucus [28]. Failure to intubate ity and morbidity. Vital organs are vulnerable in
this region, and due to the non-compressible
16 an unstable patient necessitates the establishment
nature of hemorrhage in this area, trauma-related
of a surgical airway [5].
Absolute indications for a surgical airway are deaths are relatively common when they other-
listed below: wise could have been preventable. One-fourth of
55 Trauma victims trauma deaths are due to chest trauma alone.
55 Airway obstruction Hemorrhage in the torso overall results in a mor-
55 Hypoventilation tality of 70–80%. This is due, in part, to inability
55 Persistent hypoxemia (SaO 2 < 90%) despite to control bleeding with tourniquets and
supplemental oxygen increased use of anticoagulant agents for prophy-
55 Severe cognitive impairment (Glasgow coma laxis of other cardiovascular disorders [7].
scale [GCS] score < 8)
55 Severe hemorrhagic shock
55 Cardiac arrest 16.4.1 Hemothorax
55 Smoke inhalation victims
55 Major cutaneous burn (body surface Hemorrhage resulting in shock is the leading
area > 10%) cause of early in-hospital trauma-related deaths.
233 16
Remember that most patients perish from trau- direct impact, or transmitted compression
matic injury in the first 4 h upon arrival, and hem- forces all can result in BCI, with some instances
orrhagic shock is a leading cause of this. It is the leading to a penetrating injury after sternal or
second most frequent cause of death in trauma rib fracture.
patients overall [40]. Injuries to chest wall vessels Initial assessment should be done in all
or intra-abdominal organs can cause hemorrhage patients with significant blunt trauma to the chest.
in the chest cavity when the diaphragm is rup- In these patients, an ECG should be done to assess
tured. Blood accumulates in the pleural space, for arrhythmia, ST segment abnormalities, heart
called a hemothorax, and it results in a wide array block, and signs of ischemia. E-FAST exams can
of clinical presentations. Diagnosis is made via be done to assess for hemopericardium and tam-
chest X-ray with at least 150 mL of blood present ponade. BCI can be ruled out if the patient has all
in the chest cavity when the patient is upright. of the following [12]:
E-FAST examination can identify fluid in the 1. Hemodynamically stable assessment
pleural cavity with greater sensitivity than CXR 2. Normal ECG
and is a much faster procedure to do. In an unsta- 3. Normal E-FAST examination
ble patient with blunt trauma, insertion of bilat-
eral chest tubes is warranted for both diagnostic Hemopericardium results in a necessary rapid
and therapeutic purposes [7]. resuscitation and urgent surgical treatment, as
Urgent thoracotomy is indicated in the light of survival in those with clinical status deterioration
a massive hemothorax, which is 1500 mL or more is marginal. The attending physicians should
of blood in the thoracic cavity. This has been chal- repeat E-FAST protocols in those that fail to
lenged in recent literature, suggesting patient improve or as their status worsens, even if hemo-
clinical status is a more important indicator for pericardium was not present initially.
the need of this procedure. Early preparation for Biomarkers of BCI are not solidified in the
thoracotomy has led to better outcomes, and literature to be a strong recommendation, but
thresholds have been suggested to be lowered to they have been suggested to be used in cases of
1000 or even 500 mL of blood. Perioperative man- difficult assessment. Some studies have shown
agement includes volume replacement as the that in stable patients with a normal ECG, an
main therapeutic modality for hemorrhagic elevated creatine kinase MB level is a nonspecific
shock. A massive transfusion protocol has been finding for the diagnosis of BCI. Likewise, tropo-
shown to be beneficial with early surgical consult. nin I and troponin T levels are more specific and
Angiography is not standard but can be consid- have been suggested to be helpful, but they are
ered for the diagnosis and treatment of intercostal not sensitive enough to have clinical utility as a
vessel injury [33]. screening test [12]. For example, cardiac dysfunc-
It is useful to examine for aortic injury in tion may have preceded BCI and lead to it, lead-
those who are hemodynamically unstable or with ing to increased levels of these biomarkers and
significant injury. This is usually done via con- lend a potential false clinical history.
trast chest CT for stable patients and via trans-
esophageal echocardiogram for those who are
unstable. 16.4.3 enetrating Cardiac Injury
P
(PCI)
16.4.2 Blunt Cardiac Injury (BCI) While BCI offers a good likelihood of survival if
the proper precautions are taken, penetrating car-
BCI is involved in 20% of all deaths due to motor diac injuries (PCIs) are highly lethal and offer a
vehicle collisions, with a wide range of present- small likelihood of survival. The probability of
ing pathologies, from myocardial bruise to car- arriving alive at the hospital after such an injury is
diac rupture and beyond. The right ventricle, is between 6% and 20% [37]. Again, the most com-
most commonly injured due to its proximity to mon injury is to the right ventricle due to proxim-
the chest wall, although injuries to more than ity to the chest wall, followed by the left ventricle.
one chamber occur in more than half of all These injuries usually result in hemorrhagic shock
cases. Crush injuries, deceleration injuries, or cardiac tamponade, with hemorrhagic shock
being the main cause of death at the scene. An falls from a great height, or rapid deceleration
additional threat is that the pericardium is quite events.
non-compliant, with only 50 mL of blood needed Ekeh et al. suggested that CXR misses 11% of
to lead to cardiac tamponade, so lethal injury can aortic injuries and was not an acceptable modality
occur with very little blood loss. to rule out such injuries [20]. Angiography instead
Immediate and rapid evaluation is absolutely is the gold standard to diagnose aortic injury.
necessary in these patients, through a thorough However, it is not available in all centers, most
physical examination followed by immediate patients who require aortic evaluation require CT
FAST exam of the heart, pericardium, and thorax imaging of other organ systems, so contrast CT is
to evaluate for hemothorax, hemopericardium, the most commonly used modality to diagnose
tamponade, and pneumothorax [38]. In those aortic injury. It has a sensitivity of greater than
with hemopericardium, urgent thoracotomy and 97%, specificity of greater than 85%, and a nega-
cardiorrhaphy are urgently required even when tive predictive value of 100%, leading to it being
stable. Those with left-sided hemothorax could the choice modality for evaluation of aortic
have a self-draining hemopericardium and are at injuries [18].
risk of rapid decompensation. As previously dis- The main medical management of these
cussed, this is a catastrophic perioperative com- patients includes:
plication, and the proper handling of these issues 1. Prevention and control of hypertension that
is rapid diagnosis, massive transfusion to estab- can lead to progression of the injury and
lish hemodynamic stability, and a bit of luck. subsequent hemodynamic instability
2. Control of coagulopathy, including hypother-
mia and acidosis
16.4.4 Aortic Injury 3. Correction of other life-threatening injuries
and prioritizing such injuries such that the
Sudden shearing forces, such as those in rapid patient has the greatest chance of survival
deceleration injury, can occur and severely dam- 4. Definitive surgical repair of the aortic injury
age the aorta. The proximal descending aorta is
most at risk due to the ligamentum arteriosum In those with hemodynamic instability due to aor-
being a transition point between the fixed descend- tic injury, urgent repair is indicated. It is also indi-
ing aorta and the mobile aortic arch. These injuries cated in contrast extravasation on CT with rapidly
are responsible for 15% of deaths in MVAs [21]. expanding hematoma, large hemorrhages from
There are three types of blunt aortic injury: chest tubes, and penetrating aortic injury [33].
1. Complete transection of the aorta. This
usually ends with patients dying at the scene
or shortly after arrival. 16.4.5 Tension Pneumothorax
2. Full-thickness aortic injury resulting in
16 hemodynamic instability and persistent Tension pneumothorax is a common type of
bleeding. blunt chest trauma that requires immediate diag-
3. Partial-thickness injury, most often with nosis and treatment with needle decompression,
contained hematoma. These patients may or followed by chest tube insertion. All traumatic
may not present as hemodynamically pneumothoraces should be considered for chest
unstable. tube insertion; however, observation is possible
for some patients with small pneumothoraces
As seen, a common theme is hemodynamic insta- on a single side without respiratory disease and
bility. The main challenge for the clinician in the without a need for positive pressure ventilation.
light of perioperative management is to identify All symptomatic traumatic hemothoraces should
the injury before it progresses to complete rup- be treated with chest tube insertion. Occult pneu-
ture. This is difficult due to no specific clinical mothorax can be treated with observation and
signs that allow for the rapid identification of aor- serial chest X-rays. Periprocedural antibiotics can
tic injuries, so they should be suspected in patients be used to prevent chest tube-related infectious
with high-speed MVA with frontal or side impact, complications.
235 16
16.4.6 Cardiac Tamponade sure is also commonly present and may be asso-
ciated with distension of the veins in the forehead
Cardiac tamponade occurs when fluid accumu- and scalp. It is important to note that Beck’s triad
lates in the pericardial sac, resulting in an increased of symptoms is absent in the majority of acute
pressure impeding cardiac filling, which leads to cardiac tamponade cases. Additionally, patients
decreased cardiac output. The clinical presenta- with occult cardiac tamponade may present with
tion depends heavily on the duration of tampon- the usual physical findings, but their presence is
ade and the amount of fluid that has accumulated. less common than in classic cases of cardiac tam-
Acute cardiac tamponade has a sudden onset and ponade.
presents with symptoms resembling cardiogenic Further evaluation of cardiac tamponade
shock. Potential symptoms of acute cardiac tam- calls for an EKG, chest radiograph, and most
ponade include dyspnea, tachypnea, and chest importantly echocardiography. The EKG tends
pain. The decrease in cardiac output commonly to show tachycardia and may also show low volt-
leads to hypotension, and patients who develop age. In subacute cardiac tamponade, a chest
cardiogenic shock may present with cool radiograph may show cardiomegaly. In acute
extremities, decreased urine output, and periph- cardiac tamponade, cardiomegaly is not usually
eral cyanosis. found. In echocardiography, the major signs of
Subacute cardiac tamponade comes on slowly cardiac tamponade include chamber collapse
over days to weeks, and patients may be asymp- (usually the right-sided chambers), respiratory
tomatic early on. Potential symptoms include dys- variation in volumes and flow, and IVC plethora.
pnea, peripheral edema, chest discomfort, and In patients with a moderate to large effusion,
being easily fatigued. Patients may also have swinging of the heart within the effusion may
hypotension with a narrow pulse pressure, but also be present.
those with preexisting hypertension may continue In cardiac tamponade with minimal to no
to be hypertensive. Occult cardiac tamponade, hemodynamic compromise, conservative treat-
also known as low-pressure cardiac tamponade, is ment with hemodynamic monitoring and serial
a subset of subacute cardiac tamponade where echocardiograms is a viable option in the prepara-
patients may present with intracardiac and peri- tion of the patient for surgery. Definitive treat-
cardial diastolic pressures between 6–12 mmHg. ment of cardiac tamponade involves removing the
It is usually seen in patients who are severely pericardial fluid either by percutaneous or surgi-
hypovolemic. cal drainage. Echocardiography-guided catheter
Regional cardiac tamponade occurs with a pericardiocentesis is the treatment of choice, but
localized collection of fluid applying pressure to surgical drainage may be preferred if:
a subset of heart chambers. In these patients, 1. The fluid is localized.
the usual signs and symptoms of cardiac tam- 2. The fluid reaccumulated after catheter
ponade are not present. This variant is most draining.
often found after pericardiotomy or myocardial 3. There are coagulopathy concerns.
infarction. Diagnosing regional cardiac tam- 4. There is a need for biopsy material.
ponade can be challenging and may need
advanced imaging techniques like CT or addi- Caution with pericardiocentesis should be taken
tional echocardiograph views like transesopha- if the patient has severe pulmonary hypertension.
geal or subcostal. General anesthesia may worsen hemodynamic
Physical exam findings, though not highly compromise, so catheter drainage may be required
sensitive or specific, include Beck’s triad (hypo- prior to surgical drainage to reduce the severity of
tension, muffled heart sounds, and elevated jug- the cardiac tamponade. In cases of aortic dissec-
ular venous pressure), pulsus paradoxus, and tion or myocardial rupture, pericardiocentesis
sinus tachycardia. Sinus tachycardia is present in may worsen bleeding, and surgical drainage
almost all patients, but may be absent early on, should be performed. Surgical drainage is also
or if the underlying disease process is associated preferred in cases of traumatic hemopericardium
with bradycardia. Elevated jugular venous pres- and purulent pericarditis [2, 27, 36].
16.5 Perioperative Management used and as they reach a steady state, they should
of Burn Injuries not be stopped to achieve intraoperative anesthe-
sia. Instead the dose may be increased, or they
Roughly 450,000 people present with burn inju- may be combined with other drugs to achieve
ries every year in the USA. About 40,000 of those anesthesia. One option for induction and mainte-
are hospitalized, and approximately 3400 die from nance is ketamine. It may also be the agent of
their injuries or complications [9]. The most com- choice when manipulation of the airway needs to
mon complications from burn injuries are be avoided (i.e., after fresh graft placements).
decreased cardiac output, inhalational injury, Benzodiazepines are often added to decrease the
infection, renal damage, CNS dysfunction, com- probability of dysphoria, and glycopyrrolate is
partment syndromes, and coagulopathy. Patients often added to counter the increased secretions
with burn injuries should be initially treated as caused by ketamine.
multiple trauma patients [4].
The priority in managing burn injuries is
assessing the airway. It is vital to evaluate for signs 16.6 Perioperative Management
of inhalation injury, laryngeal injury, obstruction, of Gastrointestinal
or preexisting abnormalities. A patient’s airway and Abdominal Injuries
may not appear injured, but airway edema may
follow fluid resuscitation. In patients with signifi- 16.6.1 Intro
cant risk of inhalation injury, it is safer to intubate
early than wait until after airway swelling has While traumatic torso injuries compose a rela-
occurred. tively small portion of emergency room visits,
Fluid resuscitation is another vital step as they contribute disproportionately to morbidity
delay could lead to hypovolemia and burn shock. and mortality. Blunt or penetrating traumatic
Fluid requirements for each patient may vary injury to the abdomen affects solid organs, vis-
depending on size/depth of the burn, associated cera, and vasculature [41]. Blunt trauma com-
injuries, or level of opioid usage for pain manage- prises 80% of abdominal injuries seen in the
ment. There are many fluid resuscitation formu- emergency department [32]. In blunt force
las, but current recommendations state that to trauma, the spleen is most commonly injured,
achieve adequate fluid resuscitation, a urinary with retroperitoneal and liver damage following.
output of 0.5–1 ml/kg/h should be maintained. In penetrating trauma, the organ involvement is
Patients should initially be started on isotonic somewhat unpredictable. Among civilians, vehicle
crystalloids followed by colloids. However, the accidents, blows to the abdomen, and falls are the
exact time to start using colloids is still debated, most frequent causes of blunt trauma, while gun-
though the general trend is to start them before shot and stab wounds are the most frequent causes
the previously recommended 24 h [4]. of penetrating trauma [41]. Complications of
16 Burn injuries can lead to altered pharmaco- hemorrhage, peritonitis, or evisceration are
logical and physiological responses to medica- immediate indications for emergency surgical
tions. For example, succinylcholine can cause intervention. In the absence of these indications,
hyperkalemia and induce cardiac arrest, and it is “Selective Surgical Conservatism” has become the
recommended to avoid the use of succinylcholine standard [41]. This involves performing a careful
in burn patients 48 h after injury. Additionally, examination and proceeding to the operating
burn patients will also have decreased sensitivity room only with injuries present that nonsurgical
to nondepolarizing muscle relaxants (NDMRs) interventions would not heal. In surgical patients,
[4]. Medication choices for a burn-inflicted indi- interdisciplinary care during the perioperative
vidual should be driven by that patient’s hemody- period directly affects long-term outcome.
namic and pulmonary status, as well as the The most lethal complication relevant to
potential difficulty of securing that patient’s air- abdominal trauma is hemorrhage. Hemorrhage is
way. An additional long-term consideration is responsible for 30–40% of trauma-related deaths,
that patients suffering from burn injuries will only second to central nervous system damage
likely be on elevated amounts of opioids for pain overall [26]. The majority of traumatic hemor-
management. As these medications are being rhages are related to abdominal injury, the most
237 16
serious of which are splenic and liver lacerations. death in subsequent days to weeks is possible due
Hemorrhage of more than 40% total blood vol- to organ failure from the original shock [25].
ume will lead to hemorrhagic shock with circula- A rare but possibly fatal complication from
tory system failure and cardiac arrest [25]. Several massive transfusion is intra-abdominal compart-
physiological compensation mechanisms exist, ment syndrome, which is an organ dysfunction
including sympathetic stimulation, decreased from abdominal hypertension [32]. Incidence in
vagal tone, elevated heart rate, shunting blood to trauma patients has been estimated from 1% to
vital organs, and increased release of vasopressin. 14% [32]. Early recognition of intra-abdominal
These systems function to conserve blood vol- hypertension can prevent organ failure. The diag-
ume, maintain vital organ perfusion, and dimin- nosis must be considered in patients exhibiting an
ish peripheral blood flow. If the hemorrhage onset of organ failure with a distended abdomen,
persists, it will overwhelm this compensation, and though abdominal distension is not a good predic-
a lethal triad of hypothermia, acidosis, and coagu- tor of intra-abdominal compartment syndrome.
lopathy will develop. This signals the failure of Oliguria and increased ventilatory requirements
resuscitation. Acidosis results due to poor tissue are also common symptoms. Increased jugular
perfusion and production of lactic acid which venous pressure, hypotension, tachycardia,
may be complicated further by respiratory acido- peripheral edema, or evidence of hypoperfusion
sis. Coagulopathies result both from loss of clot- may also be present. Imaging is generally unhelp-
ting factors in the blood and activation of the ful, and absolute diagnosis requires measurement
coagulation cascade from the trauma [23]. of the intra-abdominal pressure, which should be
A mainstay of treatment for hemorrhagic performed liberally [32].
patients is massive blood transfusion. A massive Perioperative management considerations begin
transfusion protocol should be with massive blood upon presentation and include rapid stabilization
loss, defined as loss of total blood volume during a and patient selection. Penetrating trauma is usually
24-h period, half of overall blood volume during clinically obvious, whereas blunt trauma may be
3 h, or at a rate of over 150 ml/min [25]. While subtle or missed. Stabilization of the patient and
transfusion replaces the blood lost, it can further elimination of any immediate life-threatening injury
complicate a coagulopathy by diluting platelets should follow the advanced trauma and life support
and clotting factors. Blood must be considered a (ATLS) protocols. The initial absence of tenderness
pharmacologic treatment, and the risks and bene- or pain on physical examination, even with hemo-
fits of administration must be assessed [25]. Blood dynamic stability, does not rule out the risk of
is the idyllic resuscitation drug from a physiologic abdominal trauma. This is especially true in patients
perspective, but transfusions carry their own risk. with distracting injuries. For example, up to 10% of
Transmission of infectious agents, overall avail- patients with seemingly isolated head trauma may
ability, storage concerns, and religious reserva- have concurrent abdominal injury. A “seat belt sign”
tions must be considered before transfusion is (ecchymosis over the seat belt area) indicates
given. If bleeding is controlled, patient outcome abdominal trauma in up to 33% of patients [32]. In
then depends upon the timing and precision of hemodynamically unstable patients, immediate
fluid resuscitation, organ system response, and resuscitation with concurrent assessment is impera-
inflammatory mediators. The American College tive. Laboratory tests are of limited value but are
of Surgeons and American Association of Blood recommended as adjunct to clinical examination in
Banks recommendations state that transfusion patients with low risk of abdominal trauma [32, 41].
should be guided by concurrent laboratory evalu- Urinalysis is recommended, as blood in the urine
ations, for example, PT, PTT, platelet count, and can herald abdominal injury in the absence of other
fibrinogen levels. Intravascular volume mainte- clinically obvious signs. Radiographic images are
nance and oxygen-carrying capacity should be useful but pose a risk as well. Patients must usually
specifically prioritized [25]. Attention should also be stabilized before radiography is obtainable, and
be paid to clotting factor and electrolyte concen- the risk of further injury during imaging must be
tration. Early administration of high levels of fresh considered. Bedside sonography – the focused
frozen plasma and platelets is critical to improving assessment with sonography for trauma (FAST) –
survival and reducing total need for red blood exam, diagnostic peritoneal lavage, or CT scan for
cells. Even if the patient survives resuscitation, evaluation of intraperitoneal fluid is used to diag-
nose injury with blood accumulation. The FAST 16.7 Perioperative Management
exam images intraperitoneal sites most likely to of Musculoskeletal Injuries [44]
accumulate blood: the splenorenal recess, the infe-
rior portion of the peritoneal cavity (pouch of Musculoskeletal injuries are quite common in
Douglas), and the hepatorenal space (Morison’s trauma-based medical situations. A wide range
pouch) in addition to the pericardial space [32, 41]. of pathologies exist, ranging from minor sprains
The FAST exam is most rapid, with CT scanning to open fractures and amputation. Early appro-
providing the best specificity. priate management of these injuries can prevent
CT is the most often used modality to diag- long-term disability and loss of limb or life. ATLS
nose abdominal trauma. An algorithm for the guidelines suggest that the first line of defense
initial workup of blunt trauma to the abdomen is against severe disability from musculoskeletal
provided (. Fig. 16.1). In these patients, failure of

injury is recognizing and controlling hemor-
nonoperative treatment is predicted by older age, rhage and immobilizing fractures. Limb-
lower Glasgow coma scores (GCS), low admission threatening injuries should be identified quickly,
systolic pressure, higher injury severity score, specifically open fractures and areas of compro-
metabolic acidosis, and a requirement for transfu- mised vascular and nerve supply. Wound irriga-
sion. It is imperative for institutions to have foun- tion, debridement of damaged tissue, control of
dationally solid management protocols. hemostasis, and antibiotic uses are all hallmarks
of management.
Key Points
55 Blunt or penetrating abdominal trauma 16.7.1 Major Hemorrhage
is a major concern of patients presenting
in the emergency department, with 25% The initial goal in a patient with major hemor-
needing surgical intervention (11). rhage is to stop the bleed. Direct pressure, via tour-
55 Patient selection, stabilization, and niquet, pressure bandage, or manual force, should
diagnostic workup are crucial factors in be used initially to complete this goal. Tourniquet
perioperative management. Sex, length use is more common in transport settings, and
of time from injury to surgery, shock at clinicians should be knowledgeable about how to
the time of admission, and cranial injury properly remove a tourniquet. It should be
affect patient outcomes (11). removed cautiously and another tourniquet should
55 The chief management distinction be on hand to ensure a controlled environment.
hinges on hemodynamic stability versus Tourniquets can be left until reassessment in the
instability. When surgery is required, operating room where more technology is avail-
effective perioperative protocols able to assist in stopping the bleed [10].
contribute to long-term outcomes.
16 55 The most threatening consideration of
16.7.2 Open Fractures
abdominal trauma is hemorrhage,
particularly from liver or spleen damage.
A mainstay treatment is massive blood An open fracture is direct exposure of the injured
transfusion, for which risks and benefits bone to the environment, usually as a result of a
must be carefully considered. high-energy injury. Contamination has a larger
55 Signs of acute compartment syndrome potential in these fractures, and severe damage
after abdominal trauma surgery, to local soft tissues is guaranteed. The timeliness
including abdominal distension and of antibiotic administration is vital in reducing
oliguria, must be recognized. the likelihood of infection. A first-generation
55 Patients with abdominal trauma have an cephalosporin is the most commonly recom-

estimated 12% (blunt trauma) or 58% mended antibiotic used in these scenarios, fol-
(penetrating trauma) mortality, which lowed by surgical debridement and irrigation
can be reduced by effective periopera- within 24 h, ideally sooner. The type of fixation
tive and major risk management (11). depends on the level of soft tissue injury and
contamination. Wound coverage should be per-
239 16
formed within 5–7 days [34]. Again, the most Perioperative management of these injury types
vital perioperative measure in these patients is solely deals with quick recognition and proper
proper antibiotic coverage and management of diagnosis.
hemostasis in case of vessel damage. Femur frac-
tures specifically have a higher likelihood of nec-
essary blood transfusion. It has been estimated 16.7.5 Major Joint Dislocation
that 40% of all femur fractures require this, and
even in the context of a closed femoral fracture, Neurovascular structures are at great risk in the
blood loss can be greater than 2.2 [13, 29]. setting of major joint dislocation, due to the
close tethering of these structures to the joints
themselves. Abnormal neurologic exams, distal
16.7.3 Pelvic Injuries extremities containing edema, and signs of vas-
cular damage should raise suspicion for neuro-
A great deal of energy is needed to create a pelvic vascular damage in the setting of a major joint
injury, and as such they are associated with dislocation. Perioperative management, if surgery
extensive body-wide injuries such as head inju- is needed, contains rapid joint relocation and sta-
ries, thoracoabdominal injuries, long-bone frac- bilization in a splint. A hip dislocation is an ortho-
tures, and resulting hemodynamic instability. pedic emergency due to risk of avascular necrosis
Pelvic fractures with blood loss and hypovolemia and should particularly be indicative of immedi-
have a mortality rate up to 20%. It is vital for cli- ate reduction and surgical consultation [1].
nicians to assess for vessel damage, specifically
the pelvic venous plexus and internal iliac ves-
sels, as injury can result in uncontrolled hemor- 16.8 Perioperative Management
rhage. Fluid resuscitation and hemorrhage of Neurological Injuries
control are vital along with stabilization of the
pelvic ring, such as with a pelvic binder followed Neurological trauma, including both traumatic
by external fixation [22]. brain injuries and damage to the spinal cord,
remains a cause of death and disability despite a
wide collection of robust evidence-based guide-
16.7.4 Compartment Syndrome lines for immediate trauma care. Traumatic brain
injury (TBI) remains the leading cause of death
Acute compartment syndrome (ACS) develops for individuals in North America between 1 and
when an accumulation of fluid inside a confined 45 years old, causing an estimated $9.1 billion in
muscular space leads to prolonged elevated pres- lifetime hospital costs and $51.2 billion in produc-
sure inside the space and a resulting ischemia of tivity losses [39]. Spinal cord injury is estimated to
myoneural units. This is a surgical emergency, as generate $500,000–$2 million in direct medical
irreversible muscular necrosis can begin as little expenses over a lifetime [39]. Falls are the most
as 6 h after initial injury. ACS is commonly due to common cause of TBIs, followed by motor vehicle
a crush-type injury. Perioperative knowledge can accidents. The order is reversed when considering
help save a patient’s limb, by assessing the 5 “Ps” in spinal cord injuries, as MVAs constitute the
the setting of a swollen extremity: majority of spinal cord injury events [39, 45].
1. Pain out of proportion Approximately 20% of TBIs need operative inter-
2. Pallor vention [41]. Paramount to treatment is avoidance
3. Paresthesia of secondary brain insults, which can exacerbate
4. Pulselessness cell death in vulnerable brain tissue. The goal of
5. Paralysis treatment in traumatic spinal cord injury revolves
around stabilization of the spine and reduction of
Tools to measure intramuscular pressure are neurological dislocations. Perioperative consider-
often used to diagnose, and a difference of less ations and management of neurogenic shock with
than 30 mmHg from diastolic blood pressure physiologic derangement will assist providers in
is concerning for ACS. Once it is diagnosed, providing the optimal outcomes to patients suffer-
emergent fasciotomies are done to save the limb. ing from neurological trauma.
16.8.1 Traumatic Brain Injury bral perfusion pressure (CPP), treat increased
intracranial pressure (ICP), provide optimal
The pathophysiology of traumatic neurological surgical conditions, avoid secondary insult, and
injury is separated into primary and secondary provide adequate analgesia and amnesia [17].
injury. Primary injury results from external Increased ICP is associated with increased mor-
mechanical insult occurring at the time of trauma, tality and worsened outcome. Patients with a
and extent of primary injury remains the single GCS of 8 or less and a CT showing mass lesion
greatest predictor of patient outcome [17]. are indicated for ICP monitoring, though the
Secondary injury is a result of physiological strength of this recommendation is limited by a
molecular mechanisms, including inflammation, lack of randomized controlled trials [8, 17]. The
beginning at the time of trauma which causes fur- majority of protocols recommend reduction of
ther damage to the brain or spine over hours to ICP to 20 mmHg or less. Appropriate sedation
days [41]. Secondary brain injury can lead to neu- may reduce metabolic demand, thus lowering
ronal death, cerebral edema, and further increase ICP. With a lack of clinical trial data supporting
in intracranial pressure which mediates more any specific protocol, sedation use and choice
extensive damage. Hypotension, hypoxemia, and of agent should be individualized according to
hyperglycemia are significant factors causing sec- specific clinical circumstances and institutional
ondary injury [17]. Hypotension and hypoxemia expertise. Monitoring of CPP aids in evaluating
have been demonstrated to be independently the somewhat variable effects of these agents on
associated with morbidity and mortality, as well ICP and blood pressure. CPP is defined as the dif-
as outcome at 6 months [17]. Effective periopera- ference between mean arterial pressure (MAP)
tive management may provide a window of and ICP (CCP = MAP-ICP) and provides a surro-
opportunity to significantly reduce consequences gate for measuring cerebral blood pressure (CBP).
of injury from TBI by treating standing secondary Low CCP is associated with secondary injury and
injuries and preventing medically or surgically worsened outcome. Autoregulation, which usu-
induced secondary injuries. ally provides a constant CBP across a wide range
Despite many provider groups having focused of MAP (50–150 mmHg), is altered in approxi-
efforts at emergently treating hypoxemia, hypo- mately a third of TBIs. The recommended CPP
tension, hypercarbia, hypo- and hyperglycemia, is goal is 60 mmHg for adults, avoiding levels below
not uncommon for these parameters to persist or 50 mmHg or above 70 mmHg [8, 17]. However,
remain undetected as patients are rushed into when feasible, efforts to control CPP should first
surgery for a group that is unprepared. Therefore, maintain ICP at low levels. This may have a larger
while the emergency department team likely has effect on cerebral blood flow, obviate employment
performed an assessment, initial stabilization, of fluids and ionotropic agents, and especially
and begun resuscitation, it is crucial for another benefit patients with more severely impaired
assessment to be performed perioperatively. autoregulation [8]. Additionally, neuroprotec-
16 Effective perioperative management also includes tive pharmacology in the perioperative period
quick evaluation, continued resuscitation (cere- may be beneficial. C urrent evidence regarding
bral and systemic), early surgery, intensive moni- pharmacological neuroprotection perioperatively
toring, and anesthetic preparation [17]. Initial suggests that CNS neuroprotection might reduce
evaluation should begin with airway, breathing, the incidence of new postoperative neurological
and circulation, followed by rapid neurological deficits, without providing benefits for periopera-
evaluation and assessment of extracranial inju- tive mortality [17].
ries, with particular attention to mechanisms of
secondary injury.
The standard for rapid neurological assess- 16.8.2 pinal Cord Injury
S
ment is use of the Glasgow coma scale (GCS) score and Trauma
and pupillary reflexes. The GCS score ranges from
3 to 15 and reflects coma severity according to Perioperative management of spinal trauma is
responsiveness of three areas: eye opening, verbal, similarly vital for the ability to treat previously
and motor response (. Table 16.1). Anesthetic
occurring secondary injury as well as prevent
focus in TBI cases should be to maintain cere- operative secondary injury. Management focuses
241 16
on physiological principles, involving the rational cal, thoracic, and lumbar spinal cord injuries
use of immobilization, careful airway manage- depends upon institutional expertise and focuses
ment, support of cord perfusion, and oxygenation on physiological principles like immobilization,
with appropriate respiratory and hemodynamic adequate oxygenation, and blood pressure sup-
sustenance [43]. Immobilization devices often port. Because secondary injury significantly con-
complicate access to the airway. No intubation tributes to loss of function and mortality, the
technique has proved superior, and clinical judg- perioperative period provides a potentially pow-
ment must be employed regarding individual sit- erful window for impacting patient lives.
uations [19]. Spinal cord blood flow is often
compromised in traumatic injuries to the spinal
cord. Hypotension is particularly dangerous in 16.9 Perioperative Management
these patients and usually results from hemor- of Electrocution Injuries
rhage from the original trauma, neurogenic
shock, or a combination thereof. Neurogenic Electrocution injuries are 5% of admissions to
shock is more likely in patients with spinal cord major burn centers (2014). The age distribution of
injury. Neurogenic shock refers to systemic vaso- these injuries is bimodal with the majority being
dilation resulting in insufficient tissue perfusion split between young children (under 6 years old)
from loss of sympathetic control above the spine and young adults. For young children, injuries
[19]. Increased blood pressure improves axonal most commonly occur in the home, and for young
function in motor and sensory tracts. adults, injuries are most commonly work-related
Several clinical studies have demonstrated (i.e., mining and construction). Lightning strikes
benefit to aggressive hemodynamic management make up a small subset of electrocution injuries
in patients with spinal cord trauma. However, (2006).
little evidence exists regarding appropriate blood Electrocution injuries can be divided into
pressure goals or specific agents. Clinical trials high- and low-voltage categories, with high-
regarding pharmacological neuroprotection over- voltage considered injuries in which voltage is
all present disappointing results, though mecha- over 1000 V. High-voltage shocks are expected to
nistic discovery continues to pose new therapeutic cause more severe injury per second of exposure
prospects [43]. There are no evidence-based and lead to greater deeper tissue damage.
guidelines regarding treatment timing, leaving Electrocution injuries can also be divided based
surgical expertise and medical center protocols to on direct vs alternating current. Direct current
determine best practice. Multimodal intraopera- causes a single contraction which tends to throw
tive monitoring (MIOM) may provide benefit to the person away from the electrical source.
further reducing secondary damage from surgery. Alternating current tends to cause repetitive con-
MIOM refers to collective monitoring of sensory- tractions which may lead to longer exposure and
and motor-evoked potentials and spontaneous is considered the more dangerous of the two. All
electromyography to help identify deterioration types of electrocution injuries can lead to cardiac,
of the spinal cord, providing the opportunity to respiratory, skin/musculoskeletal, and neurologi-
correct offending agents before provoking irre- cal abnormalities. It is important to remember
versible damage. However, the level of evidence is that the superficial skin injuries are not indicative
low that MIOM prevents or corrects new or wors- of the full extent of damage.
ening perioperative neurological damage [19]. Cardiac abnormalities can result from both
The most important perioperative manage- high- and low-voltage injuries and can include
ment principles in both traumatic brain injury arrhythmias, conduction abnormalities, and myo-
and spinal cord trauma center around controlling cardial damage. Horizontal current flow (hand to
and preventing secondary damage from surgery hand) is more likely to lead to potentially fatal
or anesthesia. Avoiding hypoxia and hypotension arrhythmias, while vertical current flow (head to
is particularly important. Management of trau- foot) is more likely to lead to myocardial tissue
matic brain injuries should focus on quick assess- damage. The most common arrhythmias are pre-
ment, continued resuscitation, rapid surgical mature ventricular contractions and sinus tachy-
intervention, rigorous monitoring, and anesthesia cardia, but ventricular tachycardia and atrial
preparation. In general, the management of cervi- fibrillation are both possible. Low-voltage alter-
nating current is more likely to lead to sudden it is important to remember to run a full physical
cardiac death caused by ventricular fibrillation. and labs to check for damage such as broken
High-voltage alternating current, or direct cur- bones, neurological deficits, acute kidney injury,
rent, is more likely to lead to asystole. The EKG or tissue necrosis. More extensive deep tissue
tends to show nonspecific ST-T wave irregularities injuries may require debridement, fasciotomy,
that tend to resolve on their own. Patients not pre- and wound exploration. Imaging (X-rays or CTs)
senting with EKG changes are unlikely to develop should be obtained if there is suspicion of spinal
life-threatening arrhythmias. Conduction abnor- injury or if there is a history of a fall and altered
malities, like sinus bradycardia and AV block, consciousness with abnormal neurologic find-
have also been reported. Myocardial injury after ings. Additional radiographs should also be done
an electrical shock can be difficult to diagnose as for any area where the patient feels pain and
there are not specific EKG changes, symptoms, or where there is an obvious deformity or decreased
abnormal myocardial pyrophosphate scans. Rare range of motion.
vascular complications include arterial spasm/ Lightning strikes are considered a special cir-
rupture and venous or arterial thromboses. cumstance. They lead to cardiac and respiratory
Respiratory arrest following a shock is com- arrest through delivery of a large quantity of direct
mon, and the patient needs prompt ventilatory current during a very short time frame. This rarely
support to avoid hypoxia-induced ventricular leads to extensive tissue destruction so aggressive
fibrillation. Ventilatory support should continue fluid resuscitation is not needed. Aside from that,
until neurological function can be assessed. management should follow the usual protocol.
The bone bears the most severe electrothermal Lichtenberg figures are rare and will resolve on
injuries including periosteal burns, bone matrix their own in a few days. Cardiac arrest is due to
destruction, and osteonecrosis. Electrocution can asystole but frequently spontaneously resolves.
lead to fractures, as well as large-joint dislocation. The respiratory arrest tends to last longer and, if
Injuries may lead to edema and tissue necrosis support is not provided, will lead to hypoxia-
that in turn can cause compartment syndrome induced ventricular fibrillation [31, 42].
and rhabdomyolysis. It is suggested to use cre-
atine kinase serum levels to measure rhabdomy-
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16
245 17
Obstetrics
R. Edward Betcher and Karen Berken
17.2 Maternal Physiology – 246
17.2.1 Cardiac – 246
17.2.2 Respiratory – 247
17.2.3 Hematologic – 247
17.2.4 Urologic – 248
17.2.5 Gastrointestinal – 248
17.2.6 Endocrine – 248
17.2.7 Skeletal – 249
17.2.8 Other Systems – 249
17.3 Fetal Development and Placenta – 249
17.4 Fetal Monitoring – 250
17.5 Anesthesia for Pregnant Patients – 251
17.6 Perioperative Care for Pregnant Patients – 252
17.7 Obstetrical Physiologic Changes Affecting
Perioperative Care – 252
17.8 Obstetrical Conditions – 253
17.8.1 Ectopic Pregnancies – 253
17.8.2 Molar Pregnancy – 254
17.8.3 Abnormal Placentation – 254
17.8.4 Placental Abruption – 255
17.8.5 Uterine Inversion – 255
17.8.6 Uterine Atony – 255
17.8.7 Postpartum Hemorrhage – 256
17.8.8 Pregnancy-Associated Hypertension – 257
17.8.9 Eclampsia – 258
17.8.10 Amniotic Fluid Embolism – 258
17.9 Summary – 258
References – 259

https://doi.org/10.1007/978-3-319-96125-5_17
246 R. E. Betcher and K. Berken
17.1 Introduction positive around 25 IU. Ovulation typically occurs

around cycle day number 14 during the average
When dealing with a patient who is pregnant, menstrual cycle of 28 days. Conception usually
health-care providers are, for all practical pur- occurs around 1–2 days later. This means preg-
poses, taking care of two patients. A guiding prin- nancy changes are occurring even before a patient
ciple for their care is “If momma isn’t doing well, realizes they are pregnant by cessation of menses.
then no one is doing well.” Care for an obstetrical This also can lead to a false negative pregnancy
patient has to take into account the physiologic test until someone is 2 or more days late for men-
changes of pregnancy that varies from the first struation.
trimester to the third trimester along with the Normal maternal weight gain with pregnancy
effects of treatment on the fetus and the placenta. is between 22 and 37 pounds (10–16.8 kg) [1]
During embryologic development, certain with the fetus, placenta, and amniotic fluid only
treatments and medication can affect formation responsible for 35–59% of this weight. Prior rec-
of organs and tissues. Adverse events can damage ommendations for weight gain of 30 pounds in
the placenta leading to growth restriction of the pregnancy were based on this, but because of the
fetus and even intrauterine fetal demise (IUFD). current obesity rates, it has now been decreased to
Through an understanding of the bodily 15–20 pounds. The rest of the weight gain in preg-
changes to the female parturient, the embryologic nancy is attributed to changes in organ systems to
development of the fetus, and development of the meet the physiologic needs associated with
placenta, management of these surgical patients pregnancy.
can become less intimidating and help avoid peri-
operative complication.
Certain conditions exclusive to obstetrics can 17.2.1 Cardiac
significantly alter normal pregnancy physiology
and increase the risks of intraoperative complica- Some of the most dramatic changes occur in the
tions. Surgical care of gravid women should not cardiovascular system to maximize oxygenation to
be withheld just because they are pregnant. This the fetus along with increased blood flow to the
leads to the need for anesthesia/surgical provid- uterus, which in turn is passed on to the fetus via
ers to understand the physiologic changes of the placenta. The heart enlarges and rotates slightly
pregnancy to modify their care for this unique which can increase its silhouette in radiologic stud-
group. ies. This enlargement along with hypertrophy
results in a remarkable increase in stroke volume
(SV). The heart rate (HR) increases by 15–20 beats
17.2 Maternal Physiology per minute during pregnancy. Preload is increased
by the upsurge in blood volume. Reduced vascular
Changes to the female body systems begin almost resistance through vasodilatation decreases after-
immediately with conception. The early embryo- load. All together this works to increase cardiac
logic tissue produces hormones and tissues, fac- output (CO) very early pregnancy by 20% and
tors that have an effect on almost every body peaks at around 50% by 32–34 weeks. Remembering
17 system. Mechanical changes occur as the result of SV × HR = CO, we can see the normal value of 4.88
the growth of the pregnant uterus, enlarging increase to 7.34 L/min in the third trimester [2, 3].
breasts, organ hypertrophy, and tissue edema. The Multi-gestations can result in an additional 20%
average gestation is 280 days, and although we increase in CO. This increase in CO can result in
discuss these effects based on trimesters, it is a larger blood loss amounts in a shorter period of
continuum that peaks at 40 weeks (full-term time with hemorrhage with masking of tachycardia
pregnancy 37–42 weeks) and then gradually until significant blood loss has occurred. CO is
resolves usually by 6–8 weeks postpartum. greatly affected by patient position and can be
Beta human chorionic gonadotropin (BHCG) reduced by mechanical compression to the vena
is the most common hormone measured to deter- cava by the gravid uterus as early as 24 weeks. This
mine a pregnancy. It typically increases by 33-49% reduces blood flow back to the heart. Placing the
every 2 days and peaks around 10 weeks of gesta- patient supine instead of a left lateral tilt can reduce
tion. Most qualitative pregnancy tests will turn CO by 25–30% [4].
Obstetrics
247 17
Blood pressure (BP) in pregnancy is variable 17.2.2 Respiratory
based on trimester. Initial drops in BP can be
noted around 8 weeks of gestation and will gradu- Upper airway edema and increased secretions
ally increase in midpregnancy and return to nor- can occur due to the increased estrogen levels
mal levels by term gestation. With this early during pregnancy. This can increase risks of anes-
decrease in BP around the time that pregnancy is thesia complications and difficulty in intubation.
diagnosed, many women with underlying hyper- Coupled with increased vascularity of the nasal
tension may not be recognized. This can lead to mucosa, epitasis frequently occurs [10].
diagnoses of preeclampsia when indeed the The thoracic region undergoes significant
patient has chronic hypertension instead. Mean changes beginning in the first trimester. Consid
arterial pressure (MAP) on average is decreased erable increase in breast size and weight can
by 5–10 mmHg and is mainly due to a decrease in apply pressure to the chest wall. Respiratory
systemic vascular resistance (SVR) leading to muscle function and maximum inspiratory and
increased blood flow to the gravid uterus. During expiratory pressures are unchanged. Elevation of
labor, there is a significant increase in CO and the diaphragm from an enlarging gravid uterus
MAP caused by 300–500 ml increase in venous will decrease the resting lung volume. This
blood by a uterine contraction along with pain reduces total lung capacity (TLC), functional
and anxiety increasing the heart rate. CO typi- residual capacity (FRC), expiratory reserve vol-
cally peaks immediately postpartum and will ume (ERV), and residual volume (RV). Patients
return to prepregnancy levels within 2–4 weeks during pregnancy have an increased progester-
after delivery [5]. one level which leads to an increased respiratory
Venous pressure increases in the lower extrem- rate. This coupled with an increase in tidal vol-
ities, as the pregnancy progresses, to as much as 25 ume (TV) results in a rise in minute ventilation
cmH2O. This increases the risks of edema and (MV). With these effects, the gravid women will
varicose veins and, coupled with stasis, leads to have an increase in PaO2 and decrease in PaCO2
deep vein thrombosis. Additionally, decreased col- resulting in respiratory alkalosis. Oxygen con-
loidal osmotic pressure means pregnant patients sumption is increased, and with apnea associ-
are at increased risk of developing pulmonary ated with intubation, desaturation can occur in
edema with preeclampsia or fluid volume overload as little as 3 min [2].
(increased cardiac preload). Brain natriuretic pep-
tide (BNP) is still a reliable test for pulmonary
edema/congestive heart failure in pregnancy [6]. 17.2.3 Hematologic
Dyspnea is a normal feature of pregnancy
beginning around 20 weeks of gestation and is A rise in blood volume starts at 6 weeks of gesta-
usually mild in nature. It can imitate heart dis- tion and increases during pregnancy with a cli-
ease, but it usually doesn’t occur at rest and isn’t max at 40–50% by 30–34 weeks of gestation.
associated with additional symptoms such as Plasma volume increases by 50%, while erythro-
chest pain with exertion, syncope, orthopnea, or cyte development is at a slower rate and averages
paroxysmal nocturnal dyspnea [7]. If these addi- 400 ml. This results in an increase in hemoglobin
tional symptoms occur, a further cardiac evalua- (Hgb) but a dilution of the hematocrit (Hct). This
tion is warranted. Troponin is preferred over is in anticipation for the significant blood loss that
CK-MB when patients are in labor as uterine con- can occur at delivery.
tractions can increase CK-MB [8]. White blood cell (WBC) also rises mildly as
Most pregnant women will exhibit a flow the pregnancy progresses. Adding in the stress
murmur with a S3 and systolic ejection murmur associated with labor, some patients can develop
along the left sternal boarder from increased flow leukocytosis (20,000 or higher WBC counts) at
through both the pulmonic and aortic valves. delivery. WBC counts alone shouldn’t be used to
Cardiac rhythm is usually limited to a mild diagnose infection. Clinical correlation is neces-
tachycardia and increased rate of benign iso- sary to make an infection determination.
lated premature atrial and ventricular contrac- Pregnancy is associated with hypercoagulation
tions thought to be associated with cardiac with a significant increased risk of venous throm-
enlargement [9]. boembolic events (VTE), but most laboratory
values remain unchanged such as prothrombin tion, and compression of the intestines by the
time (PT) and partial thromboplastin time (PTT). gravid uterus are noted. These factors, along with
Fibrinogen levels are increased, and values in the increased iron intake from prenatal vitamin
normal adult range can be associated with active therapy, can produce significant constipation.
bleeding such as placental abruption. Fibrin deg- The appendix changes position toward the
radation products (FDP) are decreased and can right upper quadrant in pregnancy as the uterus
be used in the evaluation of DIC, but D-dimer is enlarges. Significant increases in portal vein pres-
elevated and cannot reliably predict or rule out sure increase the incidents of hemorrhoids.
VTE events [2]. Increased progesterone production slows the
emptying of the gallbladder. This along with
increased production of cholesterol can increase
17.2.4 Urologic the risk of gallstone and sludge formation.
Liver size is unchanged in pregnancy, but a
Kidney enlargement is noted during pregnancy few liver lab values are affected such as increase in
along with dilation of the calyces, pelvis, vascula- alkaline phosphatase and fibrinogen. Bilirubin,
ture, and ureters. The right ureter is typically aspartate aminotransferase (AST), alanine ami-
dilated more than the left and on imaging can notransferase (ALT), gamma-glutamyl transfer-
appear as hydronephrosis. Frequent urination is a ase (GGT), and lactate dehydrogenase (LDH) are
common issue in pregnancy. This is related to unaffected [2].
increased production along with decreased blad-
der capacity from the enlarging uterus.
Increase in renal blood flow occurs in preg- 17.2.6 Endocrine
nancy leading to a 50% increase in glomerular
filtration rate (GFR) by the end of the first trimes- A small increase in the size of the thyroid is noted,
ter. This also results in an increase in creatine but hormone production for the most part
clearance. Blood creatine, BUN, and uric acid are remains close to non-pregnancy levels. Thyroid-
decreased in pregnant patients. Significant stimulating hormone (TSH) levels are close in
increases in total body water (8.5 L by term) result structure to HCG, so it is not unusual for the level
in blood volume expansion by 1.5 L. Additional to decrease in the first trimester as HCG levels
extravascular accumulation of fluid is noted in the peak around 8 weeks of gestation. Increased levels
tissue. This results in edema and a hemodilutional can be noted in the presence of hyperemesis grav-
anemia. Additionally there is a slight decrease in idarum. Free T4 levels rise slightly in the first tri-
serum potassium and calcium levels along with mester and then decrease slightly during the
increased excretion of protein, glucose, and albu- remainder of the pregnancy remaining slightly
min. Plasma osmolality is decreased because of lower than expected in non-gravid women [12].
these changes mediated by the kidneys [2, 11]. Adrenal size increases during pregnancy lead-
ing to the increased production of aldosterone,
corticosteroid-binding globulin, adrenocortico-
17.2.5 Gastrointestinal tropic hormone (ACTH), cortisol, and free corti-
17 sol as the pregnancy progresses. Cortisol levels
The average caloric increase needed for pregnancy can be 3 times higher by delivery.
and breastfeeding is between 200 and 300 kcal/ The pituitary gland enlarges significantly dur-
day. Morning sickness is a common complaint ing pregnancy with increased production of pro-
early in pregnancy peaking around 8 weeks of ges- lactin in anticipation for breast lactation after
tation and usually gone by 14 weeks. Many delivery. Decreased levels of follicle-stimulating
patients also experience increased production of hormone (FSH) and luteinizing hormone (LH)
saliva (ptyalism). The tone of the gastroesopha- are noted due to increased estrogen and proges-
geal sphincter along with decreased motility of the terone levels causing a negative feedback on the
stomach can increase the rates of reflux irritation pituitary gland. The increased size makes it vul-
of the esophagus. The data about increased risk of nerable to hypotension that can occur during a
aspiration is mixed in the literature. Decreased postpartum hemorrhage. The infarction of the
motility of the intestine, increased water absorp- gland can lead to Sheehan syndrome. This syn-
Obstetrics
249 17
drome is noted as postpartum amenorrhea and
infertility. Oxytocin levels increase during preg- –– Increased heart rate
nancy and peak during active labor leading to –– Decreased pulmonary vascular
resistance
uterine contractions. 55 Respiratory variables
The pancreas undergoes significant increased –– Decreased function residual capacity
production of insulin as part of the physiologic –– Increased minute ventilation
changes to increase glucose delivery to the placenta 55 Laboratory variables
and fetus. Pregnant women typically have fasting –– Increased PAo2 and Pao2
–– Decreased Paco2
hypoglycemia and postprandial hyperglycemia. –– Decreased serum bicarbonate (Hco3)
Some patients are not able to keep up with the –– Decreased hemoglobin and hematocrit
needed insulin production and demonstrate gesta- levels
tional diabetes. This is associated with increased –– Increased white blood cell count
risks of type 2 (non-insulin) later in their lives. –– Decreased protein S levels
–– Decreased coagulation factors XI and
Increased lipid levels are noted in pregnancy XIII levels
as cholesterol is needed for steroid synthesis and –– Increased coagulation factors I, VII, VIII,
amino acids are an energy source for the fetus. IX, and X levels
Significant increases are noted in triglycerides, –– Increased fibrinogen levels
cholesterol, and low-density lipids (LDL). Slight –– Increased D-dimer levels
–– Increased erythrocyte sedimentation rate
increase in high-density lipids (HDL) is also seen –– Decreased serum creatinine levels
in the gravid patient [2]. –– Decreased blood urea nitrogen level
(BUN)
–– Decreased uric acid level
17.2.7 Skeletal –– Increased alkaline phosphatase level
–– Increased aldosterone level
–– Increased serum cortisol, free cortisol,
Calcium levels are decreased in pregnancy associ- cortisol-binding globulin, and adreno-
ated with the decrease in serum albumin binding corticotropic hormone level
of the calcium. Additionally, increased need for –– Increased insulin level
calcium by the fetus and increased meternal kid- –– Decreased fasting blood glucose level
ney excretion are noted [13]. –– Increased triglyceride level
–– Increased cholesterol, low-density
Significant lordosis (anterior curvature of the lipoprotein, and high-density lipopro-
lumbar spine) occurs to offset the enlarging uter- tein levels
ine weight that changes balance. This can contrib-
ute to increase rates of back pain that occur late in Data from Gabbe et al. [41], American College of
pregnancy along with need for lumbar support Obstetricians and Gynecologists [42]
when sitting or supine [2].
17.2.8 Other Systems

17.3 Fetal Development
Although other body systems are affected by preg- and Placenta
nancy, they have minimal impact on the periop-
erative management of catastrophic complication. One of the biggest concerns raised by those who
deal with surgical care and anesthesia for preg-
nant patients is the effects on the fetus. While the
care of the mother is similar to a nonpregnant
Box 17.1 Physiologic Changes in Pregnancy woman, and provides familiarity to a typical case,
Key laboratory values that are different in the addition of a growing fetus brings with it some
pregnancy trepidation. This can lead to reluctance to provide
55 Hemodynamic variables
surgery or anesthesia out of worry the treatment
–– Increased cardiac output
–– Decreased systemic vascular resistance could lead to miscarriage, fetal demise, or devel-
–– Decreased blood pressure opment of a fetal anomaly. Withholding treat-
ment during pregnancy may lead to a more
detrimental situation with decline of the mother The first stage is cellular division of the
from her condition, which subsequently affects embryo. This is typically less than 31 days from
the growth and development of the fetus. An LMP. Exposure to a substance typically results in
understanding of the stages of fetal and placental an all or nothing effect on the fetus. During this
development can assist with preoperative and phase the risk of miscarriages is highest with
intraoperative planning [14]. approximately 5–20% of pregnancies miscarry-
Just like perfusion pressure and oxygenation ing. This makes it difficult to qualify if a therapy
can affect other organs and tissues in the body; was the cause of the pregnancy loss or unrelated.
the placenta with subsequent flow to the umbili- The next stage is organogenesis. From days
cal cord can be affected. Besides its ability to pro- 31–71 from the LMP, critical organs and tissues
vide for exchange of oxygen and carbon dioxide, are developing and exposures to substances can
the placenta allows for the diffusion of nutrients potentially cause malformations. The incidence of
such as glucose, proteins, and lipids to allow for major malformation is 2–3% in the general popu-
fetal growth. The placenta acts as a selective bar- lation, is usually polyfactorial in nature, and can-
rier to prevent certain substances from crossing not be tied to a single therapy.
into the fetal circulation and potentially lead to The third stage is the growth. This is where
adverse exposures. While the details of how the organs and tissues grow and the fetus enlarges in
placenta acts as a selective barrier are beyond the size. Exposure during this stage may lead to organ
scope of this chapter, certain general principles damage, restriction in function, or growth restric-
can be discussed. Lipid-soluble compounds tion of the fetus [16].
cross the placenta easier than water-soluble.
Larger molecules with higher molecular weight
have a more difficult time crossing the placenta. 17.4 Fetal Monitoring
Binding to plasma proteins can impact the
amount of a substance that can pass through the One of the guiding principles of fetal monitoring
placenta. when surgical care of a pregnant patient is neces-
Fetal development can be simplified into sary is the willingness to act on the information.
stages upon which an exposure to a drug or ther- For this reason, the degree of fetal monitoring is
apy can have a different effect. Very few therapies varied according to gestational age of the preg-
are known teratogens. Few drugs have clinical nancy. The need for monitoring in a previable
trials in pregnant patients that can demonstrate pregnancy typically is more basic, whereas the
safety of use during pregnancy. Most drugs are monitoring for a term pregnancy would need to
either felt to have little risk to the pregnancy or be more advanced [17].
consideration of their use has to show maternal Another aspect of fetal monitoring has to deal
benefits outweigh the risks. Consultation with with type of monitoring depending on access to the
web based or books discussing the effects of area of the uterus. Abdominal surgical procedures
drugs on pregnancies listed in the box will pro- with a large incision may make continuous external
vide information about specific risks with fetal monitoring nearly impossible. Consideration
medications [15]. for intermittent ultrasound assessment of the fetal
17 heart rate may be an alternative. Consultation with
an obstetrician preoperatively can help with anes-
thesia and surgical planning for the case [18].
Box 17.2 Drug Teratogen Resources
55 Micromedex, Inc.
Typically fetal cardiac activity is difficult to see
7 www.micromedex.com

on ultrasound prior to 7–8 weeks and ausculta-
55 Reproductive Toxicity Center (REPROTOX) tion with a Doppler prior to 10 weeks. The gravid
7 www.reprotox.org

uterus doesn’t rise out of the pelvis until 12 weeks
55 Drugs in Pregnancy and Lactation 11th making continuous external fetal monitoring
edition, 2017
By Briggs GG, Freeman RK, Towers CV,
unreasonable until later in the second trimester.
Forinash AB The debate for fetal monitoring in pregnancy
Wolters Kluwer has to also take into account that the fetal moni-
toring could potentially pick up maternal condi-
Obstetrics
251 17
tions that result in either decreased oxygenation Considerations for fetal monitoring should at
or perfusion to the uterus and thereby the fetus. least involve a check of the heart rate prior to and
This gives the surgical team the opportunity to after the conclusion of the surgical procedure and
correct these issues. On the opposite side of the anesthesia [12]. In the first and early second tri-
debate is that anesthesia affects the fetus and fetal mesters, this may be all that is necessary. As the
monitoring may be unreliable. It isn’t uncommon pregnancy reaches viability around 22–24 weeks,
for the fetal heart rate baseline and variability to this can incorporate expansion of the monitoring
decrease with anesthesia and falsely give the to intraoperative evaluation with either intermit-
impression of a need to intervene. This could tent or continuous monitoring depending on the
potentially lead to an unnecessary emergency type of surgery and access available to the lower
C-section. Because of these issues, the American abdomen. The level of monitoring should be done
College of Obstetricians and Gynecologist has in consultation with an obstetrician who can base
published the recommendations in the box below. the decision on gestational age, surgery type, and
available resources at the facility to act on any
abnormal findings. Besides counseling the opera-
Box 17.3 ACOG Guidelines for Fetal Moni- tive team, they can also counsel the patient and/or
toring During Surgery family.
55 If the fetus is considered previable, it is
generally sufficient to ascertain the fetal
heart rate by Doppler before and after the
procedure. 17.5 Anesthesia for Pregnant Patients
55 At a minimum, if the fetus is considered to
be viable, simultaneous electronic fetal The majority of the research related to the use of
heart rate and contraction monitoring general anesthesia in pregnant patients is restricted
should be performed before and after the
procedure to assess fetal well-being and
to retrospective studies and registries making the
the absence of contractions. conclusions limited. Most studies show that surgi-
55 Intraoperative electronic fetal monitoring cal anesthesia doesn’t increase the risk of miscar-
may be appropriate when all of the riages or fetal anomalies [14].
following apply: The optimal timing of surgery and anesthesia
–– The fetus is viable.
–– It is physically possible to perform
for pregnant patients is in the second trimester
intraoperative electronic fetal where the risk of spontaneous miscarriages has
monitoring. decreased significantly and organogenesis is
–– A health-care provider with obstetric complete [19].
surgery privileges is available and Consideration for options such as spinal or
willing to intervene during the surgical
procedure for fetal indications.
epidural anesthesia can reduce exposure of the
–– When possible, the woman has given fetus to agents. Care needs to be taken to avoid
informed consent to emergency hypotension with adequate hydration to avoid
cesarean delivery. hypotension, which can reduce uterine blood flow
–– The nature of the planned surgery will to the fetus.
allow the safe interruption or alteration
of the procedure to provide access to
Discussion of the physiologic changes associ-
perform emergency delivery. ated with pregnancy earlier in this chapter should
encourage the anesthesiologist to plan ahead for
In select circumstances, intraoperative fetal certain aspects of the surgical case. Theoretical
monitoring may be considered for previable fetuses delays in gastric emptying with relaxation of
to facilitate positioning or oxygenation the gastroesophageal sphincter can potentially
interventions.
The decision to use fetal monitoring should be
increase the risk of aspiration during intubation
individualized and, if used, should be based on [20]. Treating pregnant patients with the notion
gestational age, type of surgery, and facilities that even if fasting they can aspirate may be pru-
available. Ultimately, each case warrants a team dent. Cricoid pressure, metoclopramide, and
approach (anesthesia and obstetric care providers, antacids should be considered. Edema of the face
surgeons, pediatricians, and nurses) for optimal
safety of the woman and the fetus.
and neck associated with pregnancy, along with
American College of Obstetricians and mild thyroid enlargement, may increase the
Gynecologists [14] challenges of intubation. Some studies show
almost one third of term gravid patients may
have a class IV Mallampati airway [10, 21]. physiologic changes discussed earlier in this
Increased rate of desaturation with apnea (in as chapter, certain complications in normal preg-
little as 3 min), coupled with the airway changes, nancy require alterations in their management.
should encourage ready accessibility to airway Particular conditions exclusive to obstetrics can
tools such as glide scopes and alternatives to increase the risks of complications and/or require
endotracheal tubes. significant modifications to their management.
In normal pregnancy, airway management has
to take into account that gravid women have
17.6 erioperative Care for Pregnant
P increased edema, increased oral secretions,
Patients increased reflux, and increased gag reflex.
Partnered with the potential to desaturate in a
Because of significant compression to the vena quicker manner, efficient placement of an airway
cava and aorta by the gravid uterus, pregnant is a concern. Maternal desaturation can quickly
patients should be placed in a left lateral tilt if lead to fetal desaturation if the situation isn’t recti-
possible. If not, at least a tilt of the hips with a fied quickly.
fully padded 1 L IV bag, semicircular gel pad, or During induction, edema can lead to a class
rolled-up blanket under the right buttocks can IV Mallampati airway requiring additional tools
offer a tilt to the left. This will prevent deceased since visualization of the epiglottis and vocal
preload and cardiac output, which translates into cords may not be possible [10, 21]. Edema espe-
uteroplacental hypoperfusion. Hypercoagulability cially late in pregnancy can affect placement of
in pregnancy can increase the risks of venous oral airways while trying to establish the airway.
thrombotic events (VTE) including deep vein Additionally, this edema may prevent passage of
thrombosis (DVT). At a minimum, serial com- the usual diameter of endotracheal tube. Smaller
pression devices (SCD) should be applied. tubes may be necessary which can indirectly affect
Because of the higher molecular weight of hepa- gas exchange and pressures needed to ventilate.
rins (including low molecular weight heparin), Having the usual tools used for difficult airways
the ability to cross the placenta is limited [16]. For and suction readily available prior to induction
higher-risk cases, additional VTE prophylaxis can prevent prolonged intubation and maternal
can be used in pregnancy. desaturation. Because of the increased secretions
Typically antibiotic prophylaxis for most and reflux, cricoid pressure and the use of anes-
types of procedures can be used with the excep- thesia protocols to reduce the risks of aspiration
tion of fluoroquinolones and tetracyclines [16]. should be considered.
Penicillin-, cephalosporin-, erythromycin-, and Loss of an airway can quickly lead to maternal
vancomycin-based prophylaxis are felt to be safe desaturation with little notice prior to the rapid
(consult teratogenicity databases or your hospital drop of O2 saturation. Re-establishment of the
pharmacist about specific agents). airway, ventilation, and oxygenation can be com-
Maintenance of normal body temperature is plicated by the decrease in total lung capacity.
important to prevent peripheral vasoconstriction, During an emergency, the tendency to provide
which could affect blood flow to the uterus with increased volume and pressure while bagging
17 hypothermia. Care should be exercised to avoid with a facemask, along with relaxation of the gas-
increased body temperature as febrile illnesses have troesophageal sphincter, can rapidly lead to stom-
been discussed as a potential risk factor for miscar- ach hyperinflation and aspiration of contents.
riage and congenital anomalies early in pregnancy. Although placement of oral gastric or nasogastric
tubes can deflate this hyperinflation, it is best to
avoid this issue by carefully adjusting the volume
17.7 bstetrical Physiologic Changes
O and pressure while bagging until the endotracheal
Affecting Perioperative Care tube can be replaced.
There are progressive changes in cardiac and
Specific perioperative complications are discussed respiratory physiology (as discussed earlier in the
in detail in other chapters of this book. Some of chapter) as the pregnancy advances that can make
these complications are managed via similar ventilation complications unusual. Issues with
means as the nonpregnant patient. Because of bronchospasm and constriction from inflamma-
Obstetrics
253 17
tion can be managed in the same fashion as with in gravid patients prior to the start of procedures,
nonpregnant women. Typically the immune sys- and additional IV access or central access may be
tem is downregulated during pregnancy to pre- needed in patients at high risk for blood loss.
vent rejection of the fetus. This means that certain Close monitoring of urinary output is an inte-
types of asthma may improve during pregnancy. gral part of screening circulatory function and
The use of bronchodilators and glucocorticoids is treatment response in hemorrhage via blood flow
typically safe in pregnancy (consult teratogenicity to the kidneys and production of urine. Foley cau-
databases or your hospital pharmacist about spe- terization with a closed drainage system should be
cific agents). Ventilation-perfusion mismatch can considered for any procedure at high risk for
be seen during pregnancy associated with pulmo- blood loss in pregnant patients. Urine output of at
nary embolism and in some cases amniotic fluid least 0.5 ml/kg/h should be maintained during the
embolism. Pregnancy is a time of hypercoagula- operative course.
tion so there is an increased rate of venous throm- Recommendations for optimal blood prod-
botic event (VTE). Management of VTE is uct replacement for obstetrical patients have
unchanged by pregnancy with anticoagulation by been modified from trauma protocols and are
heparin or low molecular weight heparin. considered multicomponent [25]. Ratio of
Amniotic fluid embolism will be discussed later packed red blood cells/fresh frozen plasma/
in this chapter. platelets is now 1:1:1 [26]. Hemorrhage in preg-
Pulmonary edema can be associated with cer- nancy can quickly lead to a consumptive coagu-
tain conditions such as preeclampsia caused by lopathy with decreased fibrinogen. Fibrinogen
endovascular leakage. Treatment will be addressed levels are normally elevated above normal adult
under the preeclampsia pregnancy-associated values in pregnancy. A normal value can be mis-
hypertension heading. leading. Disseminated intravascular coagulation
Obstetrical hemorrhage is one of the leading (DIC) requires the addition of cryoprecipitate in
causes of maternal/fetal morbidity and mortality pregnancy.
[22]. Average blood loss for a vaginal delivery is
500 ml, a C-section is 1000 ml, and a cesarean
hysterectomy is 1500 ml [23]. Blood and fluid loss 17.8 Obstetrical Conditions
in pregnancy usually is masked until a significant
loss has occurred because of the increase intravas- 17.8.1 Ectopic Pregnancies
cular volume and vasodilatation that occurs in
pregnancy to increase blood flow to the uterus. Typically ectopic pregnancies occur in the fallo-
This is coupled with the increase in cardiac output pian tube and are diagnosed in the first trimester.
and slight baseline tachycardia in pregnant Thanks to advancing ultrasound technology
women. Signs of significant blood loss may not incorporated with BHCG levels, most ectopic
appear in the form of considerable tachycardia pregnancies are diagnosed prior to rupture and
and hypotension until 25% of the total blood vol- bleeding. Patients may present emergently with
ume has been lost. acute abdominal pain, significant bleeding, and
The delay of the customary signs of hypovole- blood loss from their unrealized pregnancy. It is
mia, joined with the rapid nature of blood loss not unusual to find over a liter of blood in the pel-
that can occur with pregnancy, places a high vis from a ruptured ectopic. Hemodynamic insta-
emphasis on the need to anticipate potential bility can progress rapidly requiring preoperative
blood loss and preemptively arrange for treatment and intraoperative volume resuscitation.
[24]. Early identification of bleeding and commu- Certain types of ectopic pregnancies can
nication with the rest of the OR team that bleed- result in even higher levels of blood loss or risks
ing is apparent should trigger treatment prior to based on the site of implantation. Cornual ecto-
the physiologic changes occurring. This leads to pic pregnancy (implantation in the portion of the
the need to proactively anticipate the conditions fallopian tube transversing the uterine myome-
that can lead to rapid loss of blood and have pro- trium or first portion of the fallopian tube) typi-
tocols in place for massive transfusion to obtain cally ruptures later in the first trimester or early
necessary blood products in a timely fashion [24]. second trimester. The amount of bleeding can be
Adequate diameter IV access has to be obtained profuse and quickly become catastrophic [27].
This condition requires quick surgical interven- incision point for a low transverse C-section (the
tion along with aggressive fluid/blood replace- most common type). This can result in additional
ment. Again preoperative planning for the need bleeding and difficulty reaching the fetus [31].
of blood products and large-bore IV access along Modification of the uterine incision (classical
with rapid activation of massive transfusion pro- c-section) may be necessary and result in more
tocol should be considered. blood loss. The need for crystalloid and blood
Seen more recently with the increased rates of products may be necessary; therefore, the preop-
C-sections is implantation of the pregnancy into erative planning should include adequate IV
the C-section scar. These can result in a scar dehis- access and the availability of blood products.
cence and perforation into the abdominal cavity or Placenta previa sometimes will occur because
even the bladder resulting in a severe hemorrhage of a placenta accreta, placenta increta, or placenta
[28]. These patients may require emergent hyster- percreta. All three of these conditions result when
ectomy if they are actively bleeding. This requires there is a loss of the decidua and there is invasion
planning for the need of blood products and poten- of the placenta into the underlying myometrium
tial coagulopathy that can occur with hemorrhage. causing the placenta not to separate after delivery.
Accreta is the term for when the placenta superfi-
cially invades the myometrium. Increta indicates
17.8.2 Molar Pregnancy deep myometrial invasion of the placenta. Percreta
is the most serious situation as the placenta has
Hydatidiform moles are part of gestational tropho- invaded through the myometrium and into adja-
blastic disease (GTD) and are atypical pregnancies cent tissues such as the bladder, bowel, abdominal
associated with placental hypertrophy. They are wall, and vessels. Catastrophic bleeding can occur
typically diagnosed during the first trimester by if not recognized preoperatively, and attempts are
abnormally high BHCG and snowstorm pattern made to manually extract the placenta [31].
on ultrasound. When evacuation is indicated by If diagnosed preoperatively, referral to a ter-
suction D&C, there is a significant risk for blood tiary care center with a multidisciplinary team
loss and embolization of the tissue. Preparation for should be considered. Typically, the availability of
potential large blood loss with availability of blood neonatology, general/vascular surgery, urology,
products and oxytocin (Pitocin) to help the uterus interventional radiology, and gyn oncology may be
to clamp down should be included in operative required. The perioperative team should choose a
management. If embolization was to occur, signifi- room large enough to accommodate a large team.
cant hypoxia can happen along with an inflamma- General anesthesia should be considered to allow
tory reaction that can trigger a consumptive for muscle relaxation and placement of retractors.
coagulopathy similar to amniotic fluid embolism Massive transfusion protocols should be readied,
(see management under that heading) [29]. and large amounts of blood products should be
available in-house if not in the operating room.
Some institutions may have the availability for
17.8.3 Abnormal Placentation interventional radiology to place occlusion bal-
loons or embolize vessels [32]. Urology may con-
17 This section includes issues with atypical loca- sider placement of ureteral stents. Cell salvage
tions of the placenta as well as invasion of placen- equipment should be readied if available. Rapid
tal tissue into the uterine myometrium. As the infusion devices, central venous access, and arte-
number of C-sections has increased for delivery, rial lines may be needed.
we are seeing increased numbers of patients with Typically, a fundal or posterior uterine inci-
placental abnormalities typically related to scar- sion is utilized and followed by closure of the
ring of the endometrial cavity. uterine incision. This is followed by a cesarean
A placenta previa is when part or the entire hysterectomy to prevent further hemorrhage.
placenta covers the cervix. A vasa previa is when Some small series have demonstrated the options
membranous umbilical vessels cover the cervix for conservative management with closure of the
[30]. With labor significant bleeding can occur uterine incision with the placenta left in place.
resulting in maternal/fetal distress and the need This may be considered if no significant bleeding
for emergent C-section. With a significant num- is encountered and the facility can emergently
ber of previa, the placenta may locate near the deal with a secondary hemorrhage.
Obstetrics
255 17
A very rare type of pregnancy is an intra- rotomy to resolve. Close monitoring of blood loss
abdominal pregnancy with implantation outside of and hemodynamic stabilization may be required
the uterus. The attachment of the placenta to during the replacement of the uterus [22].
bowel, peritoneal lining, omentum, or any other
intra-abdominal structure is highly vascular and
invades into the structure preventing normal sepa- 17.8.6 Uterine Atony
ration. If the placental attachment is disturbed,
significant bleeding that is difficult to control Post delivery or post C-section, subinvolution of
occurs. Packing of the abdomen, sewing the edge the uterus can occur leading to significant hem-
of the placenta in place, or use of hemostatic agents orrhage and hemodynamic instability. Certain
may be required. Perioperative preparation for sig- risk factors such as prolonged use of oxytocin,
nificant bleeding is necessary as discussed above. high parity, infection, general anesthesia, multi-
gestation, polyhydramnios, fetal macrosomia,
fibroids, and uterine inversion can all contribute
17.8.4 Placental Abruption to this condition. This can occur immediately
after delivery or can be delayed for hours or even
This is the premature separation of the placenta days after delivery [22].
from the uterine wall prior to delivery of the fetus. Quickly recognizing atony and a systematic
Typically associated with pain and uterine con- protocol for its management can help limit the
tractions, it can occur with varied signs depending impact on the patient. Immediate uterine massage
on the amount of bleeding that occurs. Most likely and emptying of the bladder are indicated.
to occur in the third trimester, it can be a source of Anesthesia should increase oxytocin IV fluid rates
fetal distress and may require emergent C-section. and implement massive transfusion protocols or
These gravid patients can have significant summon blood products for possible administra-
bleeding leading to hemodynamic instability and tion. Additional use of uterotonics is indicated in
consumptive coagulopathy requiring treatment about 25% of cases. These include methylergono-
with little prior preparation in the face of an vine (Methergine) 0.2 mg IM but is contraindi-
emergent delivery [31]. As discussed in other cated in cases of hypertension and preeclampsia.
parts of this chapter, rapid assessment for blood 15-Methyl prostaglandin F-2 alpha (Hemobate)
loss amounts and preemptive planning for the 250 mcg IM or intramyometrial can be given every
need to infuse large amounts of fluids and/or 15 min up to eight doses. This is contraindicated in
blood products is the mainstay of management. patients with asthma. Misoprostol (Cytotec) 600–
Need for platelets and cryoprecipitate may 1000 mcg can be administered PO, SL, or PR once.
become necessary on short notice [22]. Additional surgical tamponade or vessel liga-
tion can be employed. Use of intrauterine bal-
loons such as the Bakri or Ebb can help when
17.8.5 Uterine Inversion medications fail to resolve the atony. Alternatives
include using several large (60 cc) Foley catheters
Uterine inversion is when the uterine fundus or packing the uterus with Kerlix gauze [33].
invertly prolapses to or through the cervix. This If available, uterine artery embolization by the
can result in significant hemorrhage and quickly interventional radiologist may help reduce pulse
has to be attended to for successful resolution. It pressure to the uterus. Vascular ligation by the
can occur when the placenta fails to release and surgeon with O’Leary stitches to the uterine ves-
traction is placed on the umbilical cord either sels and/or utero-ovarian ligaments can have the
during vaginal delivery or C-section. It can also same effect. Hypogastric (internal iliac) artery
occur spontaneously but less likely. In order for ligation has fallen out of favor because of limited
the obstetrician to replace the uterus, relaxation of success and risks. The obstetrician may employ
the uterus may be required. Use of tocolytics such uterine compression sutures such as B-lynch
as terbutaline 0.25 mg SQ, magnesium sulfate IV before the final option of hysterectomy is consid-
or IM, halogenated inhaled general anesthetics, or ered [34]. The perioperative management of these
nitroglycerin SL has been shown to be effective in cases of postpartum hemorrhage is further dis-
these cases. Some incidences may require lapa- cussed below.
Box 17.4 Uterotonic Medications for Postpartum Hemorrhage

Druga Dose and route Frequency Contraindications Adverse effects
Oxytocin IV: 10–40 units per Continuous Rare, hypersensitivity to Usually none
500–1,000 mL as medication
continuous infusion
or IM: 10 units
Nausea, vomiting,
hyponatremia with
prolonged dosing
Hypotension can
result from IV push,
which is not
recommended
Methyler- IM: 0.2 mg Every 2–4 h Hypertension, pre- Nausea, vomiting,

gonovine eclampsia, cardiovascular severe hyperten-
disease, hypersensitivity sion particularly
to drug when given IV,
which is not
recommended
15-methyl IM: 0.25 mg Every 15–90 Asthma, relative Nausea, vomiting,

PGF Intramyometrial: min, eight contraindication for diarrhea, fever
0.25 mg doses hypertension, active (transient),
maximum hepatic, pulmonary, or headache, chills,
cardiac disease shivering hyperten-
sion, broncho-
spasm
Misoprostol 600–1,000 One time Rare, hypersensitivity to Nausea, vomiting,

micrograms oral, medication or to diarrhea shivering,
sublingual, or rectal prostaglandins fever (transient),
headache
Modified from Lyndon et al. [43], American College of Obstetricians and Gynecologists [22]
Abbreviations: IV intravenously, IM intramuscularly, PG prostaglandin
aAll agents can cause nausea and vomiting
17.8.7 Postpartum Hemorrhage require operative intervention with dilation and

17 curettage [22].
Postpartum hemorrhage is a catastrophic periop- Certain comorbidities can also contribute to
erative event and a leading cause of peripartum postpartum bleeding such as sepsis, inherited
morbidity and mortality. In addition to the disor- coagulation disorders (von Willebrand, hemo-
ders mentioned above, there are additional obstet- philia), conditions requiring anticoagulation, and
rical conditions that can cause hemorrhage. thrombocytopenia. The thrombocytopenia can
Genital tract trauma in the forms of cervical, sometimes be gestational or related to obstetric
vaginal, or perineal lacerations can require peri- disorders such as preeclampsia.
operative management. Additionally uterine rup- Successful management requires planning for
ture can occur especially in patients with prior these events. Having postpartum hemorrhage
C-section and necessitate an emergent C-section (PPH) protocols (with checklists) in place for
complicated by large blood loss. Retained placen- rapid intervention should be considered for every
tal tissue can cause significant bleeding and obstetrical facility. These protocols should include
Obstetrics
257 17
means to quickly summon needed or additional immediate delivery. If untreated, preeclampsia can
providers. Having necessary obstetrical and anes- potentially lead to eclampsia (seizures). Variations
thesia supplies available on a PPH cart can of this condition can include HELLP syndrome
increase the speed to treat [35]. (hemolysis, elevated liver enzymes, and low plate-
Massive transfusion protocols should be lets). HELLP syndrome is considered to be a severe
developed in conjunction with the institutions form of these disorders. Sometimes patients can
blood bank so that anesthesia personnel and have preeclampsia superimposed on chronic
obstetricians can urgently obtain blood products hypertension.
when emergent needs arise [26]. Adequate anes- Physiologically these patients have significant
thesia preoperative planning should consider the endovascular leakage leading to intravascular vol-
potential risk for hemorrhage with obstetrical ume depletion, edema, ascites, and pulmonary
conditions. Anticipatory use of rapid infuser edema. Additional effects can be renal and/or
lines, large-bore IV, and multiple IV access should liver dysfunction along with decreased fetal blood
be considered along with requests for blood prod- flow. Additionally these women can develop DIC,
ucts prior to induction of anesthesia. placental abruptions, acute renal failure, liver
Uterotonic agents should be rapidly available hemorrhage (subcapsular hematoma), liver fail-
for administration in the OR, labor unit, and ure, acute respiratory distress (ARDS), strokes,
postpartum unit. Some recent studies have sug- and even death. These effects can vary between
gested the use of tranexamic acid 1 g IV as an slow to rapid onset and progression [37].
adjuvant therapy to use for postpartum hemor- Treatment is usually centered on delivery at a
rhage [36]. Consideration for availability of center that can handle the maternal conditions
equipment such as cell salvage and personnel and fetus after delivery especially if premature
such as interventional radiologist can be proac- and needing neonatal intensive care. Magnesium
tively arranged. sulfate 4-6 g load over 20 min followed by 2 g/h IV
is usually employed to prevent eclampsia (phe-
nytoin is used instead of magnesium in certain
17.8.8 Pregnancy-Associated parts of the world). This is continued until 24 h
Hypertension after delivery. The dosage may need to be
reduced in the presence of decreased renal func-
Hypertension in pregnancy is a common disorder tion. Hypertension episodes are managed with
affecting between 5 and 10% of gravid females. labetalol IV, nifedipine PO, or hydralazine
Preeclampsia (hypertension with proteinuria) and IV. Labetalol IV is given as slow push 10–40 mg
gestational hypertension typically occur later in every 10 min for a maximum of 300 mg. Nifedipine
pregnancy but can occur any time after 20 weeks of PO is administered 10–20 mg every 20 min for a
gestation. It can sometimes be confused with maximum of 50 mg. Hydralazine IV is adminis-
underlying hypertension which can be masked by tered 5–10 mg every 20 min for a maximum of
decrease in blood pressure early in a gestation 25 mg [38].
when most patients are first seen for prenatal care. Perioperative care should consider the signifi-
Preeclampsia is diagnosed by elevated blood pres- cant physiologic changes associated with these
sure above 140/90 along with signs such as persis- patients. Even though these patients have signifi-
tent headache, scotomata (spots in vision), right cant edema, they are intravascularly constricted;
upper quadrant or epigastric pain, and non-depen- therefore, diuretics have little effect and can result
dant edema. Laboratory evidence of the disease in decreased uterine blood flow and fetal distress.
can include proteinuria, hemoconcentration Fluid management intraoperatively should lean
(increased hemoglobin and hematocrit), increased toward the conservative side as the endovascular
uric acid, increased LDH, and elevation of liver leakage can cause worsening generalized and pul-
enzymes. Patients are felt to have severe preeclamp- monary edema. Anesthesia should take into
sia when blood pressures are greater than 160/110. account these patients may develop thrombocyto-
Although the etiology is uncertain, the treatment is penia. Even in patients with normal platelet counts,
delivery. Mild preeclampsia is typically observed the function of the platelets may be sub-optimal
until the patient is full term or develops severe pre- which may increase the risk of complications asso-
eclampsia signs. Severe preeclampsia warrants ciated with spinal or epidural anesthesia. Bleeding
risks can increase because of preeclampsia, and diopulmonary arrest, hypoxia, coagulopathy, and/
preoperative planning should consider need for or seizure.
blood products including packed red blood cells, Although AFE can present in a multitude of
platelets, and cryoprecipitate. Intravascular con- ways, the rapid deterioration of a patient suffering
striction can mask anemia and true blood volume. from an AFE can be outlined in three progressive
Elevated blood pressures can hide hypotension stages. In phase 1, pulmonary and systemic vaso-
normally noted with excessive blood loss. Airway constriction leads to hypertension and severe O2
management in general anesthesia can be compli- desaturation. Phase 2 follows immediately and
cated by laryngeal edema and facial edema. results in decreased systemic vascular resistance
and cardiac output. In phase 3, sudden cardiac
failure, ARDS, and coagulopathy via DIC cascade
17.8.9 Eclampsia ensue. No rapid test for AFE exists; therefore, the
diagnosis remains clinical, and quick recognition
Eclampsia is the incidence of seizure activity is paramount to successful treatment as most
typically associated with preeclampsia. It can maternal mortality occurs within 30 min.
occur even in patients with little or no preeclamp- Management and treatment of AFE are sup-
sia signs. It usually will occur without warning portive and require rapid simultaneous interdis-
and usually only lasts for a few minutes. Delivery ciplinary cooperation between OB/GYNs, RNs,
is indicated, but emergent C-section is not anesthesiologists, and critical care personnel.
required. Eclampsia can occur perioperatively, Establishing large-bore IV access with pulse
and treatment is geared toward protecting the oximetry, continuous vital sign, and cardiac
patient during their seizure with padding and monitoring is essential. Respiratory support by
positioning to avoid risk of aspiration. Protection anesthesia typically requires endotracheal intu-
of the airway and supplemental oxygenation bation and mechanical ventilation. The basics of
are important. Medical treatment is usually CPR- ACLS and massive transfusion protocols
magnesium sulfate as mentioned above. Use of must be immediately available and initiated.
benzodiazepines should be reserved to patients Hemodynamic support requires judicious use of
nonresponsive to magnesium and have both IV fluids, vasopressors, inotropes, and pulmonary
access and availability for intubation. Fetal seda- vasodilators. Laboratory studies such as CBC,
tion can occur with their use. Lorazepam 2 mg BMP, PT/PTT/INR/fibrinogen, and ABGs are
can be used as a slow IV push [37]. In rare cases very useful to track treatment success; however,
of status epilepticus, general anesthesia may be treatment should never be delayed awaiting these
considered. results [39, 40].
17.8.10 Amniotic Fluid Embolism 17.9 Summary
Amniotic fluid embolus (AFE) is a rare condition Perioperative care of pregnant patients has to take
caused by fetal debris entering the maternal circu- into account the physiologic changes that occur
17 lation, which then triggers abnormal activation of during the progression of the gestation. It has to
proinflammatory mediator response systems. consider the effects the condition and its treat-
Estimates of incidence and mortality rates vary ment have on the fetus. Withholding or limiting
widely due to a lack of established standardized treatment because of pregnancy can lead to a
criteria; however, maternal mortality is believed more detrimental situation and increase the risks
to occur in 30–90% of cases. The incidence of AFE for mother and fetus. Fetal monitoring has to con-
ranges from 1:15,000 to 1:53,000 deliveries. Nearly sider the gestational age of the fetus, ability to
70% of AFE present suddenly at time of delivery intervene upon abnormalities noted, and treat-
or immediately postpartum and typically present ment options available at the particular stage of
with an otherwise unexplainable combination of pregnancy.
clinical manifestations often characterized by Understanding of obstetrical conditions can
hypotension, fetal distress, pulmonary edema, assist anesthesia and operative personnel in their
acute respiratory distress syndrome (ARDS), car- pre- and intraoperative management. Most of the
Obstetrics
259 17
critical complications associated with pregnancy 17. American College of Obstetricians and Gynecologists.
have to do with hemorrhage. Proactively antici- Antepartum fetal surveillance. ACOG Practice Bulletin
no. 145. Obstet Gynecol. 2014;124:182–92.
pating and quickly intervening are key to the opti- 18. Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan
mal management. HL, Jauniaux ER, et al., editors. Obstetrics: normal and
problem pregnancies. 7th ed. Philadelphia: Elsevier;
2017. p. 550–64.
19. Cohen-Kerem R, Railton C, Oren D, et al. Pregnancy
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17
261 18
Catastrophic Complications
in Pediatric Anesthesiology
Sonja A. Gennuso, Brendon M. Hart, Hiroki Komoto,
and Tomasina Parker-Actlis
18.2 Complications Related to Drugs – 266
18.3 Airway Complications in the Pediatric

Patient – 268
18.4 Allergic Reactions – 269

18.4.1 Treatment – 270
18.5 Postoperative Complications – 270
18.6 Anesthesia-Related Mortality – 271
18.7 Summary – 272
18.9 Answers – 273
References – 273

https://doi.org/10.1007/978-3-319-96125-5_18
262 S. A. Gennuso et al.
18.1 Introduction between 1970 and the early 1980s, almost half of
pediatric injuries resulting in malpractice litiga-
The subspecialty of pediatric anesthesiology has tion were related to adverse respiratory events.
made great strides since the open-drop technique Most of these claims were secondary to improper
described for anesthetizing patients in the nine- oxygenation or ventilation. According to this
teenth century. Anesthetic techniques for children report, these complications could have been
have been described as early as 1842. Since the prevented with adequate pulse oximetry and
inception of anesthesiology, the pediatric popula- end-tidal capnography monitoring [1].
tion was observed to have a higher incidence of Furthermore, catastrophic complications in the
anesthetic complications than adult patients. In pediatric population occur more frequently in
fact, the first recorded anesthetic-related mortali- children under 3 years old who have severe
ties were in children. Early literature describes comorbidities [2]. Cardiac arrest, hypoxic brain
cardiac arrest, ineffective anesthesia, nausea, and injury, permanent disability, and death are obvi-
vomiting as sources of morbidity and mortality. ously the most severe complications. Each one is
Although not fully understood in the mid-1800s, strongly related to difficulty with airway man-
the differences in airway anatomy and respiratory agement [1, 2]. In fact, 20% of cardiac arrests in
physiology were noted between children and children of ASA 1 or 2 status during anesthesia
adults (. Table 18.1). For example, John Snow, an are of a respiratory etiology. Additionally, anes-

anesthesiologist who provided labor and delivery thetic agents such as the volatile agents and
anesthesia to Queen Victoria, concluded in pedi- depolarizing neuromuscular blockers have also
atric patients “the effects of chloroform are more been implicated to cause anesthetic-related
quickly produced and also subside more quickly complications such as bradycardia, hyperkale-
than in adults, owing no doubt to quicker breath- mic cardiac arrest, anaphylactic and anaphylac-
ing and circulation” [1]. toid reactions, and malignant hyperthermia. In
Pediatric anesthesiology has dramatically 2015, Ghassemi et al. published a systematic
evolved from the primitive technique of ether- review and meta-analysis of acute severe com-
soaked gauze covering an unsecured airway to plications of pediatric anesthesia. This paper
micro-cuffed endotracheal tubes for proper air- reviewed 25 papers and summarized that the
way management in premature infants. most common acute severe complications in
Although rare, catastrophic anesthetic compli- pediatric anesthesia are related to airway man-
cations still occur in children more often than in agement and the respiratory system [1]. Specific
adults. Based on the American Society of diagnoses are listed as difficult bag mask ventila-
Anesthesiology Closed Claims Project reports tion, airway obstruction, and laryngospasm.
Cardiovascular events are the second most com-
mon etiology of severe morbidity and mortality
.. Table 18.1 Comparison of infant and adult in the pediatric population [1, 2]. Of note, car-
respiratory physiology diovascular events such as bradycardia and
asystole frequently occur following severe desat-
Measurement Infant Adult
uration. Thus, the origin of cardiovascular
Functional residual capacity 30 27–30 events seems to be secondary to respiratory
(ml/kg) complications. . Table 18.2 is a brief description

18 Minute ventilation 100–150 60

of diseases that are likely to have severe adverse
(ml/kg/min) airway and/or cardiovascular complications at
induction of anesthesia.
Tidal volume (ml/kg) 6–8 6–8 As advances have been made in the practice of
Respiratory rate 30–50 12–16 pediatric anesthesiology, catastrophic complica-
(per minute) tions in children have decreased. This chapter is
O2 consumption 6 3 designed to review known challenges that anes-
(ml/kg/min) thesia providers face and offer suggestions to
avoid long term morbidity and mortality.
Catastrophic Complications in Pediatric Anesthesiology
263 18
.. Table 18.2 Diagnosis likely to have airway and/or cardiovascular complications under anesthesia [3]
Diagnosis Airway concern Cardiovascular concern
Achondroplasia Possibly difficult

Sleep apnea
Albers-Schonberg Obligate mouth breather

disease Nasopharyngeal bone overgrowth
Albright hereditary QT interval

osteodystrophy Conduction defects
Alport syndrome AV conduction defects
Amyotrophic lateral Possible K+ release and cardiac

sclerosis arrest
Andersen syndrome Difficult ventilation Long QT syndrome

Difficult intubation Avoid succinylcholine
Antley-Bixler syndrome Difficult intubation
Apert syndrome Difficult ventilation

Difficult nasotracheal intubation
Beare-Stevenson Difficult intubation

syndrome
Beckwith syndrome Difficult intubation

Postoperative airway obstruction
Behcet syndrome Difficult intubation
Brachmann-de Lange Difficult intubation

syndrome
Carpenter syndrome Difficult intubation
Central cord disease MH triggered by succinylcholine
CHARGE association Difficult intubation
Cherubim Difficult airway
Saethre-Chotzen syndrome Difficult airway
Chubby puffer syndrome Upper airway obstruction
CINCA syndrome Difficult intubation
Collagen diseases Airway/difficult intubation
Congenital heart block Intraoperative arrhythmia
Cri du chat syndrome Stridor

Laryngomalacia
Difficult intubation
Crouzon syndrome Difficult mask ventilation

Postoperative airway obstruction
9 p deletion syndromes Difficult airway
Duchenne muscular Hyperkalemic cardiac arrest with

dystrophy succinylcholine
Edwards syndrome Difficult intubation
(continued)
.. Table 18.2 (continued)
Eisenmenger syndrome Right to left cardiac shunt
Epidermolysis bullosa Airway difficulty/scarring

Avoid intubation
Escobar syndrome Airway difficulty increases with age
Familial periodic paralysis Monitor serum K+/EKG
Freeman-Sheldon Very difficult intubation

syndrome
Goldenhar syndrome Difficult mask/intubation
Guillain-Barre syndrome Avoid succinylcholine – increased

K+ release
Hallervorden-Spatz Avoid succinylcholine – increased

disease K+ release
Hecht-Beals syndrome Small mouth opening
Histiocytosis X Difficult intubation
Hunter syndrome Difficult airway
Hurler syndrome Difficult airway Evaluate with EKG and echo
I-cell disease Difficult airway Evaluate with EKG and echo
Klippel-Feil syndrome Difficult airway
Klippel-Trenaunay-Weber High output cardiac failure

syndrome
Larsen syndrome Difficult intubation Congenital heart disease
LEOPARD syndrome Difficult intubation Serious arrhythmias
Leukodystrophy Avoid succinylcholine
Marfan syndrome Possible ventilation/difficult intubation Danger of aortic dissection
Marshall-Smith Difficult ventilation

syndrome
McArdle myopathy EKG abnormalities

Avoid succinylcholine
Meckel syndrome Difficult intubation Congenital heart disease
Median cleft face Possible difficult intubation

18 syndrome
Moschcowitz disease Nasotracheal intubation contraindicated
Mucopolysaccharidosis Difficult intubation EKG to assess cardiac involvement

LMA may not relieve obstruction
Myositis ossificans Gentle fiber-optic intubation recommended
Nager syndrome Limited mouth opening Evaluate with echo

Fiber-optic technique necessary
Severe upper airway obstruction; tracheos-
tomy may be necessary
(continued)
265 18
Nemaline rod myopathy Intubation may be difficult
Niemann-Pick disease Difficult ventilation from ascites and

restrictive lung disease
Noack syndrome Possible difficult intubation
Noonan syndrome Possible difficult intubation Evaluate with echo
Oculodento-osseous Difficult intubation

dysplasia
Opitz-Frias syndrome Difficult airway

Aspiration risk
Oral-facial-digital Difficult airway

syndrome
Paramyotonia congenita Check serum K+ levels
Patau syndrome Possible difficult intubation Evaluate with echocardiogram/EKG
Pierre Robin syndrome Difficult intubation Evaluate for congenital heart

Anticipate fiber-optic technique disease
Plott syndrome Airway obstruction

Aspiration
Pompe disease Airway obstruction Serious arrhythmias
Progeria Difficult intubation Assess cardiac status
Proteus syndrome Difficult intubation
Prune belly syndrome Aspiration risk

Intubation may be difficult
Pyle disease Possible difficult intubation
Rieger syndrome Possible difficult airway
Rubinstein-Taybi syndrome Possible difficult airway
Schwartz-Jampel Difficult intubation Hyperkalemic cardiac arrest with

syndrome succinylcholine
Seckel syndrome Difficult ventilation/intubation
Silver-Russell syndrome Difficult ventilation/intubation
Stickler syndrome Difficult intubation

Anticipate fiber-optic technique
Thalassemia major Difficult intubation
Treacher-Collins Difficult ventilation/intubation

syndrome Consider fiber-optic technique
Trismus- Difficult intubation

pseudocamptodactyly Consider fiber-optic technique
Werdnig-Hoffman Hyperkalemic cardiac arrest with

disease succinylcholine
Williams syndrome Cardiac arrest during induction

18.2 Complications Related to Drugs maintain anesthesia. If left at a high rate, sevoflu-
rane can react with the desiccated CO2 absor-
Anesthetic management in the pediatric popula- bent which can result in an exothermic reaction
tion can be vastly different than the adult popu- causing airway damage [4]. Another side effect
lation. There can be the potential for a multitude related to sevoflurane is, theoretically, damage to
of complications related to various drug expo- the kidneys because of compound A formation
sures in pediatrics if the provider is not aware of in the degradation of sevoflurane in the soda
those potential complications (7 Box 18.1).

lime. It is not toxic to the kidneys if the fresh gas
Oxygen, although not a drug per se, has many flow is at 2 L/min minimum [5]. Both sevoflu-
implications during pediatric anesthesia. Pure, rane and desflurane are bronchodilators, but
high flow oxygen poses a fire hazard risk, and desflurane is not used in inhalational induction
adequate steps must be taken to prevent the risk due to airway irritation. Nitrous oxide should be
of an OR fire by monitoring the oxidizer, ignition used carefully due to the potential side effect of
source, and fuel and by taking steps to prevent vitamin B12 inactivation, prompting neurologic
that triad. It is critical to keep the oxygen con- disorders [4]. In any discussion regarding inha-
centration at its minimum to maintain adequate lational anesthetics, malignant hyperthermia
gas exchange while also avoiding hypoxic com- must be discussed. Typically, the most suscepti-
plications. High flow, concentrated oxygen has ble pediatric populations affected by MH are
the potential to denitrogenate the lungs and those with neuromuscular disease. Mutations in
cause absorption atelectasis. It can cause drying the RYR1 gene account for susceptibility, and
and irritation of the mucosal surfaces and can any child with neuromuscular disease should be
increase the incidence of oxygen free radicals thoroughly worked up prior to any use of anes-
which are toxic to proteins and lipids within thetics that may cause MH [6]. Cardiac arrest
membranes of cells [4]. In premature babies, can occur in the pediatric population due to MH
high flow, concentrated oxygen can have signifi- as well as hyperkalemia. Neuromuscular disor-
cant implications in eye development, causing ders must be extensively worked up prior to any
retrolental fibroplasia [4]. depolarizing or volatile anesthetic use. The FDA
The inhalational anesthetics, as a rule, can has issued a black box warning for succinylcho-
depress the myocardium and, thus, are usually line use in the pediatric population due to the
augmented with opioids to decrease their use. potential for hyperkalemic cardiac arrest in chil-
The typical inhalational anesthetics used in dren with undiagnosed myopathies receiving
pediatrics are sevoflurane and desflurane with succinylcholine [7]. Additionally, one of the
the former generally used in induction. known side effects of succinylcholine is brady-
Sevoflurane is not irritating to the airway and is cardia and, in extreme cases, asystole, and thus if
used exclusively in induction in pediatrics [5]. succinylcholine is used, it is generally favorable
Typically, 8% concentration is used until loss of to have epinephrine or atropine on hand.
consciousness, and then it is then dialed back to Rocuronium might be a safer paralytic for use
for RSI in pediatrics.
Although sugammadex, a cyclodextrin that
forms tight complexes with rocuronium, thus
Box 18.1 Common Drug Side Effects in the inactivating it, has not been approved for pediat-
18 Pediatric Patient
55 Balance of oxygen to prevent hypoxemia
rics yet in the USA for reversal of non-
depolarizing neuromuscular blockade with
and absorption atelectasis
55 Inhalation anesthetics can depress the
rocuronium and vecuronium, its use has the
myocardium potential to decrease the use of succinylcholine
55 Inhalation anesthetics can cause emer- in practice. Succinylcholine is the only depolar-
gence delirium izing muscle relaxant. It is ultrashort acting and
55 Compound A formation in sevoflurane does not need a reversal agent due to its metabo-
55 Bronchodilation with sevoflurane and
desflurane
lism by cholinesterases. Conversely, succinylcho-
55 NO2 can cause megaloblastic anemia line can cause malignant hyperthermia, masseter
55 Rocuronium is a common allergy spasm, myalgias, and rhabdomyolysis and can
potentially cause hyperkalemic cardiac arrest
267 18
particularly in infants and children [4]. Keeping Judicious use of fluids is important in the peri-
these factors in mind, with the increasing use of operative period in pediatrics. As mentioned
sugammadex, one could argue that non-depolar- above, hypovolemia can have detrimental effects
izing muscle relaxers may be of greater benefit in which can result in cardiac arrest. Sodium chlo-
standard and rapid sequence induction. ride should be used liberally in the absence of any
Perioperative anaphylaxis is very rare in pedi- contraindications, including volume overloading
atrics, along the lines of 1:10–20,000 anesthetic disease states, cardiac failure, and fluid retention
procedures, but it is imperative to be prepared and [4]. If the child is on TPN, it is important not to
recognize immediate anaphylactic reactions. The discontinue it; rather, access should be obtained
typical culprit for allergy is the non-depolarizing with a larger catheter for the potential of rapid
muscle relaxants, particularly rocuronium. infusion if necessary [4]. Neonatal fluid require-
Additionally, bradycardia might result as an adap- ments can vary based on gestational age and
tive mechanism to allow for complete diastole birthweight. For term and low birthweight babies,
despite hypovolemia. It is critical to treat with 50–60 ml/kg per day is required for fluid require-
atropine and epinephrine in this instance because ments at 1 day of age and goes up 10–20 ml/kg per
atropine alone may precipitate cardiac arrest in day up to 5 days for a total of 180 ml/kg per day.
the pediatric patient [4]. Anaphylaxis is best For very low birthweight and extremely low birth-
treated with epinephrine and volume expansion weight preterm babies, the fluid requirements are
with fluids [8]. Anaphylaxis can be graded 1–4 greater early on with 180 ml/kg per day usually
with 1 being observation and 4 being treatment around day 4 of life [11].
with 1–3 mg epinephrine intravenously. Grade 2 The pediatric population is prone to emergence
is treated with 10–20 mcg, and grade 3 reactions delirium after general anesthesia, and a ttention has
are treated with 100–200 mcg of epinephrine [4]. been raised to the use of intranasal dexmedetomi-
A side effect of anaphylaxis is Takotsubo’s cardio- dine as a premedication to reduce emergence delir-
myopathy which is a result of either coronary ium and MAC of sevoflurane. Savla et al. report a
vasospasm from anaphylaxis or epinephrine itself. decrease in emergence delirium with 1–2 mcg/kg.
It is critical not to overuse epinephrine in anaphy- Additionally, a reduction in MAC of sevoflurane
laxis. Overuse can result in worse outcomes by 36% for LMA insertion was observed [12]. He
including increased myocardial oxygen demand, et al. also report a decreased incidence of agitation
arrhythmias from ventricular ectopy, tachycardia, and a decrease in end-tidal sevoflurane concentra-
and increased SVR. These combined may result in tion required for LMA removal with an infusion of
a worse neurological outcome post resuscitation 0.1–1 mcg/kg of dexmedetomidine [13]. Conversely,
[9]. The standard dose of epinephrine in the pedi- a combination of ketamine and dexmedetomidine
atric patient for anaphylactic shock and cardiac has been used to prevent emergence delirium,
arrest is 0.01 mg/kg IV [4]. PONV, and analgesia. Hadi et al. report that
Complications can arise during mechanical 0.15 mg/kg ketamine followed by 0.3 mcg/kg dex-
ventilation as well. Ventilating the pediatric medetomidine infused 10 min prior to emergence
patient is not without complication. Typically, it is reduces the incidence of sevoflurane-induced
judicious to start at low tidal volumes and peak emergence delirium, kept hemodynamic stability
inspiratory pressures as to prevent volutrauma during extubation, and reduced opioid require-
and barotrauma. Peak pressures should not ments after tonsillectomy [14].
exceed 15–20 cm H20, and tidal volumes should Awareness under anesthesia in the pediatric
be increased slowly until peak pressures, ETCO2, population can range anywhere from 1 in 135 by
and tidal volumes are in an acceptable range. direct questioning to 1 in 51,500 by spontaneous
Volutrauma and barotrauma take precedence questioning. Awareness is most common in the
over moderate hypercapnia to the point where it induction and emergence of anesthesia and is
is better to maintain relative hypercapnia rather most distressing under neuromuscular blockade
than increasing tidal volumes and peak pressures combined with pain. Generally, episodes last
to result in normocapnia [4]. Even at low tidal 5 min or less but are nonetheless generally dis-
volumes, an inflammatory response can be elic- tressing. Depth of anesthesia monitors may be
ited and can be detrimental in the newborn and useful in helping prevent awareness by anesthetic
pediatric populations [10]. depth [15].
18.3 Airway Complications pediatric patient to hypoxemia much quicker if

in the Pediatric Patient steps aren’t taken to adequately ventilate [16]. The
rate of CO2 production is also higher in pediat-
The pediatric airway is anatomically different rics compared to adults, 100 ml/kg/min versus
than the adult, more so in the neonate to 1-year- 60 mL/kg/min. Tidal volume remains constant
old infants, as compared to adults (7 Box 18.2). despite age, and so it is necessary to have an

The head of the pediatric patient is noticeably increased respiratory rate to prevent hypercapnia
larger in comparison to the adult counterparts, [18]. Finally, anatomic changes are more pro-
and the occiput is more prominent [16]. This can found in the pediatric airway. Since Poiseuille’s
predispose to upper airway obstruction after law governs resistance to flow, anatomic changes
induction due to the flexion of the head. A shoul- like laryngeomalacia, growths within the airway,
der roll is recommended to aid the provider in and subglottic stenosis can profoundly affect the
aligning the oral, laryngeal, and tracheal axes fresh gas flow by a factor of 16 [16]. Each of these
[16]. The next anatomical difference between disease processes must be addressed separately in
children and adults is that the tongue is relatively the workup prior to any induction.
larger and the mandible is shorter. Additionally, Mask ventilation is fundamental in airway
the adenoids and tonsils are larger and the subject management in pediatrics. Posterior displace-
of ENT surgery at a young age. These things comment of the tongue can be relieved by an oral air-
bined cause increased upper airway resistance way. The LMA also has 95–98% success rate in
and obstruction, complicating mask ventilation getting adequate ventilation in pediatrics [16].
and, ultimately, intubation [16]. The larynx is Additionally, uncuffed endotracheal tubes were
higher in children, located at about C4 versus once used more often than cuffed tubes with the
adults at C6. In the adult, the vocal chords are at a thought being that pressure would be minimized
90-degree angle to the trachea, while in pediat- to the subglottis and resistance would be mini-
rics, it is more anterior/inferior to posterior/supe- mized. Now, the thought is that cuffed tubes min-
rior orientation which can make endotracheal imize trauma and provide better ventilating
intubation more traumatic and/or challenging conditions. Uncuffed tubes may actually be asso-
[17]. The epiglottis in children is typically U ciated with more cases of laryngospasm [16].
shaped compared to a flat line in adults. The use of Overall, the pediatric airway must be managed
a Miller blade may be more advantageous in differently than the adult airway, keeping in mind
younger-aged children compared to the anatomical and physiologic differences. The anes-
Macintosh which may be used in older children, thesia provider must have access to all the materi-
as direct control over lifting the uvula can be als in the difficult airway algorithm to prevent
obtained with a straight blade [16]. unnecessary causes of morbidity and mortality.
Physiologically, pediatric patients differ from Pediatric airway emergencies, although uncom-
adults in many ways which can ultimately dispose mon in healthy children, can happen much faster
them to hypoxemia. Oxygen consumption is rela- than in their adult counterparts. The introduction
tively higher in pediatrics on the order of 6 ml/kg/ of LMAs has greatly reduced airway compromise
min vs. 3 ml/kg/min. Additionally, children have in pediatrics and allows for lesser need for the
a lower FRC. These combined can predispose a surgical airway. Fiber-optic intubation through
the LMA is considered the ultimate technique in
18 the difficult pediatric airway before moving on to
Box 18.2 Anatomic Airway Differences in surgical cannulation or tracheostomy [19]. The
the Pediatric Patient Versus the Adult Patient risk of aspiration in pediatrics has decreased with
55 Head and occiput are larger the growing support of cuffed endotracheal tubes
55 Tongue is larger and mandible is shorter in pediatrics [20].
55 Adenoids and tonsils are larger Bronchospasm, laryngospasm, and hypoxemia
55 Larynx is higher are the most frequent encountered adverse events
55 Vocal chords are anterior/inferior to
posterior/superior
in the perioperative setting with pediatric patients.
55 Epiglottis is U shaped Unrecognized, these can be life threatening and
lead to cardiac arrest. The most common predic-
269 18
tors are age of the patient, with increasing age
showing a reduction in adverse events, type of sur- Box 18.3 Clinical Criterial for Diagnosing
gery, use of desflurane, sleep disorders and obesity, Anaphylaxis
URI, emergent procedures, and lack of a pediatric Anaphylaxis is highly likely when any one of the
following three criteria is fulfilled:
specialist in anesthesia [21]. Luce et al. report a
1. Acute onset of an illness (minutes to several
decrease in the incidence of laryngospasm, post- hours) with involvement of the skin, mucosal
operative desaturation, cough, and breath holding tissue, or both (e.g., generalized hives, pruritus
with the use of an LMA when indicated compared or flushing, swollen lips, tongue, uvula)
to tracheal intubation [22]. Additionally, there was And at least one of the following:
(a) Respiratory compromise (e.g., dyspnea,
a decrease in laryngospasm-related events when
wheeze-bronchospasm, stridor, reduced
extubated deep with LMA with no change in out- peak expiratory pressure [PEF], hypox-
comes when the LMA was removed in the awake emia)
child. It is important to have emergency drugs on (b) Reduced BP or associated symptoms of
hand when treating the perioperative pediatric end-organ dysfunction (e.g., hypotonia
[collapse], syncope, incontinence)
patient. Despite optimizing risk factors for laryn-
2. Two or more of the following that occur rapidly
gospasm/bronchospasm, it is important to recog- after exposure to a likely allergen for that
nize those first initial signs and act accordingly. patient (minutes to several hours):
Positive pressure is the initial treatment for such (a) Involvement of the sink-mucosal tissue
events. If unresponsive, it is necessary to use suc- (e.g., generalized hives, itch-flush, swollen
lips, tongue, uvula)
cinylcholine for rapid relaxation in a patient with
(b) Respiratory compromise (e.g., dyspnea,
laryngospasm or bronchospasm to prevent brady- wheeze-bronchospasm, stridor, reduced
cardia and cardiac arrest. Atropine and epineph- PEF, hypoxemia)
rine should be on hand to treat bradycardia and (c) Reduced BP or associated symptoms (e.g.,
cardiac arrest. hypotonia [collapse], syncope, inconti-
nence)
(d) Persistent gastrointestinal symptoms (e.g.,
crampy abdominal pain, vomiting)
18.4 Allergic Reactions 3. Reduced BP after exposure to known allergen
for that patient (minutes to several hours):
The practice of anesthesia is pharmacologically (a) Infants and children: low systolic BP (age
specific) or greater than 30% decrease in
unique, as patients are exposed to multiple medi-
systolic BP
cations within a relatively short time span. Each of (b) Adults: systolic BP of less than 90 mm Hg
these medications has the potential to induce a or greater than 30% decrease from that
potentially life-threatening anaphylaxis [23]. person’s baseline
Therefore, it is prudent for the anesthesiologist to
be vigilant in observing patients for possible aller- Sampson et al. [34]
gic reactions as symptoms may be masked by
anesthetic agents as well as the surgical drapes.
Anaphylaxis is the most severe type of allergic
reaction and is defined as an acute allergic reac- reactions mediated by a sudden release of pre-
tion resulting from a rapid, antigen-induced formed and newly synthesized mediators from
release of potent, pharmacologically active medi- mast cells and basophils. Although causative
ators from mast cells and basophils [23]. Clinically agent cannot always be determined in periopera-
criteria for anaphylaxis have been defined by tive anaphylaxis, common culprits have been
Sampson et al. (7 Box 18.3).
determined to be neuromuscular-blocking drugs
Life-threatening anaphylaxis is rare, with life- (NMDBs) (50–70%), followed by latex (12–
time risk in the general population of 1.6% and 16.7%), and antibiotics (15%) [27] in adult popu-
perioperative anaphylaxis reported up to lations. However, in a pharmacovigilance study
1/13,000 anesthetics [24]. These anaphylactic which included 266 children (<18 years old), 122
reactions have a reported mortality rate in a of these children developed an IgE-mediated
French Survey of 3–9% [25], with a more recent anaphylaxis to the following: 41.8% reacted to
Australian study putting the mortality of 0–1.4% latex, 31.97% reacted to NMBD, and 9.02%
[26]. Perioperative anaphylaxis hypersensitivity reacted to antibiotics.
Latex is a natural product derived from the considering the use of an NMDB in a patient with
rubber tree, Hevea brasiliensis, and has been a previous NMDB allergic reaction, cis-
associated with both immediate and delayed atracurium may be a good alternative. It has been
hypersensitivity reactions. Specific subpopula- shown to have the least cross-reactivity when
tions at risk include atopic children, spinal bifida, used in those who previous suffered anaphylaxis
children who underwent surgical procedures dur- to rocuronium and vecuronium [31].
ing neonatal period, and individuals who require Antibiotics are the 3rd most frequent cause of
frequent surgical instrumentations (i.e., cath- drug-related anaphylaxis with a reported inci-
eterization). Additionally, children with specific dence of 9% [25] which is of concern in the field
food allergies including avocado, kiwi, bananas, of anesthesia considering that nearly every patient
or chestnuts are more prone to developing latex undergoing surgery receives this for surgical pro-
anaphylaxis as these share similar allergens with phylaxis. Most common agents are penicillins and
latex [28]. Diagnosis of latex allergies should cephalosporins [33].
begin with a clinical history by questioning about
atopic dermatitis, allergic rhinitis, and prior
exposure to surgery and/or latex, and prior reac- 18.4.1 Treatment
tions noted with balloon or rubber toys may help
identify patients with latex sensitivities. Latex After a patient is diagnosed clinically with anaphy-
allergies suspected by clinical history should be laxis, treatment is based on the severity of the reac-
confirmed with specific laboratory testing. Two tion using Ring and Messmer grading. Grade I
tests are available, skin prick testing and detection includes cutaneous symptoms (erythema, u rticaria,
of IgE to latex protein [29]. Prevention of anaphy- with or without angioedema). Grade II includes
laxis in pediatric population begins with limit- cutaneous symptoms and may be associated with
ing exposure to latex. Many hospitals now have cardiovascular and/or respiratory symptoms.
phased out the use of latex-containing products Grade III hallmark feature is cardiovascular col-
to avoid exposing children in the first place, thus lapse that may be associated with cutaneous symp-
mitigating the development of hypersensitivity toms and/or bronchospasm, and grade IV is cardiac
to latex. Additionally, reactions can be limited by arrest [35]. Immediate treatments are as follows: (1)
identifying those children with a latex sensitivity, withdraw the offending agent; (2) immediately dis-
so further measures can be taken to establish a continue anesthetic drugs when the anaphylactic
“latex-safe” environment, as the complete avoid- event occurs during induction; (3) maintain airway
ance of latex products is key to preventing severe with 100% oxygen; (4) provide early administration
anaphylaxis. In addition to avoiding all latex of epinephrine especially in grade II or IV reac-
products, schedule these cases as the first in the tions; (5) call for help, especially for grades III and
day, where aerosolized latex antigen is thought to IV; (6) place patient supine in Trendelenburg; and
be at its lowest level, or wait 90 min after the pre- (7) abbreviate the surgical procedure if possible
vious cases to decrease the amount of aerosolized when it occurs during surgery [35].
latex antigen [29].
Neuromuscular-blocking drugs (NMDBs)
have been the most common medication associ- 18.5 Postoperative Complications
ated with perioperative anaphylaxis in adults. In
18 pharmacovigilance data collected in France, it Postoperative nausea and vomiting (PONV) is one
was noted that NMBD was the 2nd most common of the most common complications of pediatric-
antigen associated with anaphylaxis [25]. Of the anesthesia. It is mediated by the vomiting center,
NMDBs, the current literature indicates that thought to reside in the brainstem. It receives input
rocuronium is most likely to cause anaphylactic from the pharynx, GI tract, higher cortical center
reactions compared to other NMBDs [30–32]. In (i.e., visual, gustatory, olfactory, and vestibular
an Australian analysis over a 10-year period, 80 centers), and the chemoreceptor trigger zone
cases of life-threatening anaphylaxis are associ- (CTZ) [36]. PONV risk is typically calculated for
ated with NMBD. Rocuronium was implicated in adults with the Apfel score. However, the Apfel cri-
56%, succinylcholine 21%, and vecuronium 11% teria are not fully applicable to children as the cri-
[31]. Although allergies to NMBD are rare, when teria were not developed or validated for pediatric
271 18
patients. In a study by Eberhart et al., they identi- provider), patient related (younger age, reactive
fied four independent risk factors for PONV: (1) airway, smoke exposure, recent URI), or surgery
duration of surgery ≥30 min, (2) age ≥ 3 years, (3) related (airway procedures, tonsillectomy/ade-
strabismus surgery, and (4) a positive history of noidectomy) [41]. Treatment measures should be
PONV in child or in relatives (mother, father, sib- initiated by removal of irritant stimulus, opening
lings). PONV risk was 9%, 10%, 30%, 55%, and mouth, jaw thrust, and CPAP ventilation with
70% for 0–4 risk factors met [37]. For patients with 100% oxygen. Propofol (0.25–0.8 mg/kg IV) has
low risk of PONV, prophylactic treatment may be been shown to treat laryngospasm in 76.9% of
unnecessary. In children at higher risk for PONV, cases. However, the gold standard remains succi-
several steps can be taken to lessen the occurrence nylcholine (0.1–3 mg/kg) given together with
of PONV. First, consider avoiding known inducers atropine (0.02 mg/kg) to avoid succinylcholine-
of PONV, such as nitrous oxide, volatile agents, associated bradycardia [41].
and postoperative opioids. Furthermore, consider Post-extubation stridor is typically associated
utilizing anesthesia modalities which have low with use of a tight-fitting endotracheal tube,
emetic potential such as regional anesthesia or repeated intubation attempts, traumatic intuba-
total intravenous anesthesia using propofol. tion/extubation, or coughing/straining on tube.
Finally, consider the use of prophylactic medica- This can result in mucosal trauma and airway
tions. Intravenous ondansetron (5-HT3 receptor edema and ultimately airway obstruction.
antagonist) can be given at 50–100 mcg/kg up to Treatment options include humidified air for mild
4 mg or dexamethasone 150 mcg/kg up to 5 mg. In cases. For more severe cases, consider nebulized
cases of high PONV risk, combination therapy can racemic epinephrine for immediate reduction of
be utilized using ondansetron and dexametha- edema via vasoconstriction. Also, dexamethasone
sone, as studies have supported a synergistic effect (0.5 mg/kg) may be helpful after the initial ther-
when used in combination [38]. apy, to reduce the airway edema associated with
Hypoxia in children, defined as an oxygen post-extubation stridor [36].
saturation <93%, in the postoperative setting Negative pressure pulmonary edema (NPPE)
should raise concerns, and O2 therapy should be is a complication that arises after relief of an acute
initiated. Evaluate waveform to ensure its monitor upper airway obstruction, most commonly laryn-
is providing an accurate value, and adjust probe as gospasm. This results in the development of
appropriate. If hypoxia is true, consider the fol- increased negative intrathoracic pressures which
lowing: residual anesthetics, inadequate reversal if ultimately results in increased permeability of pul-
paralytic was utilized, respiratory depression, air- monary capillaries resulting in pulmonary edema
way obstruction, and laryngospasm. [42]. Clinically, a patient will present with NPPE
Postoperatively, airway obstruction can be with the following symptoms: dyspnea, progres-
observed clinically by a seesaw breathing pattern sive cyanosis, anxiety, increased work of breathing,
and subcostal or sternal retraction. Typically, the excessive pink frothy secretions from the mouth,
obstruction is caused by the tongue falling back and cracks on auscultation [43]. NPPV is self-
and blocking the airway. Treatment includes limiting, typically resolving in 12–24 h with noth-
insertion of oral airway if tolerated, neck exten- ing more than supportive care, including
sion, opening of mouth, and jaw thrust either supplemental oxygen or CPAP if required.
alone or in combination [36]. Consider reintubation and mechanical ventilation
Laryngospasm can be defined as is a reflex clo- for a patient who cannot adequately oxygenate
sure of the upper airway as a result of glottic mus- themselves despite supplemental oxygen [44].
culature spasm. It is a protective reflex that acts to
prevent foreign material entering the tracheo-
bronchial tree [39]. However, during anesthesia, 18.6 Anesthesia-Related Mortality
prolonged laryngospasm can result in life-
threatening complications including hypoxemia Evaluation of perioperative mortality in children
bradycardia, negative pressure pulmonary edema, related to anesthesia is useful to evaluate what
and cardiac arrest [40]. Risk factors for laryngo- children are at higher risk and create better
spasm can fall under three categories: anesthesia management strategies to improve the overall
related (light plane of anesthesia, inexperienced safety in the administration of anesthesia to
children. A meta-analysis by Gonzalez et al. noted anatomy to the physiology. Because of this the man-
the following risk factors associated with periop- agement and treatment can be different and more
erative mortality. Higher rates of mortality were difficult. Take, for instance, the life-sustaining ele-
associated with developing countries compared ment of oxygen that can be too much for the neona-
to developed countries when comparing data tal human leading to retrolental fibroplasia and
from the same time frame [45]. Major risk factors abnormal proliferation of fibrous tissue during eye
were identified as age (newborns and infants less development or absorption atelectasis causing dry-
than 1 year of age are at greater risk), ASA III or ing of the mucosal and increase production of free
greater, emergency surgery, general anesthesia, radicals. The anesthetic gases used for inhalational
and cardiac surgery. In those children with coex- induction can depress the myocardium and lead to
isting comorbidities prior to surgery, complica- vitamin B12 inactivation. Drugs used to induce
tions related to airway management and immobilization can induce cardiac arrest or lead to
cardiocirculatory events were accounted for an allergic reaction that can ultimately lead to car-
majority of the causes of mortality [45]. A study diac arrest. The safe drugs used to treat anaphylactic
by Lian et al. conducted a retrospective analysis of complications, i.e., epinephrine, are themselves not
pediatric patient which were either admitted to without risk such as too much can lead to coronary
ICU or died within 30 days postsurgery to develop vasospasm. The recommended dose is 0.01 mg/kg
a preoperative risk prediction score (PRPS) to IV. Children have increase oxygen consumption
predict the likelihood of postoperative ICU leading to hypoxemia at a faster rate than adults.
admission and/or the risk of pediatric periopera- Mechanical ventilation must be optimized to the
tive death [46]. Similar risk factors associated correct tidal volumes and peak inspiratory pres-
with perioperative mortality which included sure; failure to do so can lead to hypoxemia, hyper-
age < 1 year old and patients classified as ASA III capnia, or barotrauma. Even though bronchospasm
and above. Additionally, it was noted that patients and laryngospasm are frequently encountered
with intraoperative SpO2 <90% were noted to be adverse events, they can be catastrophic. The culprit
a significant independent risk factor. Additionally, can be light anesthesia, reactive airway disease, age
it was noted that “unfasted” patients prior to sur- of patient, and type of surgery. It can be managed by
gery may be associated with emergent surgery. positive pressure, deepening the anesthesia, depo-
However, the authors mention that in their study, larizing neuromuscular- blocking agent, and epi-
emergent surgery was not completely equivalent nephrine. Post extubation stridor secondary to
to unfasted patients. Therefore, they suggest that mucosal trauma can be avoided with the use of
“unfasted” patient may be the risk factor [46]. appropriate-sized endotracheal tubes, minimizing
the amount of airway manipulation and coughing
on the tube. Treatments include dexamethasone,
18.7 Summary humidified air, and nebulized epinephrine.
Postoperative nausea and vomiting, one of the more
Overall, complications can and do occur in any common complications, has four independent risk
anesthetic procedures, but what one does to treat or factors, and prevention methods include avoidance
prevent the complication is most prudent. A pediat- of known inducers and the use of low emetic poten-
ric anesthetic case has the potential to develop into tial anesthesia.
a catastrophic perioperative complication. Some The pediatric airway in itself yields potential
18 complications include allergic reactions, postopera- for complications. The occiput is larger making a
tive nausea and vomiting, hypoxia, bronchospasm, difficult patient position, so it is recommended to
laryngospasm, post- extubation stridor, negative place a shoulder roll to align the axis, and the
pressure pulmonary edema, absorption atelectasis, tongue is larger making a difficult mask ventila-
emergence delirium, and cardiac arrest. All compli- tion, so it is recommended to use an oral airway.
cations have the potential to be classified as mild, When trying to intubate, the anatomical features
moderate, severe, or catastrophic. It is the anesthe- that make it more challenging are that the larynx is
siologist’s knowledge and preparedness that will higher, the vocal cords are slightly angled, and the
determine if the complication yields a mild, moder- epiglottis is U shaped. The use of the Miller blade
ate, or severe result. The pediatric patient is vastly for younger children and Macintosh for older chil-
different from the adult in many forms from the dren may make the intubation process easier.
273 18
18.8 Review Questions 4. De Francisci G, Papasidero AE, Spinazzola G, Galante D,
Caruselli M, Pedrotti D, Caso A, Lambo M, Melchionda
M. Maria Grazia Faticato. Update on complications in
?? 1. The American Society of Anesthesiology pediatric anesthesia. Pediatr Rep. 2013;5(1):e2.
Closed Claims Project revealed that Published online 2013 Feb 18. https://doi.org/10.4081/
catastrophic complications in pediatric pr.2013.e2.
anesthesiology were closely related to: 5. Evers AS, Crowder CM, Balser JR. General anesthetics. In:
Brunton L, Lazo J, Parker K, editors. Goodman and
A. Cardiovascular collapse
Gilman’s, the pharmacological basis of therapeutics.
B. Adverse respiratory events New York: McGraw Hill; 2006.
C. Anaphylactic reactions 6. Bamaga AK, Riazi S, Amburgey K, Ong S, Halliday
D. Improper drug administration W, Diamandis P, Guerguerian AM, Dowling JJ, Yoon
G. Neuromuscular conditions associated with malignant
hyperthermia in paediatric patients: a 25-year retro-
?? 2. Hyperkalemic cardiac arrest in Duchenne
spective study. Neuromuscul Disord. 2016;26(3):201–6.
muscular dystrophy and Schwartz-Jampel https://doi.org/10.1016/j.nmd.2016.02.007. Epub 2016
syndrome is associated with which of the Feb 23. PMID: 26951757.
following anesthetic agents: 7. Hackmann T, Skidmore DL, MacManus B. Case report of
A. Sevoflurane cardiac arrest after succinylcholine in a child with mus-
cle-eye-brain disease. A A Case Rep. 2017; https://doi.
B. Sugammadex
org/10.1213/XAA.0000000000000577. [Epub ahead of
C. Succinylcholine print] PMID:28604469.
D. Sufentanil 8. Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis
and anesthesia: controversies and new insights
?? 3. Which of the following age groups listed [Review]. Anesthesiology. 2009;111(5):1141–50.
9. Berg R, Mijasaka K, Rodriguez-Nunez A. Cardiopulmonary
below is associated with the highest risk
resuscitation. In: Nichols DG, editor. Rogers’ textbook
of anesthesia related mortality? of pediatric intensive care. Philadelphia: Lippincott
A. Neonates and infants less than 1 year Williams & Wilkins; 2008.
of age 10. Curley GF, Kevin LG, Laffey JG. Mechanical ventilation: tak-
B. Toddlers 1 to 3 years of age ing its toll on the lung. Anesthesiology. 2009;111(4):
701–3.
C. Children 3 to 8 years of age
11. O’Brien F, Walker IA. Fluid homeostasis in the neonate.
D. Children greater than 8 years of age Paediatr Anaesth. 2014;24(1):49–59. https://doi.
org/10.1111/pan.12326. Epub 2013 Dec 4. Review.
PMID: 24299660.
18.9 Answers 12. Savla JR, Ghai B, Bansal D, Wig J. Effect of intranasal dex-
medetomidine or oral midazolam premedication on
sevoflurane EC50 for successful laryngeal mask airway
vv 1. B – Adverse respiratory events placement in children: a randomized, double-blind, pla-
cebo-controlled trial. Paediatr Anaesth. 2014;24(4):433–
vv 2. C – Succinylcholine 9. https://doi.org/10.1111/pan.12358. Epub 2014 Jan 28.
13. He L, Wang X, Zheng S, Shi Y. Effects of dexmedetomi-
dine infusion on laryngeal mask airway removal and
vv 3. B – Toddlers 1 to 3 years of age
postoperative recovery in children anaesthetised with
sevoflurane. Anaesth Intensive Care. 2013;41(3): 328–33.
14. Hadi SM, Saleh AJ, Tang YZ, Daoud A, Mei X, Ouyang
W. The effect of KETODEX on the incidence and severity
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with rocuronium and succinylcholine than with atracu- Articles]. Can J Anaesth. 1990;37(2):210–8. https://doi.
rium. Anesthesiology. 2015;122(1):39–45. https://doi. org/10.1007/BF03005472
org/10.1097/ALN.0000000000000512 45. Gonzalez L, Pignaton W, Kusano P, Modolo N, Braz J, Braz
31. Sadleir PHM, Clarke RC, Bunning DL, Platt L. Anesthesia-related mortality in pediatric patients: a
PR. Anaphylaxis to neuromuscular blocking drugs : inci- systematic review. Clinics. 2012;67(4):381–7. https://
dence and cross-reactivity in Western Australia from doi.org/10.6061/clinics/2012(04)12
2002 to 2011. Br J Anaesth. 2013;110(January): 981–7. 46. Lian C, Xie Z, Wang Z, Huang C, Zhang M, Ye M, et al.
https://doi.org/10.1093/bja/aes506 Pediatric preoperative risk factors to predict postopera-
32. Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and tive ICU admission and death from a multicenter retro-
rocuronium-induced anaphylaxis. J Anesth. 2016;30(2): spective study. Paediatr Anaesth. 2016;26(6):637–43.
290–7. https://doi.org/10.1007/s00540015-2105-x https://doi.org/10.1111/pan.12905
275 19
Ambulatory and Office-
Based Surgery
Joshua E. Dibble and Arthur L. Calimaran
19.2 Definitions – 276
19.3 Facilities – 276
19.4 Patient Selection – 277
19.5 Obstructive Sleep Apnea – 277
19.6 Cardiovascular Disease – 277
19.7 Malignant Hyperthermia – 278
19.8 Preoperative Evaluation – 278
19.9 Preoperative Fasting – 278
19.10 Premedication – 279
19.10.1 Controlling Anxiety – 279
19.10.2 Preoperative Analgesia – 279
19.11 Intraoperative Management – 279
19.11.1 Technique – 279
19.11.2 Regional Anesthesia – 280
19.12 Recovery from Anesthesia – 280
19.13 Postoperative Nausea and Vomiting – 281
19.14 Postoperative Pain Management – 281
19.15 Discharge – 281
19.16 Office-Based Anesthesia – 282
19.17 Summary – 282
19.19 Answers – 282
References – 283
https://doi.org/10.1007/978-3-319-96125-5_19
276 J. E. Dibble and A. L. Calimaran
19.1 Introduction and services, while other arrangements make use

of a freestanding ambulatory surgery center. The
The first ambulatory surgery centers in the United American Society of Anesthesiologists (ASA)
States began to appear in the 1950s [1]. Today offers guidelines for ambulatory anesthesia and
ambulatory surgery has become a mainstay of surgery. Those guidelines are summarized in 7 Box
healthcare delivery across the world. In the United 19.1 [5]. They state that all ASA standard practices
States, only 20% of elective surgery occurs in an should be maintained and set expectations in
inpatient hospital setting with the rest occurring regard to staffing. Additonally, it provides guidance
in an ambulatory facility [2]. Advances in mini- as to patient care and record keeping. Government
mally invasive surgical techniques and the pres- regulation and accreditation are done by agencies
sure to control healthcare cost have driven the such as The Joint Commission, the American
trend toward procedures being performed outside Association for Accreditation of Ambulatory
of the traditional hospital setting. Organizations Surgery Facilities, or the Accreditation Association
such as the Society for Ambulatory Anesthesia for Ambulatory Health Care. Additionally indi-
(SAMBA) and the International Association for vidual states have developed regulations to ensure
Ambulatory Surgery (IAAS) have formed to pro- that safety and emergency protocols are in place.
vide guidance and promote ambulatory surgery
across the globe. The ambulatory and office set-
ting continues to grow and will no doubt have an Box 19.1 An Outline of ASA Guidelines for
impact on every practicing anesthesiologist at Ambulatory Anesthesia and Surgery
some point in their career. 1. All ASA standard practices should be followed.
2. A licensed physician must be available at all
times in person by phone until while patients
are present.
19.2 Definitions 3. The facility must be constructed and operated
in a manner that complies with all local, state,
Ambulatory surgery is a common phrase used and federal laws.
4. Staffing should consist of:
today; however the definition can vary among dif-
A. Professional staff
ferent healthcare systems. The International 1. Licensed physicians and nurses
Association for Ambulatory Surgery (IAAS) co- B. Administrative staff
founder Tom W Ogg suggested the definition: “A C. Housekeeping and maintenance staff
surgical day case is a patient who is admitted for 5. Minimal patient care should include:
A. Preoperative instructions and preparation.
investigation or operation on a planned non-resi-
B. An appropriate pre-anesthesia evaluation
dent basis and who none the less requires facilities and examination to be performed or
for recovery. The whole procedure should not reviewed and verified by an anesthesiolo-
require an overnight stay in a hospital bed.” [3] gist, prior to anesthesia and surgery.
With this guidance it is clear that the intent of C. An anesthesia plan developed with and
accepted by the patient by an anesthesi-
ambulatory surgery is to manage the entire patient
ologist.
encounter within 1 day with the expectation of D. Administration of anesthesia by anesthesi-
the patient returning to their prior place of resi- ologists, other qualified physicians, or
dence. Office-based anesthesia is performing an nonphysician anesthesia personnel
anesthetic in a venue outside a traditional hospital medically directed by an anesthesiologist.
E. Physician responsibility for patient
such as an office that does not hold accreditation
discharge.
as either an ambulatory surgery center or hospital F. Patients who receive other than unsupple-
19 [4]. mented local anesthesia must be
discharged with a responsible adult.
G. Patients must be given written postopera-
tive and follow-up care instructions.
H. Accurate, confidential, and current medical
19.3 Facilities records.
A variety of arrangements exist for the provision of Adapted from ASA Guidelines for Ambulatory
ambulatory surgery. Some facilities are integrated Surgery [5]
within a hospital to make use of existing personnel
Ambulatory and Office-Based Surgery
277 19
19.4 Patient Selection 55 Performing a physical exam prior to the date
of surgery to examine the airway and
When choosing patients for ambulatory surgery, consider factors such as neck size, tonsil size,
one must remember the expectation is for the tongue volume, and nasopharyngeal charac-
patient to return to their prior living situation on teristics that may suggest undiagnosed OSA
the same day. With this in mind, a variety of med- and if necessary warrant further work-up and
ical and surgical factors should be considered. optimization
Surgery should be done with the expectation of no 55 Factors such as OSA status, type of surgery,
need for complex postoperative care or ongoing capabilities of the outpatient facility, and need
blood loss. Patients with a suspected or known for post-op opioids should be taken into
difficult airway or unstable chronic medical con- account when determining if the procedure
ditions may be best served by having their proce- can be done on an ambulatory basis
dure done at a hospital. Historically ambulatory 55 Local anesthetic and peripheral nerve blocks
surgery was provided for patients assigned to ASA should be used when possible to minimize
physical status I or II. Currently it is common to sedation and opioid use
see ASA III or IV patients in the ambulatory set- 55 Patients should be extubated fully awake in a
ting provided their comorbid diseases are opti- lateral, semi-upright, or other non-supine
mized and stable. A retrospective review found no positions after full reversal of neuromuscular
significant differences in unplanned admissions, blockade
unplanned admission rates, unplanned contact
with healthcare services, or postoperative compli- The use of a questionnaire such as STOP-Bang
cations in ASA III patients undergoing ambula- along with a physical exam has proven effective in
tory surgery when compared to ASA I or II identifying most patients at risk of OSA [12].
patients [6]. Although more patients with an Patients with OSA can be safely treated in the
increasing number of comorbidities are being ambulatory surgical setting; however they may
treated in ambulatory surgery centers, several have a higher likelihood of difficult intubation,
conditions require special consideration. have a greater requirement for vasopressors, and
will potentially need more oxygen in the PACU
[13], so the anesthesiologist should be prepared
19.5 Obstructive Sleep Apnea for this possibility in at risk patients.
Obstructive sleep apnea (OSA) is characterized by

intermittent partial or complete airway obstruc- 19.6 Cardiovascular Disease
tion during sleep. It is estimated that up to 14% of
adult males and 6% of adult females suffer from Approximately one in three adults (32%) in the
obstructive sleep apnea [7], the majority of which United States has hypertension [14]. Hypertension
may be undiagnosed [8]. It is often seen in obesity is extremely common; however it should rarely be
but can present in non-obese individuals as well. It a reason for delaying surgery. In patients present-
is seen in children and adults. These patients have ing the day of surgery with an elevated blood pres-
an elevated risk of morbidity in the perioperative sure and no evidence of end-organ damage, no
period due to increased incidence of postopera- difference in outcomes have been shown by
tive desaturation, respiratory failure, postopera- actively treating vs delaying surgery for patient
tive cardiac events, and elevated rate of ICU optimization [15]. Thus delaying a surgery to opti-
transfers [9]. Long-term exposure to intermittent mize a patient’s hypertension is not likely to be of
hypoxia provides the physiologic basis for the benefit. If patients are on beta-blockers, they
increased risk of cardiovascular compromise [10]. should generally continue them on the day of sur-
In 2014 the ASA published updated practice gery. Debate exists on the continuation of ACE
guidelines for the perioperative management of inhibitors (ACEI) or angiotensinogen receptor
patients with OSA. Some of the consensus agree- blockers (ARBs) the day of surgery as they can be
ments include [11]: associated with refractory hypotension during
anesthesia. Low-level evidence exists that sup- facilities keep a minimum of 36 vials of dantrolene
ports the withholding ACEI/ARBs the day of sur- where any triggering agents may be deployed [20].
gery to prevent hypotension [16]. A large cohort Some ambulatory centers will prefer to exclusively
study however has shown no difference in hemo- use total intravenous anesthesia and will only have
dynamic characteristics, vasopressor require- succinylcholine on hand for emergency purposes.
ments, or cardiorespiratory complications among In this type of arrangement, it is still recom-
patients who were or were not using ACEI during mended to stock dantrolene should a MH event
surgery [17]. The decision to continue or withhold occur [20]. In the event MH is triggered in an
ACEI/ARBs should be made on a case-by-case ambulatory setting, initial efforts should be
basis. focused on dantrolene administration. Emergency
Determining a patient’s preoperative exercise medical services should then be contacted with-
tolerance is vital as it is a good approximation of out delay to transport the patient to a medical
cardiovascular status and can help guide the need center with all the capabilities to manage the
for further testing. It has been shown that patient event. The Malignant Hyperthermia Association
self-reported exercise tolerance is a sensitive way of the United States, the Ambulatory Surgery
of predicting cardiovascular perioperative com- Foundation, and the Society for Ambulatory
plications with patients who state they can walk Anesthesia have developed joint transfer guide-
less than four blocks or two flights of stairs at the lines for patients who develop acute MH in an
greatest risk [18]. This can help reduce the need ASC [21].
for further formalized testing and serve as a quick
measure for identifying patients at the highest
risk. Other specific patient factors that have been 19.8 Preoperative Evaluation
shown to increase perioperative risk are a history
of coronary artery disease, myocardial infarction, Ideally the preoperative evaluation should be
peripheral vascular disease, congestive heart fail- done with sufficient time in advance of the
ure, ventricular arrhythmia, dementia, Parkinson planned procedure to allow for additional testing
disease, and smoking equal to or greater than 20 and optimization should that be necessary. For
pack years [18]. young healthy patients, a telephone assessment
The American College of Cardiology (ACC) may be appropriate [22]. In older patients more
and the American Heart Association (AHA) task likely to have multiple comorbidities and social
force on practice guidelines published an update issues, a face-to-face assessment is advisable [23].
in 2014 [19]. Patients with coronary artery stent Routine laboratory testing is often not predictive
placement in the previous 4–6 weeks are recom- of postoperative complications [24] and should be
mended to continue antiplatelet therapy for ordered with specific management questions in
urgent, noncardiac surgery unless the risk of mind. In one study all preoperative testing was
bleeding outweighs the benefit of prevention of eliminated, and this resulted in no increased peri-
stent thrombosis. If P2Y12 platelet receptor operative adverse events or readmission within
inhibitor therapy must be stopped, it is recom- 30 days [25]. This suggests many preoperative
mended to continue aspirin and to restart P2Y12 tests are unnecessary and only contribute to
platelet receptor inhibitor therapy as soon as pos- increase costs. In the ambulatory setting, preop-
sible following surgery. For elective surgery it is erative testing should be done judicially as to not
recommended to delay surgery for 30 days post incur unnecessary delays.
bare metal stent placement and 1 year post drug-
eluting stent placement [19].
19 19.9 Preoperative Fasting
19.7 Malignant Hyperthermia The American Society of Anesthesiologists (ASA)

guidelines for preoperative fasting allow a light
Malignant hyperthermia (MH) is a possibility meal up to 6 h prior to surgery and the consump-
anywhere volatile anesthetic agents or succinyl- tion of clear liquids until 2 h prior to surgery [26].
choline are used. The Malignant Hyperthermia In the European Journal of Anesthesiology 2011
Association of the United States recommends that guidelines for preoperative fasting, patients
279 19
case basis. Alternative anxiety reduction tech-
.. Table 19.1 Summary of ASA preoperative
fasting recommendations
niques such as allowing patients to listen to music
have shown to be effective [33].
Fasting Food Example
time (h) category
19.10.2 Preoperative Analgesia
2 Clear Water, fruit juice (no pulp),
liquids coffee, tea, carbonated
beverages (no alcohol) Ambulatory patients may often be given various
analgesic agents with the intent of decreasing
4 Breast Breast milk
postoperative pain or helping attenuate
milk
hypertension associated with tracheal intubation.
6 Light Infant formula, nonhuman Acetaminophen has shown the potential to reduce
meal milk, toast
postoperative pain and opioid requirements when
8 Heavy Fried food, meat, high-fat used as part of a multimodal pain control strategy
meal foods [34]. Acetaminophen can be given orally preop-
eratively; however the duration of action is 4–6 h.
Adapted from ASA Guidelines for Preoperative
Fasting [26]
For shorter cases this may be appropriate as
plasma levels may still be therapeutic postopera-
tively. Intravenous acetaminophen administration
intraoperatively has shown to consistently pro-
should be encouraged to consume clear liquids duce therapeutic plasma levels [35].
until 2 h prior to surgery to avoid dehydration Opioids are commonly given in the periopera-
[27]. Patients should be directed to take their tive period. The administration of fentanyl prior
chronic medications with clear liquids the morn- to tracheal intubation is often done to prevent
ing of surgery. The ASA recommendations for acute elevation of blood pressure. The value of
preoperative fasting are summarized in preoperative administration of opioids for attenu-
. Table 19.1.
ating postoperative pain is unclear. Administering
controlled-release oxycodone prior to surgery has
been shown in several studies to have no benefit
19.10 Premedication in reducing postoperative pain and may increase
incidence of nausea and vomiting [36, 37]. In
19.10.1 Controlling Anxiety 2016 the American Pain Society published guide-
lines on the management of postoperative pain.
Anxiety for many patients will begin as soon as Recommendations include the use of multimodal
they are scheduled for a surgical procedure. Up analgesia that includes preoperative gabapentin
to 80% of patients may experience preoperative or pregabalin, acetaminophen, or NSAIDs and
anxiety [28]. Attenuating a patients anxiety is a the use of regional or neuraxial techniques where
vital component of the overall patient satisfac- appropriate [38].
tion and can impact a patients overall coopera-
tiveness with an anesthetic plan. An anxious
patient may be more likely to prefer general anes- 19.11 Intraoperative Management
thesia over regional techniques [29]. A visit with
the patient by the anesthesia provider just before 19.11.1 Technique
surgery has been shown to reduce patient anxiety
[30]. The use of anxiolytic medication should be Choice of anesthetic technique will be guided by
done with caution as longer-acting agents have multiple patient and local factors that at times
the potential to prolong sedation and delay may compete with each other. Ambulatory anes-
recovery [31]. A systematic review however thetic goals are aimed at providing a rapid emer-
found little evidence to support the idea that anx- gence with no or minimal postoperative nausea
iolytic premedication delays discharge after day- and vomiting (PONV) and maximum patient
case anesthesia [32]. The decision to administer comfort that limits postoperative pain while not
anxiolytic drugs should be made on a case-by- delaying discharge to home. In general the
anesthesiologist must choose between general efit of reduced PONV and excellent postoperative
anesthesia, regional anesthesia, local anesthesia, analgesia. These benefits must be weighed against
or some combination of the three. A meta-analy- potential disadvantages. Regional techniques may
sis comparing discharge time from an ambula- be contraindicated in patients on anticoagulants,
tory surgery center between patients receiving have a high failure rate if the practitioner is inex-
peripheral nerve blocks, neuraxial technique, or perienced, carry a risk of infection, and introduce
general anesthesia showed no significant differ- patients to the risk of local anesthetic toxicity.
ence [39]. This would suggest that perceived Patients who receive peripheral nerve blocks may
variation in recovery times between the tech- potentially be discharged from PACU sooner as
niques is unfounded. compared with general anesthesia [44]. This is in
Some procedures will only be possible under contrast to neuraxial techniques that can poten-
general anesthesia. Other procedures may be pos- tially increase PACU discharge times [45]. The
sible via multiple types of anesthesia, and the duration of action of lidocaine is appropriate for
decision on what technique to employ will involve outpatient surgery; however it is avoided in spinal
consideration of patient factors along with sur- anesthesia due to the incidence of local anesthetic
geon preferences. Procedures that are suitable toxicity [46]. Bupivacaine and ropivacaine are
under local anesthesia may have an advantage of alternative agents for spinal anesthesia; however
lower cost and shorter operating room time [40]. their longer duration of action can make them
General anesthesia is a common choice of anes- less desirable in the ambulatory setting [47].
thetic technique and is often induced via short- Intrathecal 2-chloroprocaine is a suitable alterna-
acting intravenous induction agents, the exception tive as it has shown to result in significantly faster
being children or needle-phobic adults where discharge times as opposed to bupivacaine [48].
inhalational induction with the volatile agent Bupivacaine when used at lower than typical
sevoflurane is performed. Propofol has properties doses and combined with an adjunct such as fen-
that make it an appealing choice for IV induction tanyl has been successfully used in spinal surgery
in outpatient surgery. It is short acting allowing in the ambulatory setting [45].
for a rapid recovery, is nonirritating to the airway,
and can reduce postoperative nausea and vomit-
ing [41]. Propofol however causes pain at the 19.12 Recovery from Anesthesia
injection site and can induce dose-dependent
apnea and hypotension after administration. Recovery is typically broken down into distinct
Maintenance of anesthesia can be with a volatile phases. Standardized methods such as the Aldrete
agent or with IV anesthetics. Total intravenous scoring system or the postanesthetic discharge
anesthesia (TIVA) with propofol may provide an scoring system (PADSS) are often employed to
advantage of less PONV as compared to the use of evaluate patients during their recovery from anes-
volatile agents [42]. Inhalational agents such as thesia. For efficiency the postanesthesia care unit
sevoflurane and desflurane have low blood solu- (PACU) should be located in close proximity to
bility that allow for rapid recovery and emergence; the operating rooms. Generally patients have
however they are associated with increased inci- completed phase I of recovery when they are alert,
dence of postoperative nausea and vomiting as oriented, able to maintain their airway, and hemo-
compared to propofol [43]. Recovery from anes- dynamically stable. It is not uncommon for
thesia maintained with propofol is comparable to patients to emerge from the operating room and
anesthesia maintained by inhalational agents [41]. advance directly for phase II. Phase II consists of
preparing the patient for discharge to home.
19 Patients are often required to sit up unassisted or
19.11.2 Regional Anesthesia ambulate, tolerate oral intake, and void prior to
completion of stage II. Common reasons for pro-
Regional anesthesia techniques such as peripheral longed PACU stay include nausea and vomiting,
nerve blocks and neuraxial techniques are com- pain, and drowsiness [49]. Having a plan in place
monplace in ambulatory surgery. It is not uncom- to manage postoperative complications such as
mon to see regional and general anesthesia PONV and pain is vital to the efficiency of an
combined. Regional anesthesia provides the ben- ambulatory surgery center.
281 19
19.13 Postoperative Nausea dence of PONV. This approach may be appealing
and Vomiting in the ambulatory surgery setting as postoperative
nausea and vomiting is one of the most frequent
Risk factors for postoperative nausea and vomit- complications encountered by patients who
ing (PONV) include female sex, non-smoker sta- undergo general anesthesia [49].
tus, use of postoperative opioids, and a prior
history of PONV or motion sickness [50]. PONV
incidence is increased following the administra- 19.14 Postoperative Pain
tion of volatile anesthetic agents and opioids. Management
Strategies that limit the use of such agents and a
multimodal approach to analgesia should be A plan for postoperative pain management should
employed whenever feasible. Various emetic be in place prior to induction of anesthesia.
pathways are thought to contribute to nausea and Multimodal analgesia is the use of two or more
vomiting, and a variety of medications exist that analgesia agents targeting pain pathways at differ-
are geared to act upon the receptors in these path- ent levels. This approach has been shown to
ways. Many different guidelines have been pub- reduce opioid use and its associated side effects
lished regarding the treatment and prevention of [53]. This should be of interest to those in the
PONV [50, 51]. A study by Dewinter and col- ambulatory setting as overreliance on opioids can
leagues has shown the use of a simplified algo- lead to increased sedation and longer PACU
rithm effective in preventing and treating PONV times. While studies are ongoing to determine the
[52]. The use of a simplified approach also makes optimal multimodal regimen, research has shown
implementation easier and increases compliance. effectiveness at reducing opioid requirements. In
This algorithm advocates the administration of particular the addition of NSAIDs or COX-2
two prophylactic antiemetics for men (dexameth- inhibitors has shown to reduce opioid use when
asone + ondansetron or droperidol) and three administered as part of a multimodal strategy
prophylactic antiemetics for women (dexametha- [54]. The use of other agents such as gabapentin
sone + ondansetron + droperidol) or two anti- or pregabalin has been advocated by the American
emetics (dexamethasone + ondansetron or Pain Society [38].
droperidol) plus propofol TIVA. For treatment of
PONV, ondansetron or/and droperidol is recom-
mended. The details of the simplified algorithm 19.15 Discharge
are summarized in . Table 19.2 [52]. This strategy

resulted in a significant 33% decrease in the inci- The focus should be patient safety when deciding
to discharge a patient. Factors such as the patients
living arrangement and home support should be
.. Table 19.2 Summary of the simplified PONV taken into account prior to scheduling ambula-
algorithm tory surgery. Before returning home patients
should be advised not to drive a motor vehicle or
Men ➔2 ➔ 5HT3 antagonist or/ operate machinery for 24 h. Patients should be
Antiemetics and first-generation given written discharge instructions, and that is
antipsychotic
verbally communicated to the patient and to peo-
Women ➔3 ➔ 5HT3 antagonist or/ ple who accompany the patient. Patients should
Antiemetics and first-generation be advised on a normal course of events during
or antipsychotic recovery and what to expect in regard to pain and
2 antiemetics
+
dressing changes. Patients should be given infor-
Propofol TIVA mation on how to contact a provider should ques-
tions arise and where to return should a worrisome
Prophylaxis Therapy
event occur. Follow-up appointments should be
Abbreviated adaptation of the Simplified PONV made with the time and location of the said
algorithm proposed by Dewinter et al. [52] appointment provided in the written discharge
information.
19.16 Office-Based Anesthesia prior planning, and coordination are key to

minimizing PACU stays and avoiding prolonged
Office-based anesthesia refers to performing an discharge times. Finally the regulations that
anesthetic in an outpatient setting such as an apply to the ambulatory setting are managed by
office that does not hold accreditation as an individual states and may vary.
ambulatory surgery center. Having a procedure
done in the office is often convenient for the
patient and surgeon. Costs associated with work- 19.18 Review Questions
ing in this setting are typically lower as opposed to
an operating room providing potential savings to ?? 1. Are patients with obstructive sleep
the patient [55]. Patient safety is especially impor- apnea (OSA) appropriate candidates for
tant in the office setting. A closed claims analysis ambulatory surgery?
in 2009 determined that the severity of injury to
patients undergoing anesthesia was greater out- ?? 2. True or false: Preoperative
side of the operating room. Respiratory events benzodiazepines cannot be
from oversedation were the most common mech- administered in ambulatory surgery due
anism of injury [56]. Anesthesia providers should to prolonged postoperative recovery
have all airway management and rescue equip- times.
ment available on site.
Regulation and oversight are done by the ?? 3. If an ambulatory surgery center only
individual states and requirements vary. Some administers anesthesia via total
states currently have no formal regulations. intravenous anesthesia (TIVA) with
Organizations such as the American Association propofol, do they have to stock
for the Accreditation of Ambulatory Surgical dantrolene?
Facilities, the Accreditation Association for
Ambulatory Health Care, and The Joint
Commission provide guidance and necessary 19.19 Answers
accreditation to office facilities. Anesthesiologists
who will operate an office-based practice should vv 1. Yes – Obstructive sleep apnea (OSA)
become familiar with the laws and regulations patients present a unique challenge to
that apply in their state. the anesthesiologist, but that diagnosis
alone does not preclude a patient for
ambulatory surgery. Patients with OSA
19.17 Summary have an increased incidence of
postoperative desaturation, respiratory
Ambulatory and office-based anesthesia is failure, postoperative cardiac events,
becoming more prevalent for a multitude of fac- and elevated rate of ICU transfers [9].
tors. Decreased costs, ease of scheduling, and With this in mind, careful consideration
increased patient satisfaction all play a role. For of the procedure to be performed, how
the anesthesiologist working in the ambulatory well the patients OSA is currently
setting, the technique of anesthetic delivery managed, and expectations for
may require alteration to facilitate quicker postoperative pain should be taken
recovery times with less incidence of PONV and into account prior to scheduling
better controlled postoperative pain control. A
19 multimodal approach to pain management is
ambulatory surgery for a patient
with OSA.
increasingly becoming the standard of care.
Proper patient selection is vital as patients with vv 2. False – As many as 80% of patients may
multiple comorbidities that are poorly con- experience preoperative anxiety.
trolled may be better served as an inpatient. A Benzodiazepines are an effective
high level of proficiency in regional and neur- anxiolytic. Longer-acting agents may
axial techniques is required as this is often not be appropriate; however
employed in the ambulatory setting. Efficiency, shorter-acting agents like midazolam
283 19
should not be withheld solely over the 10. Tamisier R, Pepin JL, Remy J, Baguet JP, Taylor JA, Weiss
concern for delaying discharge. JW, et al. 14 nights of intermittent hypoxia elevate
daytime blood pressure and sympathetic activity in
Large-scale meta-analysis has not
healthy humans. Eur Respir J. 2011;37:119–28.
shown sufficient evidence that 11. American Society of Anesthesiologists Task Force on
preoperative benzodiazepine Perioperative Management of Patients with Obstructive
administration delays discharge in Sleep Apnea. Practice guidelines for the periopera-
ambulatory surgery [32]. tive management of patients with obstructive sleep
apnea: an updated report by the American Society
of Anesthesiologists Task Force on Perioperative
vv 3. Yes – Malignant hyperthermia is Management of Patients with Obstructive Sleep Apnea.
triggered by volatile anesthetic agents Anesthesiology. 2014;120(2):268–86. https://doi.
and succinylcholine. Even if a facility org/10.1097/ALN.0000000000000053.
does not have volatile agents in stock, it 12. Chung F, Subramanyam R, Liao P, et al. High STOP-
Bang score indicates a high probability of obstructive
is likely they will have succinylcholine on
sleep apnoea. Br J Anaesth. 2012;108(5):768–75.
hand in the case of an airway 13. Stierer TL, Wright C, George A, et al. Risk assessment
emergency. Since succinylcholine is in of obstructive sleep apnea in a population of patients
the building and therefore could undergoing ambulatory surgery. J Clin Sleep Med.
possibly be administered, dantrolene 2010;6:467–72.
14. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension

should be available should malignant
among adults in the US: National Health and Nutrition
hyperthermia be triggered [20]. Examination Survey, 2011–2012. NCHS data brief, no.
133. National Center for Health Statistics, Centers for
Disease Control and Prevention, US Dept of Health
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287 20
Remote Locations
Mary E. Arthur and Chizoba N. Mosieri

20.2 Why the Increased Need for Anesthesia
in Remote Areas – 288
20.3 Classification of Remote Locations – 288
20.4 Three-Step Approach to Anesthesia
in a Remote Location – 289
20.4.1 Patient Factors – 290
20.4.2 Procedure – 290
20.4.3 Environment – 290
20.5 Standards of Care for Providing Anesthesia

in Remote Locations – 291
20.6 Types of Anesthesia in Remote Locations – 293
20.7 Perioperative Complications in Remote
Locations – 296
20.8 Location-Specific Catastrophes – 296
20.8.1 Locations Not Designed for the Administration
of Anesthesia: Psychiatry Wards and Procedure
Rooms in Emergency Departments – 296
20.8.2 Locations with Fixed Equipment: Interventional
Radiology/Neuroradiology/CT – 298
20.9 Magnetic Resonance Imaging – 298

20.9.1 Subspecialty-Specific Built Room: Dental Surgery
Units – 299
20.9.2 Specialized Diagnostic Suites – 300
20.10 General Principles of Anesthesia in Remote

Areas – 302
References – 303

https://doi.org/10.1007/978-3-319-96125-5_20
288 M. E. Arthur and C. N. Mosieri
20.1 Introduction 20.2 hy the Increased Need

W
for Anesthesia in Remote Areas
A remote anesthesia site generally refers to a
location which is distant from the main operat- The number of diagnostic, therapeutic, and inter-
ing room (OR) and may also be referred to as ventional procedures performed outside of the
nonoperating room anesthesia (NORA). In con- OR environment has increased exponentially over
trast to an OR, remote locations are typically not the past 20 years [1–3]. Pino observed that by
designed to accommodate a patient undergoing a 2007, 12.4% of all anesthetic care in the United
general anesthetic. These remote locations are States was delivered outside the OR environment,
typically designed for their intended purpose mostly by non-anesthesiologists [4]. An explosion
only (e.g., imaging) without considering the of technological advances, constraints on operat-
anesthesia-related aspects of a patient receiving ing room time, the desire of patients for sedation
anesthesia or the providers of the anesthetic. and lack of recall, and a legitimate need for anes-
Anesthetizing patients in a controlled environ- thetic care of certain patient populations such as
ment, with familiar equipment and readily avail- pediatric and mentally challenged patients all
able assistance, is an important factor to deliver contribute to the increase in popularity of anes-
safe anesthesia care. These principles may be thesia in remote areas. An aging population and
compromised, when anesthesia providers are the increasingly prolonged survival of patients
asked to provide anesthesia in sites remote from with complicated disease states have changed both
the traditional OR. The anesthesiologist is now the complexity of the interventions performed
frequently consulted to help manage patients and the acuity of the patient population. These
with advanced congenital and valvular cardiac cases involve nearly every medical specialty, gen-
diseases and comorbidities such as chronic erate volume and revenue equivalent to that of the
obstructive pulmonary disease, diabetes, renal OR, and are as demanding for anesthesiologists.
failure, morbid obesity, and obstructive sleep Cases include everything from minor procedures
apnea. Unique patient’s characteristics such as to intense cardiac procedures requiring postpro-
inability to lie flat or difficult airway add to the cedure care in the intensive care unit. The signifi-
already challenging anesthesia planning and cant improvement in monitoring and the
conduction. introduction of short-acting, fast emergence anes-
Cases performed outside of the OR are char- thetics have also contributed to the increase in
acterized by three distinct features: cases done in remote locations.
1. The remote location, i.e., the procedure, does
not take place in a typical OR.
2. Personnel performing the procedure for the
most part are not surgeons but rather 20.3 Classification of Remote
medical interventionalists or proceduralists, Locations
and the procedures and technologies used
may be novel in one way or the other. Remote locations share several design challenges.
Medical proceduralists are often highly They belong to other departments, and the deliv-
specialized consultants with limited knowl- ery of anesthesia is usually not considered in the
edge about the overall condition of their design process. They are classified based on
“referred” patients and are also uninformed design, equipment, type of procedures performed,
about the practice of anesthesiology and and specialties involved [5].
relatively inexperienced in working with Remote locations may be classified as:
another “support” physician. 1. Locations not designed for the administra-
3. Many of these procedures are performed on tion of anesthesia
20 patients deemed “too sick for surgery,” and in 2. Locations with fixed equipment
some cases the patients are critical or 3. Subspecialty-specific rooms outside the main
unstable and therefore need advanced and OR
specialized anesthesiology skills. 4. Specialized diagnostic suites
Remote Locations
289 20
Locations not
designed for the Emergency room Suturing of lacerations
1
administration of Psychiatric wards Electroconvulsive therapy
anesthesia
Computed tomography, magnetic resonance

Neuroradiology suite imaging, embolization of cerebral aneurysms,
Locations with MRI/CT transjugular intrahepatic portosystemic shunt,
2
fixed equipment Interventional radiofrequency ablation, angioplasty/stenting/
radiology thrombolysis in stroke or cerebral aneurysms,
radiation therapy
Subspecialty- Dental surgery units

specific rooms Day surgery suites Dental extractions
3 Restorative dentistry
outside the main Obstetric units
operating room Burn units
Upper gastroenterology endoscopy, esophageal

dialtion and stenting, percutaneous endoscopic
gastroscopy tube placement, endoscopic retrograde
cholangiopancreatography, colonoscopy,
cardioversion, transesophageal echocardiography,
Gastroendoscopy
electrophysiology studies and radiofrequency
Specialized Echocardiography Lab
4 ablation, implantation of biventricular pacing
diagnostic suites Electrophysiology
systems and cardioverter defibrillators, diagnostic
Catheterization lab
cardiac catheterization, percutaneous coronary
interventions, interventional techniques for
structural heart disease, transcatheter aortic valve
implantation or replacement, placement of left
ventricular cardiac assist devices
.. Fig. 20.1 Classification of remote locations
Examples of remote locations and procedure types

are shown in . Fig. 20.1. The standards of anes-

thesia care and patient monitoring are the same

regardless of location. Remote locations have dif-
ferent safety concerns which may be related to the
Patient
patient, procedure, and the environment.
20.4 Three-Step Approach

to Anesthesia in a Remote
Procedure Environment
Location
Adopting the three-step approach to anesthesia in

.. Fig. 20.2 The three-step approach to anesthesia in
remote locations helps to minimize errors remote locations
(. Fig. 20.2). There are several inherent problems

related to the patient, the procedure, and the envi- 20.4.3 Environment
ronment when providing anesthesia in remote
locations. The anesthesiologist must establish Remote locations are a less optimal environment for
what the procedure entails and how the procedure anesthesia delivery [9, 10]. Factors may include:
will be performed as well as the general health of 1. Hostile environment or design: These
the patient. The staff is unfamiliar with anesthe- locations were often designed for other
tized patients and anesthesiology equipment. In departments without considering whether
most instances, there is lack of rigorous pre- anesthesia services would be needed. The
procedural check-in processes. There is inade- environment is unfamiliar, and the room is
quate anesthesia support, and anesthesiologists cramped with unfamiliar equipment. The
are far from colleagues and back up in the event of physical setup and the anesthesia equipment
a crisis. Majority of procedures can be performed are often different from what are found in the
with moderate sedation and standard monitoring. OR, and the monitoring equipment may be
For safe and effective anesthesia to be delivered in inadequate. Since the proceduralist has the
a remote location, the three-step approach— table controls, the procedure table or fluoros-
patient, procedure, and environmental factors—is copy equipment move frequently during the
a helpful guide [6, 7]. case without warning, and so the anesthesi-
ologist must set up with this in mind, using
long intravenous lines and breathing circuits.
20.4.1 Patient Factors 2. Accessibility to the patient: Access to the
patient by the anesthesia provider is often
The preoperative evaluation will give an indication
limited by diagnostic and therapeutic
on the general health and other comorbidities of
equipment such as the MRI scanners,
the patient. However, it is highly likely that some
fluoroscopes, or endoscopy towers.
patients scheduled for procedures in remote loca-
3. Limited equipment and monitoring: Because
tions do not undergo a thorough preoperative
these patients may require intense monitor-
evaluation. Most patients are admitted on the day
ing during the case, access to the patient is
of the procedure. The nil per os (NPO) status of the
very important so that the anesthesiologist
patient and an airway assessment are very crucial
can quickly reach the patient in the event of
[8]. Several questions need to be asked: is the pro-
an airway emergency, unstable hemodynam-
cedure expected to be painful? Can the patient lie
ics, or patient movement. It should be
flat and for how long? Is a motionless field required?
remembered that all electrical equipment
Some procedures may elicit cardiovascular
must be routinely checked by the bioengi-
responses, and others may be associated with nau-
neering department before use in the
sea and vomiting. It is also important to think of
procedure rooms to avoid such problems as
postprocedure care as most remote locations are
electrocution and burns. Anesthesia equip-
not designed with a postanesthesia care unit to
ment must undergo the same stringent
monitor the patient before being transferred.
checks as in the main OR.
4. Communication: Preoperative communica-
20.4.2 Procedure tion with the proceduralist is essential and
must include contingency plans for emergen-
The anesthesiologist needs to understand the cies and complications. The anesthesia
requirements of the procedure, its potential compli- provider must have an understanding of the
cations, anticipated duration, and the specific needs procedure to provide optimum care.
of the proceduralist. The anesthetic technique may 5. Anesthesia assistance may be inadequate:
need to be modified according to the type of proce- Proceduralists and ancillary staff may be
20 dure and its requirements. Familiarity with the pro- unfamiliar with the requirements for safe
cedure ensures that the necessary drugs, equipment, anesthesia care and how best to assist
and monitoring devices are prepared [9]. The com- anesthesia providers when a difficulty is
mon procedures that may require anesthesiology encountered. Away from the OR, help from
services are listed in . Fig. 20.1.
anesthesiology colleagues in case of an
Remote Locations
291 20
emergency may not be readily available. The
.. Table 20.1 ASA equipment requirements for
location of resuscitation equipment should be anesthesia in remote locations
noted and protocols developed with the local
staff for dealing with emergencies, including 1 Reliable source of oxygen with backup
cardiopulmonary resuscitation and manage- supply, at least an E cylinder
ment of anaphylaxis. Supplies and drugs may
2 Adequate suction
not be stocked, and equipment may not be
well maintained or checked routinely. 3 Scavenging system for wastage gases
6. Hazards and noisy environment: There are 4 Self-inflating hand resuscitator bag,
hazards unique to specific locations such as adequate drugs, supplies, and equipment for
radiation in fluoroscopy and CT suites and the intended anesthetic care, standard ASA
the magnetic field in the MRI suite. In monitors, well-maintained anesthesia
machine equivalent in function to that used
radiology suites, the electrophysiology lab, in an operating room (if inhalational agents
and the cardiac catheterization lab, exposure are used)
to radiation is always a concern. There is a
5 Sufficient electrical outlets with isolated
need to protect both the patient and the electric power or electric circuits with
anesthesia provider from the effects of ground-fault circuit interrupters (if anesthe-
ionizing radiation. Lead protecting aprons tizing area is deemed a “wet location”)
and thyroid shields may be worn for pro-
6 Adequate illumination for anesthesia
longed periods, which may lead to discom- machine and monitoring equipment with
fort. An understanding of times and location battery-powered backup
of maximum exposure to radiation will help
7 Sufficient space to accommodate equipment
decrease risk to the staff. Noise generated by and allow access to patient
an MRI scanner during scanning may average
95 db in a 1.5 Tesla scanner. Protective 8 Emergency cart with emergency drugs and
CPR equipment
earplugs need to be worn by the patient and
the anesthesiologist. 9 Adequate staff to support the anesthesiolo-
7. Lighting may be inadequate: In radiology gist and reliable two-way communication for
assistance
suites, for example, lighting may be dimmed
to enhance images. The anesthesiologist must 10 Anesthetizing area should be up to code
be exceptionally vigilant since complications with respect to building, safety, and facility
standards
may be missed with disastrous consequences.
8. Temperature regulation: Cold temperatures 11 Postprocedure management in accordance
are maintained in most imaging suites to with ASA Standards for Postanesthesia Care
as well as equipment and staff appropriate
accommodate the sophisticated computer
for transport
systems operating the imaging equipment.
Because this makes it uncomfortable for the American Society of Anesthesiologists Committee
awake patient and the staff, heat conservation on Standards and Practice Parameters [14]
techniques and temperature monitoring need
to be considered.
The American Society of Anesthesiologists (ASA) 20.5 tandards of Care for Providing

S
closed claims project is tasked with identifying Anesthesia in Remote
major areas of anesthesia-related patient injury Locations
and developing strategies to improve patient safety
[11–13]. Emerging patterns of injury from ongo- The ASA has also devised standards for basic
ing analysis of the ASA closed claims database anesthesia monitoring in remote locations. The
have led to improved safety in anesthesia delivery anesthetic techniques used for procedures in
in remote locations. As a result the ASA has devel- remote locations range from monitored anesthe-
oped standards of care for providing anesthesia in sia care (MAC) to regional and general anesthe-
remote locations (ASA equipment requirements sia. The choice of anesthetic depends on the
for remote locations are listed in . Table 20.1) [14].
patient’s condition, the procedure involved, and
the anesthesiologist’s level of comfort with and ation and avoid delivery of a hypoxic mixture when
preference for a particular anesthetic. Specific using an anesthesia machine, an oxygen analyzer
procedure requirements may also determine the with a low oxygen concentration limit alarm should
choice of anesthetic. It is often the choice of the be used to measure the concentration of oxygen in
proceduralist or based on standard protocol of the the patient breathing system. A pulse oximeter with
institution; however, the anesthesiologist must a variable pitch pulse tone with a low threshold
ensure that the best and safest technique for each alarm audible to the anesthesiologist should be
patient is chosen. used as a quantitative method of assessing blood
The same level of care expected in the OR oxygenation. Adequate illumination and exposure
should be delivered in remote locations of the patient are also necessary to assess color.
(. Fig. 20.3). The ASA standards for basic anes-

thetic monitoring apply to all anesthesia care and Ventilation Qualitative clinical signs of ade-
are intended to encourage quality patient care. quacy of ventilation such as chest excursion,
They apply to all general anesthetics, regional observation of the reservoir bag, and auscultation
anesthetics, and MAC. The standards for basic of breath sounds are useful. Quantitative moni-
anesthetic monitoring were approved by the ASA toring of the volume of expired gas is strongly
House of Delegates in 1986 and were last amended encouraged. Continual end-tidal CO2 analysis
in 2010 and affirmed in 2015. using a quantitative method such as capnography,
capnometry, or mass spectroscopy should be in
Standard I Qualified anesthesia personnel shall use from the time of endotracheal tube/laryngeal
be present in the room throughout the conduct of mask airway (LMA) placement until extubation
all general anesthetics, regional anesthetics, and or removal of LMA. When capnography is used,
monitored anesthesia care. The objective of this the end-tidal CO2 alarm should be audible to the
standard is to ensure the presence of qualified anes- anesthesiologist and should have a device capable
thesia personnel at all times due to the rapid of detecting disconnection of components of the
changes in patient’s status during anesthesia. breathing system. During regional anesthesia as
well as moderate to deep sedation, adequacy of
Standard II During all anesthetics, the patient’s ventilation using both qualitative clinical signs
oxygenation, ventilation, circulation, and tempera- and monitoring of exhaled carbon dioxide is
ture shall be continually evaluated. necessary.
Oxygenation Oxygen supply either from the wall Circulation To ensure adequate circulation, every
oxygen or cylinder should be available to last for the patient should have an electrocardiogram contin-
duration of procedure. To ensure adequate oxygen- uously displayed from beginning of the anesthesia
.. Fig. 20.3 Typical OR

setting
20
Remote Locations
293 20
until preparing to leave the anesthetizing location,
.. Table 20.2 JCAHO hospital requirements for
and arterial blood pressure and heart rate should administration of anesthesia
be evaluated and determined at least every 5 min.
Additionally, for every patient undergoing general 1 Administration of anesthesia by qualified and
anesthesia, circulatory function should be con- credentialed personnel trained to rescue a
tinually evaluated by at least one of the following: patient from general anesthesia
palpation of pulse, auscultation of heart sounds, 2 Continuous physiologic monitoring equip-
monitoring of a tracing of intra-arterial pressure, ment during the procedure, availability of
ultrasound peripheral pulse monitoring or pulse resuscitation equipment
plethysmography, or oximetry. 3 Registered nurse involved in periprocedural
care
Body Temperature Body temperature should be
4 Access and capability of administering intrave-
monitored continuously when clinically significant nous fluids, medication, and blood products
changes in body temperature are intended, antici-
pated, or suspected. 5 History, physical consent, and discussion of
risk, benefits, and alternatives with the patient
In addition to the ASA monitoring stan- or representative before anesthesia
dards, it is important to have appropriately
functioning suction apparatus, appropriately 6 Appropriate postprocedure care including
monitoring, assessment, and discharge by a
sized airway equipment, and basic drugs needed
licensed practitioner
for life support during an emergency. There
should be open communication between the 7 ASA standard guidelines for capnography
care teams. To underscore the importance of the
dangers that can be encountered delivering
anesthesia in remote locations, the joint com- of depth of sedation – a definition of general anes-
mission on the accreditation of healthcare orga- thesia and levels of sedation/analgesia. This was
nizations (JCAHO) has also come up with approved by the ASA House of Delegates October
hospital requirements for the administration of 1999 and last amended on October 15, 2014
anesthesia (. Table 20.2).
(. Table 20.4) [19]. MAC does not describe the

continuum of depth of anesthesia, but rather it

describes “a specific anesthesia service in which an
20.6 ypes of Anesthesia in Remote
T anesthesiologist has been requested to participate in
Locations the care of a patient undergoing diagnostic or thera-
peutic procedure.” [19]. Because sedation is a con-
The most common anesthesia delivered in remote tinuum, it is not always possible to predict how an
locations is monitored anesthesia care [12] fol- individual patient will respond, hence the need for
lowed by general and regional anesthesia [11, 12]. the presence of a trained anesthesia provider.
Monitored Anesthesia Care MAC is a planned General Anesthesia This is a drug-induced loss of
procedure during which the patient undergoes local consciousness during which patients are not arous-
anesthesia together with sedation and analgesia. able, even by painful stimulation. The ability to
MAC was the predominant anesthetic technique in independently maintain ventilator function may be
remote location claims, occurring more frequently impaired, and patients may require assistance in
(50/58 vs 6%) than OR claims (. Table 20.3). In a
maintaining a patent airway, and positive-pressure
closed claims analysis comparing MAC with gen- ventilation may be required. Many remote sites
eral and regional anesthesia, MAC claims were may not have medical gas supply lines and gas scav-
higher in older and sicker patients compared to enging systems that meet air exchange and electri-
general claims (p < 0.025), and more than 40% of cal safety standards, making delivery of general
the cases involved death or permanent brain dam- anesthesia very risky. Adequate hemodynamic
age similar to general anesthesia claims [15–18]. monitoring and the ability to obtain immediate
The patient’s consciousness evaluation is of extreme qualified anesthesia assistance present potentially
importance during the surgical procedure per- significant risks for the patients. Patients who have
formed with MAC. The ASA created the continuum had a procedure under general anesthesia require
.. Table 20.3 Context-sensitive half-life of intravenous opioids and sedative-hypnotic drugs
Intravenous Elimination Context-sensitive Intravenous Elimination Context-sensitive

opioids half-life half-life sedative-hypnotic half-life half-life
drugs
Fentanil 2–4 h 200min (6 h Propofol 4–23 min 3–18 min

infusion), 300min
(12 h infusion)
Remifentanil 3–10 min 3–4 min Ketamine 2–4 min Similar to propofol
Alfentanil 111 min 50–55 min Dexmedetomidine 2–3 h 4–250 min
Etomidate 2.9–5.3 mins Shorter than

propofol
Methohexital 4 min
Midazolam 1.7–2.6 min
Diazepam 20–50 min
Lorazepam 11–22 min
Thiopental 11 min
.. Table 20.4 Continuum of depth of sedation
Minimal sedation Moderate sedation/ Deep sedation/analgesia General

anxiolysis analgesia anesthesia
(conscious sedation)
Responsiveness Normal response Purposeful response Purposeful response Unarousable

to verbal to verbal or tactile following repeated or even with
stimulation stimulation painful stimulation painful stimulus
Airway Unaffected No intervention Intervention may be Intervention

required required often required
Spontaneous Unaffected Adequate May be inadequate Frequently

ventilation inadequate
Cardiovascular Unaffected Usually maintained Usually maintained May be

function impaired
Anesthesiologist [19]
expert recovery care. This may be provided either that equipment, including the anesthesia machine,
in the procedure room by appropriately qualified is functioning and that anesthetic drugs, as well as
recovery staff or in the recovery room of operating lifesaving emergency drugs, a difficult airway cart,
rooms. In this latter situation, the availability of and defibrillators, and an assistant who can help in case
familiarity with appropriate equipment during of an emergency, are available [4, 5, 7, 9, 17].
20 transfer should be verified prior to the procedure.
In certain circumstances a patient may need to be Regional Anesthesia Regional anesthesia pro-
ventilated in the postoperative period. The avail- vides sensory blockade of a region without altering
ability of an intensive care unit (ICU) bed should be the normal anatomic features of the area. Nerve
confirmed prior to the procedure. It is ultimately damage from regional anesthesia in remote loca-
the responsibility of the anesthesiologist to ensure tions was much lower than claims in the OR, likely
Remote Locations
295 20
because less regional anesthesia is done in remote but continuous infusion techniques with propo-
locations. In a closed claims analysis of all surgical fol and dexmedetomidine are becoming increas-
anesthesia claims, regional anesthesia claims with ingly popular for maintaining a stable level of
death or permanent brain damage were less sedation in remote locations. Benzodiazepines,
(p < 0.01) when compared to general and MAC particularly midazolam, are still the most widely
claims [15]. Little has been studied about the use of used for sedation in remote locations to relieve
regional anesthesia in anesthesiology practice at situational anxiety during MAC cases. Careful
remote locations, and the reason for this is proba- titration in 1 mg increments every 5–10 min is
bly multifactorial in nature. Ultrasound-guided necessary to avoid oversedation and respiratory
blocks require an entirely new skill set for practi- depression. Propofol sedation offers advantages
tioners and entail both a financial commitment for over the other sedative-hypnotics because of its
the cost of equipment and professional commit- rapid recovery and favorable side effects pro-
ment to learn the techniques. The successful incor- file. A carefully titrated subhypnotic infusion
poration of peripheral nerve blocks into a practice of 25–75 mcg/kg/min produces a stable level of
requires a critical evaluation of the practice, look- sedation with minimal cardiorespiratory depres-
ing for blocks that fill specific needs and choosing sion and a short recovery period. Supplemental
techniques and drug combinations that offer the oxygen should always be provided when using
highest likelihood of success. Ideally, the drugs sedative-hypnotic drugs. Propofol sedation can be
selected for peripheral nerve blocks should have a supplemented with potent opioid and nonopioid
rapid onset and excellent safety profile. The desired analgesics. In comparing propofol and midazolam
duration of action and degree of motor blockade for patient-controlled sedation, midazolam was
should always be considered. A 20% intralipid associated with less intraoperative recall. Low-
emulsion infusion should be available to reverse dose ketamine infusion can be used for sedation
local anesthesia toxicity of intravascular amide and analgesia in remote locations without produc-
agent injection [20, 21]. Detailed information ing significant cardiorespiratory depression [23,
must be given to patients as to the duration and 24]. Combining a rapid onset, short-acting seda-
extent of the block, the need to protect the insen- tive-hypnotics(e.g., methohexital, propofol) with
sate limb, and the need for oral analgesic medica- a rapid short-acting opioid analgesic (e.g., alfent-
tions prior to the return of severe pain. Discussion anil, remifentanil) are better suited for continuous
of the post-block deficit with the surgeon and infusion because of precise titration to meet the
timely follow-up should be included as a plan for unique and changing needs of the patient [25].
neurologic evaluation. This has facilitated the use of total intravenous
anesthesia (TIVA) techniques in remote locations.
Intravenous Anesthetic Drugs Used in Remote loca- The context-sensitive half-life has to be consid-
tions Sedative-hypnotic drugs with a shorter ered in choosing drugs for continuous infusion
duration of action and wider safety margins (. Table 20.3). Because none of the currently

tend to be used in remote locations as part of a available IV drugs can provide a complete anes-
MAC technique. Subhypnotic dosages of intrave- thetic state without prolonged recovery times and
nous (IV) anesthetics can be infused to produce undesirable side effects, a combination of drugs
sedation, anxiolysis, and amnesia and enhance which provide hypnosis, amnesia, hemodynamic
patient comfort without producing periopera- stability, and analgesia is appropriate [26–28].
tive side effects such as respiratory depression Etomidate has minimal cardiovascular and
or postoperative nausea and vomiting (PONV). respiratory depressant effects and is quite useful in
Additionally, it should provide for ease of titra- high-risk patients. But pain on injection, excit-
tion to the desired level of sedation while provid- atory phenomena, adrenocortical suppression,
ing for a rapid return to a “clear-headed” state on and a high incidence of PONV have limited its use
completion of the surgical procedure. For cardiac [29]. Ketamine produces a wide spectrum of phar-
procedures, rapid reversibility of the sedative state macologic effects including sedation, hypnosis,
may result in earlier extubation and a shorter stay analgesia, bronchodilation, and sympathetic ner-
in the ICU [22]. Intermittent bolus injections of vous system stimulation [23, 24, 28]. The adverse
sedative-hypnotic drugs (e.g., midazolam 1–2 mg, cardiovascular, cerebro-dynamic, and psychomi-
ketamine 0.25–0.50 mg/kg) can be administered, metic effects of ketamine can be minimized by
prior administration of a benzodiazepine or a 55Aspiration

sedative-hypnotic such as propofol. New insights 55Desaturation
into the pharmacokinetics and dynamics of the IV 55Apnea greater than 15 s
anesthetics as well as the development of infusion 55Airway obstruction
pumps to facilitate IV drug delivery have greatly 55 Anesthesia-related complication:
enhanced the use of TIVA techniques in remote 55Inadequate anesthesia
locations. The shorter context-sensitive half-lives 55IV-related complications
of the newer sedative-hypnotics make these drugs 55Unplanned intubation
very useful for continuous infusions for the main- 55Prolonged anesthesia
tenance of anesthesia and sedation in remote loca- 55Secretions requiring treatment
tions [25–27]. 55Unintended deep level of anesthesia
55Unplanned use of reversal agents
55Unexpected need for bag-mask ventilation
20.7 Perioperative Complications 55Emergency sedation/anesthesia consulta-
in Remote Locations tion required
55Difficult intubation
The ASA closed claims database has provided 55Esophageal intubation
insight into the nature of adverse events associated 55Lack of scavenging
with anesthesia and sedation in remote locations. 55Pain
Bhananker et al. examined all surgical anesthesia 55Malignant hyperthermia
claims associated with MAC compared to general 55 Cardiac:
and regional anesthesia. Close to half the claims 55Cardiac arrest
were classified as preventable with better monitor- 55Unexpected change in heart rate, blood
ing such as capnography and audible alarms [13, pressure of 30%
30]. Oversedation resulting in respiratory depres- 55Hypothermia
sion was found to be an important factor in patients 55Agitation
during MAC [15, 30]. ASA closed claims data 55Delirium
found that events in remote locations were often 55 Gastrointestinal:
judged as being preventable by better monitor- 55Vomiting in a non-gastrointestinal
ing. Injurious respiratory events were significantly procedure
more common in remote location claims, with 55Nausea and vomiting
inadequate oxygenation/ventilation as the most 55 Procedure-related complications:
common specific adverse event (. Table 20.5).
55Cardiac tamponade
The predominant anesthetic technique in 55 Death
remote location claims was MAC cases. Majority
of the complications happened in the gastrointes-
tinal suite followed by either cardiology or radiol-
ogy. The severity of injuries was greater, and the
proportion of death was almost double in remote 20.8 Location-Specific Catastrophes
location claims versus operating room claims. The
anesthesia care was judged by the reviewers as 20.8.1 ocations Not Designed
L
substandard in a majority of remote location for the Administration
claims, and a large proportion of injuries were of Anesthesia: Psychiatry
considered to be preventable by better monitor- Wards and Procedure Rooms
ing. More patients suffered permanent brain in Emergency Departments
damage and death in remote locations compared
20 to operating room claims. Perioperative compli- Electroconvulsive therapy for patients with major
cations in remote locations may include: depression, mania, certain forms of schizophre-
55 Respiratory: nia, and Parkinson’s syndrome requires anesthe-
55Stridor sia and neuromuscular blockade to prevent
55Wheezing physiological and physical trauma.
55Coughing Electroconvulsive therapy may be carried out in
Remote Locations
.. Table 20.5 ASA Closed Claims Database Analysis in remote locations
ASA Closed Claims analysis remote location vs operation room
# of Location with MAC Resp Inadequate CVS Equipment Substan- Preventable by Permanent Death
claims highest claims oxygenation/ failure/ dard care better brain
1,2 ventilation malfunction monitoring damage
Metzner 87 vs 1. GI suite 2. 50 vs 44 vs 21 vs 3% 10 vs 14 vs 13% 54 vs 37% 32 vs 8% 14 vs 10% 54 vs 29%

et al 3287 Cardiology 6% 20% p < 0.001 16% p < 0.01 p < 0.001 p < 0.001
Robbertze 24 vs 1. GI Suite 2. 58 vs 38% 33 vs 2% 13% 21% 63 vs 29% 25 vs 7% 8 vs 9% 54 vs 24%

et al 1927 Cardiology and 6% p < 0.001 p = 0.003 p = 0.007
radiology
20 297
.. Fig. 20.4 Fluoroscopy
safety
1mR/h
34 mR/h
Fluoroscopy unit 4 mR/h

117 mR/h
51 mR/h
31 mR/h 1 mR/h
3mR/h
Control room
< 1 mR/h
the psychiatry ward, and more recently most hos- arterial thrombolysis (e.g., endovascular stent-
pitals have moved it to the postanesthesia care ing). Transjugular intrahepatic portosystemic
unit (PACU) for safety reasons. The physiologic shunts are used to treat the complications of
effects are a grand mal seizure, i.e., a tonic phase portal hypertension particularly variceal bleed-
which lasts 10–15 s and a clonic phase of 30–50 s. ing. Common procedures performed in the neu-
The first reaction is a bradycardia and hypoten- roradiology suite include embolization of vascular
sion followed by hypertension, tachycardia, malformations and cerebral angioplasties. Some
increases in ICP, intraocular and intragastric of the procedures may require rapid transition
pressures, and 5–10 min of ECG changes. between deep sedation and an awake responsive
Anticholinergic pretreatment with glycopyrro- state. As contrast media may be used, a history of
late/atropine is needed to prevent the transient a reaction to contrast media should be ruled out.
asystole and bradycardia. An added advantage is Smooth emergence is essential, and it is impor-
the anti-sialagogue effects of the anticholinergics. tant to avoid coughing and bucking by the patient.
Methohexital was once the drug of choice. But Access to the patient and to the patient’s airway
currently propofol, etomidate, and thiopental can be a challenge because of the fixed equipment
may also be used. Procedure rooms in emergency which might be in the way. There is high exposure
departments should have appropriate physiologi- to radiation for both patient and the anesthesia
cal monitoring systems to allow safe analgesia and provider (. Fig. 20.4). Understanding the areas

sedation. Wall oxygen, suction and resuscitation with the highest exposure to radiation in relation
equipment, drugs as well as adequate lightening to the fluoroscopy unit is key to avoiding overex-
are essential in these room. Capnography [30] posure (. Fig. 20.4) [31].

and pulse oximetry should be available when pro-

cedures are done under deep sedation.
20.9 Magnetic Resonance Imaging
20.8.2 Locations with Fixed The area of interest must be close to the MRI coil,
Equipment: Interventional so patient positioning is very important. There is
Radiology/Neuroradiology/CT limited access to the patient’s airway, and remote
20 viewing of the patient might be necessary. The
Several procedures may be performed in the aperture is narrow, and obese patients may not fit
interventional radiology suite requiring anesthe- into the MRI scanner (. Fig. 20.5). If the anes-

sia (. Fig. 20.1). Procedures include embolization

thesiologist has to stay with the patient, it is a
techniques (e.g., in the treatment of subarachnoid noisy environment, and hearing protection is key
hemorrhage and portosystemic shunts) and intra- [32, 33].
Remote Locations
299 20
.. Fig. 20.5 Radiology
suite with fixed equipment
The American College of Radiology has Inadequate sedation may result in patient
defined four safety zones within MRI facilities. movement and a failed study. Of particular impor-
These zones are zones 1 through 4 and correspond tance, never take an oxygen cylinder into the MRI
to levels of increasing magnetic field exposure and suite. Deaths have resulted as the cylinder is sucked
hence a potential safety concern (. Fig. 20.6).
into the magnetic coil. Never take a ferromag-
55 Zone 1: The magnetic field is less than 5 Gaus netic metal into the MRI suite, and this includes
(0.5mT), and area is freely accessible to the laryngoscopes, scissors, stethoscopes, and mobile
general public. phones. In an emergency take the patient out of
55 Zone 2: Is the interface between the unregu- the MRI room. Do not take emergency equipment
lated zone and the strictly controlled zone. to the patient. Patients with mental disorders and
55 Zone 3: The RF magnetic fields are suffi- pediatric patients may require deeper sedation or
ciently strong to present physical hazard to general anesthesia [32].
unscreened patients and personnel.
55 Zone 4: Synonymous with the MR magnet
room. Has the highest and greatest risk, and 20.9.1 Subspecialty-Specific Built
all ferromagnetic objects must be excluded. Room: Dental Surgery Units
Understanding the zones is important to prevent Jastak et al. conducted a closed claim analysis of
harm to patients and personnel. Monitoring is a 13 anesthetic-related deaths and permanent inju-
challenge in the MRI suite. Rapidly changing ries in the dental office setting between 1974 and
magnetic fields produce ST- and T-wave artifacts. 1989. Evaluation of intraoperative monitoring
If the ECG wires are in a loop, the magnetic field revealed a lack of vigilance. Hypoxia secondary to
may heat the wires and leads leading to thermal airway obstruction or respiratory depression led
injury [34]. to all the deaths with the exception of one who
Special considerations for monitoring include survived with severe brain damage. Ten out of the
increased length of capnography and need for plas- thirteen cases were considered avoidable by
tic components of blood pressure cuffs. Monitor appropriate patient selection, timely monitoring,
pulse oximetry. Patients need to be induced in the and effective response to adverse occurrences
holding area on an MRI safe stretcher and then [35]. Dental surgery units should have appropri-
transported to the MRI room. No metals should be ate physiological monitoring systems, i.e., capnog-
taken into the room. Only MRI-compatible anes- raphy, pulse oximetry, BP, and ECG monitoring to
thesia machines and monitoring equipment should allow safe analgesia and sedation. Additionally,
be used. Patient should be taken back to the hold- wall oxygen, suction, resuscitation equipment and
ing area for emergence and extubation. drugs should be available.
b
Entrance
Zone I
Patient dressing/holding
Zone II
Zone II
Zone IV
Zone III
Computer room
Magnet
Control room
.. Fig. 20.6 a MRI suite. b MRI zones
20 20.9.2 Specialized Diagnostic Suites location include endoscopic retrograde cholan-

giopancreatography (ERCP), upper gastrointes-
20.9.2.1 Gastroendoscopy tinal endoscopy, and colonoscopy. General
More than half of claims from remote locations anesthesia with endotracheal intubation may be
occurred in the gastrointestinal suite (. Fig. 20.7) required if deep sedation is needed in the prone
[11, 12]. Common procedures performed in this position [36].
Remote Locations
301 20
.. Fig. 20.7 Endoscopy
unit
20.9.2.2 Electrophysiology Lab/ VT, typically take 4–8 h. These procedures often
Cardiac Catheterization Lab require a greater number of ablations (up to 100 or
The number of diagnostic and therapeutic inter- more ablative energy pulses) [37]. Advanced 3-D
ventions performed in electrophysiology (EP) electro-
anatomic mapping systems that require
labs has increased exponentially over the past patients to remain motionless on the fluoroscopy
10 years (. Fig. 20.8). This includes catheter-based

table for the entire procedure are used. Patient
electrophysiology studies and ablations as well as motion may lead to distortion of the map, render-
implantation of permanent pacemakers and ing it unusable; therefore, general anesthesia with
transvenous cardioverter-defibrillator devices. paralysis may be the preferred anesthesia method
The rate of major complications associated with during these procedures. Preferred anesthetic
catheter ablation procedures is less than 3%. agents are those least expected to affect the auto-
Specific complication rates reported from a multi- nomic nervous system, cardiac refractoriness, and
center study of catheter ablation for supraventric- intracardiac conduction especially during the
ular tachycardia include groin hematoma (3%), post-ablation testing phase of the procedure.
transient heart block or heart block not requiring Propofol does not produce a significant prolonga-
a permanent pacemaker (2%), pericardial effusion tion of sinus node recovery time. Midazolam,
(1.9%), complete heart block (1%), cardiac tam- alfentanil, propofol, and sevoflurane do not affect
ponade (0.6%), and transient hypotension (0.6%). inducibility or maintenance of supraventricular
Event rates for other complications were less than tachycardia. The use of an esophageal temperature
0.4% [37–39]. monitoring during catheter ablation for AFib is
For monitored anesthesia care, the preferred recommended. A luminal esophageal temperature
medications include short-acting opiates such as probe is most accurate when it is advanced or
remifentanil and alfentanil [25]. Propofol is the withdrawn to position the thermistor tip in closest
most commonly used sedative-hypnotic. The proximity to the ablation catheter the moment RF
anesthesia provider may need to lighten the anes- energy is delivered [40]. Frequent adjustment
thetic to modulate autonomic tone. Ketamine, under fluoroscopic guidance may be required.
which maintains sympathetic tone, may be used This allows the anesthesia provider to alert the
together with a propofol infusion [23, 24, 28]. electrophysiologist of any sudden increases in
Coughing as well as partial or total airway obstruc- intraluminal temperature (>0.2 °C) indicative of
tion resulting in snoring or paradoxical abdominal esophageal interaction during RF application.
motion can be problematic during intracardiac Every anesthesiologist involved in patient care in
mapping. Catheter ablations for more complex the EP lab should wear a dosimeter to track cumu-
arrhythmias, such as atrial fibrillation (AFib) or lative radiation exposure (. Fig. 20.8). In a 2005

Control room EP suite
Fluoro
Anesth
Fluoro Monitors
Bed
Monitors
.. Fig. 20.8 Schematic courtesy of the Medical College of Georgia, used with permission
study, it was found that the aggregate radiation Anesthesia-related complications as well as
exposure for all members of the anesthesiology procedure-related complications should be
department doubled after the introduction of an considered. Take into consideration procedures
EP lab [31]. The range of exposure levels was wide, that may involve significant blood loss. Consider
making dosimeter tracking even more crucial. the length of the procedure as well as supply and
support functions or resources. The main operat-
ing room should be alerted in the event of a
20.10 eneral Principles of Anesthesia
G procedure-related complication which might
in Remote Areas require emergency surgery in the operating room.
Cardiac procedures should only occur in remote
Several factors should be considered for safe locations where there is a cardiothoracic surgeon
delivery of anesthesia in remote locations. in house or on back up, should there be a need to
A thorough preoperative evaluation is impor- take the patient to the operating room emer-
tant to determine if it is safe for the procedure to gently. The operating room crisis checklists
20 occur in a remote location. Patient selection is should be available in all remote locations where
very important and should not be overlooked. sedation and anesthesia are used [41, 42]. Keeping
Understanding the procedure is very important, a record of the airway assessment and manage-
and having good communication with the proce- ment, intraoperative events, and complications is
duralist and his/her team is key. important to guide the anesthesia team for any
Remote Locations
303 20
.. Fig. 20.9 Communica-
tion between the
anesthesiologist and the
Anesthesia-related Procedure-related
proceduralist as well as the
complications complications
team in the remote
location is important, first
to understand the
procedure and also to have
a contingency plan in case
of any adverse events
Post anesthesia Intensive care

Operating room
care unit unit
future procedures. Postprocedure recovery either 7. Souter KJ. Anesthesiologists and remote locations.
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sia Evaluation. Anesthesiology. 2012;116(3):522–38.
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25. Kapila A, Glass PS, Jacobs JR, Muir KT, Hermann DJ, 38. Scheinman MM, Huang S. The 1998 NASPE prospec-
Shiraishi M, et al. Measured context-sensitive half- tive catheter ablation registry. Pacing Clin Electro-
times of remifentanil and alfentanil. Anesthesiology. physiol: PACE. 2000;23(6):1020–8.
1995;83(5):968–75. 39. Shook D, Gross W. Offsite anesthesiology in the cardiac
26. Hill SM. Pharmacokinetics of drug infusions. Contin catheterization lab. Curr Opin Anaesthesiol.
Educ Anaesth Crit Care Pain. 2004;4(3):76–80. https:// 2007;20(4):352–8.
doi.org/10.1093/bjaceaccp/mkh021. 40. Perzanowski C, Teplitsky L, Hranitzky PM, Bahnson
27. Bailey JM. Context-sensitive half-times: what are they TD. Real-time monitoring of luminal esophageal tem-
and how valuable are they in anaesthesiology? Clin perature during left atrial radiofrequency catheter
Pharmacokinet. 2002;41(11):793–9. https://doi. ablation for atrial fibrillation: observations about
org/10.2165/00003088-200241110-00001 esophageal heating during ablation at the pulmo-
28. Atiyeh R, Arthur M, Berman A, Castresana M. The utility nary vein ostia and posterior left atrium. J Cardiovasc
of ketamine in facilitating the induction of isoprotere- Electrophysiol. 2006;17(2):166–70. https://doi.
nol-refractory idiopathic ventricular tachyarrhyth- org/10.1111/j.1540-8167.2005.00333.x.
mias. J Cardiothorac Vasc Anesth. 2009;23(3):373–8. 41. Hepner DL, Arriaga AF, Cooper JB, Goldhaber-Fiebert
Epub 2008 Jun 20. SN, Gaba DM, Berry WR, et al. Operating room crisis
29. Forman SA. Clinical and molecular pharmacology of checklists and emergency manuals. Anesthesiology.
etomidate. Anesthesiology. 2011;114(3):695–707. 2017;127(2):384–92.
30. Kodali BS. Capnography outside the operating rooms. 42. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR,
Anesthesiology. 2013;118(1):192–201. https://doi. Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN,
org/10.1097/ALN.0b013e318278c8b6 Smink DS, Gawande AA. Simulation-based trial of
31. Katz JD. Radiation exposure to anesthesia personnel: surgical-crisis checklists. N Engl J Med. 2013;368(3):
the impact of an electrophysiology laboratory. Anesth 246–53.
20
305 21
Equipment Problems
Benjamin Homra and Allison Clark
21.2 Anesthesia Machine Checklist – 306
21.3 Anesthesia Machine: Perils and Pitfalls – 308

21.3.1 Breathing Circuit – 310
21.3.2 Ventilator – 310
21.3.3 Vaporizers – 311
21.3.4 Supplemental Oxygen Supply – 311
21.3.5 Anesthesia Machine – 311
21.4 Patient Injuries – 311
21.5 Management of Anesthesia Equipment

Failure – 312
21.5.1 Breathing Circuit Problems – 312
21.5.2 Ventilator – 313
21.5.3 Vaporizer – 313
21.5.4 O2 Supply – 313
21.5.5 Anesthesia Machine – 313
21.6 Plan for Machine Failure – 314
21.8 Answers – 315
Bibliography – 315

https://doi.org/10.1007/978-3-319-96125-5_21
306 B. Homra and A. Clark
the same. The twenty-first century has seen the

Key Points evolution of the anesthesia machine to include
55 The pre-anesthesia checklist should be new complex mechanical and electronic moni-
performed prior to patient care and toring systems, making the task of conducting a
when done correctly prevents the vast thorough PAC challenging. Furthermore, one
majority of patient injury due to checkout procedure is no longer applicable to all
equipment failure. anesthesia workstations. Variance in design
55 Anesthesia providers should be aware of among the manufacturers means that a PAC
the common causes of equipment must be tailored to the individual machine. For
malfunction and should be competent in these reasons, the ASA’s updated pre-anesthesia
recognizing and addressing these issues. checkout guidelines for 2008 aimed at creating
55 Simulation training is becoming an general principles for all anesthesia delivery sys-
integral part of anesthesia provider tems [1]. The idea was for individual anesthesia
training. departments to take these principles and develop
their own PAC that best utilized their resources
so that a PAC could be performed consistently
and expeditiously.
21.1 Introduction The role of the anesthesia department varies
from institution to institution, but by and large,
As anesthesia care providers, our first duty is to the anesthesia provider’s role is expanding to
provide patient safety. Modernization of anesthe- include duties outside of the operating room.
sia delivery equipment and monitoring, as well as Because of their duties both in and out of the
improvements in provider training, has led to operating room, providers rely more heavily on
measureable improvements in patient safety and a ancillary staff to assist them with making sure
decline in reportable adverse events due to equip- anesthetics are delivered safely and efficiently. The
ment malfunction in the Anesthesia Closed 2008 PAC guidelines include ancillary staff such
Claims database. Anesthesia providers should be as anesthesia technicians and/or biomedical tech-
trained on the recognition and management of nicians in the pre-check process. The guidelines
common equipment failures to reduce the risk of name 15 specific items that should be checked as
patient injury. Training should occur through a part of a complete PAC. The responsibility of who
combination of studied learning, on-site training may check the items depends on the complexity
by shadowing experienced anesthesia providers, of the task and falls into one to four categories:
and simulation training to get a “run-through” of provider, technician, technician or provider, or
an emergency situation before it actually occurs technician and provider. The ability to have both
in the clinical setting. Anesthesia providers should providers and technicians assist with the PAC
be competent in performing all aspects of the pre- adds redundancy to the process with the goal of
anesthesia machine checklist, be aware of how to reducing errors and patient harm [2].
both recognize and manage common equipment The modern anesthesia machine is analogous
problems and how to best prevent equipment to the smartphone. In both industries, manufac-
malfunction from happening in the first place. turers compete to improve existing machines and
Similar to flying a plane, vigilance in preparedness add new software and hardware to create a more
of anesthesia equipment malfunction leads to user-friendly experience. For all the bells and
safer anesthesia care. whistles, a smartphone is guaranteed to perform a
few basic universal functions. Similarly, all anes-
thetic machines must be able to supply medical
21.2 Anesthesia Machine Checklist gases (such as nitrogen dioxide and oxygen)
mixed with anesthetic vapors through a positive
The first pre-anesthesia checkout (PAC) recom- pressure-generating ventilator that can safely dis-
21 mendation was developed in 1993 by the pose of expired gases through a scavenging sys-
American Society of Anesthesiologists (ASA). At tem. There must also be a form of monitoring
that time, the selection of anesthesia delivery both the system and patient as well as a suction
systems was few, and their operation was largely apparatus to clear the airway [1, 3]. These require-
Equipment Problems
307 21
ments are pervasive among anesthesia societies within the anesthesia care location and
around the world and have been adopted and checked daily.
individualized by anesthesia departments [4–6]. 55 Item #2: Confirm suction is adequate to clear
As previously mentioned, ASA’s 2008 PAC patient’s airway. Traditionally, suction is
guidelines name 15 specific tasks that both anes- measured by allowing the suction tubing to
thesia providers and technicians should perform attach to the hand or thumb. This method is
to ensure the pre-check is complete. The following dependent on the weight of the tubing itself.
is a brief summary of those specific items. A PAC Reliable suction is able to support the total
summary can be found in . Table 21.1.
weight of standard tubing, which is about
55 Item #1: Ensure a self-inflating manual 6 feet.
ventilation device (SIMVD), such as the 55 Item #3: Confirm the workstation is supplied
Ambu Bag ™ (Ambu, Ballerup, Denmark), by AC power and the backup battery is
and backup oxygen source are both available charged. Anesthesia machines run on AC
and functioning. The ability to manually power and have a built-in battery in case of
ventilate a patient is of utmost importance power failures. Most machines have indica-
when there is an equipment failure. The tors showing which power source is being
Ambu Bag serves as a means to provide room utilized.
air when needed. Additionally, an oxygen 55 Item #4: Ensure appropriate patient monitor-
cylinder should be immediately available ing and check corresponding alarms.
.. Table 21.1 PAC tasks to be completed daily or after a machine is moved or vaporizers changed
Task Responsible party
Item #1 Verify auxiliary oxygen cylinder and manual ventilation device (Ambu Bag) Provider and tech
are available and functioning
Item #2 Verify patient suction is adequate to clear the airway Provider and tech
Item #3 Turn on anesthesia delivery system, and confirm that AC power is available Provider or tech
Item #4 Verify availability of required monitors, including alarms Provider or tech
Item #5 Verify that pressure is adequate on the spare oxygen cylinder mounted Provider and tech
on the anesthesia machine
Item #6 Verify that the piped gas pressures are ≥50 psig Provider and tech
Item #7 Verify that vaporizers are adequately filled and, if applicable, that the filler Provider or tech
ports are tightly closed
Item #8 Verify that there are no leaks in the gas supply lines between the Provider or tech
flowmeters and the common gas outlet
Item #9 Test scavenging system function Provider or tech
Item #10 Calibrate or verify calibration of the oxygen monitor, and check the Provider or tech
low-oxygen alarm
Item #11 Verify carbon dioxide absorbent is fresh and not exhausted Provider or tech
Item #12 Perform breathing system pressure and leak testing Provider and tech
Item #13 Verify that gas flows properly through the breathing circuit during both Provider and tech
inspiration and exhalation
Item #14 Document completion of checkout procedures Provider and tech
Item #15 Confirm ventilator settings, and evaluate readiness to deliver anesthesia Provider
care (anesthesia time-out)
Standards of monitoring are clearly defined 55 Item #11: Verify carbon dioxide absorbent is
and include blood pressure, pulse oximetry, not exhausted. Absorbent often turns a
electrocardiography, capnography, and characteristic color indicating that it has been
temperature. Monitors should clearly display desiccated. Other method to test for CO2
these readings and have functioning alerts to rebreathing is by checking the capnography.
make the anesthesia provider aware of The inspired CO2 concentration (FiCO2)
changes. should read <4.
55 Item #5: Verify that the spare oxygen cylinder 55 Item #12: Breathing system pressure and leak
is adequately pressurized. The spare cylinder’s testing. The complete circuit must be tested to
valve should remain closed after checking. ensure that adequate pressures can be
The type of machine (pneumatically powered generated during both manual and mechani-
versus electrically powered ventilators) cal ventilation and that the APL valve can
dictates how quickly the oxygen will be used. relieve pressures during manual ventilation.
An oxygen cylinder for a pneumatically Automated processes now evaluate for leaks
powered ventilator may only provide 30 min and the compliance of the circuit, which
of gas. adjusts the volume delivered by the ventilator.
55 Item #6: Verify that piped gas pressures are 55 Item #13: Verify that gas flows properly through
>50 psig. Gas arriving from a central source the breathing circuit during both inspiration
can fail. Ensure before the day begins that an and expiration. Leaks through unidirectional
adequate gas pressure is available. valves are too slight to be detected visually. A
55 Item #7: Check vaporizer levels and secure technician can assess for valve incompetence,
filler ports. To prevent light anesthesia and but this would be too cumbersome to perform
recall, ensure the vapor levels are sufficient daily. Instead, capnography can detect backflow
for the case. Machines equipped with low through a valve.
agent alarms will alert the provider to low 55 Item #14: Document completion of checkout
vapor levels intraoperatively. If the machine procedures. Documentation helps the provider
does not have automatically closing filler keep track of checkout tasks and serves as a
ports, retighten the valves after refilling to record should any adverse events occur.
prevent leaks. 55 Item #15: Confirm ventilator settings and
55 Item #8: Check for leaks in the gas supply evaluate readiness to deliver anesthesia care.
lines. The flow of gas from the common gas This is analogous to a “time-out” in which the
outlet through the anesthetic vaporizers must anesthesia provider can confirm that all the
be evaluated daily. Machines with automated proper tasks have been completed and the
leak tests are common but often do not machine is ready to deliver the correct
include leaks at the level of the vaporizer. The anesthesia to the correct patient. It protects
automated test should be repeated for each against errors caused by pressure or haste.
vaporizer.
55 Item #9: Test scavenging system function. The The ASA created these recommendations as a
connections that remove used anesthetic gas guideline for anesthesia providers to suit their
from the patient prevent the gases from own practice. They form the backbone of safe
contaminating the patient and room. These anesthesia practice for which the provider should
connections should be checked daily. Some make a daily effort to fulfill.
scavenging systems use positive and negative
pressures to protect against pressure fluctua-
tions in the breathing circuit. This more 21.3 Anesthesia Machine:
specialized task can be completed by a Perils and Pitfalls
technician.
55 Item #10: Calibrate the oxygen monitor and Gas delivery systems have advanced tremen-
21 check low oxygen alarms. The monitor dously from what was first used in the nineteenth
should be calibrated to read 21% for room air. century’s famed Ether Dome at Massachusetts
Test by setting the alarm to sound at a higher General Hospital. The father of anesthesia’s,
oxygen concentration than 21% while William T.G. Morton, 1846 device was a simple
sampling room air. glass bulb containing an ether-soaked sponge
Equipment Problems
309 21
with two openings – one with a mouthpiece for system is also now more complex with multiple
inhalation and the other a valve to bring in room connections, mechanical components, and elec-
air. As . Fig. 21.1 shows, gas delivery has become
tronics, which increases the chance of equipment
much more sophisticated and monitored. The failures.
.. Fig. 21.1 Comparison a
of Morton’s etherizer a to
the most recent GE Avance
workstation b
b
.. Fig. 21.2 Adverse
anesthetic outcomes Both Equipment failure Only Provider error only
involving equipment. (Data
14
from the 2013 Closed
Claims Analysis Update by 12
Mehta et al.)
10
0
er
ly
e
to
ui
in
pp
riz
cic
ila
h
po
su
ac
nt
g
m
Va
in
Ve
ge
th
ia
es
xy
ea
th
lo
Br
es
ta
An
en
m
le
pp
Su
An equipment failure is defined as an unex- the anesthetic breathing system (ABS). Much of
pected malfunction of a device, despite routine the ABS components lie underneath the surface.
maintenance and previous uneventful use. The multiple mechanical components and con-
Equipment misuse is defined as incidents origi- nections that make up the ABS are all sources for
nating from human fault or error associated with failure and misuse. Disconnections, blockages,
the preparation, maintenance, or deployment of a leaks, valve malfunctions, and carbon dioxide
medical device. Furthermore, equipment misuse absorber failures can lead to patient injury. Caplan
was nearly three times more common than equip- et al.’s [7] survey showed that disconnections were
ment failures in a 1997 analysis of closed insur- the most frequent incidents, while obstruction of
ance claims by the ASA [7]. Despite this, Caplan the expiratory limb can be the most rapidly injuri-
et al.’s study concluded that only 2% of the 8496 ous. Obstruction of the expiratory limb through a
claims dating to 1985 were related to equipment mechanical distortion or a blocked valve backs up
issues. Most other claims were due to other fac- pressures into the lung quickly leading to baro-
tors like difficult airway, sudden changes in vitals, trauma. The most recent update of claims from
etc. Trending these claims through the decades 1990 onwards listed eight breathing circuit inci-
shows that anesthesia equipment claims decreased dents with four being from obstruction and no
as a proportion of general anesthesia claims over claims due to disconnections [8].
time [8]. These equipment issues were separated
into five categories: breathing circuit, ventilator,
vaporizer, gas tank, and anesthesia machine 21.3.2 Ventilator
(. Fig. 21.2). A fundamental knowledge of the

perils and pitfalls inherent with each component The mechanical ventilator frees up the anesthe-
of the gas delivery system can help the provider tist’s hands from manually ventilating and allows
identify equipment failures intraoperatively. for the provider to focus attention elsewhere when
needed. Unfortunately, because the ventilator is
21 21.3.1 Breathing Circuit
so automated, the provider may forget important
steps to ensure the ventilator is working properly.
As a result, ventilator misuse is far more common
The plastic disposable circuit that attaches to the than ventilator equipment failure [9]. Turning on
machine is the tip of the iceberg when it comes to the ventilator may seem intuitive; however, there
Equipment Problems
311 21
are multiple clinical scenarios in which the venti- empty, incorrect positioning or missing compo-
lator may accidently be left off. In fact, the four nents, and vaporizer malfunction.
ventilator claims from the most recent report
were all due to provider failure to turn on the ven-
tilator [8]. Some examples include after position 21.3.4 Supplemental Oxygen Supply
change, upon transfer of an intubated patient
from the ICU to the OR, after discontinuing car- A spontaneously breathing patient in the immedi-
diopulmonary bypass, and after placement of a ate postoperative period should receive supple-
chest tube. Other common ventilator misuses by a mental oxygen to correct hypoxemia associated
provider include inappropriate settings for tidal with recovery from anesthesia and surgery.
volume or respiratory rate, inappropriate pressure Unfortunately, provider error has accounted for
limits, inappropriate inspiratory-expiratory ratio all of the claims in this category [8]. Improvised
setting, failure to reset fresh gas flow leading to techniques to deliver oxygen without proper tub-
increased tidal volumes, and deactivating or ing or mask were most common. Situations such
inappropriate use of the ventilator and threshold as these events often result in barotrauma and
pressure alarm limit (TPAL) alarms. The ventila- pneumothorax. Additionally, mislabeled or mis-
tor is also subject to equipment failures. read gas tanks may lead to serious injury if
Troubleshooting issues with ventilator should another gas is mistaken for oxygen, such as carbon
include a check of the bellows, as there may be a dioxide.
hole or poor seal between the bellows and casing.
21.3.5 Anesthesia Machine

21.3.3 Vaporizers
Anesthesia machine breakdowns do not typically
The agent analyzer provides the concentration of result in significant adverse events. A proper
vaporized agent that is inspired by the patient. It is anesthesia checkout should identify any machine
factory calibrated and should be within 10–15% failures before the case begins. For intraoperative
of the vapor concentration dial setting. Vaporizer failures, a backup machine should be on standby
discrepancies occur when the agent analyzer for emergencies. The anesthesia provider may be
reads differently than the dial setting on the required to manually ventilate the patient while
machine [10]. Common problems that result in awaiting functioning equipment.
an inappropriately increased vaporized agent The categories described above should pro-
concentration lead to overdose or potentially vide an adequate survey of the equipment failures
lethal doses of anesthetic agent. Overfilling the and equipment misuses encountered on a daily
vaporizing chamber with liquid agent spills liquid basis. It requires an anesthesia provider to be ever
agent into the bypass. The fresh gas is meant to vigilant to safeguard against his or her own omis-
bypass the vaporizer; however, it comes in contact sions and errors as well as factors outside of his or
with the spilled liquid agent, thus resulting in her control.
inappropriately high concentrations. Additionally,
the “pump effect” may also raise the agent con-
centration without adjusting the dial. When back 21.4 Patient Injuries
pressures are applied to the breathing circuit, such
as with intermittent positive-pressure ventilation, In April of 1982, ABC’s 20/20 aired an episode
the anesthetic vapor may get pushed back through entitled “The Deep Sleep: 6,000 Will Die or Suffer
the bypass and mix with fresh gas. This effectively Brain Damage.” It would become a watershed
increases the vapor output. Alternatively, the moment for the practice of anesthesia. Not sur-
vaporizer may provide too little anesthetic agent, prisingly, in the few years following the episode’s
typically as a result of provider misuse. The most release, the anesthesia community intensified
common outcome in the claims update was light their focus on patient safety. Organizations such
anesthesia (n = 14) and overdose (n = 3) [8]. These as the ASA Committee on Patient Safety and Risk
claims were instances of the vaporizer not being Management and the independent Anesthesia
turned on, failure to notice the vaporizer was Patient Safety Foundation were formed to reduce
morbidity and mortality. The ASA Closed Claims 21.5 Management of Anesthesia
database, created in 1985, collects closed malprac- Equipment Failure
tice claims for review so that sources of technical
failure and human error can be identified. Rather Anesthesia providers should display competency
than using resources to fight for tort reform, lead- in the management of a variety of equipment fail-
ers in the 1980s began analyzing litigation as a ures. Development of this competency should
way to improve the specialty. Anesthesiology is occur during training through self-study, shad-
now considered to be one of the leading special- owing experienced anesthesia care providers, and
ties in addressing patient safety [11]. simulation training. Significant improvement in
For all the steps taken to ensure safety, adverse provider training and equipment design has led to
events do still occur that result in injury and occa- greater patient safety over the past several decades,
sionally death. Adverse events run a wide spec- and as a result litigation claims have seen a dra-
trum in anesthesia, ranging from oral injuries to matic decline [8].
peripheral nerve injuries to death and major dis- First and foremost, it is imperative to have a
ability [12]. Whether these events are the fault of SIMVD and alternative oxygen source to deliver
the provider, the equipment, or the anesthetic oxygen to the patient in the event of equipment
itself is difficult to delineate. A recent study of gas failure ([8, 14–16].
delivery equipment claims found that provider
error alone constituted the majority of claims
(68%), while equipment failure accounted for a 21.5.1 Breathing Circuit Problems
smaller portion (13%) and provider error with
equipment failure made up the last 18% [8]. Mehta et al.’s closed claims update revealed that
Of the 6022 claims reviewed by Mehta et al. in 9.6% of critical incidents under anesthesia occur
their closed claims update, only 0.2% involved due to circuit leaks [8]. In these instances, a low-
equipment failure. Injuries associated with vapor- pressure alarm should notify the provider of the
izer malfunctions included light anesthesia with problem. Most instances are due to low pressure
patient awareness and anesthetic overdose result- between the circuit and the patient, such as a cir-
ing in brain damage. Failure of the breathing circuit disconnect. However, the leak could be due to
cuit also commonly resulted in death/brain malfunction from the patient, such as an endotra-
damage secondary to hypoxia. There was one cheal tube (ETT) cuff leak, all the way to the
reported case of a machine leak leading to hypoxia machine, including the ventilator bellows, CO2
and cardiac arrest in a pediatric patient. There canister, vaporizer, flow sensor, or oxygen pipe-
were no equipment failures associated with the line [16]. If a leak occurs, start at the patient and
supplemental oxygen supply and ventilators. work backward to the machine to inspect for the
The drawback to only analyzing malpractice source.
claims for patient injury is that less severe adverse The first problem encountered may be a cir-
outcomes may never end up as litigation. A large cuit leak due to ETT cuff tear. Alarms that may
German quality assessment project attempted to sound include the low-pressure alarm and the
standardize self-reporting by forming a list of 63 capnometer alarm. A leak may be detected by
pitfalls, events, and complications (PECs) and administering a breathing and hearing leak
defined five degrees of severity based on the out- around the ETT. While troubleshooting, admin-
come of each PEC [13]. Their report concluded ister 100% FiO2 by manual ventilation. Check
that PECs caused by technical equipment was rare the pilot balloon for proper inflation, reinflate
(0.07%), had no fatal outcomes, and were gener- the cuff, and if the leak remains, exchange the
ally less severe. ETT. This may be performed by simply remov-
In summary, equipment failures are often rec- ing the faulty ETT or placing a cook catheter to
ognized by providers before injury occurs and perform tube exchange. Moving toward the
subsequently go unreported. Therefore, those fail- machine, a circuit disconnect or tear in the cir-
21 ures that are missed or that the provider had no cuit tubing may be the reason for a low-pressure
control over tend to be more catastrophic result- leak. Inspection of the circuit may reveal the dis-
ing in death or brain injury. connect or defect, and the circuit should be
Equipment Problems
313 21
repositioned or replaced [14]. Circuit leaks may may be silenced. Ventilator settings should be
also occur due to disconnect of the gas sampling confirmed and appropriate for the patient (neo-
line. nate, pediatric, or adult settings) to ensure
Obstruction in any given part of the breathing appropriate volume and pressure is being deliv-
circuit may also occur and prevent inadequate ered [8]. If issues with the ventilator arise, man-
oxygen delivery during anesthesia. Again, trou- ual ventilation should be performed until the
bleshooting an obstruction should begin at the issue is resolved.
patient and work backward toward the machine.
The anesthesia provider may be alerted by the
high peak airway pressure alarm or capnometer 21.5.3 Vaporizer
alarm. Begin by auscultating the patient’s lungs to
rule out bronchospasm (treat with bronchodila- Failure to turn on or fill the vaporizer may result
tor), pneumothorax (may require chest tube in light anesthesia; both of these issues are easily
placement), or main stem intubation (reposition corrected. If vapor overdose is suspected, the
the ETT). The ETT should be suctioned to rule patient should be ventilated with 100% oxygen
out mucous plugging or any other obstruction in until the end-tidal agent is appropriate and the
the ETT. Kinking of the ETT may require replace- vaporizer should be changed. If a leak is deter-
ment of a fresh ETT [14]. mined to be originating from the vaporizer, it
Circuit obstructions due to manufacturing should be inspected to ensure the caps are
defects have been reported [17]. Obstruction may tightly sealed, O rings are appropriately posi-
also occur due to stuck inspiratory or expiratory tioned, and the vaporizer is properly seated
valve or at the APL valve [8]. Inspect the valves for [8, 14, 16].
free movement during inspiration and expiration;
consider changing the valves if residue is present.
Consider placing a fresh circuit if concern for cir-
cuit obstruction due to kinking, secretions, or 21.5.4 O2 Supply
defective circuit exists.
Incidences of both circuit leaks and obstruc- Significant patient harm may result due to mis-
tion have been reported due to problems with the use of oxygen supply equipment. If alarm mal-
CO2 absorbent canister. Circuit leaks may occur function is suspected, consider recalibration of
if the canister is not properly seated, in which the oxygen sensor or replacement with a fresh
case the provider should be alerted by the low- oxygen cell. If an issue exists with the main gas
pressure and capnometer alarm. Alternatively, supply (suspicion of gas line crossover or fail-
obstruction may occur at the CO2 canister due to ure), disconnect the anesthesia machine from
blockage from absorbent granules or a broken the central supply, and turn on the backup oxy-
canister [18]. The CO2 canister should therefore gen tank located on the back of the anesthesia
be inspected for a leak due to improper position- machine. Again, ventilating with a free stand-
ing or obstruction due to any source, respectively. ing oxygen tank may be necessary while trou-
Similarly, failure may occur at the level of the bleshooting occurs. Supplemental oxygen
gas scavenging system. Fresh gas flows should be delivery materials should only be used as their
evaluated, conduits should be inspected, and manufacturer intended; improper use of oxy-
obstruction should be evaluated for due to kink- gen delivery tubing, masks, nebulizers, or
ing, occlusion, or problems with the vacuum con- wrong gas tanks has resulted in significant
trol or relief valves [16]. patient harm [8].
21.5.2 Ventilator 21.5.5 Anesthesia Machine
Failure to simply turn on the ventilator after If machine failure is suspected, the device should
induction, position changes, cardiopulmonary be removed from the patient care location and
bypass, etc. may result in patient harm. evaluated by a biomedical technician or other
Ventilator alarms should sound; however, these appropriate personnel.
21.6 Plan for Machine Failure recognized low FiO2 delivery, most did not recog-
nize the elevated FiN2O. These exercises are
The best plan for anesthesia equipment failure is important and again stress the necessity to switch
prevention. Equipment failure may be costly, to manual ventilation with an alternative oxygen
with patient safety at risk, procedural delays, source when central supply oxygen problems
and added expenses for additional supplies and arise [15]. Similarly, Waldrop et al. simulated a
personnel [16]. number of scenarios involving anesthesia equip-
Prevention begins with a complete machine ment failure for anesthesia trainees. They found
check, realizing that due to variation in available that provider skills varied widely; however, senior
anesthesia equipment, it is not possible to rely on residents performed better than their junior
one universal PAC. It is well established that simply counterparts [14]. Approaching these situations
performing the automatic self-test is incomplete through simulation rather than entirely during
and may miss a variety of equipment problems patient care, where seconds truly count, allows for
[17–19]. There are several recurring themes in the better anesthesia provider training, self-evalua-
literature regarding closed claims from anesthesia tion, thorough feedback, and measurement of
equipment problems. First, it is imperative that a progress over time.
SIMVD and alternative oxygen source are present
and functioning. Second, any steps in the pre-anes-
thetic machine checklist not automatically per- 21.7 Review Questions
formed by the machine must be performed by the
anesthesia provider, i.e., incorporating a “test lung” ?? 1. Your capnography tracing, which a
into the circuit, as well as performing the low-pres- moment ago displayed a normal
sure leak test with each vaporizer on (. Table 21.2).
capnogram with an ETCO2 of 32, now
Simulation training has been shown to expose reads zero. The low-pressure alarm
knowledge gaps in dealing with equipment mal- sounds. What is your first step?
function, as anesthesia technicians often perform A. Call for help.
a bulk of equipment maintenance and trouble- B. Silence the alarm, O2 saturation is
shooting. Mudumbai et al. tested anesthesia train- 100%.
ees by presenting them with a scenario where a C. Check the CO2 canister.
pipeline crossover existed between the central D. Check the patient circuit for a
oxygen and nitrous dioxide. While most trainees disconnect.
.. Table 21.2 PAC tasks to be completed prior to each procedure
Task Responsible party
Item #2 Verify patient suction is adequate to clear the airway Provider and tech
Item #4 Verify availability of required monitors, including alarms Provider or tech
Item #7 Verify that vaporizers are adequately filled and, if applicable, that the filler Provider or tech
ports are tightly closed
Item #11 Verify carbon dioxide absorbent is fresh and not exhausted Provider or tech
Item #12 Perform breathing system pressure and leak testing Provider and tech
Item #13 Verify that gas flows properly through the breathing circuit during both Provider and tech
inspiration and exhalation
Item #14 Document completion of checkout procedures Provider and tech

21 Item #15 Confirm ventilator settings and evaluate readiness to deliver anesthesia Provider
care (anesthesia time-out)
Equipment Problems
315 21
?? 2. Which of the following is true regarding not fulfill all of these checkout
the pre-anesthesia checklist? procedures, and there are several steps
A. The ASA checklist is updated that must be performed manually to
regularly and applicable to all fully ensure proper function. The
anesthesia delivery machines. checklist is divided into tasks that
B. Anesthesia providers must perform should be performed by the anesthesia
several steps manually for provider, technician, and both.
completion.
C. Machines with automated checklists vv 3. A – Provider error is cited in a majority
will perform the entire of anesthesia closed claims related to
recommended check. equipment problems, with most
D. Both anesthesia providers and occurrences happening in the absence
technicians should perform each of equipment failure. One-third of
step in the checklist. these claims could have been
prevented by a proper pre-anesthesia
?? 3. Which of the following is the leading checkout.
cause of patient harm due to anesthesia
equipment issues?
A. Provider error Bibliography
B. Provider error and equipment
malfunction 1. Sub-Committee of ASA Committee on Equipment and
C. Equipment malfunction Facilities. Recommendations for pre-anesthesia check-
D. None of the above out procedures. 2008. Retrieved from https://www.
asahq.org/resources/clinical-information/2008-asa-
recommendations-for-pre-anesthesia-checkout
2. Al Suhaibani M, Al Malki A, Al Dosary S, Al Barmawi H,
21.8 Answers Pogoku M. Pre-use anesthesia machine check; certi-
fied anesthesia technician based quality improvement
vv 1. D – The anesthesia provider may be audit. Anesth Essays Res. 2014;8(3):354–60. https://doi.
alerted to a circuit leak by both the org/10.4103/0259-1162.143142.
3. Goneppanavar U, Prabhu M. Anaesthesia machine: check-
capnography and low-pressure alarms.
list, hazards, scavenging. Indian J Anaesth. 2013;57(5):533–
When a leak occurs, the provider should 40. https://doi.org/10.4103/0019-5049.120151.
place the patient on 100% FiO2 and 4. Association of Anaesthetists of Great Britain and
inspect for the source of the leak Ireland (AAGBI), Hartle A, Anderson E, Bythell V,
starting at the patient and working Gemmell L, Jones H, et al. Checking anaesthetic equip-
ment 2012: association of anaesthetists of Great Britain
backward toward the machine. Common
and Ireland. Anaesthesia. 2012;67(6):660–8. https://
causes include ETT cuff leak, circuit doi.org/10.1111/j.1365-2044.2012.07163.x.
disconnect, and CO2 or vaporizer 5. Cassinello F, Ariño JJ, Bartolomé Ruibal A, de la Pinta JC,
malposition. Silencing of patient alarms de la Quintana FB, Espinosa ME, Grupo de Trabajo de
leads to delays in recognition and la Sociedad Española de Anestesiología, Reanimación y
Tratamiento del Dolor para el desarrollo de Directrices
management of equipment failure. If
para procedimientos de chequeos previos a la aneste-
initial troubleshooting does not resolve sia de la SEDAR, et al. Spanish Society of Anaesthesia
the issue, the patient should be (SEDAR) guidelines for pre-anaesthesia checking
oxygenated with a SIMVD and procedures. Revista Espanola de Anestesiologia
alternative oxygen source, and the Y Reanimacion. 2012;59(4):210–6. https://doi.
org/10.1016/j.redar.2012.03.002.
provider should call for additional help.
6. Dobson G, Chong M, Chow L, Flexman A, Kurrek M,
Laflamme C, et al. Guidelines to the practice of anesthe-
vv 2. B – ASA Recommendations for sia – revised edition 2017. Can J Anaesth. 2017;64(1):65–
Pre-Anesthesia Checkout Procedures is 91. https://doi.org/10.1007/s12630-016-0749-0.
meant to merely serve as a template for 7. Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse
anesthetic outcomes arising from gas delivery equip-
organizations to develop their own
ment: a closed claims analysis. Anesthesiology.
facility-specific pre-anesthesia 1997;87(4):741–8. Retrieved from http://www.ncbi.
checklists. The automated check does nlm.nih.gov/pubmed/9357874
8. Mehta SP, Eisenkraft JB, Posner KL, Domino KB. Patient 14. Waldrop WB, Murray DJ, Boulet JR, Kras JF.

injuries from anesthesia gas delivery equipment: a Management of anesthesia equipment failure: a sim-
closed claims update. Anesthesiology. 2013;119(4):788– ulation-based resident skill assessment. Anesth Analg.
95. https://doi.org/10.1097/ALN.0b013e3182a10b5e. 2009;109:426–33.
9. Woodcock BJ. Mechanical ventilators. In: Lobato EB, 15. Mudumbai SC, Fanning R, Howard SK, Davies MF, Gaba
Gravenstein N, Kirby RR, editors. Complications in DM. Use of medical simulation to explore equipment
Anesthesia. 3rd ed. Philadelphia: Lippincott Williams & failures and human-machine interactions in anesthe-
Wilkins; 2007. p. 1,008. sia machine pipeline supply crossover. Anesth Analg.
10. Abel M, Eisenkraft JB. Vaporizers. In: Lobato EB,
2010;110:1292–6.
Gravenstein N, Kirby RR, editors. Complications in 16. Woodworth G, Kirsch JR, Sayers-Rana S. The Anesthesia
anesthesia. 3rd ed. Philadelphia: Lippincott Williams & technician and technologist’s manual: all you need to
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11. Gaba DM. Anaesthesiology as a model for patient 17. Yang KK, Lewis IH. Mask induction despite circuit

safety in health care. BMJ (Clinical Research Ed). obstruction: an unrecognized hazard of relying on
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ncbi.nlm.nih.gov/pubmed/10720368 Case Rep. 2014;2:143–6.
12. Aitkenhead AR. Injuries associated with anaesthesia. 18. Moreno-Duarte I, Montenegro J, Balonov K, Schumann
A global perspective. Br J Anaesth. 2005;95(1):95–109. R. Increased resistance to flow and ventilator failure
https://doi.org/10.1093/bja/aei132. secondary to faulty CO2 absorbent insert not detected
13. Schwilk B, Muche R, Bothner U, Goertz A, Friesdorf W, during automated anesthesia machine check: a case
Georgieff M. Quality control in anesthesiology. Results report. Anesth Analg Case Rep. 2017;8:192–6.
of a prospective study following the recommendations 19. Eng TS, Durieux ME. Automated machine checkout
of the German Society of Anesthesiology and Intensive leaves an internal gas leak undetected: the need for
Care. Anaesthesist. 1995;44(4):242–9. Retrieved from complete checkout procedures. Anesth Analg. 2012;
http://www.ncbi.nlm.nih.gov/pubmed/7785752 114:144–6.
21
317 22
Perioperative Medication
Errors
Blas Catalani, Steven Boggs, and Ezekiel Tayler
22.2 What Is a Medication Error? – 319
22.3 How Is a Medication Error Classified? – 319
22.4 Perioperative Medication Errors

and Anesthesiology – 319
22.4.1 Taxonomy of Anesthesia-Related Medication
Errors – 322
22.5 Summary – 325
References – 325

https://doi.org/10.1007/978-3-319-96125-5_22
318 B. Catalani et al.
sola dosis facit venenum Annually in the United States, an estimated 7000
“The dose makes the poison” deaths result from preventable medication errors
Paracelsus (1493–1541) [2]. The Network for Excellence in Healthcare
Innovation (NEHI) calculates that there are over
3.8 million medication errors on inpatients each
year [3], and the cost of these errors is approxi-
22.1 Introduction mately $4.2 billion annually [4]. Lahue and col-
leagues [5] estimate that inpatient preventable
There has always been a necessary balance in ADEs associated with injectable medications
medicine between the principles of diagnosis and increase the annual US payer costs by $2.7–5.1
treatment. However, the resources required to billion and average $600,000 in extra costs per
achieve such a balance are constantly changing. hospital.
While the applied elements of medical diagnos- The sheer number of prescribed medications
tics continue to evolve scientifically, the selection administered worldwide leads to the large capac-
and delivery of a particular treatment regimen ity for errors in administration. In the United
still require a human touch. Accordingly, at its States alone, the total number of dispensed medi-
most fundamental level, the successful delivery of cal prescriptions has grown annually from 3.953
a specific therapeutic intervention and the pre- billion in 2009 to 4.453 billion in 2016 [6]. Even
vention of error require administration of the with six sigma performance (an error rate of 3.4
correct medication in the correct dose via the defects per million opportunities), medication
correct route at the correct time to the correct errors would still occur in 1309 cases with the
patient. These fundamental steps are made aforementioned US prescription data in the set-
increasingly difficult by the ever- expanding ting of pharmacy-regulated processes for dispens-
diversity and variable potency of medications ing medications. Even in such a regulated
available to practitioners. environment, it is unlikely that six sigma perfor-
To appreciate the magnitude of medications mances could be obtained. Additionally, this data
use in the United States, data from the Centers for does not account for medication administration
Disease Control and Prevention (CDC) [1] shows within hospitals which shifts perspective to high-
that: light the overall volume of medications adminis-
55 From 2011 to 2014 the percentage of persons: tered and underscore the obstacle to eliminating
55Using at least one prescription drug in the medication errors.
past 30 days: 48.9% It is important to note that the probability that
55Using three or more prescription drugs in an error will occur is influenced substantially by
the past 30 days: 23.1% the quality of the handoff of care between provid-
55Using five or more prescription drugs in ers [7]. The error rate increases as the total num-
the past 30 days: 11.9% ber of patient care handoffs between providers
55 Among physician office visits (2015): increases [8]. This informs an appreciation for
55Number of drugs ordered or provided: 3.7 data reflecting the incidence of perioperative
billion medication errors. Staender and Mahajan esti-
55Percent visits involving drug therapy: mate the overall incidence of minor events or
76.2% complications during anesthesia to be 18–22%,
55Most frequently prescribed therapeutic while the incidence of severe complications is
classes: analgesics, antihyperlipidemic approximately 0.45–1.4%, and mortality occurs at
agents, antidepressants a rate of 1:100,000 anesthetics [9]. Nanji et al.
55 Among emergency department visits (2014): reported 5.3% of medication administrations
55Number of drugs ordered or provided: during 277 operations involved a medication
317.6 million error and/or an adverse drug error (a rate consis-
55Percent of visits involving drug therapy in tent with previous studies) and of those errors,
emergency departments: 79.6% 79.3% were preventable [10]. These errors have
55Most frequently prescribed therapeutic also been found to be (unsurprisingly) higher
classes: analgesics, antiemetic or anti- among anesthesia providers with less experience
22 vertigo agents, minerals, and electrolytes (e.g., trainees) [11].
Perioperative Medication Errors
319 22
In evaluating the perioperative medication 22.3 ow Is a Medication Error
H
error rate, one must recognize the limitations of Classified?
the data and identify likely barriers to compre-
hensive reporting of medication errors. The Many methods of categorizing and stratifying
most prominent barriers include lack of aware- medication errors have been proposed. When
ness on the part of the provider that they have considering how to classify drug-related events,
committed an error, an insufficient (or total lack there are two constructs one can use to categorize
of a) reporting infrastructure, fear of punish- medication errors (ME), adverse events (AE) and
ment for self- reporting a medication error adverse drug reactions (ADR).
(regardless of patient outcome), and provider Option 1: Ackroyd-Stolarz et al. (2006) pro-
apathy. pose a simplified system which separates drug-
related problems (DRPs) into those which are
associated with injury and those which are not
22.2 What Is a Medication Error? [15] (. Fig. 22.1).

Option 2: Aronson and Ferner formulate a sys-

To give some structure to an analysis of medica- tem with medication errors (MEs) which do not
tion errors, we must first define certain terms. cause adverse events (AEs), AEs that are not reac-
MEDICATION: A “medication” is a product tions to medications and each possible permuta-
that contains a compound with proven biological tion including adverse drug reactions (ADRs) [12,
effects, plus excipients or excipients only. A medi- 14] (. Fig. 22.2).

cation is administered as a placebo, to prevent In both models, it is emphasized that “near

disease, to diagnose illness, to modify physiologi- misses” and events that do not cause actual injury
cal function, to treat a disease, or to induce and are not to be minimized, as they may be harbin-
maintain anesthesia [12]. gers of defective systems and can be used to pre-
ERROR: Pertinent definitions for “error” vent adverse events in the future.
describe an act of unintentional deviation from Option 3: The Agency for Healthcare Research
truth or accuracy that may be committed through and Quality (AHRQ) describes a series of catego-
ignorance, deficiency, or accident and fails to ries into which a medication error can be classi-
achieve what should be done. Importantly, an fied but does not utilize the familiar ME/ADE/
error may produce something by mistake [13]. ADR terms. Instead, it describes scenarios that
MEDICATION ERROR: Ferner and Aronson exemplify the error category being described [16]
(2006) emphasize that “medication errors” are (. Table 22.1).

failures in the treatment process that leads to, or In all cases, further classification of the actual
has the potential to lead to, harm to the patient cause of the error can and must be made. Ferner
[14]. and Aronson go so far as to delineate the psycho-
When a medication error occurs along, the logical origins of an error and differentiate between
“continuum of medication use” must be defined. “mistakes,” “slips,” and “lapses” on the part of the
Accordingly, medication errors can occur during provider [12, 14] (. Fig. 22.3).

the following time periods on this continuum:

55 Manufacturing
55 Compounding
55 Prescription (i.e., medication selection by a 22.4 Perioperative Medication
provider) Errors and Anesthesiology
55 Transcription (i.e., actual writing of a
prescription by a provider) From the perspective of anesthetic practice, medi-
55 Distribution/dispensing (i.e., obtaining the cation errors beyond provider control must be
medication by the patient; e.g., pharmacy fills discounted (e.g., manufacturing, compounding).
a prescription) In turn, emphasis must be placed on types of
55 Administration (i.e., delivery to the patient’s medication errors which occur with greater
body; e.g., IV, PO, PR, IM, SQ, TD, frequency in the perioperative environment. The
topical, SL) circumstances in which a patient and anesthesia
55 Monitoring following administration provider encounter one another create a role
INJURY NO INJURY
Drug-Related (Therapy) Drug-Related

Problems that Result in (Therapy) Problems
Injury (Drug-related
Morbidity)
Medication
Errors
Medication
Errors Potential
ADEs
ADEs
ADRs
.. Fig. 22.1 Relationships between the different types injury occurs, but it is still important to distinguish
of problems associated with medication use. All of the between medication errors and ADEs for the purpose of
shaded circles are also considered to be medication this diagram because not all ADRs result from medication
misadventures. Drug-related morbidity is always the errors. (Above Figure (. Fig. 22.1 per caption) from

result of some DRP; however, only some DRPs result in Ackroyd-Stolarz et al. 2006. PMID: 17138513 7 https://

injury. All medication errors are classified as ADEs when www.ncbi.nlm.nih.gov/pubmed/17138513)
for those providers that is singular among

practitioners in that they may draw up, dilute and
I. Adverse events that are not reactions administer medication without the participation
to a medicine of an intermediary pharmacist, nurse, or the
patient themselves.
For the purposes of consistency between spe-
2. Adverse drug reactions
(ADRs) (not from errors) cialties and patient care environments, the termi-
nology related to medication errors as a function
3. ADRs of the occurrence on the aforementioned
(from “continuum of medication use” must be redefined
medication in terms of the provision of anesthesia:
errors) 55 “Prescription” of a medication by an
4. Medication errors anesthesia provider (MD, CRNA) will refer to
that cause events the decision to treat a patient circumstance
that are not ADRs (e.g., elevated blood pressure) with a
particular medication (e.g., nitroglycerin).
5. Medication errors
55 “Distribution/dispensing” will refer to the
that don’t cause
adverse events actual procurement and manipulation of a
medication (e.g., picking up a medication vial
and drawing into a syringe).
55 “Administration” will continue to refer
.. Fig. 22.2 A Venn diagram showing the relation between
to the actual delivery of the medication
adverse events, adverse drug reactions, and medication
errors; the sizes of the boxes do not reflect frequencies of to the patient (e.g., into the IV line,
onto/into the patient’s skin/muscle/
22 the events illustrated. (. Figure 22.2 from Aronson 2009

PMID: 19594526 (sourced by Aronson from a collaboration membranes, etc.).

article: Ferner and Aronson [14], PMID 17061907))
321 22
.. Table 22.1 AHRQ categories of medication error classification – MATCH toolkit for medication reconciliation.
(Agency for Healthcare Research and Quality (7 http://www.ahrq.gov/professionals/quality-patient-safety/

patient-safety-resources/resources/match/matchtab6.html))
Category Description Example
A No error, capacity to cause error NA
B Error that did not reach the patient NA
C Error that reached patient but unlikely to cause Multivitamin was not ordered on admission
harm (omissions considered to reach patient)
D Error that reached the patient and could have Regular release metoprolol was ordered for
necessitated monitoring and/or intervention to patient instead of extended release
preclude harm
E Error that could have caused temporary harm Blood pressure medication was inadvertently
omitted from the orders
F Error that could have caused temporary harm Anticoagulant, such as warfarin, was ordered
requiring initial or prolonged hospitalization daily when the patient takes it every other day
G Error that could have resulted in permanent Immunosuppressant medication was uninten-
harm tionally ordered at one-fourth the dose
H Error that could have necessitated intervention Anticonvulsant therapy was inadvertently
to sustain life omitted
I Error that could have resulted in death Beta-blocker was not reordered postoperatively
Errors
When actions are intended but not performed
Mistakes Skill-based errors (slips and lapses)

Errors in planning actions Errors in executing correctly-planned actions
I. Knowledge- 2. Rule-based 3. Action-based 4. Memory-based

based errors errors errors (slips) errors (lapses)
2a. Good rules 3a. Technical

not applied or 2b. Bad rules
errors
misapplied
.. Fig. 22.3 The classification of medication errors based on a psychological approach. (. Figure 22.3 from Aronson

2009 PMID: 19594526 (sourced by Aronson from a collaboration article: Ferner and Aronson [14], PMID 17061907))
55 “Transcription” will refer to documentation 55 “Monitoring following administration” will

of a medication administration (and thus continue to refer to continual evaluation of
must be placed after the administration the patient after drug administration for
event in the perioperative care desired effect and/or adverse drug effects/
setting). reactions (ADEs/ADRs).
22.4.1 Taxonomy of Anesthesia- 55Electronic medical record (EMR) alerts to

Related Medication Errors draw provider attention to relevant patient
(. Fig. 22.4)

contraindications or drug minutiae
55Proper forethought/planning to ensure the
22.4.1.1 Perioperative (Pre-/Post-op) most appropriate medications that are
and Intraoperative (Operating available
Rooms and Labor
Medication errors related to distribution/dispens-
and Delivery) ing (procurement/manipulation) can result from:
Prescription (decision)-related medication errors 55 Failure to dilute properly (e.g., phenyleph-
in the perioperative setting are largely due to one rine, insulin)
of three inciting events: 55 Sound-alike medications (dopamine vs.
55 Treatment without consideration of patient dobutamine)
factors (e.g., failure to recognize patient drug 55 Look-alike (phenylephrine vs. ephedrine)
allergies when deciding to treat; failure to (. Fig. 22.5)

perform a comprehensive medication 55 Similar-colored labeling (even on prepackaged

reconciliation) medications) (. Figs. 22.6, 22.7, and 22.8)

55 Improper dosage of the correct medication 55 Prevention strategy:

(e.g., selection of milligram/mg dosing where 55Tall-man lettering (DOPamine vs.
micrograms/mcg are indicated) DOBUTamine)
55 Improper duration of action for desired effect 55Pharmacy preparation of prepackaged,
(e.g., treatment of acute/short-lived derange- prelabeled syringes, or any infusions
ments with long-acting medications and vice needed
versa): 55Pharmacy placement of ALERT labels on
55 Prevention strategy: look-alike, sound-alike medications (refer
55Performing a comprehensive preoperative to . Fig. 22.4)

medication reconciliation
e Op
ativ er
at
p er in
rio gR
Pe oo
m
Lack of communication
Poor anesthetic plan
Distractions
Not calling for help
Lack of materials
Lack of personnel
Lack of vigilance
y
ver
IC Deli
.. Fig. 22.4 Key elements U &
r
of perioperative care and bo
common circumstances La
that may lead to an
anesthetic “error”. (Image
courtesy of Dr. Ezekiel
Tayler)
22
323 22
.. Fig. 22.5 Look-alike labeling within the same drug

class. (Photo courtesy of Dr. Blas Catalani)
.. Fig. 22.8 Look-alike vial sizes and cap colors with

minor differences in labeling between entirely different
medications. (Photo courtesy of Dr. Blas Catalani)
55 Right route, to the

55 Right patient
55 Prevention strategy:
55Adherence to the “five-right” confirmation
.. Fig. 22.6 Look-alike labeling between two entirely protocol
different medications. (Photo courtesy of Dr. Blas Catalani) 55Reducing perioperative distractions
55Multiple patient identifiers (wristbands,
time-out protocols)
Lastly, errors related to transcription (documenta-

tion) can result in myriad ADRs due to absent,
incomplete, or inaccurate documentation lead-
ing to:
55 Repeat dosing of recently dosed medication
(with or without ADEs)
55 Subsequent overdose (e.g., narcotics, anti-
.. Fig. 22.7 Another example of look-alike labeling
between two entirely different medications this time with emetics) or sustained/potentiated effects (e.g.,
the same volume despite different syringe sizes. (Photo paralytics, antihypertensives) of certain medi-
courtesy of Dr. Blas Catalani) cations
55 Prevention strategy:
55Bar code scanning with computer confir- 55Computerized/electronic medication
mation of medication prior to opening of administration record (eMAR) to facilitate
vials/drawing up drug into a syringe review of administered medications across
multiple venues (pre-, intra-, post-op)
Administration (delivery)-related medication error 55Bar code scanners linked to eMAR
occurs in all three phases of perioperative care 55Timely documentation of medication
(pre-, intra-, postoperative) when providers fail to administrations by provider
consistently adhere to what the AHRQ refers to as
the “five rights” [17] – administration of the: 22.4.1.2 Intensive Care Unit (ICU)
55 Right medication, in the Unless specifically boardcertified in care critical
55 Right dose, at the care, the presence of an anesthesiologist within
55 Right time, by the the intensive care unit (ICU) may be segregated
into transporting patients to and from the unit for drugs to ensure compatibility with the ICU pumps
surgical procedures, emergent situations (e.g. air- and protocols, so that pumps can be programed
way management), or acute pain management. correctly. Unfamiliar concentration parameters
The nature of anesthesia care is focused on the (e.g., mcg/kg/min vs. mg/min vs. cc/hr) and/or
management of sick and debilitated patients. improper pump settings can confuse management
Accredited anesthesiology residency programs among the staff. The opportunity should be given
mandate 4 months of critical care exposure [18] to the receiving care team to have all questions
for this reason. The ICU is a dynamic environ- answered prior to the departure of the anesthesia
ment with multiple layers of healthcare providers, provider from the ICU. At the end of a long, chal-
which opens the door to numerous potential lenging surgical and anesthetic case, there is a
errors. With more variables in the system, medi- strong tendency to have a hasty sign-out. However,
cal errors in the ICU have been well documented less than full sign-out can lead to future errors in
[19–22]. As a consultant walking into such an patient management and outcome.
environment, an anesthesiologist should have a In an emergent situation, despite any chaos
good understanding of the inner workings of the surrounding a patient, one should seek out a
ICU and who to speak with when questions arise. nurse, resident, or physician responsible for the
Meticulous attention must be made to the patient and ask about drug allergies, the cause of
types of drugs infusing into the patient and to current medical condition(s), and any knowledge
which lines they are infusing. Once the patient of difficult airway issues from the past. A perfect
leaves the ICU, the anesthesiologist is responsible example of an attempt to prevent a non-error
for the types of drugs administered and the routes adverse drug reaction is the selection of a non-
in which they flow. All medications should be depolarizing paralytic (NDP) agent over succinyl-
accounted for prior to leaving the ICU and docu- choline in an airway emergency. A decision to use
mented upon arrival to the OR if actively infus- a NDP over succinylcholine could ostensibly pre-
ing. Physicians and nurses must anticipate and vent the potential ADR of succinylcholine-
prevent foreseeable events. As an example, induced hyperkalemic cardiac arrest; most
patients should not be discharged from the ICU patients in the ICU have been immobile for some
with vasoactive medications that could run out period of time leading to the proliferation of extra-
during transport. In an elevator or other location, junctional acetylcholine receptors. Fortunately,
this could lead to a cardiac arrest or anoxic event with the introduction of sugammadex, this deci-
due to hypotension. Another error could involve a sion can be made more liberally in institutions
patient on total parenteral nutrition. Failure to that have this medication that has been relatively
check glucose levels and to administer insulin newly released in the United States. The principle
therapy throughout a case could result in hypo- holds, however, that sometimes a question that
glycemia and seizure activity without clinical takes 15–30 s to answer can mitigate catastrophic
manifestation if paralytics are used. When it consequences.
comes to management of invasive lines/catheters, If a hospital utilizes an acute pain service
vigilance is essential. Connecting an intravenous (APS), then an ICU could be the site for the place-
catheter (IV) to an existing thoracic epidural ment of innumerable types of pain control regi-
would have disastrous consequences. mens. ICU nurses may not be credentialed to
Upon returning a patient to the ICU after an manage epidurals, ketamine infusions, or nerve
OR procedure, a proper sign-out should occur block catheters, so orders and management for
directly between the anesthesia provider and both such interventions may fall solely on the anesthe-
the ICU attending for medical/surgical issues and siologist. Aside from giving the wrong dosage
the ICU nurse assigned to care of the patient. In and/or incorrect medication to a patient, there are
particular, a review of all medications actively many system breakdowns that can occur while
infusing, identification of the lines into which they managing an APS. Many providers will allow for
are infusing, and notation of any recent bolus med- the consulting physicians to enter orders, but these
ications (e.g., paralytics, analgesics, etc.) should be orders must be checked against existing order sets.
discussed. It is imperative that drug concentrations A patient in severe chest pain who receives a tho-
are noted and that the ICU knows what they are. racic epidural or continuous peripheral nerve
22 They may have to obtain different concentrations of block catheter may not need a patient-controlled
325 22
analgesic (PCA) anymore, or it need only be con- Money: The Imperative for Computerized Physician
tinued at a much lower dose. If the PCA is not Order Entry in Massachusetts Hospitals. 2008. Retrieved
13 Mar 2018, from https://www.nehi.net/writable/pub-
addressed, respiratory depression (or arrest) could lication_files/file/cpoe20808_final.pdf.
occur. Nerve catheter sites should be checked 4. Massachusetts Technology Collaborative (MTC) and
daily, and communication with the nursing staff NEHI. Saving Lives, Saving Money: The Imperative for
about their existence should occur routinely. CPOE in Massachusetts. 2008. Retrieved 13 Mar 2018,
Additionally, nurses may not know the signs/ from https://www.nehi.net/bendthecurve/sup/docu-
ments/Hospital_Readmissions_Presentation.ppt.
symptoms of local anesthetic toxicity or location 5. Lahue BJ, Pyenson B, Iwasaki K, et al. National Burden
of lipid emulsion. If a paging system or other route of preventable adverse drug events associated with
of communication is not set up by the APS, harm inpatient injectable medications: healthcare and medi-
could be brought to the patient without any notifi- cal professional liability costs. Am Health Drug Benefits.
cation of the APS. It is important to take owner- 2012;5(7):1–10.
6. Statista. Pharmaceutical Products & Market. n.d.
ship of the patient, medications, and devices to Retrieved 13 Mar 2018, from Total number of medical
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medical-prescriptions-issued/.
22.5 Summary 7. Agarwala AV, Firth PG, Albrecht MA, et al. An electronic
checklist improves transfer and retention of critical
information at intraoperative handoff of care. Anesth
The scope of perioperative care is vast, and, con- Analg. 2015;120(1):96–104.
sequently, the potential for medication errors to 8. Saager L, Hesler BD, You J, et al. Intraoperative transi-
occur in these areas is likewise extensive. There tions of anesthesia care and postoperative adverse out-
are numerous primary attendings, consulting comes. Anesthesiology. 2014;121(4):695–706.
9. Staender SE, Mahajan RP. Anesthesia and patient safety:
physicians, fellows, residents, nurses, medical stu- have we reached our limits? Curr Opin Anaesthesiol.
dents, and support personnel all caring for 2011;24(3):349–53.
patients whose clinical complexity ranges from 10. Nanji KC, Patel A, Shaikh S, et al. Evaluation of periop-
simple procedures to those with the most com- erative medication errors and adverse drug events.
plex multifactorial, surgical, and medical diseases. Anesthesiology. 2016;124(1):25–34.
11. Cooper L, DiGiovanni N, Schultz L, et al. Influences
With all of the possible interactions, the potential observed on incidence and reporting of medication
for errors is significant. To distill all of the lessons errors in anesthesia. Can J Anaesth. 2012;59(6):562–70.
in this chapter, communication is the fundamen- 12. Aronson JK. Medication errors: definitions and classifi-
tal key to reduce ADRs. It is more important to cation. Br J Clin Pharmacol. 2009;67(6):599–604.
ask twice than act once. The consequences of peri- 13. Error. n.d. Retrieved 13 Mar 2018, from https://www.
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operative medication errors, according to Wahr 14. Ferner RE, Aronson JK. Clarification of terminology in
et al., “require that vigorous attempts be made to medication errors: definitions and classification. Drug
assess vulnerabilities in medication safety that Saf. 2006;29(11):1011–22.
exist in our operating rooms” [23]. It is imperative 15. Ackroyd-Stolarz S, Hartnell N, MacKinnon NJ.
that healthcare providers involved in “continuum Demystifying medication safety: making sense of the
terminology. Res Social Adm Pharm. 2006;2(2):280–9.
of medication use” continue strive for continual 16. Agency for Healthcare Research and Quality. Table 6:
reduction in the rate of medication error occur- Categories of Medication Error Classification. 2012.
rence and thereby improve patient outcomes. Retrieved 13 Mar 2018, from Medications at Transitions
and Clinical Handoffs (MATCH) Toolkit for Medication
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17. Agency for Healthcare Research and Quality. Glossary –
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Center for Health Statistics. n.d. Retrieved 13 Mar 2018, Safety Network: https://psnet.ahrq.gov/glossary/fiver-
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fastats/drug-use-therapeutic.htm. 18. Accreditation Council for Graduate Medical Education.
2. Institute of Medicine. In: Kohn L, Corrigan J, Donaldson ACGME Program Requirements for Graduate Medical
M, editors. To Err Is Human. Washington, DC: National Education in Anesthesiology. 2017. Retrieved 13 Mar
Academy Press; 1999. 2018, from https://www.acgme.org/Portals/0/PFAssets/
3. Massachusettes Technology Collaborative; New ProgramRequirements/040_anesthesiology_2017-07-
England Healthcare Institute. Saving Lives, Saving 01.pdf.
19. Camire E, Moyen E, Stelfox HT. Medication errors in IATROREF study: parts I and II. Am J Respir Crit Care
critical care: risk factors, prevention and disclosure. Can Med. 2010;181(2):134–42.
Med Assoc J. 2009;180(9):936–43, E28-E29. 22. Osmon S, Harris CB, Dunagan WC, et al. Reporting of
20. Garrouste-Orgeas M, Philipart F, Bruel C, et al. Overview medical errors: an intensive care unit experience. Crit
of medical errors and adverse events. Ann Intensive Care Med. 2004;32(3):727–33.
Care. 2012;2(1):2. 23. Wahr JA, Abernathy JH, Lazarra EH, et al. Medication
21. Garrouste-Orgeas M, Timsit JF, Vesin A, et al. Selected safety in the operating room: literature and expert-based
medical errors in the intensive care unit: results of the recommendations. Br J Anaesthesiol. 2017;118(1):23–43.
22
327 23
Physiologic Monitoring:
Technological Advances
Improving Patient Safety
Jeffrey A. Planchard
23.2 Basic Science – 329

23.2.1 Circulation – 329
23.2.2 Ventilation – 329
23.2.3 Oxygenation – 329
23.2.4 Temperature – 330
23.2.5 Depth of General Anesthesia (DGA) – 330
23.3 Advanced Cardiac Monitoring – 330

23.3.1 Thermodilution – 330
23.3.2 Continuous Cardiac Output (CCO) – 331
23.3.3 Pulse Contour Analysis – 331
23.3.4 Transesophageal Echocardiography (TEE) – 332
23.4 Depth of General Anesthesia (DGA)

Monitoring – 333
23.4.1 EEG Devices – 334
23.4.2 Auditory Evoked Potential (AEP) Monitors – 335
23.7 Answers – 336
References – 336

https://doi.org/10.1007/978-3-319-96125-5_23
328 J. A. Planchard
23 Key Points 55 Transesophageal echocardiography (TEE)

55 The ASA has established guidelines for is a helpful tool for real-time interpreta-
basic monitoring of four parameters tion of cardiac function. TEE is the single
during anesthesia: circulation, ventila- most sensitive tool for monitoring wall
tion, oxygenation, and temperature. motion abnormalities. Its major draw-
55 The standard ASA monitors provide no backs are availability and the learning
way to measure certain aspects of the curve required for proper use.
circulatory system such as preload, 55 Depth of general anesthesia (DGA)
afterload, contractility, cardiac output, monitoring extrapolates frontal lobe
stroke volume, etc. electroencephalogram data to quantify
55 The gold standard for measuring cardiac the level of consciousness. While data is
output is thermodilution. While standard limited, DGA has been shown to be
measurement requires a PA catheter, useful in certain patient populations.
newer methods such as pulse contour
analysis have allowed minimally invasive
technologies to proliferate.
Case
A 52-year-old male with a past Vasopressor requirements appears hypokinetic. The left
medical history including increase. Consistently, the FloTrac ventricle seems normal to slightly
nonalcoholic steatohepatitis, reads very low values for cardiac enlarged. The patient goes into
end-stage liver disease, hyperbili- output. Unaware that the FloTrac is cardiac arrest. Compressions
rubinemia, coagulopathy, and inaccurate in low-resistance begin. After 30 min of ACLS, the
hypertension undergoes pathologies like cirrhosis and in patient expires.
orthotopic liver transplantation. hemodynamically unstable Afterward, the surgeon asks
After the patient is anesthetized, patients, the anesthesiologist the anesthesiologist what
radial and femoral arterial lines, a decides to give more volume. After happened.
central venous catheter, and TEE four additional liters of crystalloid “Enlarged right ventricle – um,
probe are placed for intraoperative and blood products, the cardiac probably a PE,” says the anesthesi-
monitoring. Rather than place a output improves, but the central ologist. “And to think, I even used
Swan-Ganz catheter, the anesthesi- venous pressure rises significantly. our new FloTrac device.”
ologist decides to use the new Suddenly, the patient’s blood Autopsy is negative for
FloTrac system the hospital has just pressure drops precipitously. pulmonary embolism. The patient
purchased. Transesophageal echocardiogra- died from right heart failure.
The new liver is reperfused, phy is begun, revealing a grossly
starting the neohepatic phase. enlarged right ventricle that
23.1 Introduction of oxygen delivery in the fresh gas flow. Ventilation

is either assessed qualitatively or via capnography
Monitoring the patient during the perioperative if an advanced airway is in place. Circulation is
and intraoperative periods is the essential role of monitored via electrocardiogram and blood pres-
the anesthesia provider. Technological advances in sure measurements. Temperature can be measured
anesthetic monitoring over the past several anywhere in the body without a specified location.
decades have made delivery of anesthesia consid- These are minimum standards, and the complexity
erably safer [20]. As a result, the American Society of the case will dictate using more advanced clini-
of Anesthesiologists has established guidelines cal tools capable of measuring more variables, with
recommending standard monitoring of oxygen- finer precision, in time-sensitive fashion, using the
ation, ventilation, circulation, and body tempera- least invasive means possible [2].
ture. Monitoring oxygenation requires use of Especially over the last decade, physiologic
variable-pitch pulse oximetry and quantification monitoring technology has expanded well past
Physiologic Monitoring: Technological Advances Improving Patient Safety
329 23
the confines of standard ASA monitors to become Using standard ASA monitors, MAP is measured
a major industry. In fact, the global market for with conventional oscillometric or invasive blood
anesthetic monitoring devices was valued at $820 pressure monitoring, and HR can be determined
million in 2014 and is forecast to balloon to $1.61 from EKG. However, CVP, preload, afterload,
billion by 2020 [22]. contractility, and SVR are not typically measured.
With the vast array of products on the market, In the event of sudden hypotension with no
it is essential that the modern anesthesiology pro- change in heart rate, standard monitoring there-
vider familiarize him or herself with these prod- fore leaves several variables unaddressed [1].
ucts, their indications, and potential pitfalls. To
avoid the impracticality of discussing every prod-
uct on the market, this discussion is limited to 23.2.2 Ventilation
more of the common physiologic monitors avail-
able: advanced cardiac monitors and depth of Ventilation is the movement of air during respira-
general anesthesia monitors. Proper implementation, the purpose of which is to deliver extrinsic
tion of these devices may help prevent myriad gas (oxygen, anesthetic, etc.) into the circulatory
clinical disasters. system via the alveoli. Modern anesthesia machines
will automatically quantify respiratory rate, tidal
volumes, and minute ventilation. Capnography
23.2 Basic Science (CO2 monitoring) serves as a confirmation of gas
exchange at the level of the alveolus [29]. More
23.2.1 Circulation subtly, capnography also confirms ongoing
perfusion of the tissues, as CO2 is the essential by-
The circulatory system operates analogously to an product of metabolism. However, capnography
electrical circuit. Cardiac output (CO), blood measured via end-tidal CO2 (PETCO) varies from
pressure (BP), and systemic vascular resistance arterial CO2 (PaCO2) because of dead-space ven-
(SVR) correspond to current (I), voltage (V), and tilation. Furthermore, PETCO can be affected by
resistance (R), respectively. Accordingly, Ohm’s changes in tidal volume, respiratory rate, fevers,
law: hyper- or hypocatabolic state, pulmonary emboli,
cardiac output, inadequate CO2 reabsorption, and
V = I´R sampling error [28].
can be adapted to [5] 23.2.3 Oxygenation

BP = CO ´ SVR Oxygenation is the measure of oxygen delivery
For purposes of calculation, BP = mean arterial (DO2) to the tissues. Essential components of this
pressure (MAP) − central venous pressure (CVP). process are:
1. Delivery of oxygen-rich fresh gas flow
2. Adequate ventilation to deliver this oxygen to
MAP - CVP = CO ´ SVR / 80
the alveoli
3. Diffusion of alveolar oxygen into the blood
CO is the product of heart rate (HR) and stroke
stream
volume (SV). The latter is dependent on preload,
4. Uptake of dissolved oxygen by hemoglobin
afterload, and contractility. The coefficient, 80, in
5. Transport of hemoglobin to the tissues via
the above equation is to adjust for the proper units
convection
[18]. As stroke volume is dependent on preload,
6. Diffusion of oxygen bound to hemoglobin
afterload, and contractility [46], a more complete
from the capillary to cell in sufficient quantity
picture of the circulatory system is therefore
to meet metabolic demand [45]
expressed:
Standard monitoring measures this process at
MAP - CVP = HR ´ SV
only two locations: the delivery of fresh gas at the
{preload, afterload, contractility} ´ SVR
level of the machine (1) and pulse oximetry (5).
330 J. A. Planchard
23.2.4 Temperature 23.3.1 Thermodilution

23
Despite being a standard ASA measurement, there First described by Fegler in 1954, “thermodilution”
is no standard location recommended for taking measures CO by analyzing changes in local blood
the patient’s temperature. This can be problematic temperature following the bolus of cold solution
as temperature can vary by several degrees based [14]. Injecting fluid (usually 10 cc of either cooled or
on location of measurement. Temperature inde- room temperature solution) into the proximal port
pendently affects immune function, clotting, of a pulmonary artery catheter momentarily alters
metabolic rate, and blood chemistry. Further, the the blood temperature in the right atrium. With
complications of hypothermia can include each cardiac cycle, the cooled bolus is diluted into
increased risk of cardiac morbidity, coagulopathy the remainder of the blood volume until no further
(and thus risk of transfusion), delayed wound temperature deviation is present. When graphed
healing, and prolonged hospitalization [36]. over time, the area under the temperature change
curve is inversely proportional to the CO [25].
The CO can be calculated using the Stewart-
23.2.5 epth of General Anesthesia
D Hamilton equation:
(DGA)
V ´ (Tb - Ti ) K1 ´ K 2
While the ASA has no guideline on monitoring Q=
anesthetic depth, modern anesthesia machines Tb ( t ) dt
utilize mass spectrometry to measure the inspired
and expired concentrations of anesthetic gas.
These values are compared to the mean alveolar where
concentration (MAC), the average expired gas Q = cardiac output
concentration that will prevent 50% of patients V = volume of injectate
from moving to a surgical stimulus, to determine Tb = blood temperature
anesthetic depth. However, what MAC value Ti = injectate temperature
guarantees unconsciousness, recall, or lack of K1 and K2 = corrections for specific heat and
movement varies by individual [3]. Accordingly, density of the injectate and for blood and dead-
more advanced techniques seek to avoid anesthe- space volume
sia awareness by measuring depth of general anes- Tb(t) dt = area under the curve of temperature
thesia (DGA). These technologies focus on frontal change over time [25].
lobe EEG and auditory evoked potential analysis. While this calculation is considered the gold stan-
These modalities are increasingly becoming rou- dard of cardiac output calculation, some consid-
tine measures for DGA [9]. erations arise:
1. Placement of a Swan-Ganz catheter is
required [16].
23.3 Advanced Cardiac Monitoring 2. Quantity and speed of injection should be
constant for serial measurements.
Cardiac output (CO) can be used to calculate 3. CO varies with respiration, so it is recom-
stroke volume (SV) and systemic vascular resis- mended that measurements be taken at the
tance (SVR) based on parameters already mea- same phase of the respiratory cycle.
sured via standard ASA monitors (HR and MAP) 4. The basic assumptions of thermodilution can
and equations previously elucidated: SV = CO/ be undermined by severe tricuspid regurgita-
HR and SVR = CO/(MAP − CVP). HR can be tion, an intracardiac shunt, or other IV fluid
easily determined from ECG, plethysmograph, or entering the heart at the same time [27].
arterial line. MAP is measured throughout every 5. While cold solution (0–4 °C) elicits a better
case via cuff or arterial line. Technology has been measurement than room temperature
developed to accurately determine CO in clinical solution, colder temperatures may induce
situations because of the extra clinical informa- bradycardia and cause a decrease in cardiac
tion this data point can provide [46]. output [23].
331 23
23.3.2 ontinuous Cardiac Output
C overestimation of CO. If an intra-aortic balloon
(CCO) pump (IABP) is present, CO will be overesti-
mated – as the inflation of the pump will be erro-
A modified pulmonary artery catheter developed neously factored into the HR – and the stroke
by Edwards Lifesciences measures cardiac output volume created by the pump will be included in
on a continuous basis. Relying on the same scien- the measurement [21].
tific principles as thermodilution, these catheters As SV varies with the phases of the respiratory
use imbedded copper filaments to heat a small cycle, the important variable of stroke volume
portion of blood in the right ventricle. The resul- variation (SVV) can be introduced. SVV is
tant temperature change is recorded by a thermis- defined as the percentage change in SV between
tor at a more proximal point on the catheter [24]. its relative maximum and minimum within the
Advantages to using this technique include the respiratory cycle. SVV has been validated as an
automatic data generation and the avoidance of indicator of patient fluid responsiveness. In gen-
repeated fluid boluses into the heart, as these eral SVV < 10% indicates a patient unlikely to
boluses carry the risk of infection and over time benefit from fluid administration. In contrast,
alter the patient’s blood volume. Although ther- SVV > 15% indicates a patient who would likely
modilution is considered the clinical gold stan- benefit from fluid administration [11].
dard, CCO has been adopted at many institutions
because of its ease of use and reliability. Studies 23.3.3.1 PiCCO System
have shown that CCO technology correlates well The pulse index continuous cardiac output
to manual thermodilution methods [21]. (PiCCO) system utilizes both transpulmonary
thermodilution and pulse contour analysis to cal-
culate cardiac output. It requires both central
23.3.3 Pulse Contour Analysis venous and arterial cannulation. Thermodilution
is used for calibration of the device, which must
In 1904, Erlanger and Hooker introduced the be done every 8 h. A cold fluid bolus is injected
principle that CO is proportional to arterial pulse into a central line. Temperature changes are
pressure. Pulse contour analysis takes this idea detected by a thermistor attached to a specially
further, analyzing the shape of the arterial wave- designed arterial line (usually placed in the femo-
form and area under its systolic portion as corol- ral artery). Once calibrated, continuous cardiac
laries to CO. As each systolic ejection of the heart output is then calculated based on pulse contour
is analyzed, SV can be determined beat to beat. analysis [16]. In addition to cardiac output, the
When multiplied by HR, the CO can be deter- PiCCO system calculates global end-diastolic
mined [24]. volume, intrathoracic blood volume, and extra-
The major advantage of pulse contour analysis vascular lung water, global ejection fraction, con-
is its minimally invasive profile. Namely, a pulmo- tractility, and SVR [24].
nary artery catheter is no longer required to mea- PiCCO has been studied extensively and
sure cardiac output. This technology therefore found to correlate well with traditional thermodi-
avoids the potential complications associated with lution in most cases. Its use is less reliable in aortic
the PA catheter: infection, cardiac arrhythmias, aneurysms, severe valvulopathies, during periods
breakage or knotting of the catheter, and trauma of rapid temperature change, and with the use of
to or even rupture of the pulmonary arteries [13]. an IABP [16, 21].
The devices that rely on pulse contour analysis uti-
lize an arterial line, either in isolation or in con- 23.3.3.2 LiDCO System
junction with a venous cannulation site [16]. The lithium dilution cardiac output (LiDCO) sys-
Since cardiac output is determined exclusively tem uses a variation of thermodilution, measur-
from the shape of the arterial waveform, a high- ing dilution of lithium rather than changes in
fidelity signal must be assured. An overdamped or temperature. Lithium is injected into a central or
underdamped signal will render the remainder of peripheral vein, and its concentration is detected
the analysis unreliable [24]. Cardiac arrhythmias in a peripheral arterial line [11]. Two versions
(e.g., atrial fibrillation) can also cause unreliable exist: LiDCO plus and LiDCO rapid. With LiDCO
results. Severe aortic insufficiency will also cause plus, lithium is used to calibrate the system, which
332 J. A. Planchard
needs to be done every 8 h, similar to PiCCO [21]. the arterial waveform at 2000 different data
23 LiDCO rapid doesn’t rely on lithium thermodilu- points. The arterial waveform is sampled every
tion and instead uses a nomogram with which to 20 s to generate with new results [24]. CO is
calculate CO. It is an uncalibrated system most determined by the equation:
used perioperatively to trend SV values [1].
Both LiDCO systems utilize a variation of pulse CO = PR ´ SDBP ´ c
contour analysis called “pulse power analysis.”
Rather than calculating the area under the arterial
waveform, the power of every beat is extrapolated PR = pulse rate
from the waveform itself. A key assumption is that, SDBP = standard deviation of 2000 arterial data
following correction for compliance and calibra- points in relation to pulse pressure
tion, power and flow have a linear relationship. χ = An individualized conversion factor [19]
Once calibrated, the LiDCO system calculates CO, Pulse rate differs from heart rate in that the sys-
SV, SVV, and pulse pressure variation (PPV) on a tem only considers fully “perfused beats,” i.e.,
continuous basis [35]. Like SVV, PPV is a useful beats with a full systolic wave, automatically elim-
indicator of volume responsiveness [16]. inating PVCs or other poorly perfused cardiac
Beyond the limitations common to pulse con- contractions [12].
tour/power analysis (e.g., IABP, poor arterial The individualized conversion factor, χ, is
waveforms), LiDCO plus devices have more finite based on the patient’s characteristics (age, gender,
limitations secondary to lithium. LiDCO plus height, weight) and waveform characteristics
should not be used for patients <40 kg, in patients (e.g., skewness, kurtosis) which are used to esti-
already taking lithium, or in the first trimester of mate vascular compliance [24].
pregnancy [1, 16]. High levels of nondepolarizing It is important to note that FloTrac has been
neuromuscular blockers in the bloodstream may noted to perform poorly when measuring patients
cause the electrode to drift, necessitating recali- in certain situations. Unacceptable performance
bration [21]. Additionally, testing requires the has been shown in studies including patients at
withdrawal of 3–4 cc of blood per use, which in extremes of vascular tone such as patients with cir-
critically ill patients may be inadvisable [11]. rhosis undergoing liver transplant, septic shock, or
Major advantages to both LiDCO systems hemodynamic instability requiring large doses of
compared to PiCCO are it is less invasive (no CVC vasopressors [6]. In a 2014 meta-analysis, Slagt
required), its algorithm is somewhat more resis- et al. found improvement in the accuracy of the
tant to dampening, and it does not require fluid technology with subsequent generations, though
boluses. However, the variables measured are up to 30% bias in the latest generation. FloTrac was
fewer, and it relies on an electrode to detect lith- also found to be particularly inaccurate in patients
ium ion which must be replaced every 3 days [16]. with sudden changes in vascular tone [41].
While most validation studies have shown a One reason for the unreliability of the tech-
good correlation between LiDCO plus and tradi- nology during hemodynamic instability is the
tional thermodilution, two studies have found an placement of the device. While a peripheral arte-
unacceptable difference between the two modali- rial line allows for minimally invasive analysis,
ties in the context of cardiac surgery. Conversely, radial arterial lines can be subject to constriction
SVV and PVV data derived from LiDCO plus has when vasopressors are being used in large doses
been shown to be clinically reliable in practice [21]. or in hemodynamically unstable situations [39].
Consequently, cardiac output can be greatly
23.3.3.3 FloTrac System
underestimated in these patients.
The FloTrac system (Edwards Lifesciences) uti-
lizes pulse contour analysis as its method to deter-
mine cardiac output and only requires a peripheral
arterial line. Unlike PiCCO and LiDCO plus, 23.3.4 Transesophageal
FloTrac does not need to be calibrated. Rather, its Echocardiography (TEE)
calculations are based on a database of patient
characteristics preloaded into every machine. The Transesophageal echocardiography is a subject
FloTrac determines stroke volume by analyzing large enough to fill books of its own. However, the
333 23
modern anesthesia provider will need to be famil- invasive means. Pulmonary emboli can be
iar with TEE and its applicability in clinical situa- visualized directly using the mid-esophageal
tions. What follows is a quick review of the major ascending aorta short-axis or upper esophageal
benefits of quick TEE analysis in terms of the infor- aortic arch short-axis views. From the mid-
mation this modality can provide about a patient’s esophageal four-chamber view, the RV would
hemodynamic status. TEE allows for visualization appear grossly dilated with wall motion severely
of all four chambers of the heart simultaneously in decreased. Accordingly, the LV volume should
real time. It can be used as an instant means to appear decreased [33]. McConnell’s sign is pre-
evaluate wall motion abnormalities, ejection frac- served RV apical contraction in the setting of RV
tion, volume status, pulmonary emboli, contractil- free wall akinesis and is associated with
ity, valvular abnormalities, intracardiac thrombi, PE. However, a recent study found sensitivity and
and intracardiac shunts, and cardiac output [33]. specificity of 70 and 33%, respectively. Accordingly,
TEE is the most sensitive means of detecting it should be used with caution [7].
wall motion abnormalities, as they can be visual- CO can be calculated using TEE. A calcula-
ized directly [10]. Of all the standard views, the tion of stroke volume is made by measuring the
trans-gastric short-axis view allows for easiest flow through the left ventricular outflow tract
visualization of wall motion abnormalities, as the (LVOT), which is commonly chosen because it
distributions of all three (left anterior descending, maintains its dimensions during systole. First, in
left circumflex, and right) coronary arteries can the mid-esophageal long-axis view, the diameter
be seen simultaneously [33]. of the LVOT (LVOTd) is measured. Second, in the
Ejection fraction can be estimated in the deep trans-gastric long-axis view, pulsed wave
trans-gastric mid-papillary short-axis view, by Doppler is taken through the left ventricular out-
fractional area change (FAC). FAC is the percent- flow tract, creating a flow wave. The area of this
age change in the left ventricular end-diastolic wave, called the velocity time integral (VTI), is
area (LVEDA) compared to the left ventricular then measured. The VTI represents the distance
end-systolic area (LVESA): traveled in one beat by a red blood cell and is
expressed as a distance (cm). This is multiplied by
LVEDA - LVESA the area of the outflow tract to create a cylindrical
FAC = ´ 100% column of fluid, representing stroke volume.
LVEDA
Cardiac output is then determined by the follow-
ing equation [34]:
Note that FAC is based on area and is therefore
not equivalent to ejection fraction but rather cor- CO = HR ´ p ( LVOTd / 2 ) 2 ´ VTI
related to ejection fraction. A normal value for
FAC is >35%. Additionally, ejection fraction may
be directly measured by Simpson’s method of
discs. While the method will not be fully explained 23.4 epth of General Anesthesia
D
here, it involved simultaneous examination of the (DGA) Monitoring
LV in X-plane, i.e. two views, 90 degrees apart
from one another. These views together allow for As discussed in a previous chapter, anesthesia
estimation of volume via addition of ellipsoid, awareness is a rare but damaging situation. What
longitudinal discs [8]. constitutes awareness is different for each patient
Volume status can be determined by gross and can range from quick moments of recall to
examination of the ventricles. While quantitative periods of pain. The anesthesia provider has his-
measurements exist, most volume measurements torically used “responsiveness” as a measure of
are purely qualitative, determined by examination anesthetic depth: whether a patient moves to
of the ventricles to determine if they seem “empty” stimulus, exhibits a change in vital signs, etc. [37].
or “full.” An empty ventricle would appear hyper- However, if given a paralytic medication, an awake
dynamic, with a high ejection fraction and low patient may remain completely still while under-
end-diastolic volumes [33]. going great distress. Additionally, fluctuations in
TEE is unique among modalities as it can con- vital signs can be masked by vasoactive medica-
firm the existence of thromboembolisms via non- tions (e.g., β-blockers) that are commonly given as
334 J. A. Planchard
part of the anesthetic technique. Because of the known anesthetic depth. These tracings were then
23 severe consequences for both patient and provider visually discriminated to give the spectrum on
of an awareness event, DGA monitoring, if vali- which the numerical score is based [31].
dated, would provide discernible benefit [26]. The validation of BIS as a clinical tool has
What constitutes consciousness is a difficult been controversial, with studies coming up with
question that has flummoxed philosophers and conflicting results. A 2014 Cochrane meta-analy-
scientists for centuries. Although the molecular sis found BIS monitoring helps prevent awareness
pathways of anesthesia’s effects on the brain have in high-risk populations when compared with
been established, no monitor exists which can using clinical signs but found no difference in
determine in binary fashion whether a patient is using BIS in comparison with monitoring end-
conscious [15]. Rather, monitors of anesthetic tidal gas concentrations [30]. However, other
depth have thus far relied on measurable outputs studies have studied outcomes with BIS and
of brain activity. Unlike the heart, lungs, liver, etc., found only limited indications for its use [26, 43].
whose activity can be measured in discrete met- One recent study found BIS to be inferior to mon-
rics, the brain works in a subtler way that is less itoring end-tidal gas concentrations in critically
amenable to quantification [37]. ill patients [4].
Of all the DGA monitors, BIS is the oldest,
most clinically tested, and most adopted. As a
23.4.1 EEG Devices result, BIS has become the standard by which all
other DGA monitors have been assessed. This
The most reliable and scientifically sound data does not mean BIS is the “gold standard” DGA
comes from measuring the brain’s electrical activ- monitor. No methodology for assessing the “best”
ity, the electroencephalogram (EEG). Anesthesia’s DGA monitor has been validated. BIS simply has
effects on a patient’s EEG have been definitively the most data with which to assess its use [26].
characterized. As one increases the depth of anes-
thesia, the pattern exhibits a high-amplitude and 23.4.1.2 Entropy Monitor
lower-frequency pattern. Beta waves become less On the market since 2003, the entropy DGA mon-
frequent, while alpha and delta waves appear itor relies on the assumption that as depth of anes-
more commonly. As depth increases further, thesia increases, the entropy (or chaotic nature) of
bursts of alpha or beta waves become separated by EEG waveform decreases. Therefore, the regular-
periods of low-amplitude or isoelectric activity, ity of brain activity is used as a proxy for anes-
termed burst suppression. At its most profound, thetic depth. Unlike other EEG monitors, entropy
anesthesia can create a totally isoelectric EEG produces two scores: state entropy (SE) and
[37]. Because this pattern has been established, response entropy (RE). SE is a numerical score
most products measuring anesthetic depth on the (0–91) which is based on EEG. RE (on a scale of
market today utilize technology that interprets 0–100) is based on both EEG and EMG. The dif-
EEG data. ference between the two numbers is supposed to
denote the action of the forehead muscles, which
23.4.1.1 BIS Monitor is detected, but not accounted for, in BIS measure-
First introduced in 1992, the bispectral index ments [42].
(BIS) monitor analyzes the EEG of a patient’s fron-
tal lobe to produce a numerical score representing 23.4.1.3 Narcotrend
anesthetic depth. A four-lead EEG is placed on the Introduced in 2001, the Narcotrend monitor is a
patient’s forehead to monitor frontal lobe activity. three-electrode EEG placed on the patient’s fore-
The waveform measured is then examined by an head. The EEG is analyzed with the depth of anes-
algorithm that examines amplitude, frequency, thesia classified using a six-letter system: A
and phase of certain aspects of the wave. The pre- (awake) to F (profound anesthesia) with E repre-
cise algorithm used is proprietary. A score from 0 senting the ideal state for surgery. Like BIS,
(no brain activity) to 100 (an awake patient) is Narcotrend was developed based on a database of
produced, with the ideal anesthetic depth being patients at certain anesthetic depths. The respec-
characterized in the range of 40–60. BIS was tive EEGs were visually discriminated to create
developed using a data based on patient EEG’s of the scale on which the score is based [38, 42].
335 23
As one of the most studied monitors, a num- the curve inversely proportional to the cardiac
ber of clinical conclusions can be made about output. Despite being the most reliable means of
Narcotrend. Only Narcotrend and BIS have measuring cardiac output, standard thermodilu-
enough clinical studies behind them to demon- tion requires a pulmonary artery catheter and
strate clinical utility in some patients. Additionally injection of outside fluid bolus and only provides
these two technologies are the only DGA moni- incremental data.
tors to be routinely used in children. Compared to Continuous cardiac output monitors are spe-
BIS, Narcotrend is more resistant to interference cialized pulmonary artery catheters that use ther-
from EMG based on its algorithm [26]. modilution principles but without an external fluid
bolus. Instead of cold injectate, a copper wire incre-
mentally heats upstream fluid. The technology
23.4.2 uditory Evoked Potential
A takes measurements automatically and more fre-
(AEP) Monitors quently but is not truly “continuous” as each mea-
surement takes time to derive. Continuous cardiac
An auditory evoked potential (AEP) is the evoked output still requires a pulmonary artery catheter,
response of the brain to repeated auditory stimuli which carries its own unique complication profile.
as measured by an EEG. Middle latency auditory Pulse contour analysis is a means of measur-
evoked potential (MLAEP), taken 10–100 ms ing cardiac output solely by analyzing the wave
after the signal, represents the earliest cortical form of an arterial line. PiCCO and LiDCO
response to an auditory stimulus. Amplitudes and require calibration utilizing central venous can-
latencies of AEP signals have been shown to cor- nulation, with LiDCO further requiring the use of
relate to anesthetic depth. An AEP is less prone to lithium, which limits its clinical applicability.
artifact that an EEG, which would yield theoreti- FloTrac systems do not require calibration and
cal benefit to this modality. While these technolo- can be used solely with an arterial line. All pulse
gies have been developed for commercial use, contour systems require a high-fidelity wave form
studies demonstrating their clinical utility have that is not damped. Further, intra-aortic balloon
been limited [40]. However, one study found the pumps, aortic insufficiency, and the use of vaso-
new AEP/2 monitor to perform poorly compared pressors can affect the analysis. FloTrac software
to BIS in pediatric populations [17]. In contrast has been shown to be inaccurate in hemodynami-
other studies have demonstrated that use of AEP cally unstable patients as well as those with abnor-
can improve the titration of drugs, decrease the mal physiologic profiles such as cirrhosis.
incidence of postoperative nausea and vomiting, Transesophageal echocardiogram is a useful,
and shorten recovery room stays [32, 44]. clinically validated monitor that allows visualiza-
tion of the heart and measurement of key param-
eters. Quantitative measurements of cardiac
23.5 Conclusion output, valvular abnormalities, and ejection frac-
tion can be obtained by trained practitioners.
Advanced physiologic monitors for use in anes- Qualitative analysis of filling volumes, wall
thesia are a billion-dollar industry that only con- motion abnormalities, emboli, effusions, and con-
tinues to expand. These monitors are necessary tractility can be made in real time by less experi-
for diagnostic purposes when problems occur enced users. The major limitations of TEE are the
that cannot be identified by “standard” ASA mon- cost of the technology and the training required
itors. Choice of when to use these monitors by the anesthesiologist to interpret the data. While
depends on the patient’s history and the proce- complications have been reported including ther-
dure planned. mal and physical injury to the esophagus, the
Cardiac output monitoring allows extrapola- incidence is very low. Further, the absolute con-
tion of numerous hemodynamic variables and traindications to TEE are limited.
can be measured by increasingly noninvasive Depth of general anesthesia (DGA) monitor-
means. The gold standard for measuring cardiac ing uses electroencephalograms to extrapolate
output is thermodilution, where cold solution is levels of consciousness, the goal of which is to
injected into the heart. The temperature deviation prevent anesthesia awareness. Most monitors on
created is measured over time, with the area under the market today use frontal lobe analysis to pro-
336 J. A. Planchard
duce a numerical score denoting consciousness. not include these devices as part of
23 A range is designated to indicate the “adequate” basic monitoring for an anesthetic.
depth of anesthesia. While this technology has
not been shown to be cost-effective in every case, vv 2. C – Trans-gastric mid-papillary short-axis
frontal lobe monitoring has been shown to help view. This view allows for visualization of
prevent awareness in total intravenous anesthet- the left and right ventricles in cross
ics and situations where the level of anesthetic section, allowing for examination of the
gas needs to be minimal (e.g., hemodynamic major coronary distributions. None of
instability, trauma). Auditory evoked potentials the other views can achieve this.
measure the response of the brainstem to sounds
delivered through headphones. While the tech- vv 3. E – 41. BIS is measured on a scale of
nology has been shown to correlate to anesthetic 0–100, with 0 representing maximum
depth, it is not commonly used in practice today. anesthetic depth and 100 correlating to
an awake patient. The target range for
general anesthesia is 40–60.
23.6 Review Questions
?? 1. Which of the following is not a References

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337 23
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339 24
Quality of Care
in Perioperative Medicine
Matthew R. Eng, Tayyab Khan, and Ramla Farooq
24.2 History of Patient Safety and Quality Efforts – 340
24.3 Approaches to Quality Improvement – 342

24.3.1 Evaluation and Management of Adverse
Outcomes – 342
24.3.2 Quality Management – 343
24.5 Answers – 345
References – 345

https://doi.org/10.1007/978-3-319-96125-5_24
340 M. R. Eng et al.
24.1 Introduction is most well known for his 14 points which started
the total quality management movement [2]. They
Clinical performance in healthcare has become helped transform the Japanese production of
24 increasingly scrutinized as pressures mount to goods by shifting the focus of quality improve-
contain costs and increase quality of care. Quality ment upstream toward the scrutiny of the system
of care has become a focus of hospital commit- and processes.
tees, insurance providers, government agencies, Deming was an engineer, whose 14 points and
and healthcare providers. The discipline of quality system helped identify any aberration or flaw
of care is focused on the tracking, analysis, and within a process and removed deficiencies one at
reduction of errors so as to ensure improved a time. His 14 points are as follows: constant
patient outcomes while containing cost. improvement of product, adopt the new philoso-
Improvement in the quality of healthcare is phy, cease dependence on inspecting the end
fundamental to the integrity of anesthesiologists product to accomplish quality, build long-term
and other physicians. In the perioperative envi- relationships with trust and loyalty, train while on
ronment, collecting data on processes and out- the job, improve processes constantly and end-
comes as well as eventual evaluation of this data lessly, key leadership to supervise production,
may ensure a culture of safety and provision of encourage positive morale with no fear in the cul-
quality care. Collaborative efforts by the health- ture, interdepartmental barriers must be broken
care team in the operating room are important to down to streamline collaboration, eliminate quo-
this process, as well as multidisciplinary efforts to tas but rather inspire with leadership, allow every
assure the quality of care throughout a patient’s worker to indulge in the pride of his own work-
hospital course. Finally, protocols and evidence- manship, install the ability for employees to attain
based programs should be developed and self-improvement and continuing education, and
enforced to assure the best practice medicine for exhort the entire workforce to accomplish trans-
delivering the best possible quality of care. formation within the company. These 14 points
were fundamental in improving the quality of
Japanese products, aiming for the goal of deliver-
24.2 History of Patient Safety ing what the customer wants with precision and
and Quality Efforts consistency. In Deming’s analysis of the system,
he sought to identify individual impairments,
The medical specialty of anesthesiology has been removing them one by one. At the time this was a
a model for patient safety and, in turn, quality of paradigm shift; process was improved upon rather
care [1]. The consistency of safety is fundamental than attempting to fix individual workers.
to the improvement of quality in perioperative While Deming and Juran introduced the con-
medicine. Patient safety and quality of care in cept of industrial quality improvement, the medi-
anesthesiology have been influenced by the early cal community has also sought methods to
development of industrial quality and in the improve quality of healthcare. The need for qual-
establishment of quality standards in medicine ity of care in healthcare can be traced back to Dr.
and hospital management. Ernest Codman in 1910. A surgeon from Boston,
The history of industrial quality of Japanese Dr. Codman sought to track patient outcomes by
products was revolutionized by two American utilizing an “end results system” to help identify
men following World War II between 1950 and adverse outcomes and clinical errors. He estab-
1960. In a remarkable implementation of program lished the first mortality and morbidity confer-
and culture, two men from the United States, ence at the Massachusetts General Hospital in
W. Edwards Deming and Joseph M. Juran, helped Boston after joining Harvard Medical School fac-
transform the industrial quality of Japanese prod- ulty to help identify errors and prevent harm in
ucts. Deming and Juran were largely credited for the delivery of healthcare. The morbidity and
what many would later refer to as the “Japanese mortality conference program has been adopted
post-war economic miracle.” While most Japanese in clinical departments throughout the world as a
products had always been competitive in price, mainstay of quality and safety. His interest in
the quality was well known to be inferior. Juran patient outcomes and quality in healthcare leads
has been called the father of quality, and Deming to the formation of the American College of
Quality of Care in Perioperative Medicine
341 24
Surgeons and the Hospital Standardization which was an independent foundation that was
Program. The American College of Surgeons con- initially funded by the ASA. The formation of the
tinued to lead the initiative in improving quality APSF was the vision of Dr. Ellison C. Pierce, Jr.,
of healthcare, and by 1917, they developed the Chairman of Anesthesiology at Harvard Medical
Minimum Standards for Hospitals. In this, hospi- School and President of the ASA [5]. The goal of
tal visits and inspections were required to receive patient safety and reduction of preventable anes-
certification by the American College of Surgeons. thetic accidents was formally addressed by the
One of the first collaborations in healthcare- organization through newsletters, investigations,
related efforts toward quality of care was the devel- and organized safety programs. As a result of pur-
opment of the Joint Commission on Accreditation suing safety and quality of care, anesthesiologists
of Hospitals. It was formed in 1951 in a partner- began to see their malpractice premiums decrease
ship between the American Medical Association, and were applauded by the Wall Street Journal in
the American Hospital Association, the Canadian 2005 for this initiative as a profession [6].
Medical Association, and the American College of Since the formation of the Anesthesia Patient
Physicians [3]. The goal and mission of the Joint Safety Foundation, the quality and safety in the
Commission on Accreditation of Hospitals have field of anesthesiology have improved for a mul-
been to “continuously improve health care for the titude of reasons. The development of improved
public, in collaboration with other stakeholders, and diverse patient monitoring devices and
by evaluating health care organizations and inspir- pharmacological advances in anesthesiology
ing them to excel in providing safe and effective have aided practitioners in providing better care.
care of the highest quality and value.” With the Pulse oximetry, advanced ventilators, capnogra-
passage by Congress, in 1965, of the Social Security phy, fiber-optic endoscopes, video laryngo-
Amendments, hospitals that were accredited by scopes, and ultrasound are just a few of the many
the Joint Commission on Accreditation of technological advances in the field of anesthesia
Hospitals were now eligible to participate in which have improved quality and safety.
Medicare and Medicaid programs. As of 2017, the Pharmacologic anesthetics with faster onset and
Joint Commission inspects and qualifies over offset, less hemodynamic effects, and less overall
21,000 healthcare facilities and programs as the side effects have also contributed greatly to the
oldest and largest accrediting body in the nation. safety and quality in anesthesiology. The
As leaders in industrial quality improvement American Society of Anesthesiologists estab-
discovered, many in the field of anesthesiology also lished a standard of care for monitoring a patient
found that the greatest strides in quality improve- while utilizing an anesthetic. The ASA Standards
ment are accomplished through establishing a cul- for Basic Anesthetic Monitoring, first defined in
ture and system of constant quality improvement. 1986, has helped ensure that only qualified anes-
This was a shift in the approach to providing medi- thesia personnel are properly monitoring venti-
cal care for most clinicians, as the focus is often on lation, oxygenation, temperature, and circulation
one patient at a time. Creating a system to provide [7]. Many revisions and consensus statements
an improvement in outcomes for an entire cohort have helped refine these standards over the years,
of patients only began to take shape in the twenti- and this has served as a universally accepted
eth century. Dr. Avedis Donabedian was one of the standard of monitoring for anesthesia providers.
first physicians to put this together in 1966. In Many of the previously described organiza-
Evaluating the Quality of Medical Care, Dr. tions and institutions as well as a plethora of oth-
Donabedian distilled the quality of medical care ers were developed around the ideas of W. Edwards
into providers, the delivery of care, and the clinical Deming, Dr. Ernest Codman, Dr. Ellison Pearce,
outcomes [4]. He defined a model that could help and Dr. Avedis Donabedian. Quality of care in
quantify, analyze, and improve the quality of care. medicine is a very complex system, and the neces-
In 1983, the American Society of sity for providing safety and quality only contin-
Anesthesiologists formed the ASA Committee on ues to increase in a system with constrained
Patient Safety and Risk Management in response resources and little margin for error. Individual
to rising medical malpractice insurance premi- medical professionals as well as large healthcare
ums. This subsequently leads to the formation of networks have important roles in delivering qual-
the Anesthesia Patient Safety Foundation in 1985, ity healthcare in our complex healthcare system.
24.3 Approaches to Quality to capture incidents and events for the unique fea-
Improvement tures of each organization and practice. Some of
the features of an incident reporting system that
24 24.3.1 Evaluation and Management
may be helpful include a system that is easy to
access, an option of anonymity, secured data, an
of Adverse Outcomes ability to organize and analyze data easily, and the
ability to produce reports [13].
The prevention of adverse events requires a thor- Latent errors are often the difference in what
ough understanding of the processes and prac- might cause an adverse event to occur. While
tices, a comprehensive reporting of adverse human errors may be a component of the root
events, and a collaborative effort to analyze and cause, discovering latent errors is ultimately the goal
strategically revise processes to prevent further of analyzing adverse events. The Joint Commission
harm. With so many safety mechanisms in place on Accreditation of Healthcare Organizations has
and conscientious medical providers, adverse developed a policy with respect to the analysis of
events are often the result of many independent adverse events, requiring a root cause analysis of all
errors that align to allow for harm to take place. adverse events that affect patients [14]. Root cause
Before adverse events can be reduced, they analysis can be a laborious endeavor, and it may be
must first be identified. With negative conse- difficult to quantify the results of these studies. The
quences, personal shame, lack of confidence in adverse event trajectory can be best described
the system, poor education regarding quality ini- through models including the Swiss cheese models
tiatives, and concern of implicating others, often [15] and bow tie diagrams [16].
times adverse events are under reported [8]. In In the Swiss cheese model, a set of parallel bar-
fact, physicians are the least likely to self-report riers to prevent harm exist within a system. In
any adverse events [9]. Especially in “near miss” order for an adverse event to actually occur, holes
situations where no harm actually occurred, clini- due to errors or system failures must occur on
cians are even less likely to report these events. every cascading barrier level. The layers of Swiss
The World Health Organization defines adverse cheese must then align in an unfortunate manner
events: “An event or circumstance, which could such that the fail-safe mechanisms are unable to
have resulted, or did result, in unnecessary harm prevent an adverse event. While the Swiss cheese
to a patient” [10]. It is clear that it is of great model may aid in patching up some of these bar-
importance to capture “near miss” events as riers or perhaps even implementing a new layer,
opportunities to serve as an additional data point effort should also be given toward creating sys-
to help guide safety and quality policy. Reported tems to anticipate and recover from such adverse
adverse events occur at a rate of between 5.3 and events if they occur with frequency.
10.7% of patients in the hospital according to ICD Often used in industrial quality systems and
billing codes that indicate adverse events [11]. most notably nuclear power plants, bow tie dia-
Despite under reporting, there is a great opportu- grams may be of some benefit in preventing
nity to investigate adverse events, analyze, and adverse events in healthcare [16]. A bow tie dia-
strategically devise ways to reduce the risk of fur- gram centers around an adverse event that may
ther adverse events. occur. On the left side of the diagram, all risks and
A system of detecting of adverse events should preventive measures are listed. On the right side
be in place so that medical providers are not the of the diagram, all possible adverse events and
only source of reporting. Electronic medical recovery options and outcomes are listed. The
records, routine peer review, pathology reports, bow tie diagram has great potential for not only
incident monitoring, and medicolegal resources preventing adverse events but minimizing dam-
should be utilized to help identify adverse events. age or recovering from adverse events once they
Tracking “near misses” should also be in the occur. The bow tie diagram is most significant in
framework of adverse event reporting. Industrial this discussion for describing the importance of a
quality control systems have demonstrated that recovery plan in the event of an adverse event.
when “near misses” and minor adverse events are The Institute for Safe Medication Practices has
tolerated, a higher rate of catastrophic events can a nine-level strategy to reducing errors, ordered
ensue [12]. Systems need to be adequately tailored from the lowest to highest strength and reliability:
343 24
(1) suggestions to be more careful or vigilant, (2) machine that is equipped with a proportioning
education and information, (3) rules and policies, system that prevents any delivery of a final
(4) reminders and checklists, (5) redundancies, inspired oxygen concentration of less than 21%.
(6) standardization, (7) automation and comput- Adverse events are most often the unfortunate
erization, (8) forcing functions, and (9) fail-safes result of latent errors within a system and human
and constraints [17]. Suggestions can be helpful in error. The identification of adverse events is the
a motivated culture of healthcare providers and first step toward reducing risk through effective
are likely the easiest practice to employ. incident reporting systems. Next, the adverse
Suggestions to be more careful or vigilant are also event should be analyzed with a root cause analy-
the least effective because any inherent latent fac- sis, illustrating where the faults may lie in a Swiss
tor is not considered, and dissemination and cheese model or bow tie model. Appropriate
effectiveness of suggestions are widely variable. interventions that range from suggestions to fail-
Education and information can be helpful, moti- safe and constraint systems should be applied.
vating with a greater understanding of the overall
benefit of a modification of practices. This method
relies on the individual provider and can lose 24.3.2 Quality Management
effectiveness over time unless routinely enforced.
Rules and policies improve the protection of the A strong and responsive quality management
overall system by providing a legal framework for program is essential to the optimal functioning of
the conduct of an organization. It is less effective perioperative services. Patient satisfaction, patient
on the individual level because it is often hard to safety, surgical excellence, and overall operating
keep track of all of the rules and policy details. room efficiency are difficult to ensure without
Reminders and checklists are often utilized in the such a process in place [18]. Anesthesiologists are
operating room through time-out procedures and considered the physician specialists to address
have been very successful in the aviation industry. operating room management and patient safety in
Providers who routinely perform checklists and the perioperative setting and should be quality
reminders must always be vigilant against fatigue management leaders in these areas. An effective
and inattentiveness that may present during quality management program will increasingly be
repetitive tasks. Redundancies help reduce error valued in an era of reimbursement that is based
in a greater extent, providing an extra barrier that not only on volume but also on outcome.
must be errant according to the “Swiss cheese Developing a quality management program
model” previously described. While not a guaran- requires departmental support from the highest
tee against error, redundancies reduce them level of authority. A quality management officer
greatly. Standardization of processes is an impor- should be selected and enjoy the full support of
tant tool in reducing errors. A consistent stan- senior leadership such that all providers are
dardized team who follows a standardized expected to acknowledge adverse outcomes and
approach is much less likely to make an error remain committed to the process of quality
because of the familiarity and simplification of improvement. The role and work of the officer
variables. Automation and computerization are should be respected as an integral part of the
some of the greatest tools in modern healthcare to department’s functioning.
protect patients from harm. Mechanisms such as Supporting a quality management officer should
barcode scanning prior to medication adminis- be a committee, comprised of members represent-
tration protect a patient from errors such as wrong ing the various stakeholders in a group or depart-
dose, wrong medication, or wrong patient. ment. Anesthesiologists, CRNAs, AAs, nurses, and
Compliance with automation and computeriza- trainees should constitute the committee and work
tion safety systems is mandatory, and any devia- together to define performance metrics. Importantly,
tion from the process must be immediately the stakeholders should be not only of a diverse
addressed. The best and strongest level of error selection of clinical representatives from different
reduction strategies is in fail-safe and constraint departments but also of a wide sampling of experi-
systems. In these systems, there is not any possi- ence inclusive of senior members and junior mem-
bility that a patient would experience harm. An bers. Metrics can be thought of as “top down” or
example of one of these systems is the anesthesia “bottom up.” That is, top-down metrics are those
already collected through CPT/ICD coding as well with the complex calculations and production of
as quality measures required by programs such as charts or reports.
the Surgical Quality Improvement Project. In reporting quality management measures,
24 Bottom-up metrics include sentinel events or reports can be based on individual anesthesiolo-
adverse outcomes [19]. Both metrics are important gists or at the aggregate system level and may have
to overall quality management and require the sup- varying levels of privacy in reporting. For the
port of providers, nursing, hospital IT, and/or the individual provider, it can be helpful to report
billing department. Additional measures of quality compliance and performance as compared to the
should be established through the committee pro- average. For example, a particular provider may
cess in partnership with all stakeholders. have pain scores or patient satisfaction scores that
The first step in organizing a quality manage- are significantly worse than the average provider.
ment project is to begin harvesting pertinent data This type of report may be shared confidentially
in a top-down approach. In the age of electronic with each provider, as this may be a very sensitive
medical records, many data points are already issue. In preparing such reports, the data should
collected en masse. Requesting data from techni- be risk adjusted as some anesthesiologists may
cal support specialists and the medical informat- care for a more difficult or easier population.
ics department can yield a great deal of Other types of reports for individuals may include
information. A patient’s ASA physical status clas- adverse events such as perioperative complica-
sification, comorbidities, admitting diagnosis, tions. Again, these reports should be shared with
length of stay, pain scores, vital signs, and a pleth- the provider with sensitivity. On an aggregate
ora of other information may be extracted from level report, the responsibility should be shared
the electronic medical record. Another valuable by the entire hospital or group. These reports may
source of data may be in the billing information. be shared with the hospital, the group, or may
Data collected in the billing information includes even be compelled to share publicly. Handwashing
the ICD code, length of operation, age, sex, ASA compliance reports or central line infection
codes, procedures, and more. Organized data may reports are familiar quality management reports
have already been collected through other depart- that occur in many hospitals these days to help
ments such as through a nursing quality manage- encourage healthcare workers to take all precau-
ment project. It may be worthwhile to inquire tions to improve on these metrics. As more infor-
surgical colleagues and nurses about any overlap- mation becomes available to the public, there are
ping quality management projects. In addition to often quality measures that become accessible
hospital projects and collaborative quality man- [20]. The Joint Commission or Medicare Physician
agement programs, many quality management Quality Reporting System may require certain
projects are designed to help improve perfor- quality measures to be reported. In the eyes of the
mance on Consumer Assessment of Healthcare public, the confidence in providers can be unwit-
Providers and Systems (CAHPS) scores and tingly challenged and often due to poor reporting.
Surgical Care Improvement Project (SCIP) scores. The quality management team should ensure that
Finally, the quality management team may find it any publicly reported data is as best risk adjusted
best to collect data directly. Creating a form, ques- as possible, which may invariably be flawed [20,
tionnaire, or poll standardizes the data collection 21].
process and may deliver information not available The “bottom-up” approach to quality manage-
in any of the aforementioned methods. ment addresses unusual events, adverse outcomes,
The valuable data that has been collected must and sentinel events. Self-reporting of these
be translated into useful reports through careful adverse events is often low as clinicians may fear
analysis. Sorting out the most pertinent data medicolegal consequences, insult to their reputa-
points is one of the most skillful requirements in tion, perceived disruption in the patient-physician
analyzing the data. Retrospectively analyzing data confidence, or lack of confidence in benefit of
can be difficult to perform without incurring cer- reporting. Further, near miss events are even less
tain biases; however identifying trends and link- reported. Communicating a well-known alert sys-
ing causal relationships should be attempted. A tem protocol for reporting incidents along with a
medical statistician may be employed to assist responsive quality management team can greatly
improve reporting. Once an incident is reported,
345 24
it must be addressed in an expeditious manner. If following is the strongest strategy level
there is concern that a practice is unsafe or may to reduce errors?
cause imminent harm to a patient, there should A. Reminders and checklists
be a system in place for immediate review of pro- B. Rules and policies
tocols. All other incidents should be addressed C. Standardization
according to priority of severity. Low-level inci- D. Fail-safes and constraints
dents should be reviewed on a monthly basis in a E. Suggestions to be more careful or
quality management committee. It should be vigilant
determined whether there is a pattern of practice
that may lead to further adverse events and what
changes could be implemented. The quality man- 24.5 Answers
agement committee should communicate with
hospital risk management regarding adverse vv 1. E
events that could result in a legal predicament.
A quality management team and officer are
important to the success of quality improvement vv 2. B
in the perioperative setting at any hospital. Success
of the individual provider and the perioperative
team depends on the consistency of safety and per- vv 3. D
formance assured by the quality management
team. In “top-down” and “bottom-up” approaches,
the refinement of outcomes and reduction of
References
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2002;97(6):1335–7.
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?? 1. Which of the following are reasons that 3. Bindman AB, Grumbach K, Keane D, Rauch L, Luce
JM. Consequences of queuing for care at a public hospi-
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events? 4. Donabedian A. Evaluating the quality of medical care.
A. Medicolegal consequences Milbank Mem Fund Q. 1966;44(3):166.
B. Professional reputation 5. Stoelting RK, Khuri SF. Past accomplishments and
C. Lack of confidence in quality future directions: risk prevention in anesthesia and
surgery. Anesthesiol Clin. 2006;24(2):235–53. v.
management system 6. Hallinan JT. Heal thyself: once seen as risky, one group
D. Disruption of patient confidence of doctors changes its ways. Wall St J. 2005;21:1.
E. All of the above 7. Standards for basic anesthetic monitoring [Internet].
American Society of Anesthesiologists. Available from:
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8. Leape LL. Reporting of adverse events. N Engl J Med.
quality management includes all of the
2002;347(20):1633–8.
following except: 9. Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S,
A. Collecting data from electronic Chen J. Voluntary electronic reporting of medical
medical records and billing errors and adverse events. An analysis of 92,547
information reports from 26 acute care hospitals. J Gen Intern Med.
2006;21(2):165–70.
B. Identifying adverse events
10. Conceptual Framework for the international classifica-
C. Creating quality management tion for patient safety [Internet]. WHO/IER/PSP. 2009.
reports for the hospital and Available from: http://www.who.int/patientsafety/
individual providers taxonomy/icps_full_report.pdf
D. Analyzing performance metrics with 11. Australian Institute of Health and Welfare. From the
Australian Institute of Health and Welfare. Med J Aust.
medical statisticians
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?? 3. According to the Institute for Safe 12. Jehring J, Heinrich HW. Industrial accident prevention:
Medication Practices, which of the a scientific approach. Ind Labor Relat Rev. 1951;4(4):609.
13. Guffey PJ, Culwick M, Merry AF. Incident reporting at 18. Dutton RP. Why have a quality management program?
the local and national level. Int Anesthesiol Clin. Int Anesthesiol Clin. 2013;51(4):1–9.
2014;52(1):69–83. 19. Dutton RP, Dukatz A. Quality improvement using auto-
14. Percarpio KB, Vince Watts B, Weeks WB. The effective- mated data sources: the anesthesia quality institute.
24 ness of root cause analysis: what does the literature Anesthesiol Clin. 2011;29(3):439–54.
tell us? Jt Comm J Qual Patient Saf. 2008;34(7):391–8. 20. Rodrigues R, Trigg L, Schmidt AE, Leichsenring K. The
15. Reason J. Human error: models and management. public gets what the public wants: experiences of
BMJ. 2000;320(7237):768–70. public reporting in long-term care in Europe. Health
16. Pitblado R, Weijand P. Barrier diagram (bow tie) quality Policy. 2014;116(1):84–94.
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2014;33(4):355–61. 1997;278(19):1600–7.
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Pharm Assoc. 2010;50(2):e70–1.
347 25
Professional Liability
Jonathan P. Eskander, Tara Marie P. Eskander,
and Julia A. LeMense
25.1 Introduction: Professional Liability Related

to the Practice of Anesthesiology – 348
25.1.1 Background on Medical Responsibility and Origins
of Medical Malpractice – 348
25.1.2 Statistics on Medical Malpractice – 349
25.2 Medical Malpractice – 349

25.2.1 Duty of Care – 349
25.2.2 Dereliction – 349
25.2.3 Direct Cause – 350
25.2.4 Damages – 350
25.3 Reducing Risk of Claims and Medical Errors – 350

25.3.1 Meeting the Standard of Care – 351
25.4 Lawsuits: What to Expect – 351
25.5 Countersuits – 352
25.6 Psychological Impact and Effect on Practice – 352
25.9 Answers – 353
References – 353

https://doi.org/10.1007/978-3-319-96125-5_25
348 J. P. Eskander et al.
care and improved patient safety, poor patient

Call out box outcomes may be unavoidable with physicians fac-
Anesthesiologists are leaders in the arena of ing possible medical malpractice claims. Medical
patient safety yet still practice in high-risk malpractice litigation starkly contrasts the practice
environments, which can increase the likeli- of medicine and is unfamiliar territory for many
hood of malpractice lawsuits. Regardless physicians. Understanding the nature of these
25 of appropriate quality care and a focus on claims and precautions to safeguard against liabil-
patient safety, poor patient outcomes may be ity prepares physicians to address a claim or law-
unavoidable. Medical malpractice litigation suit while maintaining their license and practice.
is unfamiliar territory for many physicians. The following chapter provides a brief review
Knowledge of medical malpractice in anes- of professional liability in anesthesia, focusing on
thesia and professional liability insurance are background information, basic definitions, key
essential in helping protect an anesthesiolo- concepts, examples, and resources.
gist’s practice, license, and personal finances
from certain legal threats. Policies have been
developed and task forces established to 25.1.1 Background on Medical
investigate significant trends in previously Responsibility and Origins
uninvestigated complications, and profes- of Medical Malpractice
sional liability claims are frequently reviewed
and published by the Anesthesia Closed The concept of medical responsibility is more
Claims Project to help physicians ensure than 4000 years old, dating back to the time of
patient safety and quality improvement. This Babylonian kings and Roman law. The Code of
chapter highlights major aspects of profes- Hammurabi dating back to 2030 BCE provided
sional liability in anesthesia, focusing on that “If the doctor has treated a gentlemen with
background information, basic definitions, a lancet of bronze and has caused the gentleman
key concepts, examples, and resources. to die, or has opened an abscess of the eye for a
gentleman with a bronze lancet, and has caused
the loss of the gentleman’s eye, one shall cut off his
hands.” [1]. Documentation of legal responsibility
25.1 Introduction: Professional for medical wrongs also existed under Roman law
Liability Related to the Practice and was later incorporated into English common
of Anesthesiology law (following the Norman Conquest of 1066).
English common law, from which US medical
Over the last several decades, advances in the field malpractice law derives, provides a framework for,
of anesthesiology relating to devices, techniques, and the history of, medical malpractice decisions
clinical practice, and drugs have greatly improved [1]. An early medical malpractice case held that
patient outcomes through a noticeable reduction both a servant and his master could sue for dam-
of anesthesia-related injuries. Additional sup- ages against a physician who had treated the ser-
port of the American Society of Anesthesiologists vant and worsened his sickness by employing bad
(ASA) to demonstrate proactive approaches to medicine [1]. The law applicable to medical mal-
patient safety with the ASA Closed Claims Project, practice continued to evolve, and, in 1532, formal
the Anesthesia Patient Safety Foundation, and opinions of healthcare workers were required in
the Foundation for Anesthesia Education and every case of violent death—a prelude to requir-
Research has allowed the practice of anesthesia ing medical expert testimony to establish the
to remain a patient-centered profession focused standard of care in negligence claims [2]. In the
in continually improving patient safety. Better United States, medical malpractice claims started
patient outcomes have resulted in a decrease in the to appear in the 1800s [3]. Interestingly enough,
average cost of professional liability insurance pre- prior to the 1960s, medical malpractice lawsuits
miums. However, despite these advances, the field were uncommon in the United States [4]. Today,
of anesthesia remains a high-risk environment still lawsuits filed by patients alleging m
alpractice by a
susceptible to significant events resulting in mor- physician are relatively common and have greater
bidity and death. Regardless of appropriate quality influence on medical practice than ever before [5].
349 25
25.1.2 Statistics on Medical acceptable care to others. Due to the nature of
Malpractice their occupation and by oath, physicians are obli-
gated to provide reasonable and acceptable care to
In 1986, to improve healthcare quality, the all their patients. A duty of care only exists when a
Congress and the Department of Health and doctor-patient relationship has been established.
Human Services established the National This is the easiest element for a patient-plaintiff
Practitioner Data Bank (NPDB) to central- to prove. For example, once an anesthesiologist
ize data related to medical malpractice claims. sees a patient preoperatively and agrees to pro-
If a malpractice claim payment is made on the vide anesthesia care, a doctor-patient relationship
behalf of a healthcare provider, then federal law is formed, and a duty of care exists. Some other
mandates that this information be reported to examples of general duties include performing an
the NPDB. Since 1990, this data demonstrates a appropriate patient examination, consultations
decrease in the overall number of reports of mal- with physician specialists, maintaining medical
practice payments but an increase in payment records, obtaining an informed patent consent,
size even after accounting for inflation. According and adhering to privacy and other laws [7].
to NPDB data, in 2005, anesthesia-related cases After the doctor-patient relationship is estab-
accounted for 3.3% of all reports with the median lished, the anesthesiologist must treat the patient
payment of $200,000. From incident to payment, within the standard of care. The standard of care
malpractice cases take approximately 3–5 years does not have a uniformly agreed definition and
to resolve [6]. Of note, amounts and frequency of varies from state to state, making it ripe for litiga-
malpractice payments vary significantly by state tion. Some state courts take into account location
owing mainly to differences in state law. and how another physician may treat a patient in
similar circumstances. Other state courts apply
a national standard, meaning an anesthesiolo-
25.2 Medical Malpractice gist is held accountable based on the reasonable
and prudent actions of other anesthesiologists in
Legally, medical malpractice refers to professional the nation and how they would address a similar
negligence, which requires an injured patient to circumstance. Therefore, it is not sufficient for an
prove that poor quality medical care resulted in anesthesiologist to act in good faith or in accor-
injury and that the injury is related to the physi- dance with the norms of their specific region or
cian’s bad actions. A medical malpractice claim current hospital or institution. Most jurisdictions
is a creature of state law in the United States, with use a national standard of care, while a minority of
subtle variations across states in the elements of the courts use a locality standard. In some cases, more
cause of action and potential differences in the stan- than one standard of care could exist. The standard
dards of care, burdens of proof and production, and of care imposed by the court with jurisdiction over
limitations on types and amounts of damages that a a particular medical malpractice case could even
successful plaintiff can recover. To prove negligence, be determined by a group of respected physicians.
the patient’s claim must address four key elements: Because of these disparities, the presiding court
1. Duty will often establish the applicable standard of care
2. Dereliction (i.e., breach) of the duty after hearing testimony from expert witnesses and
3. Direct cause then making a legal determination that will be
4. Damages applied to the facts of the particular case.
All four elements must be proven by the patient-

plaintiff to win a medical malpractice case against 25.2.2 Dereliction
the defendant-anesthesiologist.
Dereliction is known more commonly as breach of
duty. A judge presiding over a medical malprac-
25.2.1 Duty of Care tice case may also rely on the testimony of medi-
cal expert witnesses to help determine whether
Legal duty is based on the notion that each per- the defendant-anesthesiologist failed to meet the
son has a responsibility or obligation to provide applicable standard of care. Based on the testimony
accepted by the judge and the facts of the case, if 25.2.4 Damages
the court finds the defendant-anesthesiologist at
fault for an omission or a failure to act within the The last element of a medical malpractice cause
standard of care, then the plaintiff-patient will of action is damages. A plaintiff-patient who fails
have established a breach of duty. to prove that they suffered damages as a result of
the injuries caused by a physician’s breach of duty
25 cannot recover from the defendant physician. In
25.2.3 Direct Cause the simplest terms, there are three types of dam-
ages: punitive, general, and special. Punitive dam-
The third element of the cause of action is determin- ages are reserved for defendant-anesthesiologists
ing whether the defendant-anesthesiologist caused whose negligence is determined to be willful or
the plaintiff-patient’s injury. Specifically, the ques- reckless. General damages include pain and suf-
tion is whether the physician’s breach of duty is the fering, which are considered to be damages that
proximate cause of the patient’s injuries. Proximate directly result from the injury caused by the phy-
causation is one of a number of types of causation sician. Special damages are those that arise as
under the law and is determined by answering two a consequence of the injury and are reasonably
questions: (1) Would the injury have occurred if foreseeable, such as medical expenses and oppor-
not for the action by the defendant-anesthesiol- tunity costs (sometimes referred to as consequen-
ogist (also known as “but for cause”) and (2) did tial damages). In jury trials, the jury decides on
the harm caused by the defendant-anesthesiologist the amount of the medical malpractice damage
contribute substantially to the plaintiff-patient’s award, which typically correlates with the sever-
injuries despite other factors. If the answer to both ity of the injury and to the degree of which the
of these questions is yes, then the court may find defendant-anesthesiologist is found to be negli-
that the plaintiff-patient has satisfied the causa- gent [7–10]. Each year in the United States, nearly
tion element of the medical malpractice claim by 60,000 medical malpractice claims are filed, and
proving that the defendant-anesthesiologist’s act or about 30 percent result in damage awards to the
omission is the cause of the injuries. plaintiff [11].
Ordinarily, the patient-plaintiff bears the bur-
den of proof for all elements of a medical mal-
practice case. However, in some cases, especially 25.3 Reducing Risk of Claims
anesthesia malpractice cases, the anesthesiologist and Medical Errors
defendant may have to prove that they did not
cause the harm. This shift in the burden of proof Undesirable patient outcomes occur in any field of
from patient to physician may occur in after the medicine. According to some studies, patients are
patient has shown that the physician had exclusive less likely to sue a healthcare provider when the
control of the thing (e.g., anesthesia) that caused patient perceives the provider as caring, commu-
the injury even though there is no evidence that the nicative, honest, and appropriately apologetic [12,
physician is negligent. It is based on the legal doc- 13]. Unfortunately, there is a lack of consensus
trine of res ipsa loquitur, Latin for “the thing speaks on the optimal response to a medical error. After
for itself.” It is invoked when a plaintiff establishes a a full disclosure and a carefully crafted apology,
rebuttable presumption that the physician was neg- patients and their families may be less likely to sue
ligent and without the negligence, the injury would for damages [14]. Routine use of full disclosure
not have occurred. Under the care of anesthesiolo- after a medical error is controversial, however,
gists, anesthetized patients lack awareness of sur- due to the potential for unintended medicolegal
roundings and inability to fully prevent or protect consequences [15]. In response, some states are
themselves from injury; therefore, this doctrine is adopting “apology laws,” which make apologies
more likely used in anesthesia malpractice cases inadmissible as evidence of provider wrongdo-
versus other types of malpractice claims [7]. In ing, to encourage communication after adverse
this case, an anesthesiologist needs to demonstrate outcomes. In response to medical error and
that the injury would have occurred in typical cir- undesirable outcomes, clear communication with
cumstances in the absence of negligence while also co-workers is paramount and provides a clear
proving that he or she was not negligent. establishment of the adverse event circumstances
351 25
and key happenings, in addition to thorough doc- Thorough documentation of the anesthesiolo-
umentation that limits speculation or conjecture, gist’s presence during key and critical periods as
such as providing non-conflicting narratives and well as recording communication of anesthetic
imparting the full truth [6]. Finally, risk manage- plans with subordinates provides a strong narra-
ment personnel should be consulted in regard to tive in reducing liability risk. Failure to meticu-
medical error concerns and adverse events. lously document these situations is not only bad
practice, it also creates an opening for patient-
plaintiff attorneys to insinuate that inadequate
25.3.1 Meeting the Standard of Care supervision existed [6].
Vigilance in meeting the standards of care such as

ensuring informed consent, consistent, and detailed 25.4 Lawsuits: What to Expect
documentation and exercising empathy with
patients can reduce likelihood of malpractice claims. The stages of a medical malpractice claims gener-
ally are as follows:
25.3.1.1 Informed Consent 55 Stage 1: Injury or death
Informed consent must be obtained prior to any 55 Stage 2: Attorney consultation
procedure with the anesthesiologist including an 55 Stage 3: Investigation
adequate explanation of the procedure, possible 55 Stage 4: Medical expert consultation
alternatives, and associated risks. The patient must 55 Stage 5: Service of process and commence-
indicate an understanding of the aforementioned ment of the action by filing the case
procedure and risks and then provide consent for 55 Stage 6: Discovery
treatment. Since anesthesia comes with risks sepa- 55 Stage 7: Settlement or trial
rate from surgery, anesthesiologists should obtain
consent separately from surgeons. Patients should Of note, the aforementioned stages of a medical
have enough time to decide to either accept or refuse malpractice lawsuit vary slight state by state.
treatment. If the patient is unable to give informed During the initial stages, a lawyer and patient
consent or given reasonable amount of time to must determine if the doctor-patient relationship
process the information provided, then a legally existed and gather evidence to prove the elements
recognized surrogate may decide for the patient. of the case (refer to the four D’s of medical mal-
Surrogates may include next of kin or legal appoint- practice). After the plaintiff ’s attorney gathers
ments. When in doubt about the ability of a surro- information, he or she will likely contact a medical
gate to provide informed consent, first consult with expert. If the case has legal merit and is financially
hospital or clinical risk management personnel. viable, then the plaintiff may approach the physi-
cian prior to filing a complaint or will formally
25.3.1.2 Medical Records commence the action by filing the c omplaint with
and Documentation the court and serving the defendant(s) with a sum-
All healthcare providers should keep meticulous mons and complaint detailing the allegations and
documentation of patient encounters. Medical the damages sought. At the same time, or immedi-
documentation becomes the patient’s narrative. ately following commencement of the action, the
Any information not included in that narrative, parties are entitled to conduct discovery (inspec-
in effect, did not happen in the eyes of third par- tions, document requests, interrogatories, requests
ties (including experts, judges, and members of for admissions). This discovery period is often fol-
juries). Therefore, it is essential for anesthesiolo- lowed by a period of negotiation, which may lead
gists to make notes of any pertinent events in a to a settlement or the parties will proceed with a
patient’s medical record. trial, although the parties are free to negotiate and
Anesthesiologists assuming a supervisory settle at any point in time during the litigation and
role in the management of anesthetists may are often encouraged by judges to schedule time to
be faced with vicarious liability in which the resolve matters as soon as possible to avoid incur-
anesthesiologist assumes responsibility for the ring expenses, inconveniencing litigants, and bur-
omissions or actions of his or her subordinates. dening the court system.
25.5 Countersuits
Closed claims database
Countersuits (claims made by a defendant against In 1985, the closed claims database was
the plaintiff in the original action) often appear to developed by the ASA to study anesthesia-
provide the only plausible means of legal recourse related injuries resulting in medical mal-
by a defendant physician against a plaintiff patient practice claims. Notable trends include
25 and may be tempting for some who feel they are decreasing surgical anesthesia claims but
the target of a malicious or harassing lawsuit by a increasing acute and chronic pain manage-
patient or their representatives. However, the like- ment claims [19]. The following are common
lihood of success in a countersuit is quite poor. In groups of claims in the database: death, 34%;
a successful countersuit, the healthcare provider nerve damage, 16%; brain damage, 12%;
must prove the patient had malicious intent when and others, 38% [12]. Notably, monitored
filing a lawsuit in the first place. anesthesia care (MAC) is associated with the
highest incidence of death and permanently
disabling injury. Among obstetric anesthesia
25.6 Psychological Impact and Effect claims are maternal death, 22%; newborn
on Practice brain damage, 20%; and headache 12% [19].
The legal process can be lengthy and disruptive. As

a result, this can lead to trauma with personal and 25.7 Conclusions
emotional sequelae [16, 17]. Specifically, medi-
cal malpractice stress syndrome (MMSS) bears Anesthesiologists should carry medical mal-
resemblance to post-traumatic stress disorder practice insurance to protect personal assets
(PTSD) and occurs after a healthcare provider is from potential lawsuits. While litigation can be
sued. MMSS typically manifests as anger, inability highly stressful for physicians and their families,
to concentrate, or irritability among many others increased knowledge, understanding, and docu-
[18]. Some physicians may choose to self-medicate mentation processes can be useful tools. Methods
during this process leading to substance abuse to minimize the risk of liability should be added to
problems that may affect the day-to-day opera- the anesthesiologist’s armamentarium. Generally,
tions thereby compromising patient care [18]. it is agreed that effective communication as well
Therefore, it is imperative the physician accused as obtaining informed consent preoperatively and
of malpractice seeks support, reflects on career practicing within the standard of care as deter-
positives, maintains hobbies, and engages the legal mined by peer review are important tools used
process by participating actively in his defense. to minimize the risk of liability. Additionally,
These actions might allow a healthcare provider to adequate documentation and an appropriate
avoid internalization of negative feelings and pos- response to a medical error or a bad outcome may
sibly mitigate stress secondary to litigation. further decrease the chances of a lawsuit.
zz Recommended Resource for Further Reading

Resource Brief description
Manual on professional liability: An informational manual An in-depth manual written by the ASA in
compiled by the ASA Committee on professional liability 2010 that details specific information about
(7 http://monitor.pubs.asahq.org/article.aspx?articleid=

professional liability in anesthesia while
2435869&_ga=2.231724316.225485226.1498174565- providing checklists and additional resources
2045035840.1495231300)
Additional resources
National Practitioner Data Bank

7 https://www.npdb.hrsa.gov/

Anesthesia closed claims project

7 http://depts.washington.edu/asaccp/welcome-anesthesia-closed-claims-project-its-registries

353 25
25.8 Review Questions References
?? 1. Which of the following concepts are 1. Powis Smith JM. Origin & history of Hebrew law. Chi-
included in the definition of malpractice? cago: University of Chicago Press; 1931.
2. Everad v. Hopkins, 80 English Reports 1164 (1615).
A. Duty 3. Bal SB. An introduction to medical malpractice in the
B. Dereliction United States. Clin Orthop Relat Res. 2009;467(2):339–47.
C. Damages 4. DeVille KA. Medical malpractice in nineteenth-century
D. Direct cause America: origins and legacy. New York: NYU Press; 1990.
E. All of the above 5. Sloan FA, Bovbjerg RR, Githens PB. Insuring medical
malpractice. New York: Oxford University Press; 1991.
(These are the four D’s of malpractice. 6. ASA Committee on Professional Liability. Manual on
Each of these elements is required to professional liability. Schaumburg: American Society
meet the criteria for malpractice.) of Anesthesiologists; 2010.
7. Taragin MI, Willett LR, Wilczek AP, et al. The influence
?? 2. Which of the following are appropri- of standard of care and severity of injury on the reso-
lution of medical malpractice claims. Ann Intern Med.
ate steps to take to minimize potential 1992;117:780–4.
liability? 8. Peters PG. What we know about malpractice settle-
A. Good communication between phy- ments. Iowa Law Review. 2007;92:1783–833.
sician and patients as well as family 9. Ogburn PL Jr, Julian TM, Brooker DC, et al. Perinatal
member medical negligence closed claims from the St. Paul
Company, 1980-1982. J Reprod Med. 1988;33:608–11.
B. Obtaining appropriate informed con- 10. Rosenblatt RA, Hurst A. An analysis of closed obstetric
sent and adequate recordkeeping malpractice claims. Obstet Gynecol. 1989;74:710–4.
C. Adhering to the standard of care 13. Studdert DM, Mello MM, Gawande AA, et al. Claims,
D. All of the above errors, and compensation payments in medical mal-
(In addition to all of the above, appro- practice litigation. N Engl J Med. 2006; 354:2024–2033.
11. Luce JM. Medical malpractice and the chest physician.
priate management of a negative out- Chest. 2008;134:1044–50.
come will further mitigate the risk of a 12. Duclos CW, Eichler M, Taylor L, et al. Patient perspec-
lawsuit.) tives of patient-provider communication after adverse
events. Int J Qual Health Care. 2005;17:479–86.
?? 3. Countersuits are often successful. True or 13. Levinson W, Roter DL, Mullooly JP, et al. Physician-
patient communication. The relationship with mal-
false? practice claims among primary care physicians and
A. True surgeons. JAMA. 1997;277:553–9.
B. False 14. Colon VF. 10 ways to reduce medical malpractice

(To be successful in a countersuit, the exposure. Physician Exec. 2002;28:16–8.
healthcare provider must prove there 15. Leape LL. Reporting of adverse events. N Engl J Med.
2002;347:1633–8.
was malicious intent.) 16. Nash L, Tennant C, Walton M. The psychological impact
of complaints and negligence suits on doctors. Austra-
las Psychiatry. 2004;12:278–81.
25.9 Answers 17. Charles SC, Wilbert JR, Kennedy EC. Physicians’ self-
reports of reaction to malpractice litigation. Am J Psy-
chiatry. 1984;141:563–5.
vv 1. E 18. Diagnostic criteria from the Diagnostic and Statistical
Manual of Mental Disorders,4th Edition, with text revi-
vv 2. D sion (APA 2000) (DSM-IV-TR) for Acute Stress Disorder
(DSM-IV-TR 308.3) and Post-Traumatic Stress Disor-
der (DSM-IV-TR 309.81) other than Criterion A (the
vv 3. B
stressor), describe the signs and symptoms suffered
by physicians who suffer MMSS.
19. Metzner J, Posner KL, Lam MS, Domino KB. Closed
claims’ analysis. Best Pract Res Clin Anaesthesiol.
2011;25(2):263–76.
355 26
Medical Malpractice
J. L. Epps and Courtney E. Read
26.1 Proof of Malpractice – 357

26.1.1 Duty – 357
26.1.2 Breach of Duty – 357
26.1.3 Causation – 357
26.1.4 Damages – 358
26.2 Process of Trial – 358

26.2.1 Initial Pleadings – 359
26.2.2 Discovery – 359
26.2.3 Depositions – 359
26.2.4 Trial – 360
26.2.5 Legal Fees: Impact in Medical Malpractice – 360
26.2.6 Verdicts – 360
26.2.7 Appeals – 361
26.2.8 Settlement – 361
26.2.9 Expert Witness – 361
26.3 Anesthesiology: At-Risk Specialty? – 362

26.3.1 Indemnity Payments: All Physicians – 362
26.3.2 Indemnity Payments: Anesthesiologists – 363
26.3.3 How to Minimize the Risk of Liability – 363
26.3.4 Adverse Events – 363
26.3.5 The Medical and Anesthesia Records – 363
26.4 Medical Malpractice Insurance – 364
26.5 Professional Liability (Tort) Reform – 365

26.5.1 Noneconomic Damages Cap – 365
26.5.2 Provider Apology – 365
26.5.3 Joint and Several Liability – 366
26.5.4 State Patient Compensation Funds – 366
26.5.5 Contingency Fees – 366
26.5.6 Collateral Source Rule – 366
26.5.7 Punitive Damages – 366

https://doi.org/10.1007/978-3-319-96125-5_26
26.5.8 Expert Witness – 367
26.5.9 Certificates of Merit/“Good Faith” – 367
26.5.10 Loss of Chance – 367
26.6 Cyber Liability – 367

26.6.1 HITECH – 367
26.6.2 Costs of a PHI Breach – 367
26.6.3 Cyber Liability Insurance – 368
26.7 Social Media Liability – 368
26.9 Answers – 369
References – 369
Medical Malpractice
357 26
26.1 Proof of Malpractice an expert. Other states adhere to a “locality” rule.
In this circumstance, the anesthesiologist is held
For medical malpractice to occur, a healthcare pro- to the “recognized standard of acceptable profes-
vider (hospital, physician, nurse practitioner, etc.) sional practice in the profession …in the commu-
causes an injury to a patient through a negligent act nity in which the defendant practices.” Under the
or omission. The negligence could be due to errors “locality rule,” the question is whether the physi-
in diagnosis, treatment, or follow-up care. A plain- cian acted in accordance with what a physician in
tiff who asserts medical malpractice on the part of a the same or similar locality (a contiguous state)
healthcare provider has to prove (1) the recognized would have done, which has to be proven by an
standard of acceptable professional practice in the expert familiar with the community in which the
profession and specialty as it relates to the circum- anesthesiologist practices. In Shipley v. Williams,
stances of the case (duty); (2) that the provider 350 S.W. 3d 527, 553 (Tenn. 2011), the Tennessee
failed to act in accordance with the acceptable Supreme Court recognized that “the national
standard of care (breach); (3) as a proximate result standard is representative of the local standard”
of the breach, the patient suffered injury that would allowing expert testimony as to a national stan-
not have otherwise occurred (causation); and (4) dard of care after it has been established that the
patient incurred damages as a result of the injury expert is familiar with the community in which
(damages). Monetary damages, if awarded, typi- the defendant provider practices [2].
cally take into account both actual economic loss
and noneconomic loss, such as pain and suffering.
26.1.2 Breach of Duty
26.1.1 Duty During trial, the jury must determine if the anes-
thesiologist either did something that should not
When the patient is seen preoperatively and the have been done or failed to do something that
anesthesiologist agrees to provide anesthesia care should have been done. Both sides will present
for the patient, a doctor-patient relationship is testimony from experts as to what duty was owed
established, which creates a duty to the patient. to the patient by the anesthesiologist and whether
In the most general terms, the duty that the or not the anesthesiologist acted according to the
anesthesiologist owes to the patient is to adhere standard of care of anesthesiologists in that com-
to the “standard of care” for the treatment of the munity or on a national level as it relates to the
patient. This “standard of care” means that a phy- circumstances of the case at issue. In other words,
sician will act with the same degree or skill as any did the anesthesiologist act in a reasonable and
reasonable and prudent doctor under the same or prudent manner in the specific situation and ful-
similar circumstances at the time of the treatment fill his or her duty to the patient? If the jury finds
in question. The standard of care encompasses the that a breach of that duty occurs, the jury will
training, education, and skills of a similar physi- then have to determine whether that breach was
cian facing the same or similar circumstances. In the cause of the patient’s injury.
most claims for medical malpractice, the standard
of care must be determined by expert testimony
as a layperson, a typical juror, cannot determine 26.1.3 Causation
from their own knowledge and experience how a
physician would act under the same or similar cir- The legal definition of causation varies signifi-
cumstances. Currently 29 states and Washington, cantly with the intuitive medical understanding of
DC, require only that a claimant demonstrate a a “cause” of harm. The proof of causation in medi-
“national standard of care” through expert tes- cal malpractice hinges on the following concepts:
timony. In practical terms, this means that an 1. The injury would not have occurred but for
anesthesiologist may be held accountable for his the action of the anesthesiologist (but for
or her actions according to what any reasonable causation).
and prudent anesthesiologist, from anywhere in 2. The action of the anesthesiologist was a
the United States, would do or not do under the substantial factor in the injury despite other
same or similar circumstances as testified to by causes (proximate or legal cause).
358 J. L. Epps and C. E. Read
3. The preponderance of evidence (>50%) 26.1.4 Damages

shows that the actions of the anesthesiologist
were at fault (more likely than not). For a medical malpractice case to be viable, the
4. The “facts” speak for themselves (res ipsa patient must show that significant damages resulted
loquitur). from an injury received due to the medical negli-
gence. If the damages are small, the cost of pursuing
26.1.3.1 Res Ipsa Loquitur (The Facts the case might be greater than the eventual recov-
Speak for Themselves) ery. The types of damages alleged by a plaintiff may
26 The doctrine of res ipsa loquitur is often alleged include that the injury resulted in disability, loss of
against anesthesiologists in malpractice suits. income, pain and suffering, hardship, or signifi-
In order for the doctrine of res ipsa loquitur cant past and future medical bills. Furthermore, a
to apply, two requirements must be met. First, surviving spouse or parent may sue on behalf of
the plaintiff has to prove that in the absence of a deceased patient for the wrongful death of their
negligence, the injury would not typically occur. spouse or child, which would include damages
In other words, the “facts speak for themselves” relating to the value of the deceased patient’s life
that negligence occurred. Second, any injury and damages relating to services provided by that
must have been caused by something under the spouse such as childcare or housekeeping. Damages
exclusive control of the anesthesiologist. The are grouped into several categories:
application of this doctrine is somewhat contro- 55 Pain and suffering which directly result from
versial as complications and bad outcomes from the injury (general)
medical treatment can occur absent any negli- 55 Actual damages as a consequence of the
gence on the part of a provider. Under anesthe- injury such as medical, lost income, funeral,
sia, patients have been rendered insensible and etc. (special)
are unable to protect themselves from their envi- 55 Punishment for wanton, fraudulent, willful,
ronment. The anesthesiologist has placed the or reckless negligence (punitive)
patient in this situation and is presumed to have 55 No intent to punish the physician but to
exclusive control over the patient. For example, make an example of the case to prevent any
in an Indiana case, the res ipsa loquitur doctrine other physician from doing the same thing
was found to apply in a malpractice lawsuit (exemplary)
filed against an anesthesiologist and hospital
where a board supporting a patient’s arm during Thirty-five states have passed laws imposing
surgery became detached leaving the arm dan- statutory caps on certain types of damages, par-
gling toward the floor for an unknown period ticularly on noneconomic damages and punitive
of time. The anesthesiologist repositioned the damages [5]. These laws limit the amount and
patient’s arm but the patient suffered an injury type of damages that can be recovered against a
to the nerves in the affected limb. While oth- physician. Recently, the United States House of
ers may have also had control over the patient Representatives drafted a bill, H.R. 4771, the Help
during surgery, the court in Thomson v. Saint Efficient, Accessible, Low-cost, Timely Healthcare
Joseph Regional Medical Center, 26 N.E.3d 89 (HEALTH) Act of 2016, which in part proposed
(Ind. Ct. App. 2015) found that multiple persons a cap of $250,000 on noneconomic damages, like
could have exclusive control as they too had a pain and suffering. This bill was opposed by the
duty to monitor the positioning of the plaintiff ’s American Bar Association [6].
arm during surgery [3]. However, in Magette v.
Goodman, 771 A.2d 775 (Pa. Super. Ct. 2001),
the superior court held in part that the trial court 26.2 Process of Trial
did not act erroneously in declining to instruct
the jury as to the doctrine of res ipsa loquitur as The legal system in the United States is based
the plaintiff failed to establish the requirements on adversarial advocacy, which promotes self-
of this doctrine in which the patient died during resolution of civil disputes. As a result, medical
surgery as death can occur while under anesthe- malpractice cases often do not proceed to trial. The
sia in the absence of any negligence on the part trial process consists of (1) initial pleadings, (2) dis-
of the anesthesiologist [4]. covery, (3) depositions, (4) trial (5), and appeal [7].
Medical Malpractice
359 26
26.2.1 Initial Pleadings by a plaintiff ’s attorney. Once the case is filed,
attorneys submit a list of questions from one
A healthcare provider will likely become aware party to another to gather preliminary and demo-
of a lawsuit after being served with a complaint. graphic information. The recipients must answer
Almost all states have some pre-suit require- the questions under oath but do so with assistance
ments, such as giving notice to a physician of a of their attorneys.
claim before a complaint is formally filed in the
court. For example, 22 states such as Florida,
Massachusetts, Tennessee, and Texas currently 26.2.3 Depositions
require that a “certificate of good faith” must be
filed alongside the initial complaint. This certifi- Depositions are formal proceedings in which
cate must state that the plaintiff (or the plaintiff ’s a person involved in a lawsuit is questioned by
attorney) has consulted with one or more medical counsel under oath with a recording made for
experts who have themselves provided a written later use in court. Typically, the patient’s attorney
statement confirming: will notify the attorney defending the doctor that
55 Competency and qualifications to express an a deposition of the doctor is needed. All parties
expert opinion under state law agree upon a convenient time and place. Many
55 A “good faith basis” to bring the medical defense lawyers prefer that the deposition take
malpractice lawsuit based on a review of the place in an area of the physician’s comfort either
medical records and other evidence the defendant physician’s attorney’s office or the
defendant physician’s office, if possible. A deposi-
Seventeen other states such as Indiana require that tion begins with a court reporter administering
all proposed medical malpractice claims must be the same oath that the party being deposed would
submitted to a medical review panel for review take if the testimony were to be before a judge and
prior to proceeding to court [8]. In such a situa- jury. A verbatim record of all that is said during
tion, a healthcare provider will become aware of a the deposition is then available to all parties for
potential lawsuit well before a complaint is filed in later use in court. Depositions of a defendant phy-
the court. If a healthcare provider receives such a sician are usually attended by the attorneys for the
notice letter, that healthcare provider’s insurance plaintiff and any defendants named in the lawsuit,
carrier should be notified immediately. the court reporter, and, on occasion, other defen-
After the clinician is made aware of a poten- dants named in the lawsuit and not being deposed
tial claim or after the individual is served with a and, sometimes, the patient or patient’s family
complaint, the insurance carrier will likely retain members. Only the attorneys may ask questions
counsel on behalf of the defendant in the lawsuit. of the witness being deposed.
The clinician will meet with the appointed attor- When an expert witness or the defendant phy-
ney to review and discuss the allegations raised sician is deposed, the plaintiff ’s attorney directly
by the plaintiff. The chart applicable to the facts questions the physician. Afterwards, the defen-
of the alleged claim will be reviewed together dant or expert witness is asked questions by coun-
in order for the attorney to file an answer to the sel for any co-defendants named in the lawsuit or
complaint on behalf of the clinician. if necessary, by his/her legal team. This exchange
of questioning continues until all q uestions by
both parties are answered. Facts asserted during
26.2.2 Discovery deposition can be used to contradict the physi-
cian’s later testimony in court. Depositions pro-
Between the filing of the suit and trial, an exten- vide advance notice of all of the significant clinical
sive period of information sharing and factual evidence and conclusions that each witness in a
understanding between the plaintiffs and defen- malpractice action expects to offer at the trial.
dants (discovery) occurs. This process is facili- Each legal team uses this adversarial process to
tated by requests for documents, interrogatories, determine how best to minimize and defeat the
and depositions. A request for medical records, positions taken by a witness. In contrast to televi-
hospital billing information, and/or clinic note sion and the movies, questions can be asked that
(documents) is usually the first step undertaken may not be relevant or admissible at the trial, such
that many objections that would be raised at the explanation of what took place concerning the
trial do not apply. Essentially, the scope of what subject patient. The defendant’s appearance, atti-
can be asked of a physician in a deposition is tude, and testimony can have immense impact on
very broad. In “lawyer speak,” discovery is often the final outcome.
referred to as a “fishing expedition,” in which an
attorney is “fishing” for any and all information
that may potentially be relevant to the lawsuit. 26.2.5 Legal Fees: Impact in Medical
Depositions are not only a useful tool for purposes Malpractice
26 of the trial, but these depositions are oftentimes
used in dispositive motions, such as motions for Attorneys for the plaintiff are generally hired by
summary judgment, and may also be evaluated in the patient on a contingency fee basis. In other
terms of settlement. words, the lawyer collects payment only if dam-
Treating physicians not named as defendants ages are awarded. Criticisms of this payment
are frequently deposed. Each physician must model believe that it encourages medical mal-
carefully consider any informal conversations practice lawsuits. These contingency fees apply to
with either the plaintiff ’s or defendant’s legal monetary damages awarded by a court and from
counsel about a patient’s care without receiving an settlement. Since most medical malpractice cases
order from the court or consent of the patient due never go to jury trial, the 5–50% contingency fee
to HIPAA concerns. Furthermore, some states applies regardless if the monetary awards are from
explicitly prohibit ex parte communications with the court or by agreement as a result of settlement.
a defendant physician’s attorney about the treat- In contrast, the defense legal team is appointed
ment of a patient, which is the subject of a medi- by the medical malpractice insurance company
cal malpractice lawsuit, without that attorney first on behalf of the physician. All legal fees are typi-
obtaining an order from the court. cally paid by the defendant’s insurance company.
However, the defendant physician can hire his
own personal legal counsel at his/her own expense
26.2.4 Trial if desired.
Medical malpractice lawsuits require hours
During the trial, the burden of proof lies with and hours of physician and attorney time sorting
the plaintiff who must through their attorney through a complex medical record system, exhaus-
convince the jury that it was more likely than tive research into the medical and legal literature,
not that the physician was negligent. The “more and multiple interviews with expert witnesses. The
likely than not” standard of legal proof required in process of legal discovery and subsequent negotia-
medical malpractice litigation is significantly less tions between the plaintiff and defense team may
demanding than the “beyond reasonable doubt” last several years, particularly if the case goes to
standard required to convict criminal defendants. trial. The financial cost to the plaintiff ’s attorney
In other words, an impartial jury, after hearing often exceeds “six figures” to pay fees for expert
and considering all the information found during testimony, court costs, and court reporter fees in
discovery, has to conclude there is a greater than addition to the time and money to prepare the
50% probability that professional negligence did case in anticipation of the trial. It has been esti-
occur in order for a physician to be liable (pre- mated that a plaintiff ’s costs are approximately
ponderance of the evidence). 35% percent of the amount recovered if the plain-
In addition to proving that a breach of stan- tiff recovers anything for his or her claim [9].
dard of care did not occur and that the actions of
the defendant did not cause the plaintiff injury,
the defendant anesthesiologist must remember 26.2.6 Verdicts
that a jury is assessing the credibility of the wit-
nesses and is deciding which position taken by What ultimately happens when patients sue? The
the parties is most persuasive. The defendant results are often surprising to many physicians.
physician through his or her counsel and with According to the Physician Insurers Association
the use of his or her experts must convince the of America, 61% of these cases are dropped or dis-
jury that the defense position is the most credible missed, and 32% are settled. Of the 7% who go to
Medical Malpractice
361 26
trial, only 2% actually result in a plaintiff verdict. When there is strong evidence to suggest that
Physicians win 80% to 90% of the jury trials with the standard of care was met, many reasons exist to
weak evidence of medical negligence and even forego settlement despite potential pressure from
50% of the trials where strong evidence of medi- the insurance carrier to do so. Settlements, like
cal negligence occurred [10]. adverse judgments, are reported to the National
Practitioner Data Bank. State licensure status
may be jeopardized and the physician’s reputation
26.2.7 Appeals damaged publicly. Medical malpractice insur-
ance rates may increase, coverage terminated, and
Once a verdict is reached, the losing party can future insurance options more difficult to obtain.
either file a motion for a new trial or appeal the In most published studies, the likelihood and
result to the next higher court level. In some states, size of a settlement payment correlate with the
a dissatisfied plaintiff may appeal the amount strength of the evidence supporting negligence
of damages awarded to them when judgment is on the part of the physician [11]. When juries and
entered in their favor. A physician defendant settlements err (based upon independent review),
may also appeal for a reduction in the amount of the error is more likely to favor the defendant
damages awarded. In general, a jury trial almost physician than the plaintiff patient.
always ends with the “final say.” Jury verdicts are
overturned on appeal only if the law was applied
incorrectly. 26.2.9 Expert Witness
Additionally, as result of many states’ pre-suit
requirements for medical malpractice claims, In most trials, a witness does not render an opin-
many cases are dismissed by the trial court and ion but instead states the facts as the witness per-
appealed in the initial stages of a litigation due ceives the events that occurred. Expert witnesses
to an actual or perceived procedural defect in are routinely used in medical malpractice cases
the initial filings by the plaintiff and his or her and are specifically retained by the plaintiff and
counsel. As such, these lawsuits may be dismissed the defense to render opinions. A “jury of peers”
without reaching the merits of the plaintiff ’s lacks the expertise to take the facts as presented by
claim. Alternatively, if a defendant is unsuccessful the “fact witnesses” and reach a conclusion. As a
at the appellate level concerning these procedural result, expert testimony is required to prove there
issues, the litigation process is prolonged. was a breach of duty of care by the physician as
well as causation. During discovery, there may be
no evidence of malpractice concerning a particu-
26.2.8 Settlement lar provider resulting in a dismissal of a plaintiff ’s
claim against that provider.
Many physicians may settle cases to avoid the The American Medical Association “encour-
nuisance, harassment, and financial risk inherent ages physicians to recognize their ethical duty as
in jury trials. A verdict which exceeds the policy learned professionals to assist in the administra-
limit places the financial responsibility on the tion of justice by serving as experts” [12]. As a
physician for the balance of defense and indem- result, some physicians serve in this role to discour-
nity (sum of money paid as compensation) costs. age inappropriate medical practice and to improve
Most insurance policies allow the physician to patient safety. Others are motivated financially by
have input into the settlement decision, giving the the fees that the expert witness receives. Expert
physician the authority to decide whether to settle witnesses often request a retainer fee (>$2000),
or proceed with litigating the claim (consent-to- charge $350 per hour (or more) for file review/
settle clause). However, some professional liabil- preparation and $500 per hour (or more) for tes-
ity insurance carriers can settle a claim over the timony. Desirable expert witness characteristics
objection of the policyholder. include board certification in the specialty of the
Why would this occur? Payouts for medical defendant physician, subspecialty experience and
malpractice claims are at least two times greater certification when appropriate, effective commu-
for claims that go to verdict than those that settled nication skills, unbiased testimony, and familiarity
before trial. with the local standard of care.
Expert witnesses must have “knowledge, skill, siology is an at-risk specialty for medical mal-
experience, training, or education” which will “help practice suits. The practice of anesthesiology
the trier of fact to understand the evidence or to can be considered an intersection of patient ill-
determine a fact in issue.” See, e.g., Fed. R. Evid. ness, highly invasive procedures/techniques, and
702. Under this broad standard, a family prac- potentially lethal drugs. Furthermore, the anes-
titioner could provide expert witness against an thesia care team model invokes vicarious liabil-
anesthesiologist. Some states do require a physi- ity from supervision of mid-level care providers
cian testifying as an expert witness in a medical such as certified nurse anesthetists and anesthesia
26 malpractice case to be of the same specialty as the assistants. Anesthesiologists may be named in
defendant. Others may require an expert witness lawsuits despite appropriate care on their part due
testifying in that state to be licensed there. In 2001, to medical misadventures by other physicians.
the United States Court of Appeals for the Seventh Despite these risk factors, estimates indicate
Circuit held that the American Association of that 7% of more than 40,000 anesthesiologists
Neurological Surgeons, a professional society, in the United States have a claim filed annually
could discipline one of its members on the basis against them with 2% resulting in indemnity pay-
of testimony in a malpractice case [12]. In 2004, ment. In comparison, this result is the same as the
the American Society of Anesthesiologists (ASA) average of all physicians in the analysis of data
approved a mechanism for reviewing testimony of from a large professional liability insurer with a
expert witnesses in closed cases as well as providing nationwide client base. Of note, the frequency of
a means for suspension or expulsion from the ASA. indemnity claims did not correlate with the high-
Anesthesiologists testifying for both sides are est average payments [1].
usually very experienced. Defense expert wit-
nesses are more likely to have a higher scholarly
impact and to practice in an academic setting. 26.3.1 Indemnity Payments:
A higher proportion of plaintiff experts testify All Physicians
repeatedly in medical malpractice cases than their
defendant counterparts [13]. The highest average payouts usually occur for
patients suffering quadriplegia, brain damage, and
the need for lifelong care. The mean indemnity
26.3 Anesthesiology: At-Risk payment was $300,000 with a median of $110,000
Specialty? across specialties. The difference between mean
and median reflects a skewed distribution toward
Medical malpractice lawsuits are a relatively com- large payments of more than $1 million in some
mon occurrence in the United States (. Fig. 26.1). specialties such as obstetrics and gynecology,
Many physicians intuitively believe that anesthe- pathology, anesthesiology, and pediatrics [1].
.. Fig. 26.1 Graph
showing the 2016 Average premium for $1M/$3M policy
malpractice payments $31
against physicians
$29
$27
$25
Thousands
$23
$21
$19
$17
$15
2002 2004 2006 2008 2010 2012 2014 2016
Medical Malpractice
363 26
26.3.2 Indemnity Payments: course of action and any recommended follow-up,
Anesthesiologists (3) recording communication with other services
and care providers, and (4) detailing all patient
According to the American Society of Anes visits and conversations with the family includ-
thesiologists closed claim analysis, the most ing who was present each time. Documentation
common injuries from medical practice from in the medical record is essential as the anesthetic
1990 to 2007 were death (26%) and nerve injury record is not reviewed by most clinicians.
(22%) [14]. A more recent review of anesthesia- A provider should not admit a wrongdoing in
related mortality and morbidity trends reported the written medical record. Events may be inter-
by a large national malpractice insurance com- preted differently later when new information
pany revealed that death (18%) and nerve injury becomes available. Accusations blaming other
(14%) were again the most common injuries services of wrongdoing after an adverse event
when dental damage was excluded. The average make the whole institution’s care appear substan-
indemnity payment for an anesthesia claim was dard. Lawyers representing plaintiffs benefit from
$309,066, compared to $291,000 for all physician physicians pointing fingers at each other.
specialties [15].
26.3.5 The Medical and Anesthesia

26.3.3 How to Minimize the Risk Records
of Liability
In making written records in practice, a physi-
Patients who sue are more likely to be unhappy cian should not cross out incorrect entries in
with the interpersonal relationship with their the medical record. Instead, the clinician should
physician than the actual outcome of the care they place one horizontal line through the incorrect
received. Following an adverse event, patients entry leaving it legible. Then, the provider would
report greater satisfaction and are less apt to sue add the correct information with date, time, and
when they perceive the physician as personal, signature. If possible, the preferred method is to
communicative, and caring. When a complication place an addendum elsewhere in the record with-
occurs, the physician should be open, honest, and out altering the original entry. Events should be
readily available. In the event of a complication described as they unfolded without speculation.
that may or may not be caused by physician neg- As discussed in detail below, medical records
ligence, the physician should closely collaborate should not be altered upon notice of a lawsuit.
with the hospital’s division of risk management to The impact of electronic medical records
proactively approach the patient and/or the fam- (EMR) on medical malpractice liability has yet to
ily and decide upon a corrective course of action. be fully appreciated. Four core functional areas
Zhou et al. demonstrated that successfully pass- of anesthesia information systems are present
ing the oral primary certification examination in in all EMRs, namely, documentation of clini-
anesthesiology is associated with a decreased risk cal findings, laboratory and imaging findings,
of subsequent license actions including those due computerized order entry, and clinical decision
to malpractice [16]. support. In some malpractice cases, the docu-
mentation within EMRs may establish a provid-
er’s guilt, whereas in others it may help mount a
26.3.4 Adverse Events defense. For example, gaps in documentation of
vital signs would be readily apparent in an elec-
If an adverse event occurs, the physician may have tronic anesthesia record where these measure-
difficulty recalling specifics about the case at a ments are automatically recorded. All data in an
time remote from the procedure. Anesthesia pro- EMR is time stamped (metadata). This electronic
viders should document adverse events not only footprint can be used to determine when docu-
in the anesthesia record but also the main medical mentation actually occurred. The discoverability
record by (1) describing pertinent details without and permissibility of metadata in malpractice
speculation (“just the facts”), (2) establishing the litigation is determined by state law. In the era of
paper records, some anesthesiologists commonly Term Definition

recorded their standard documentation, such as
the presence on induction, at less hectic times of Insurance options
the procedure. Examples exist in closed medical Purchase A contract with a commercial
malpractice claims where metadata proved that company for coverage against
a postoperative note actually occurred minutes liability claims and when damages
after surgery began. A paucity of research curare awarded
rently exists to determine the risks and benefits of Self-insure A monetary fund is established for
26 an EMR specifically as it applies to the practice of use in defense of liability claims
anesthesiology [17]. and when damages are awarded
“Going bare” A medical provider is practicing

26.3.5.1 Notice of a Lawsuit without professional liability or
A clinician should notify the insurance carrier medical malpractice insurance
immediately upon receipt of a notice of a law- Limits
suit. Additionally, the physician should gather
all pertinent records, including a copy of the Individual Maximum payment for any
claim individual claim
anesthetic record, billing statements, and corre-
spondence concerning the case. Upon review of Annual Maximum payment for the entire
the medical record, a clinician should not alter aggregate year
any previous entry or discuss the case with any- Policy type
one, including colleagues who may have been
Claims made Covers any claim made and filed
involved, operating room personnel, or friends. during the policy period
For a successful defense to occur, physicians
named in the suit must cooperate fully with the Tail Covers any claim made during the
policy period but filed after the
attorney provided by the insurer in answering policy period has ended
the complaint.
Occurrences Covers any claim made during the
policy period irrespective of when
the claim was filed
26.4 Medical Malpractice Insurance
Terms
Medical malpractice insurance is considered a Premium Money paid for professional
“necessary evil” by most anesthesiologists. Most liability coverage
anesthesiologists will not consider practicing Consent to The physician must give approval
medicine without professional liability insur- settle to the insurance company to
ance. “Going bare” is a relatively uncommon settle a claim
practice but has adherents who believe that the
cost of medical malpractice insurance is simply
too high or that a lack of insurance will lessen the
likelihood of being a “deep pockets” target. Most The average premium for mature $1 M/$3 M
hospitals mandate medical malpractice cover- policies has steadily declined (. Fig. 26.2) with an

age for independent anesthesia providers. The average annual premium of $17,000. The variation
vast majority of anesthesiologists now purchase in premiums from state to state is significant and
a “claims-made” policy with individual claim dependent upon multiple factors to include the
and annual aggregate limits of $1 million and $3 provider’s personal claim history, urban vs. rural
million, respectively. According to the American location, and region of the country (. Fig. 26.3)

Society of Anesthesiologists, only 21% of insur- [18]. In contrast to popular belief, physicians
ance companies wrote mainly or exclusively are often the “victors” in malpractice suits. Stud-
occurrence policies. ies show that physicians successfully defended
Medical Malpractice
365 26
.. Fig. 26.2 The average
premium for $1M/$3M Average premium for $1M/$3M policy
$31,000
$29,000
$27,000
$25,000
$23,000
$21,000
$19,000
$17,000
$15,000
2002 2004 2006 2008 2010 2012 2014 2016 2018
malpractice lawsuits being filed usually occur in

Lower states that have passed tort reform laws.
7% Areas where tort reform have focused include
Same the following:
26%
26.5.1 Noneconomic Damages Cap

Higher
67% A limitation on the amount awarded for noneco-
nomic damages such as loss of consortium or pain
and suffering is often the first step in state tort
.. Fig. 26.3 Malpractice premiums: pain versus reform. Earnings loss and medical bills attributed
anesthesiology to the injury are less likely to be limited. Certain
states combine the cap to include both economic
80 to 90% of the time when weak evidence was and noneconomic damages. Currently caps range
presented to jury as to breach of the standard of from $250,000 (noneconomic damages) to over
care. Even when there is strong evidence of medi- $2 million dollars (economic and noneconomic
cal negligence, 50% of juries find in favor of the damages combined). Caps on damages are con-
physician defendant [19]. troversial topics particularly to the plaintiffs and
their attorneys. Many states which have success-
fully passed tort reform that specifically target
26.5 Professional Liability (Tort) caps on damages have seen these laws rule uncon-
Reform stitutional by the state supreme court.
Many physicians and legislators have lobbied vig-

orously for tort reform. Historically, reasons for 26.5.2 Provider Apology
tort reform have centered on the increased costs
of medical malpractice insurance premiums for Any comment which can be viewed to be an
both hospitals and individual providers. Also, admission of wrongdoing can be used as an
most people assume the risk of excessive judg- admission of liability in some states. A simple
ments awarded in medical malpractice lawsuits apology or expression of sympathy by the provid-
escalates the overall cost of healthcare to the ers can be used against them in court. Other states
consumer. Decreases in the amount of the plain- have statues governing tort law that prohibit this
tiff ’s average award and the number of medical from occurring.
26.5.3 Joint and Several Liability KS, LA, NE, NM, NY, PA, SC, and WI) have active
patient compensation funds. Many other advan-
Many anesthesiologists believe that the limits tages often exist when physicians practice in states
of their liability policies should be at a mini- with patient compensation funds. Medical mal-
mum value ($500,000/$1,000,000 as opposed to practice claims are reviewed by an approved com-
$3,000,000/$5,000,000 or higher) for fear of becom- mission for legitimacy before damages are awarded
ing the “deep pocket.” Under the doctrine of joint reducing frivolous claims. States with patient com-
and several liability, if an injury occurs, a plaintiff pensation funds often also have a statute of limita-
26 may purse a claim against any one party (the “deep tions on claims, monetary caps on damages, and
pocket”) as if they were jointly liable with the other limits on attorney fees. Opponents of PCFs empha-
party for the injury. The purpose of this doctrine is size that some states limit the total amount paid by
to compensate a plaintiff (“make them whole”) for the funds each year by waiting until the money is
their injuries when another defendant is insolvent. available or by paying out larger awards over time.
While pure joint and several liability still exists
in some states in this country, several states have
26.5.5 Contingency Fees
modified or abolished this doctrine as part of tort
reform. In states that adhere to modified joint and
Some states have abolished contingency fee
several liability, a solvent defendant may only be
arrangement between plaintiffs and their attor-
responsible for the entire verdict if the percentage
neys in medical malpractice cases. The lawyer
of fault attributed to that defendant meets a certain
is paid a fixed percentage of the amount finally
threshold. Other states subscribe to several liabil-
paid to the client. If the plaintiff loses, neither the
ity where a defendant is only responsible for the
plaintiff nor the lawyer will be awarded money.
damages that correspond to the percentage of fault
allocated to the defendant by the fact finder.
26.5.6 Collateral Source Rule
26.5.4 State Patient Compensation
Some plaintiffs request payment for damages
Funds that are eventually paid for by health or disability
insurance and not by the plaintiff. Some plaintiffs
Many states mandate that an anesthesiologist or request payment for damages that are eventually
certified registered nurse anesthetist have medical paid or have been paid for by health or disability
malpractice coverage but limit the provider’s legal insurance and not by the plaintiff. The collateral
liability to a fixed amount. Any amount awarded source rule is a rule of evidence that states that
for damages in excess of the provider’s limits is evidence that the plaintiff has received compensa-
paid out of a designated state fund. The state fund tion from another source other than the damages
pays for larger settlements and awards for damages sought from the defendant is inadmissible. Tort
reducing what the primary insurance companies reform advocates argue for the abrogation of this
must pay (excess liability fund or excess coverage rule so that the plaintiff can ultimately only recover
fund). For example, in Louisiana any individual damages for those expenses that were paid by the
award in excess of $100,000 shall be paid from the plaintiff or on the plaintiff ’s behalf as opposed to
patient compensation fund, while in Indiana the what was charged, but not ultimately paid by the
fund makes payments for individual awards in insurance company. Some states have abrogated
excess of $250,000. In contrast, New York’s patient this rule in context of medical malpractice cases.
compensation fund starts payment when the
award exceeds $1.3 million. As a result, the clini-
cian becomes a lower risk allowing the insurance 26.5.7 Punitive Damages
carrier to offer a more competitive premium. The
average premium for malpractice coverage in states Punitive damages are awarded in addition to
where a patient medical malpractice compensation actual damages as a way of punishing the defen-
fund exists is usually among the lowest in the coun- dant. Many states limit the amount of punitive
try. Of note, New York’s premium rates are still the damage awards to a percentage of the compensa-
highest in the country. Currently nine states (IN, tory award or by a flat cap.
Medical Malpractice
367 26
26.5.8 Expert Witness for the medical negligence of the physician, then
the jury could find that the patent’s heirs would
In several states, through tort reform, a medical receive compensation for the 10% chance of loss
expert that is to testify against a defendant must of life [21].
now be board-certified in the same specialty as
the defendant. Some states limit the geographic
location of experts testifying in their courts by 26.6 Cyber Liability
requiring them to be licensed in that state “or
a contiguous state” during the year prior to the Over the last several years, millions of people
incident, which is the locality rule as discussed have had their personal health information (PHI)
above. “hacked” by cyber criminals. This loss of private
information can place patients and physicians
at much greater financial risk than simple credit
26.5.9 Certificates of Merit/“Good card fraud. The personal identity theft can esca-
Faith” late to both prescription and insurance fraud.
In other states, tort reform includes additional

measures meant to ensure that only cases with 26.6.1 HITECH
merit reach the jury. As mentioned supra, several
states have passed pre-suit requirements includ- The Health Information Technology for Economic
ing filing a certificate of good faith as part of tort and Clinical Health Act of 2009 (HITECH)
reform. In Tennessee, as a result of passing laws mandates that entities protect against unauthor-
as to pre-suit notice requirements, specifically ized use or disclosure of PHI which includes not
filing a certificate of good faith, medical practice only the physician practice but also any business
suits fell 36%, and medical malpractice premiums associates. Any unauthorized acquisition of PHI
decreased 40% [20]. is presumed to be a data breach and must be
reported to the federal government unless there
is no significant harm to the individual. This risk
26.5.10 Loss of Chance for “potential harm” is based on a four-factor test:
1. Nature and extent of PHI disclosed
Traditional standards for negligence in medical 2. Who was the unauthorized viewer/user of the
malpractice cases require the plaintiff to prove that PHI
the physician’s deviation from standard of care 3. Whether the PHI was used or viewed
“more likely than not” caused the injury. When 4. Whether the risk was mitigated
a patient has <50% chance of survival before the
presumed negligence occurred, the usual standard According to the Department of Health and
of “more likely than not” would prevent success- Human Services (HHS), a stolen or lost laptop
ful litigation on behalf of the plaintiff. However, computer or mobile device with unencrypted PHI
a plaintiff may have a “loss of chance” claim if it accounts for 60% of unauthorized disclosures and
is proven that a favorable outcome to the plaintiff 16% (almost 30 million) of patients. In contrast,
was more likely than not diminished due to the computer hacking by criminals account for 9% of
negligent conduct of the provider. the total number of disclosures of PHI affecting
For example, a patient with less than a 50% almost 100 million patients.
chance of survival following a motor vehicle
accident undergoes emergency surgery, devel-
ops anaphylaxis from antibiotic therapy, and 26.6.2 Costs of a PHI Breach
dies intraoperatively. A review of the medical
record documents that a family member clearly The Office for Civil Rights within HHS determines
relayed an allergy to the antibiotic administered the level of fault and subsequent fine. The level of
prior to surgery. If the plaintiff ’s expert wit- fault will likely be considered willful neglect if the
nesses can convince a jury that the decedent physician practice has not implemented privacy
would have had a 10% survival chance except rules that meet Health Insurance Portability and
% of U.S. adults who use at least one social media site, by age
100
75
26 50
25
0
2006 2008 2010 2012 2014 2016
18-29 30-49 50-64 65+
.. Fig. 26.4 Percentage of adults in the United States who use at least one form of social media, by age
Accountability Act (HIPAA) standards. The finan- The online resources such as available to phy-
cial implications of a breach in patient PHI can be sicians UpToDate and PubMed have changed
disastrous to an individual or group practice. The the practice of medicine. Social media allows
fines which can be imposed by OCR are as high as for two- way communication online between
$1.5 million per year per type of violation. Other healthcare providers and those seeking medical
costs include patient notification, credit monitor- information. As a result, many view social media
ing services, and expert consultations (public rela- as an invaluable platform for health communica-
tions, legal counsel, information technology, etc.). tion to the general population as well as address-
ing the specific questions by individual patients.
Unfortunately, the use of social media has inher-
26.6.3 Cyber Liability Insurance ent liability risk. To minimize these risks, health-
care providers should follow several principles.
The potential costs of a breach in protection of First, remember that every post is “public” and
patient PHI are enormous. Many believe that deci- “permanent” even if you thought it was a “private”
sion to purchase cyber liability coverage is not a discussion [24]. Physicians should avoid giving
“yes or no” decision, but rather what limits of liabil- specific answers to particular medical questions
ity should be obtained. Some medical malpractice to an online post without giving disclaimers that
insurance coverage policies provide cyber liability your thoughts are for information only and that
coverage. Careful evaluation is needed to deter- patients should seek advice from their personal
mine if there is coverage for both electronic and physicians about their individual health needs.
“hard copy” PHI and breaches by business associ- Nonetheless, any medical information posted
ates. The costs covered by the policy should include online must be factual. Clinicians should follow
fines, patient notification, legal fees, cyber extor- customary disclosure practices when discussing
tion, data recovery, and credit monitoring [22]. any device, service, or medication for which you
receive compensation. Practitioners should not
post any information that can identify a patient
26.7 Social Media Liability (text, video, picture, or sound). Even when
exchanging test messages between physicians
The use of social media like LinkedIn, Facebook, about specific patient issues, the use of HIPPA
Twitter, Instagram, etc. have exploded in use from compliant text messaging services as opposed to
an estimate of 5% of the Internet users in 2005 to conventional SMS text messages is recommended
69% in 2017 across all ages (. Fig. 26.4) [23].
[25]. Finally, physicians should be very cautious
Medical Malpractice
369 26
about the use of social media or text messaging 3. Thomson v. Saint Joseph Regional Medical Center, 26
when providing patient care. Patients can and will N.E.3d 89 (Ind. Ct. App. 2015).
4. Magette v. Goodman, 771 A.2d 775 (Pa. Super. Ct. 2001).
misconstrue physician actions. http://www.ncsl.org/research/financial-services-and-
commerce/medical-liability-medical-m alpractice-
laws.aspx
26.8 Review Questions 5. Weiss DC. ABA opposes federal medical-malpractice
bill that caps pain and suffering damages, Mar. 23, 2016.
www.a bajoournal.com/news/article/aba_opposes_
?? 1. For a patient to be successful in proving
federal_medical_malpractice_bill_that_caps_pain_
medical malpractice, the patient must and_suffering_d
prove that the physician acted 6. Bal BS. An introduction to medical malpractice in the
negligently while providing care and that United States. Clin Orthop Relat Res. 2008;467(2):339–
this negligence resulted in injury. 47. https://doi.org/10.1007/s11999-008-0636-2.
7. https://w w w.m edicalmalprac ticelaw yers.c om/
A. True
medical-malpractice-state-laws/
B. False 8. Hyman DA, Silver C. Five myths of medical malpractice.
Chest. 2013;143(1):222–7. https://doi.org/10.1378/chest.
?? 2. Anesthesiologists in the United States: 12-1916.
A. Purchase an “occurrences” $3 mil- 9. Phillip PG. Twenty years of evidence on the out-
comes of malpractice claims. Assoc Bone Joint Surg.
lion/$5 million malpractice policy
2009;467:352–7.
B. Are usually self-insured for medical 10. Peters PG. Twenty years of evidence on the out-

malpractice comes of malpractice claims. Clin Orthop Relat
C. Purchase a “claims made” $1 mil- Res. 2008;467(2):352–7. https://doi.org/10.1007/s11999-
lion/$3 million policy 008-0631-7.
11. AMA Policy on Expert Witness Testimony in CEJA Opin-
D. Are at greater risks for successful mal-
ion E-9.07.
practice suits compared to their peers in 12. Austin v. American Association of Neurological Sur-
other specialties due to res ipsa loquitur geons, 253 F.3d 967 (7th Cir. 2001).
13. Radvansky BM, Farver WT, Svider PF, Eloy JA, Gubenko
?? 3. States that have established patient com- YA, Eloy JDMD. A comparison of plaintiff and defense
expert witness qualifications in malpractice litigation
pensation funds often:
in anesthesiology. Anesth Analg. 2015;120:1369–74.
A. Place caps monetary caps on damages 14. Metzner J, Posner KL, Lam MS, Domino KB. Closed
B. Establish a statute of limitations on claims’ analysis. Best Pract Res Clin Anaesthe-
claims siol. 2011;25(2):263–76. https://doi.org/10.1016/j.
C. Set limits on attorney fees bpa.2011.02.00.
15. Ranum D, Ma H, Shapiro FE, Chang B, Urman RD. Anal-
D. Pay out larger awards over time
ysis of patient injury based on anesthesiology closed
E. All of the above claims data from a major malpractice insurer. J
Healthc Risk Manag. 2014;34(2):31–42. https://doi.
org/10.1002/jhrm.21156.
26.9 Answers 16. Zhou Y, Sun H, Culley DJ, Young A, Harman AE, War-
ner DO. Effectiveness of written and oral specialty
certification examinations to predict actions against
vv 1. A the medical licenses of anesthesiologists. Anesthesi-
ology. 2017;126(6):1171–9. https://doi.org/10.1097/
vv 2. A aln.0000000000001623.
17. Mangalmurti S, et al. Medical malpractice liability

in the age of electronic health records. Surv Anes-
vv 3. E
thesiol. 2011;55(6):317–9. https://doi.org/10.1097/
sa.0b013e3182379506.
18. Burkle CM. Professional liability trends in 2017: things
References are stable for now, but hold on to your hats! ASA
Monit. 2017;81:48–9.
1. Jena AB, Seabury S, Lakdawalla D, Chandra A. Mal- 19. Biggs DA, McClure H. Professional liability reform:

practice risk according to physician specialty. N Engl the state of the states. Am Soc Anesthesiol Monit.
J Med. 2011;365(7):629–36. https://doi.org/10.1056/ 2017;79:14–7.
nejmsa1012370. 20. South T. Medical malpractice suits drop in Tennessee;
2. Shipley v. Williams, 350 S.W. 3d 527, 553 (Tenn. 2011). 2008 reforms praised, panned. Times Free Press. 2013,
December 3.
21. Burkle CM, Hyder JA. The changing environment of 24. Campbell, L., Evans, Y., Pumper, M., & Moreno, M. A.
legal liability: the loss of chance doctrine and what it (2016) Social media use by physicians: a qualita-
could mean for anesthesiologists. Am Soc Anesthesiol tive study of the new frontier of medicine. BMC Med
Monit. 2014;78:48–9. Inform Decis Mak 16, 91. Retrieved November 6, 2017,
22. Epstein J, Semo J, Parker B. Protecting PHI and
from https://doi.org/10.1186/s12911-016-0327-y
cyber liability insurance. Am Soc Anesthesiol Monit. 25. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse

2016;80:14–8. BW. Social media use in the United States: implica-
23. Social Media Fact Sheet. 2017, January 12. Retrieved tions for health communication. J Med Internet Res.
November 06, 2017, from http://www.pewinternet. 2009;11(4):e48.
org/fact-sheet/social-media/
26
371 27
Closed Claims Project

Overview
Adam P. Roth, Patrick O. McConville, and Robert Craft
27.1 V. Methods to Reduce Most Common Claims – 373

27.1.1 History of Closed Claims Project and Its Registries – 373
27.2 Postoperative Visual Loss – 373

27.2.1 Ischemic Optic Neuropathy – 373
27.2.2 Cortical Blindness – 374
27.2.3 Retinal Ischemia – 374
27.2.4 Acute Angle-Closure Glaucoma – 374
27.2.5 Posterior Reversible Encephalopathy – 374
27.2.6 External Ocular Injury – 374
27.3 Neurologic Injury After Non-supine Shoulder

Surgery – 375
27.3.1 Causes – 375
27.3.2 Risk Factors – 375
27.3.3 Prevention – 375
27.4 Anesthesia Awareness – 376

27.4.1 Incidence – 376
27.4.2 Patient Risk Factors – 376
27.4.3 Surgical Risk Factors – 376
27.4.4 Anesthetic Risk Factors – 376
27.4.5 Sequelae of Anesthesia Awareness – 377
27.4.6 ASA Practice Advisory – 377
27.5 Obstructive Sleep Apnea Death and Near Miss

Registry – 378
27.5.1 Preoperative Evaluation – 380
27.5.2 Preoperative Preparation – 380
27.5.3 Intraoperative Management – 380
27.5.4 Postoperative Management – 381
27.5.5 Criteria for Discharge to Unmonitored Settings – 382

https://doi.org/10.1007/978-3-319-96125-5_27
27.6 Pediatric Perioperative Cardiac Arrest (POCA)
Registry – 382
27.6.1 General Pediatric Population – 382
27.6.2 Congenital and Acquired Heart Disease – 383
References – 385
Closed Claims Project Overview
373 27
27.1 V. Methods to Reduce Most neuropathy, accounting for around 90% of regis-
Common Claims try cases of POVL, followed by retinal ischemia,
cortical blindness, posterior reversible encepha-
27.1.1 History of Closed Claims lopathy, and acute angle glaucoma. Due to the
Project and Its Registries often irreversibility of the majority of cases, the
focus as anesthesiologists is identifying patients
In the early 1980s, professional liability insurance at risk and minimizing risks to the greatest extent
coverage had become nearly unaffordable for possible.
many medical professionals due to soaring insur-
ance premiums. Anesthesiologists were perceived
as especially bad risks, representing only 3% of 27.2.1 Ischemic Optic Neuropathy
insured physicians but accounting for 11% of total
dollars paid due to patient injury. Hypothesizing Either the anterior or the posterior portion of
that the prevention of patient injury would result the optic nerve can be damaged perioperatively
in a domino effect of decreased claims, a reduc- from various causes and is therefore categorized
tion of payments, and subsequently reduced lia- as anterior ischemic optic neuropathy (AION)
bility insurance premiums, the Anesthesia Closed or posterior ischemic optic neuropathy (PION).
Claims Project was created in 1984 by the presi- Both forms manifest most commonly as painless
dent of the American Society of Anesthesiologists vision loss postoperatively.
(ASA), Ellison C. Pierce, Jr, MD, with the goal of The anterior optic nerve is supplied by the pos-
identifying the major areas of anesthetic-related terior ciliary artery. When hypoperfusion occurs
patient injury. through the PCA from either arteritic or non-
In 1984, a paucity of information existed on arteritic causes, ischemia may result. Arteritic
the scope and cause of anesthetic-related injury AION can occur at any time in patients with con-
in the United States, largely because significant ditions such as temporal arteritis. Non-arteritic
anesthesia injury is a relatively rare occurrence. AION can occur perioperatively in patients who
One of the most cost-effective approaches to data have risk factors to such insults such as those with
collection was found to be the study of insurance a history of vascular disease, diabetes mellitus,
company closed claims, which typically consisted hypertension, hypotension, prone positioning
of the hospital record, anesthesia record, narrative during surgery, sleep apnea, and migraines [2, 3].
statements of the involved healthcare personnel, Cardiac surgery, including CABG, is most often
expert and peer reviews, and the cost of settle- associated with AION [4].
ment or jury awards [1]. To date this initiative Posterior ischemic optic neuropathy may
consists of the Anesthesia Closed Claims Project also be categorized as arteritic or non-arteritic.
and its attendant Registries: The non-arteritic form of PION occurs most fre-
55 Postoperative Visual Loss (POVL) Registry quently following spine surgery [4]. As in ante-
55 Anesthesia Awareness Registry rior ischemic optic neuropathy, PION-induced
55 Obstructive Sleep Apnea (OSA) Death and blindness occurs as a result of hypoperfusion of
Near Miss Registry the optic nerve. Hypotension, anemia, increased
55 Neurologic Injury after Non-Supine Shoulder venous pressure, the prone position, and ocular
Surgery (NINS) Registry pressure perioperatively may be contributing
55 Pediatric Perioperative Cardiac Arrest factors [5, 6]. The prone position may lead to
(POCA) Registry increased venous pressure and resistance to blood
flow or direct orbital pressure. Avoidance of direct
orbital pressure and the prone position, however,
27.2 Postoperative Visual Loss does not eliminate all cases of PION; therefore,
the cause is possibly multifactorial [7–9].
Visual loss after a surgical procedure is a rare While the incidence of ischemic optic neu-
but devastating complication. While some of the ropathy is higher in cardiac surgery patients, most
causes may be temporary or treatable, in most cases of ischemic optic neuropathy are in spine
cases the damage is permanent. The major causes surgery patients. A study comparing 80 cases
from most to least frequent are ischemic optic from the ASA Postoperative Visual Loss Registry
374 A. P. Roth et al.
to 315 controls found that obesity, male sex, the or genetic predisposition who receive certain
use of the Wilson frame, longer anesthetic dura- medications including antihistamines, antipar-
tion, greater estimated blood loss, and decreased kinsonian medications, anticholinergic agents, or
percent colloid administration were indepen- others may present with ocular pain and blurred
dently associated with ischemic optic neuropathy vision. Elevated intraocular pressures require
after spinal fusion surgery [10]. urgent treatment from an ophthalmologist to
lower intraocular pressure [13].
27.2.2 Cortical Blindness

27.2.5 Posterior Reversible
27 Hypoperfusion or embolism of the posterior cere- Encephalopathy
bral artery may result in ischemia to the occipital
cortex perioperatively. This may result in partial Commonly known as PRES, posterior reversible
or complete visual field deficits that may or may encephalopathy is an uncommon source of post-
not be reversible. Causes of cortical blindness in operative visual loss that may be accompanied
the perioperative period include cardiac arrest, by other neurological symptoms such as head-
hypoxemia, intracranial hypertension, hemor- ache, seizures, or altered levels of consciousness.
rhage, vascular occlusion, thrombosis, intracra- Patients with severe hypertension or other dis-
nial hemorrhage, vasospasm, and emboli [11]. eases that result in cerebral edema are at risk for
Treatment for suspected cortical infarct is as in PRES. Autoimmune diseases, malignancy, chemo-
any suspected cerebral vascular accident and therapy, infections, vasculitis, and preeclampsia
depends on whether or not the insult is due to are associated with PRES. As evident in the name
hemorrhage or ischemia. The prognosis may be of the condition, posterior reversible encephalopa-
improved with prompt diagnosis and treatment thy may be temporary with proper treatment [14].
but in some cases may be irreversible.
27.2.6 External Ocular Injury

27.2.3 Retinal Ischemia
Trauma to the cornea is the most common cause of
Decreased perfusion to the retina may result in ocular injury in the perioperative period. Abrasions
partial or complete visual field deficits. The retina or lacerations may result in inflammation that can
is supplied by the central retinal artery. Systemic result in infection. Patients commonly complain
hypotension, occlusion from emboli or thrombo- of a painful irritation of the eye or a foreign body
sis, increased intraocular pressure from excessive sensation. Most cases self-resolve, but ophthalmic
external pressure, or impaired venous drainage can consultation may be recommended when visual
all result in central retinal artery occlusion (CRAO). changes are present. Topical anesthetics or irriga-
Most commonly the deficits are unilateral. Painless tion may be effective for pain relief.
vision loss results but may be accompanied by facial As discussed previously in this section, post-
edema or trauma to the eye. Rapid diagnosis may operative visual loss (POVL) is a rare complica-
result in possible treatment in cases of increased tion after surgery, and therefore specific causes
intraocular pressure. Improper positioning result- are poorly understood. Most cases are irrevers-
ing in ocular pressure or impaired venous drainage ible; therefore, identification of patients at risk
from excessive prolonged Trendelenburg position- and prevention may be the most important steps
ing may be avoidable causes [12]. to avoid this devastating complication. The ASA
task force released an updated practice advisory
in 2012 and made several recommendations [15]:
27.2.4 Acute Angle-Closure 55 Consider informing patients in whom pro-
Glaucoma longed procedures, substantial blood loss,
or both are anticipated that there is a small,
A rare form of perioperative ocular injury, acute unpredictable risk of perioperative visual loss.
angle-closure glaucoma, may result in permanent 55 Systemic blood pressure should be monitored
vision loss. Patients with a history of cataracts continually in high-risk patients.
375 27
55 The use of deliberate hypotension for spine disease, cardiovascular disease, atrial fibrillation,
surgery patients should be determined on a carotid artery disease, infective endocarditis,
case-by-case basis. diabetes mellitus, and patent foramen ovale and
55 Central venous pressure monitoring should include male gender, smoking, and advanced
be considered in high-risk patients. age. Surgical risk factors include major vascular,
55 Colloids should be used along with crystal- neurologic, and cardiac operations. Perioperative
loids to maintain intravascular volume in adverse events include cardiac arrest, dysrhyth-
patients who have substantial blood loss. mias, embolic events, and severe hypotension.
55 A transfusion threshold that would eliminate Neurological injuries and ischemia after other
the risk of perioperative visual loss related to types of surgery including shoulder surgery are
anemia cannot be established at this time. less understood, and risk factors are less well
55 There is insufficient evidence to provide guid- defined [18, 29].
ance for the use of alpha-adrenergic agonists
in high-risk patients during spine surgery.
55 Direct pressure on the eye should be avoided 27.3.3 Prevention
to prevent CRAO. The high-risk patient
should be positioned so that the head is level As with any perioperative adverse event, pre-
with or higher than the heart when possible. vention requires identification of patients with
55 Consideration should be given to the use of significant risk factors and minimizing the risks
staged spine procedures in high-risk patients. to the patient through all means available. While
specific risk factors for neurologic injury in the
non-supine shoulder surgery patient are difficult
27.3 Neurologic Injury After Non- to identify, factors that contribute to neurological
supine Shoulder Surgery injury in general should be optimized in the peri-
operative period. The focus of these neuroprotec-
A rare but serious complication of shoulder sur- tion elements includes maintenance of cerebral
gery is catastrophic neurological injury such as perfusion pressure, blood glucose control, reduc-
stroke, spinal cord injury, ischemic brain injury, or ing embolic load, hypothermia, hemoglobin
death. While the exact causes of these infrequent concentration, arterial CO2 tension, brain tissue
complications are not fully understood, a number oxygen tension, and osmotherapy [30]. While
of mechanisms have been suggested. Paired with controlling many of these elements in the periop-
identification of patients with risk factors, preven- erative period for non-supine shoulder surgery is
tion of this devastating complication is necessary not feasible, some factors have been the focus of
to the extent possible. investigations.
27.3.3.1 Blood Pressure Management

27.3.1 Causes Identification of appropriate blood pressure
parameters to allow for sufficient cerebral per-
Suggested possible causes for neurologic injury fusion pressure in the sitting position is still
after non-supine shoulder surgery include the unknown. Traditional estimations of cerebral
beach chair position [16–28] as well as reduced autoregulation between MAP of 50–150 mmHg
cerebral perfusion pressure resulting in ischemia may not be appropriate for all patients due to indi-
[17, 18, 26, 29]. vidual variation, particularly in the beach chair
position [31, 32]. Cerebral perfusion pressure can
decrease approximately 15% when the head is
27.3.2 Risk Factors raised above the position of the heart. Blood pres-
sure monitoring on the arm or the wrist therefore
Risk factors for neurologic injury after surgery should take the reduction in cerebral perfusion
have been categorized into patient risk factors, pressure into account when managing in the peri-
surgical risk factors, and perioperative adverse operative period. While some authors advocate
events. Patient risk factors are similar to those for a MAP within 20% of baseline, definitive rec-
at risk for perioperative stroke, cerebrovascular ommendations are not available.
27.3.3.2 Neuromonitoring 27.4.1 Incidence

for Ischemia
Monitoring for ischemia in the sitting posi- The overall incidence of anesthesia awareness
tion may be done with an awake patient under under general anesthesia has been evaluated in
regional anesthesia. For general anesthesia multiple studies over many years and is most com-
cases however, electroencephalography, transcra- monly cited to be between 0.1 and 0.2% [42–44].
nial Doppler, somatosensory evoked potentials
(SSEPs), and cerebral oximeters may be used to
monitor for cerebral ischemia. Cerebral oxim- 27.4.2 Patient Risk Factors
eters have reported a high incidence of cerebral
27 desaturation in patients in the beach chair posi- A history of alcohol or drug abuse has been asso-
tion [19, 24, 33–35]. Cerebral desaturation events ciated with an increased incidence of intraopera-
however have not been correlated with neuro- tive awareness in some studies [45, 46]. Chronic
logical injury. Transcranial Doppler may be lim- drug or alcohol abuse may increase tolerance
ited by technical difficulty [35] or could not be for anesthetic agents, thus resulting in an over-
performed due to the lack of a bone window in all increased risk in such patients. Females have
10–15% of the population [36]. SSEPs are useful shown in some studies to be at higher risk than
for regional but not global ischemia and may be men for intraoperative awareness. It has been
of limited use in beach chair shoulder surgery suggested that females emerge more quickly from
[37]. Continuous electroencephalography is the anesthesia than their male counterparts [47, 48].
most sensitive way to monitor for cerebral isch- Higher incidences of awareness have been found
emia in the perioperative period [38–41]. Such in the young [44, 49–51] as well as the elderly [52].
monitoring however is limited due to the need of
a trained neurophysiologist to interpret the elec-
troencephalography and allow for interventions 27.4.3 Surgical Risk Factors
to correct ischemia.
Cardiac surgery where cardiopulmonary bypass is
27.3.3.3 CO2 Monitoring used has been associated with an increased inci-
Hypocapnea with mechanical ventilation can cause dence of awareness. The range of awareness in such
cerebral vasoconstriction. Continuous monitoring studies varies considerably but is above 1% in sev-
is necessary with general anesthesia in the sitting eral studies [53–55]. Surgery for cesarean section
position. Establishment of the degree of Alveolar- likewise has been linked to an increase in aware-
arterial gradient may prevent relative hypocapnea ness under general anesthesia compared to the
in patients with altered pulmonary mechanics, overall incidence although not to the same degree
such as those with chronic obstructive pulmonary as cardiac surgery [46, 56, 57]. Trauma surgery has
disease (COPD). been found in comparison to have much higher
incidences of awareness. Studies have found as
many as 40% of poly-trauma patients may experi-
27.4 Anesthesia Awareness ence awareness [58, 59]. In the above three surgical
procedures, concerns or findings of the inability to
Awareness under general anesthesia is an infre- tolerate the same levels of anesthetics have been
quent but potentially terrifying experience for discussed as possible reasons that these surgeries
patients. As opposed to wakefulness which rep- have a greater incidence of awareness.
resents intraoperative patient arousal without
the ability to remember the event, awareness can
have significant consequences postoperatively. 27.4.4 Anesthetic Risk Factors
The incidence of awareness under anesthesia, or
recall, varies depending on patient, surgical, and Despite the choice of using a total IV anesthetic,
anesthetic factors present. Methods to reduce the inhaled anesthetic, or a balanced anesthetic,
incidence continue to be evaluated for success, awareness is still possible during surgery. Inhaled
but despite all available modalities, some patients anesthetics can have equipment malfunction, loss
continue to experience this complication. of vaporizer, or lack accurate monitors to measure
377 27
their concentration. Total IV anesthetics rely on in the area of awareness, and develop recommen-
an uninterrupted flow into the venous system. dations to help reduce the incidence of awareness
Kinking of tubing or infiltration of veins may under anesthesia.
result in awareness under anesthesia. The admin- Regarding preoperative evaluation, they rec-
istration of a balanced anesthetic compared to a ommend a history and physical assessment that
total IV anesthetic may decrease the incidence of focuses on risk factors for awareness under anes-
awareness [60]. thesia including age, sex, and history of awareness
Additionally the avoidance of the use of neu- and tolerance to drugs. They also recommend
romuscular blocking drugs may add a degree of considering the type of surgery the patient will
protection from awareness during anesthesia. The have as some surgical cases have an increased
minimum alveolar concentration to prevent wake- risk of awareness as described previously in this
fulness is approximately 1/3 that required to pre- chapter. Only patients at increased risk for intra-
vent movement to surgical stress on average. The operative awareness should be counseled on the
ability of the anesthesia provider to monitor for possibility of awareness.
movement in response to surgical stress, rather than In the pre-induction phase, the task force
being masked by the use of paralytics, is another recommends strict adherence to anesthesia
tool to prevent awareness. The use of neuromus- machine and equipment checklist protocol. Many
cular blocking medications should be reserved for cases of intraoperative awareness can be pre-
patients that cannot tolerate higher doses of IV or vented by proper identification of malfunction-
inhaled anesthetics or for surgical cases that require ing equipment including circuit leaks, vaporizer
muscle relaxation. Several studies have supported malfunction, or gas monitoring. The task force
this increase in awareness in patients that have recommends that the use of amnestic drugs for
received neuromuscular blocking drugs. One meta- awareness prophylaxis should be decided on a
analysis found that those receiving neuromuscular case-by-case basis.
blocking drugs had almost twice the incidence of Intraoperative monitoring should include the
awareness compared to those patients who did not depth of anesthesia and should be multimodal.
receive neuromuscular blocking drugs [61]. Clinical signs such as patient movement, as well
as monitoring systems such as EKG, capnography,
blood pressure, and end-tidal anesthetic concentra-
27.4.5 Sequelae of Anesthesia tion, should be used routinely to prevent awareness.
Awareness The use of brain function monitors has expanded
dramatically in the past 20 years. The task force
Patients who experience awareness under anes- agrees that such monitors should be considered in
thesia should be counseled about their experience patients at increased risk of awareness periopera-
as they are at increased risk for psychological dis- tively. They acknowledge that there is insufficient
orders. These include post-traumatic stress dis- evidence to justify their use in high-risk patients as
order (PTSD) or other emotional disorders [47, a standard. Their use, according to the task force,
62]. In a review of reported cases in the literature, should be determined on a case-by-case basis.
Ghoneim and others found that approximately Intraoperative and postoperative interven-
15–20% of patients who experienced awareness tions in patients who are determined to have
developed nightmares, sleep disorders, or daily experienced awareness were investigated by the
anxiety [46]. Psychiatric or psychological coun- task force. They were unable to reach a consensus
seling and treatment may be necessary for these regarding the value of administering additional
patients who experience such complications. benzodiazepines or the administration of post-
operative questionnaires in patients deemed to
have experienced awareness. They did agree that
27.4.6 ASA Practice Advisory a structured interview should be taken in these
patients and that they should be offered psycho-
In 2006 the American Society of Anesthesiology logical counseling [63]
issued a practice advisory for Intraoperative A 2016 Cochrane Review of 160 randomized
Awareness. The ASA appointed a task force of ten controlled trials focused on the use of various
members to review literature, consult with experts monitors as well as medication administration in
the prevention of intraoperative awareness. They costly and resource-intensive, creating a substantial
found that anesthetic depth monitors had simi- barrier to widespread use. To assist the anesthesi-
lar effectiveness in preventing awareness to the ologist in diagnosing this prevalent sleep disorder
conventionally used clinical and electrical moni- during the preoperative evaluation, a variety of alter-
toring. They also found that benzodiazepines native screening tools exist. Published in 2008, the
reduced awareness when compared to ketamine STOP Questionnaire was the first screening tool for
and thiopental. They also found that ketamine OSA that was validated in surgical patients and con-
and etomidate reduced the incidence of wakeful- sists of four simple yes/no questions:
ness when compared to thiopental. Likewise not 55 S – Do you snore loudly (louder than talking or
surprisingly, higher doses of inhaled anesthetic loud enough to be heard through closed doors)?
27 agents reduced wakefulness in comparison to
lower-dose inhaled agents [64].
55 T – Do you often feel tired, fatigued, or sleepy
during the daytime?
55 O – Has anyone observed you stop breathing
during your sleep?
27.5 Obstructive Sleep Apnea Death 55 P – Do you have or are you being treated for
and Near Miss Registry high blood pressure?
Obstructive sleep apnea (OSA) is characterized Utilizing this screening tool, a patient is deemed
by periodic, partial, or complete obstruction of to be at high-risk for undiagnosed OSA if two or
the upper airway due to a reduction of pharyngeal more positive responses are obtained. To further
muscle tone during sleep. Acutely this can result increase the sensitivity of this screening tool, four
in episodic oxygen desaturation and intermittent additional variables were subsequently incorpo-
hypercarbia, while, chronically, cardiovascular rated, resulting in the STOP-BANG questionnaire:
dysfunction due to systemic and/or pulmonary 55 B – BMI > 35 kg/m2
hypertension, cardiac dysrhythmias, and right 55 A – Age > 50 years
heart failure (cor pulmonale) [58, 65] can ensue. 55 N – Neck circumference >43cm (17 inches)
The gold standard for definitive diagnosis is poly- in male and 41 cm (16 inches) in female
somnography (PSG) and utilizes an apnea hypop- 55 G – Male gender
nea index (AHI), defined as the average number
of abnormal breathing events per hour of sleep With respect to the STOP-BANG question-
(apneic event refers to cessation of airflow for 10 s, naire, the likelihood of disease is based upon the
while hypopnea occurs with reduced airflow and following:
concomitant desaturation ≥4%) [66]. Severity of 55 Low risk: Yes to 0–2 questions
disease is based on an AHI, as follows: 55 Intermediate risk: Yes to 3–4 questions
55 Mild OSA: AHI ≥ 5 but <15 per hour 55 High risk: Yes to 5–8 questions or:
55 Moderate OSA: AHI ≥ 15 but <30 per hour 55 Yes to two or more of four STOP ques-
55 Severe OSA: AHI ≥ 30 per hour tions + male gender
55 Yes to two or more of four STOP ques-
OSA is the most prevalent sleep-breathing distur- tions + BMI > 35 kg/m2
bance, affecting 24% of men and 9% of women in the 55 Yes to two or more of four STOP questions
general population [67, 68]. Even more noteworthy + neck circumference> 43cm (17 inches)
are the estimates that nearly 80% of men and 93% in male and 41 cm (16 inches) in female
of women with moderate to severe sleep apnea are
undiagnosed [69]. The anesthetic implications of this Various other questionnaires have been validated
are profound as untreated OSA patients are known in the surgical population including those such as
to have a higher incidence of difficult intubation, the Berlin Questionnaire and ASA Checklist, which
numerous postoperative complications, increased will not be discussed further within this chapter
intensive care unit admissions, and greater dura- (. Table 27.1).

tion of hospital stay [70]. Hence, it is woefully inad- The inherent collapsibility of the upper airway
equate to ask patients if they suffer from sleep apnea, and associated systemic effects of the disease place
as the reply will far too often be a misguided “no.” surgical OSA patients at increased risk of serious
Unfortunately, routine screening with PSG is both complications, including:
379 27
.. Table 27.1 Berlin Questionnarie and ASA Checklist
Berlin Questionnaire ASA Checklist STOP Questionnaire STOP-Bang Questionnaire
Netzer [30] Gross [32] Chung [29] Chung [29]
Clinician-administered Clinician-administered Self-administered Clinician-administered
Validated in primary care Validated in perioperative Validated in Validated in perioperative

setting and perioperative setting perioperative setting setting
setting
10-item 14-item 4-item B-item
3 categories: Snoring, 3 categories: predisposing No categories No categories

daytime sleepiness, characteristics, symptoms
driving of OSA, complaints
High risk if 2 or more High risk if 2 or more High risk if 2 or more High risk if 3 or more
categories score positive categories score positive items score positive items score positive
For AHI >30 For AHI >30 For AHI >30 For AHI >30
Sensitivity 87% Sensitivity 87% Sensitivity 80% Sensitivity 100%
Specificity 46% Specificity 36% Specificity 49% Specificity 37%
PPV 32% PPV 28% PPV 30% PPV 31%
NPV 93% NPV 91% NPV 90% NPV 100%
For AHI >15 For AHI >15 For AHI >15 For AHI >15
Sensitivity 79% Sensitivity 79% Sensitivity 74% Sensitivity 93%
Specificity 51% Specificity 37% Specificity 53% Specificity 43%
PPV 51% PPV 45% PPV 51% PPV 52%
NPV 78% NPV 73% NPV 76% NPV 90%
Complicated scoring Clinician required to Concise, easy-to-use Improve sensitivity

procedure complete checklist compared with the STOP
questionnaire
55 Twofold higher risk of pulmonary compli- apnea, this registry and its recommendations focus
cations in OSA patients after noncardiac solely on obstructive sleep apnea, the most common
surgery vs. non-OSA patients with OSA form. Central sleep apnea, defined as the cessation
patients more likely to receive ventilatory of airflow without respiratory effort [74], affects
support [71] very few patients and is of little concern to the anes-
55 Fifty-three percent incidence of postoperative thesiologist, except under three circumstances [75]:
delirium in OSA patients vs. 20% in non- 55 Central sleep apnea with snoring – patients
OSA patients [72] should be treated as if they have OSA.
55 Increased odds of postoperative cardiac events 55 Central sleep apnea due to heart failure.
including myocardial infarction, cardiac arrest, 55 Central sleep apnea with hypoventilation
and arrhythmias (OR 2.1), respiratory failure syndrome – patients may require unantici-
(OR 2.4), desaturation (OR 2.3), ICU transfers pated assisted ventilation during surgery and
(OR 2.8), and reintubations (OR 2.1) [73] postoperatively.
It should be mentioned that while sleep apnea can Aside from its vast anesthetic implications,
be classified as either (a) obstructive sleep apnea chronic untreated OSA leads to multisystem
(OSA), (b) central sleep apnea, or (c) mixed sleep disease and is an independent risk factor for
increased all-cause mortality in the general popu- the delivery of outpatient surgery for a variety
lation [76, 77]. It is for these reasons that the of medical procedures. ASA guidelines on the
Society of Anesthesia and Sleep Medicine and perioperative management of OSA patients
the Anesthesia Closed Claims Project established advise that superficial surgery, minor orthope-
the Obstructive Sleep Apnea (OSA) Death and dic surgery under local/regional anesthesia, and
Near Miss Registry – to investigate unanticipated lithotripsy may be performed as day surgery
perioperative deaths and near misses in patients cases [79]. In 2012, the Society for Ambulatory
with OSA and identify common themes or factors Anesthesia (SAMBA) developed a consensus
associated with OSA-related adverse periopera- statement addressing OSA patients and ambu-
tive events. Inclusion criteria for cases submitted latory surgery that is summarized below (see
27 to this Registry include:
55 Age of 18 years or older
. Fig. 27.1) [80].

Lastly, the need for high-dose oral opioids in

55 Event occurred between 1993 and 2016 the postoperative setting is often a contraindica-
tion for ambulatory surgery in the OSA patient
Given the overwhelming evidence linking the to the risk of respiratory compromise that may go
diagnosis of OSA with adverse perioperative unrecognized following discharge.
outcomes, precautions, specifically emphasizing
airway maintenance and frequently associated
cardiopulmonary abnormalities, should be taken 27.5.2 Preoperative Preparation
to reduce complications in this group of patients.
In 2014, the ASA Task Force on Perioperative 55 Consider preoperative initiation of continu-
Management of Patients with Obstructive Sleep ous positive airway pressure (CPAP), particu-
Apnea released updated practice guidelines and larly if OSA is severe. Consider noninvasive
made several recommendations [78]; a compre- positive pressure ventilation if response to
hensive, but not complete, list follows. CPAP is not adequate.
55 Patients with known or suspected OSA may
have difficult airways and should be man-
27.5.1 Preoperative Evaluation aged according to the “Practice Guidelines
for Management of the Difficult Airway: An
55 In patients with the possibility of OSA, a Updated Report.”
protocol should be established to allow evalu-
ation preoperatively with ample time for
preparation of a perioperative management 27.5.3 Intraoperative Management
plan.
55 Preoperative evaluation should include a 55 Due to the propensity for airway collapse,
comprehensive review of previous medical patients with OSA are highly susceptible to
records, if possible. the respiratory depressant and airway effects
55 Review of sleep studies is encouraged. of sedatives, opioids, and inhaled anesthetics;
55 If preoperative evaluation suggests that a therefore, the potential for postoperative respi-
patient has OSA, a joint decision between the ratory compromise should be considered with
anesthesiologist and surgeon should be made the selection of intraoperative medications.
regarding the necessity of a formal sleep 55 For superficial procedures consider the
study and possible indicated OSA treatment use of local anesthesia and/or peripheral
prior to surgery. nerve blocks with or without moderate seda-
55 The patient and his/her family, as well as the tion.
surgeon, should be informed of the potential 55 If moderate sedation is used, ventilation
implications of OSA on the patient’s periop- should be continuously monitored by cap-
erative course. nography due increased risk of undetected
airway obstruction.
Of paramount importance is how to integrate 55 Consider CPAP or using an oral appliance
the known or suspected OSA patient into during sedation to patients previously treated
today’s healthcare climate that often focuses on with these modalities.
381 27
Preoperative evaluation
Patient with presumptive

Patient with known OSA diagnosis of OSA
Optimized Patients with Optimized co-morbid conditions

comorbid conditions non-optimized AND
AND comorbid conditions Postoperative pain can be managed
Able to use CPAP after discharge predominantly by using non-opioid
analgesic techniques
Proceed with Not suitable for ambulatory Proceed with

ambulatory surgery Surgery, may benefit from ambulatory surgery
diagnosis and treatment
Preoperative considerations:
Comorbid conditions include hypertension, arrhythmias, heart failure, cerebrovascular disease, and
metabolic syndrome.
If OSA is suspected during the preoperative evaluation, one could proceed with a presumptive
diagnosis of OSA albeit with caution.
Educate surgeon, patient and family (see the text for details)
Intraoperative considerations:
Non-opioid analgesic techniques, when possible.
Postoperative considerations:
Exercise caution in OSA patients who develop prolonged and frequent severe respiratory events
(e.g., sedation analgesic mismatch, desaturation, and apneic episodes) in the postoperative period.
.. Fig. 27.1 Society for Ambulatory Anesthesia (SAMBA) consensus statement addressing OSA patients and ambula-
tory surgery that is summarized below
55 General anesthesia with a secured airway is pref- oids) and risks (respiratory depression from
erable to deep sedation without a secure airway. rostral spread) of using an opioid or opioid-
55 Unless a contraindication exists, patients with local anesthetic mixture rather than a local
OSA should be extubated awake. anesthetic alone.
55 If neuromuscular blocking drugs are utilized, 55 Avoid background infusions (basal rate) of
full reversal should be verified prior to extu- opioids if patient-controlled analgesia (PCA)
bation. is used.
55 When possible, extubation and recovery 55 Consider multimodal analgesic options to
should occur in the lateral, semi-upright, or reduce need for opioids.
other non-supine positions. 55 Supplemental oxygen should be supplied to
patients with OSA until they are able to maintain
their baseline oxygen saturation on room air.
27.5.4 Postoperative Management 55 Caution must be exercised as this may
increase the duration of apneic episodes
55 Regional anesthetic techniques should be and possibly hinder the detections of atel-
considered to reduce or eliminate the need of ectasis, transient apnea, and hypoventila-
systemic opioids. tion by pulse oximetry.
55 If neuraxial analgesia is planned, weigh the 55 Unless contraindicated by the surgical proce-
benefits (decreased need for systemic opi- dure, CPAP or noninvasive positive pressure
ventilation (with or without supplemental the Committee on Professional Liability of the

oxygen) should be continuously administered American Society of Anesthesiologists (ASA) and
to patients who were using these modalities the American Academy of Pediatrics Section on
preoperatively. Anesthesiology to investigate the incidence and
55 Consider having patients bring CPAP or causes of cardiac arrest, defined as the need for
noninvasive positive pressure ventilation CPR or death, in pediatric patients during the
equipment with them to the hospital to administration of or recovery from anesthesia.
improve compliance. It was closed in 2005 after collecting 373 cases of
55 If possible, maintain non-supine positions cardiac arrest (all submitted anonymously) and
throughout the recovery process. representing 73.5 million pediatric anesthetics
27 55 Hospitalized patients at increased risk of
respiratory compromise from OSA should
across approximately 68 medical centers (58–79
institutions were enrolled in the Registry each
have continuous pulse oximetry monitoring year), including both academic institutions and
after discharge from the recovery room. community hospitals throughout the United
55 If frequent or severe airway obstruction or States and Canada. Of the anesthesia care provid-
hypoxemia occurs during postoperative ers involved with this registry, 95% were certified
monitoring, initiation of CPAP or noninva- by the American Board of Anesthesiology (or the
sive positive pressure ventilation should be equivalent), and 82% had fellowship training in
considered. pediatric anesthesiology.
27.5.5 Criteria for Discharge

27.6.1 General Pediatric Population
to Unmonitored Settings
In the July 2000 edition of Anesthesiology, Ann
55 Discharge from the PACU to an unmonitored
Bailey, MD (a pediatric anesthesiologist at UNC
setting (i.e., home or unmonitored hospital
Hospitals, Chapel Hill, NC), published the follow-
bed) should not occur until the patient is no
ing findings with respect to the potential cause(s)
longer at risk of postoperative respiratory
of perioperative cardiac arrest in the pediatric
depression. This can potentially result in a
population as a whole after evaluating data col-
prolonged PACU course due to the propen-
lected from 1994 to 1997.
sity for airway obstruction and/or central
respiratory depression.
55 Patients should be observed in an unstimu- zz Most common causes:
lated environment, preferably while asleep, 55 Medication, usually halothane overdose, and
when assessing adequacy of oxygen satura- cardiovascular.
tion levels on room air. 55 Infants <1 year of age accounted for 55% of
arrests.
Of note, case submission to this registry was 55 ASA III–V patient and emergencies were
closed on December 31, 2016. Cases are currently associated with increased risk.
undergoing data cleaning and analysis for future
publication. zz Results:
55 Incidence of <0.015% (150 anesthetic-related
deaths in over 1 million anesthetics).
27.6 Pediatric Perioperative Cardiac 55 55 events were medication related:
Arrest (POCA) Registry 55 26 arrests were due to halothane alone and
11 were halothane + other medications.
Beecher and Todd first recognized the increased 55 Two arrests were ASA III patients who are
risk of perioperative cardiac arrest in children, as arresting during an inhalational induction
compared to adults, in their 1954 pivotal study with sevoflurane.
published in the Annals of Surgery [81]. Fifty 55 Four cases were secondary to intravascu-
years later, in 1994, the Pediatric Perioperative lar injection of bupivacaine + epinephrine
Cardiac Arrest (POCA) Registry was formed by during caudal placement.
383 27
55 Most cardiac causes involved underlying
cardiovascular disease (discussed in detail
below), ASA III–V patients, or hemorrhage. Lesion n (% of 127)
55 Respiratory events accounted for 20% of all
cardiac arrests (nine events due to laryngo- Pulmonary artresia 2
spasm) in mostly ASA I–II patients. Double inlet left ventricle 1
Left-to-right shunt 23 (18%)

zz Summary:
55 Healthy kids <1 year of age can suffer from Ventricular septal defect 9
cardiac arrest under anesthesia, usually due to Patent ductus arteriosus 5
medication overdose and/or airway obstruc-
Atrioventricular canal 4
tion. Less healthy kids who have cardiac arrest
related to anesthesia have a higher mortality. Combined lesions (ASD, VSD, PDA) 5
Obstructive lesions 20 (16%)
27.6.2 Congenital and Acquired Aortic stenosis 13a

Heart Disease Coarctation of the aorta 6
Aortic obstruction 1
The final report from the POCA Registry, pub-
lished in the May 2010 edition of Anesthesia- Cardiomyopathy 16 (13%)
Analgesia, examined all available data in the Dilated 4
registry (1994–2005) with the aim of comparing
anesthesia-related cardiac arrests in children with Hypertrophic 2
heart disease to those without heart disease [82]. Restrictive 1
Children were classified as having heart disease
Disease specific
if they had congenital or acquired disease, with
the most common conditions including single Duchenne muscular dystrophy 4
ventricle, left-to-right shunts (septal defects), Renal disease 2
obstructive lesions (coarctation of the aorta, aor-
AIDS 1
tic stenosis, pulmonary stenosis), cardiomyopa-
thy, tetralogy of Fallot, and truncus arteriosus. Unspecified 2
Tetralogy of Fallot 15 (12%)

27.6.2.1 Risk Factors for Cardiac Arrest
Congenital or acquired heart disease accounted Truncus arteriosus 6 (5%)
for 127 (34%) of patients in this Registry. Nearly Miscellaneous 23 (18%)
half (47%) of cardiac arrests occurred at the age of
Pulmonary hypertension 4
6 months or younger, while 70% of cardiac arrests
occurred in children 2 years or younger. The cul- Status post-heart transplant 3
prit cardiac lesions were more or less equally split Heart block 3
across several major defects; see . Table 27.2.

Wolff-Parkinson-White 2
O therb 11
.. Table 27.2 Cardiac Lesions in Children with
Heart Disease
AV atrioventricular, ASD atrial septal defect, VSD
Lesion n (% of 127) ventricular septal defect, PDA patent ductus arterio-
sus, AIDS acquired Immunodeficiency syndrome
aTwo with Williams syndrome and 4 with pulmo-
Single ventricle 24 (19%)
nary stenosis
Hypoplastic left heart syndrome 9 bOther includes anomalous pulmonary veins, coro-
nary artery disease, Ebstein’s anomaly, interrupted

Double outlet right ventricle 5 aortic arch, left ventricular hypertrophy, myocardi-
Unbalanced AV canal 4 tis, prolonged QT syndrome, sick sinus syndrome,
systemic hypertension, transposition of the great
Tricuspid artresia 3 vessels, and unspecified (1 each)
27.6.2.2 Location of Cardiac Arrest 27.6.2.4 Etiology of Arrest

Cardiac arrests in children with heart disease Cardiovascular causes of cardiac arrest were most
were most commonly reported in the general common.
operating room (n = 69, 54%). The most frequent Please refer to . Fig. 27.2 and . Table 27.3 for

surgical procedures were gastrointestinal pro- further details.

cedures (i.e., fundoplication, gastrostomy tube
placement, esophagogastroduodenoscopy, and 27.6.2.5 Outcome Following Arrest
colonoscopy; n = 17). This was followed by ear, Overall mortality for pediatric patients with heart
nose, and throat procedures (myringotomy with disease exceeded patients without heart disease
tube placement, bronchoscopy, choanal atresia (33% vs. 23%); however, when ASA physical sta-
27 repair, and tracheostomy; n = 16) and placement tus III–V patients were compared, there was no
of permanent central venous catheters (Broviac difference between groups (34% for both). For
catheter or Port-A-Cath; n = 13). Urologic, patients with heart disease, there was no asso-
orthopedic, ophthalmologic, plastics, dental, and ciation with age, phase of care, cause of cardiac
thoracic procedures each accounted for five cases arrest, or year of cardiac arrest. Mortality rates
or less. following cardiac arrest in the cardiac OR, gen-
eral OR, and catheterization laboratory were 45%,
27.6.2.3 Anesthetic Phase During 26%, and 33%, respectively.
Cardiac Arrest
Contrary to the commonly accepted notion that 27.6.2.6 Summary
the greatest degree of cardiovascular instability 55 In the setting of POCA, children with under-
occurs during the induction of and/or emer- lying heart disease were sicker, more likely to
gence from general anesthesia, cardiac arrest in arrest due to cardiovascular causes, and less
children with heart disease occurred most com- likely to survive when compared to children
monly during the maintenance phase (48%) of without heart disease.
anesthesia. This seemingly implicates the surgi- 55 Greater than 50% of all cardiac arrests in
cal procedure itself or its resultant noxious stim- children with heart disease occurred in the
uli as provocative factors in POCA, although general OR.
this is not proven or supported in the literature. 55 Patients with single ventricle, aortic stenosis,
The presurgical and postsurgical periods cor- and cardiomyopathy were of particular inter-
related with 36% and 16% or cardiac arrests, est due to the frequency of cardiac arrest and
respectively. the high mortality rates that followed.
.. Fig. 27.2 Causes of

anesthesia-related cardiac 60
arrest associated with heart
disease (n = 127) versus
non-heart disease * Heart disease (n=127)
(n = 245). *P = 0.03,
Non-heart disease (n=245)
**P = 0.01
40
% of cases in group
**
20
0
Cardiovascular Medication Respiratory Equipment Other
385 27
.. Table 27.3 Cardiac arrest causes in patients .. Table 27.3 (continued)

with pre-existing heart disease
CV cardiovascular
Cause of arrest n (% of 127) aOne case each: air embolism, hypovolemia from
surgical redaction, left ventricular outflow

Cardiovascular 63 (50%) obstruction, pecemaker failure, right-to-left shunt,
severe valvular dysfunction, vagal response,
Myocardial ischemia 5 (4%)
acidosis, pulmonary hypertensive crisis, myocardial
Hyperkalemia 3 (2%) dysfunction, and severe coronary artery disease
bOne case each: epinephrine-induced ventricular
“ Tet” spell 3 (2%) fibrillation, prostacyclin effect, and intravascular
Hypovolemia: preexisting 3 (2%) injection of local anesthetic
cOne case each: esophageal intubation, premature
Sudden arrhythmia 3 (2%) extubation, penmothorax, endobronchial

intubation, presumed respiratory, and cause
Hypovolemia-blood loss 2 (2%) unclear
Other miscellaneous CV causea 11 (9%)
Presumed CV: unclear etiology 33 (26%)
Medication 25 (20%) Overall, the take-home message from the POCA

Inhaled anesthetic CV depression– Registry is that high ASA physical status and
emergency surgery are independent predictors of
Halothane 8 (6%) mortality from perioperative cardiac arrest and
Sevoflurane 6 (5%) that patients with congenital heart disease were
at significant and increased risk of perioperative
Isoflurane 1 (1%)
cardiac arrest during noncardiac procedures.
Intravenous drug CV depression Additionally, data also suggests that the use of
Prapofol 1 (1%) halothane is particularly hazardous for infants.
Narcotics 1 (1%)
Wrong dose 3 (2%) References

Medication combinations 2 (2%)
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389 28
Peer Review
in Perioperative
Medicine
Ophélie Loup and Markus M. Luedi
28.1 Peer Review by Definition – 390
28.2 Personal Attitude to Establish a Peer Review-

Friendly Culture: From Improving Oneself to
Learning – 391
28.3 Organizational Culture to Establish a Peer

Review-Friendly Environment: From Blaming
to Encouraging – 391
28.4 Dimensions and Situations for Peer Review – 392

28.5 Mindsets Required for Change Management
Derived from Peer Review – 393
28.8 Answers – 395
References – 395

https://doi.org/10.1007/978-3-319-96125-5_28
390 O. Loup and M. M. Luedi
Success is not final, failure is not fatal: it is the “information about reactions to […] a person’s
courage to continue that counts. performance of a task, etc. which is used as a basis
—Winston Churchill for improvement.” Further, depending on the cul-
tural setting and the mindsets of the protagonists
Interactions in the perioperative setting are involved, feedback might be weakened by confu-
complex and include factors such as time and sion between content of the feedback and the rela-
performance pressures, high-risk patients, acute tionship between parties.
situations, intergenerational differences [1], and Even though both feedback and peer review
the high impact and necessity of interprofessional can be formalized as process-oriented tools to
teamwork [2]. While audits, checklists, guide- improve performances and patient care, feedback
lines, and practice advisories have significantly is of a more hierarchical nature, usually initiated
improved safety in the perioperative setting, and led in a vertical top-down fashion. Peer review,
human qualitative factors such as adaptive coor- on the contrary, is a less hierarchically influenced,
28 dination, emotional intelligence, resilience [3, 4], horizontal assessment from a co-worker of simi-
and peer review are of tremendous importance lar knowledge and expertise. . Figure 28.1 illus-

for perioperative leadership too. In this chapter, trates the different levels of interaction within a
we discuss the value of peer review to prevent, hierarchy at which the processes of peer review
manage, and learn from catastrophic periopera- and feedback take place.
tive events. The search for a greater amount of assessment
We define catastrophic perioperative compli- opportunities in the workplace, as well as the dif-
cations as consequential, unexpected, unplanned ferent hierarchical directions in which these inter-
events that should not happen or have happened actions take place, may be a reflection of a more
and that are or were potentially preventable. global phenomenon, initiated by the new genera-
When they do happen, they can affect patients, tion of workers, known as the Millennials. Indeed,
peers, equipment, clinical infrastructure, leader- Millennials are characterized by their expectation
ship, and departmental strategy, i.e., being the of close relationships and frequent feedback from
best performing department with the fewest com- supervisors [6], as well as a preference for a flatter
plications. Catastrophic perioperative complica- hierarchy and a team-oriented environment [7].
tions have myriad causes. Pressure from advances in management
sciences, the rise of a multicultural and multi-
generational workforce together with the ever-
28.1 Peer Review by Definition increasing patient safety, and quality requirements
are encouraging both the implementation and
Peer review is not primarily a teaching tool but
rather an assessment by a peer, e.g., according
to the Oxford Dictionary, “a person of the same
age, status, or ability as another specified person.”
Additionally, peer review is rather intended to
improve both personal and organizational per-
Hierarchy
formance. Peer review is a well-established prac-

tice in corporate cultures and in some medical
systems, but recognition of its value is only just
emerging in others and in relation to preventing,
managing, and learning from catastrophic peri-
Peer review Feedback
operative events.
Contrary to peer review, feedback, i.e., a
conversation with “a view to narrowing the gap .. Fig. 28.1 Peer review and feedback take place
between observed and desired performance,” between different levels in the hierarchy of an organiza-
is an established and well-recognized teach- tion. Both of these process-oriented tools can be formal-
ized to improve performance and patient care, however
ing and supervision tool in clinical training to peer review, in contrast to feedback, is a less hierarchically
reinforce good and improve poor performance influenced, horizontal assessment from a co-worker of
[5]. The Oxford Dictionary defines feedback as similar knowledge and expertise
Peer Review in Perioperative Medicine
391 28
refinement of peer review in medicine. This is of been described as crucibles of leadership [9]. In
even greater importance in the setting of periop- brief, Peter Drucker advised being one’s own career
erative and acute medicine, where interactions are manager by constantly evaluating three questions:
complex and the potential for catastrophic com- “what are my strengths?”, “how do I work?”, and
plications significant. “what are my values?” [10]. We suggest to add a
Peer review provides the framework for a fourth question, i.e., “how can I learn from and
systematic evaluation of both an individual’s per- improve my weaknesses and/or mistakes?”
formance and medical systems of care and offers Jim Collins suggested that deep personal
both individuals and medical systems the oppor- humility and intense professional will represent
tunity to improve their performances with the the “level 5 leadership” [11], a mindset enabling
ultimate goal to reduce morbidity and mortality. all of the above questions. Regardless of whether
one is targeting personal or corporate leadership
»» Peer review and feedback take place between goals, individuals should feel like the one leader
different levels in the hierarchy of an organi- of their own continuous improvement, and appli-
zation. Both of these process-oriented tools cation of such self-motivating characteristics will
can be formalized to improve performance help them throughout their career.
and patient care, however, in contrast to In addition to that, it may be necessary for
feedback, peer review is a less hierarchically individuals to make some adaptive changes to be
influenced, horizontal assessment from a co- able to react to feedback more easily and in a con-
worker of similar knowledge and expertise. structive way. Performance reviews of all kinds
remain too often perceived as blame or personal
criticism, and fears and assumptions about it can
28.2 Personal Attitude to Establish generate maladaptive behaviors such as cyni-
a Peer Review-Friendly Culture: cism, procrastination, denial, brooding, jealousy,
From Improving Oneself to or self-sabotage. Learning to acknowledge nega-
Learning tive emotions, reframing constructively fear and
criticism, creating support systems, and reward-
“Success is not final, failure is not fatal: it is ing oneself can help individuals to make positive
the courage to continue that counts” (Winston adaptive changes toward feedback [12].
Churchill). The sentiment expressed in this state-
ment suggests the cultural frame and personal- »» The application of self-motivating charac-
teristics described in leadership sciences,
ity traits required to implement and maintain an
such as “… thirst for constructive criticism,
institutional environment in which peer review is a
a self-deprecating sense of humor, comfort
constant presence that proactively drives improve-
with ambiguity and change, passion for
ment in one’s performance. Such self-motivating
work itself, optimism in the face of failure,
characteristics are well described in leadership and
an ability to develop others, sensitivity to
human resource sciences. In 1996, the American
cross-cultural differences, and effectiveness
psychologist Daniel Goleman published a land-
in leading...”, as well as adaptive changes for
mark paper on “what makes a leader,” introduc-
individuals to react more easily to feedback,
ing the self-management and relationship skills
are necessary components of individual atti-
of self-awareness, self-regulation, motivation,
tude to favor a peer review-friendly culture.
and empathy, as well as social skills such as emo-
tional intelligence. He concluded that a thirst for
constructive criticism, a self-deprecating sense of
humor, comfort with ambiguity and change, pas- 28.3 Organizational Culture
sion for work itself, optimism in the face of failure, to Establish a Peer Review-
an ability to develop others, sensitivity to cross- Friendly Environment:
cultural differences, and effectiveness are crucial From Blaming to Encouraging
[8]. Similarly, an appetite for life-long learning
and self-development, an attitude towards finding Even though necessary, a change in personal
meaning in and learning from negative events, and attitude alone will not be sufficient to establish a
the ability to emerge from adversity stronger have peer review-friendly culture. Peer review does
not happen by itself. When defining, building, workplace. While the output of working groups
and adjusting the mission, vision, and culture of comprises results from individuals acting under
an organization or department (i.e., defining what individual accountability, the output of a team is
has to be done, how priorities should be embraced, the product of mutual accountability. Achieving
and what a “perfect world” would look like), it is such status requires that team members listen,
essential to remember the importance of people respond constructively, provide support, and
being guided by a sense of purpose and being share an essential commitment to the common
responsible for their relationships [13]. It should purpose [16], dimensions to be defined in an
be part of an organization’s/department’s mission organization’s/department’s mission and vision.
to want to evolve from a peer review-adverse, or It is an unfortunate fact in medicine that indi-
even blaming culture to promote an open and sup- viduals and care systems tend to learn in a more
portive peer review environment. Indeed, not only robust way from suboptimal performances and
the fear of performance review, but also the lack of from the occurrence of near-missed and adverse
28 it can generate a dysfunctional work environment. events, which can be particularly critical in the
Different barriers and incentives have been setting of perioperative medicine. However, one
described for related topics in perioperative med- of the most valuable keys to improvement is based
icine. Sanchez and Barach, for example, describe in the occurrence of these primarily “negative”
individual, organizational, and societal dimen- events. To turn complications in perioperative
sions for successful learning from adverse events medicine into an opportunity for change and
[14], which can be adopted in establishing a suc- improvement, personal attitude and application
cessful culture of peer review. of leadership’s characteristics, individual’s effort
Although useful, peer review can be a poten- to adapt to reviews, as well as organizations’ pri-
tially sensitive process and needs to be managed ority in creating an open, supportive, and mindful
correctly to avoid unwanted repercussions. Peer environment for peer review are mandatory ele-
review should be honest, fair and unbiased, rel- ments to ensure optimal learning from complica-
evant and adapted to people and situations, not tions in perioperative medicine and help improve
tied to merit increase, should not increase the the strategies to avoid them and reduce morbidity
feeling of job pressure. and mortality. Organizations which understand
Already 50 years ago, Frederick Herzberg the multifaceted benefits of promoting a collabor-
argued that extrinsic incentives work only as long ative and peer review-friendly culture will benefit
as it takes to get the next raise, if at all, whereas from it at many different levels.
intrinsic rewards, such as the opportunity to
achieve and to grow into greater responsibility, »» It should be part of an organization’s/depart-
ment’s mission to want to evolve from a peer
are the only effective ways to motivate people
review-adverse, or even blaming culture to
[15]. The new generation of workers are eager to
promote an open and supportive peer review
connect and involve themselves with causes in the
environment. Indeed, not only the fear of per-
workplace and put greater value on being organi-
formance review, but also the lack of it can
zational influencers.1 Today’s worker requires an
generate a dysfunctional work environment.
environment in which teamwork thrives.
With processes becoming more complex and
workers being more eager to connect, the time
spent by workers collaborating with colleagues 28.4 Dimensions and Situations
keeps increasing significantly. This fact provides for Peer Review
organizations such as perioperative medicine
with optimal settings and a great opportunity to Having established an atmosphere of trust with
implement a more collaborative, team-oriented, a culture of peer review, departments involved
and peer review-favorable environment in the can progress to a benchmarking process specifi-
cally aimed at reducing catastrophic periopera-
tive complications, e.g., by increasing professional
1 Jean Case, Millennials and the power of influence,
June 24 2015, Forbes. Printout from 7 https://www.

competencies. The explicit inclusion of peer
forbes.com/sites/jeancase/2015/06/24/millennials- review dimensions in a departmental mission
influence/#a5178c5095c8, accessed Sept 30 2017. and vision statement is of essence. The associated
393 28
can be used to correct and further align perfor-
mances with the departmental directives. In the
situation of an ongoing catastrophic perioperative
event, peer review can help reinforce the need for
Professional a strong collaborative approach.
performance
Peer review of compliance with an organiza-
tion’s/department’s strategy is more complex and
depends on an appropriately defined mission and
vision, as well as values and directives. Again,
however, strengths, weaknesses, opportunities,
and threats can be addressed proactively, retro-
Compliance Personality spectively, or acutely. In the situation of an ongo-
with traits ing catastrophic perioperative event, peer review
strategy
might rather focus on providing appropriate sup-
port, backed up by the departmental culture.
Personality traits are probably the most com-
plex dimension to address in peer review. It is del-
.. Fig. 28.2 Professional performance, compliance with
icate and difficult to make objective observations,
the organization’s/department’s strategy, and personality and there is uncertainty whether psychological
traits as dimensions to be included in peer review pro- dimensions are a learnable function, an inherent
cesses to help preventing, managing, and learning from trait, or a combination of the two [4]. Established
catastrophic perioperative complications. All dimensions methods such as Myers-Briggs personality indica-
can be benchmarked with the departmental mission,
vision, and values, defined in the strategy
tor tests [17] or components of 360° feedback pro-
grams within and across departments involved
values should be exemplified by leadership. The in perioperative care can provide insight. In the
dimensions of professional performance (i.e., the moment of a catastrophic perioperative event,
delivery of established best medical practice), peer review of personality traits is probably best
compliance with departmental strategy (i.e., avoided or conducted by a peer who under-
department’s specific directives), and personality stands the support needs of the affected indi-
traits (i.e., a person’s pattern of behaviors revealed vidual. Different styles for such moments have
in different situations), which are included in peer been described [18], including coercive (“do this,
review, interact and overlap (. Fig. 28.2). The

now, how I tell you”), authoritative (“come with
parameters of strengths, weaknesses, opportuni- me”), pacesetting (“if I have to tell you, you are
ties, and threats with respect to each dimension the wrong person for the job”), or coaching (“try
can be addressed proactively, retrospectively, and this”) styles. The choice to conduct the review and
acutely and can be benchmarked with the depart- the choice of style are subject to the discretion of
mental mission, vision, directives, and values, the reviewing peer.
defined in the departmental strategy. The process »» Professional performance, compliance with
can help to highlight strengths or weaknesses not departmental strategy, and personality traits
only in individual but also in collaborative, struc- can be addressed preventively, retrospec-
tural, and infrastructure performances. tively, and acutely, and can be benchmarked
Professional performance is probably the easi- with the departmental mission, vision, and
est dimension to evaluate through peer review, values, defined in the strategy.
because medical standards and benchmarks are
globally available and exist independently from
the departmental mission and vision. Addressing 28.5 Mindsets Required for Change
strengths, weaknesses, opportunities, and threats Management Derived
proactively can help individuals to meet appro- from Peer Review
priate clinical standards and hence prevent cata-
strophic perioperative complications. Addressing Every dimension of emotional intelligence intro-
them retrospectively when debriefing such events duced by Daniel Goleman [8] and described
can help highlight unexpected deficiencies and previously can be incorporated and tested in job
.. Fig. 28.3 With a peer

review system in place,
Vision for the
both individuals and
departments involved in
perioperative
perioperative medicine
setting
can systematically improve
to prevent, deal with, and Peer review
learn from catastrophic
events. Additionally, such a
system can help to leverage Catastrophic
catastrophic perioperative perioperative
events for change manage- complication
ment and align a depart-
ment’s mission to its vision Mission in the perioperative setting
28
interviews for positions in perioperative medi- and not a new way to monitor or judge
cine.2 This might be the first step in ensuring the them.”3
promotion and perpetuation of a peer review- 55 “Make sure that any employee, at any level,
friendly culture and may help to select individuals feels empowered to participate.” “Encourage
showing specific personality traits and qualities in frequent, timely recognition” and “empower
line with this concept and the company’s culture, managers to track results.”3
thus setting the stage for a career-long process
that is in the best interest of the individual and When benchmarking professional performance,
of the department. Eric Mosley, founder of the compliance with strategy, and personality traits
conference “WorkHuman: Unlock the Future of with the organization’s/department’s mission,
The Human Workplace,” recommends that to suc- vision, and values, leadership has to remember
cessfully build, maintain, and support an effective that, by nature, people are usually reluctant to
peer review system, leadership must “ensure that alter habits; they need help and management
the metrics on which people are recognized are of their emotions. Both leadership and peers in
aligned with your company’s mission.” perioperative medicine have to be aware that
The exact process of peer review can vary. change is not an event but rather a process that
However, regardless of the strategy chosen, Eric requires time, has to follow specific steps, and
Mosley3 advises to favor the following points to has to be planned strategically in advance [19].
give the peer review process the best chance to Therefore, John P. Kotter advises communicating
bring constructive elements and succeed in the a vision proactively, empower others to act on
long term: it, and institutionalize new approaches [derived
55 “Pick a program that is intuitive, easy to use, from peer review] [19]. . Figure 28.3 illustrates

fun, interactive, engaging, and fully mobile how a peer review system for catastrophic peri-
[because] peer reviews shouldn’t feel like work.”3 operative events can help both individuals and
55 “Position the program as a change designed departments involved in perioperative medicine
to help recognize and celebrate employees, to systematically improve to prevent, deal with,
and learn from catastrophic perioperative events.
Additionally, such a system can help to lever-
2 Markus M Luedi et al.: Screening future employees for age catastrophic perioperative events for change
emotional intelligence as a crucial step towards management to align a department’s mission to
improved perioperative efficiency and patient safety. its vision.
Printout from 7 http://www.esahq.org/~/media/ESA/
»» Both leadership and peers in perioperative

Files/Downloads/Resources-Abstracts-Euroanaesthe-
sia%202017/ESA2017_HI.ashx, accessed Sept 30 medicine have to be aware that change is not
2017.
an event but rather a process that requires
3 Eric Mosley: Creating an effective peer review system.
Printout from 7 https://hbr.org/2015/08/creating-an-

time, has to follow specific steps, and has to
effective-peer-review-system, accessed Sept 30 2017. be planned strategically.
395 28
28.6 Conclusion ity, intended to provide information
pertinent to self-improvement by the
Peer review provides a valuable leadership tool reviewed individual.
for individuals and organizations to improve in
the face of ever-increasing complex workplace vv 2. According to Eric Mosley, to successfully
settings and is a key element toward preventing build, maintain, and support an effective
and dealing with catastrophic perioperative com- peer review system, leadership in periop-
plications. Peer review and feedback take place erative medicine must “ensure that the
between different levels in the hierarchy of an metrics on which people are recognized
organization. While the concept of feedback has are aligned with your company’s mission.”
been institutionalized across various settings over “Pick a program that is intuitive, easy to
the past decades, successful peer review depends use, fun, interactive, engaging, and fully
heavily on individual and departmental culture, mobile [because] peer reviews shouldn’t
which might have to be built strategically over feel like work.” “Position the program as
the long term. Professional performance, compli- a change designed to help recognize
ance with organization/department strategy, and and celebrate employees, and not a new
personality traits are dimensions to be included way to monitor or judge them.” “Make
in peer review processes among acute care physi- sure that any employee, at any level,
cians to help preventing, managing, and learning feels empowered to participate.” “Encour-
from catastrophic perioperative complications. age frequent, timely recognition” and
Aiming at reducing morbidity and mortality, it “empower managers to track results.”
is the responsibility of respective departments’
leadership to build a culture, implement a system, vv 3. Professional performance, compliance
and encourage individuals to participate in peer with strategy, and personality traits are
review to avoid and attenuate catastrophic peri- dimensions to be included in peer review
operative complications. processes. Institutional mission, vision,
and values can help benchmarking and
also be subjected to change manage-
28.7 Review Questions ment deriving from peer review.
?? 1. What are the crucial differences between

traditional feedback and peer review in References
the perioperative setting?
1. Shangraw RE, Whitten CW. Managing intergenera-

tional differences in academic anesthesiology. Curr
?? 2. What dimensions were suggested to Opin Anaesthesiol. 2007;20(6):558–63. https://doi.
successfully build, maintain, and support org/10.1097/ACO.0b013e3282f132e3.
an effective peer review system? 2. Doll D, Kauf P, Wieferich K, Schiffer R, Luedi

MM. Implications of perioperative team setups for
operating room management decisions. Anesth
?? 3. What dimensions can be subjected to
Analg. 2017;124(1):262–9. https://doi.org/10.1213/
peer review among acute care physicians ane.0000000000001672.
to prevent, manage, and learn from 3. Luedi MM, Boggs SD, Doll D, Stueber F. On patient
catastrophic perioperative complications, safety, teams and psychologically disturbed pilots.
and what benchmarking can be applied? Eur J Anaesthesiol. 2016;33(3):226–7. https://doi.
org/10.1097/eja.0000000000000403.
4. Luedi MM, Doll D, Boggs SD, Stueber F. Successful
personalities in anesthesiology and acute care medi-
28.8 Answers cine: are we selecting, training, and supporting the
best? Anesth Analg. 2017;124(1):359–61. https://doi.
vv 1. Contrary to feedback, which is a teach- org/10.1213/ane.0000000000001714.
5. Cantillon P, Sargeant J. Giving feedback in clinical set-
ing tool to reinforce specific measures,
tings. BMJ. 2008;337:a1961. https://doi.org/10.1136/
peer review is not primarily a teach- bmj.a1961.
ing tool but rather an assessment by 6. Myers KK, Sadaghiani K. Millennials in the workplace:
someone of the same status and abil- a communication perspective on millennials’ organi-
zational relationships and performance. J Bus Psychol. 14. Sanchez JA, Barach P. Capturing, reporting, and learn-
2010;25(2):225–38. ing from adverse events. In: Surgical patient care.
7. Huyler D, Pierre Y, Ding W, Norelus A. Millennials in the Cham: Springer; 2017. p. 683–94.
workplace: positioning companies for future success. 15. Herzberg F. One more time: how do you motivate
SFERC 2015. 2015. p. 114. employees. Boston: Harvard Business Review Press;
8. Goleman D. What makes a leader. Harv Bus Rev. 1968.
2004;82(1):82–91. 16. Katzenbach JR, Smith DK. The discipline of teams: Harv
9. Bennis WG, Thomas RJ. Crucibles of leadership. Harv Bus Rev. 1993;71(2):111–20.
Bus Rev. 2002;80(9):39–45, 124. 17. Tzeng OC, Outcalt D, Boyer SL, Ware R, Landis D. Item
10. Drucker PF. Managing oneself. Boston: Harvard Busi- validity of the Myers-Briggs type indicator. J Pers
ness Review Press; 2008. Assess. 1984;48(3):255–6. https://doi.org/10.1207/
11. Collins J. Level 5 leadership: the triumph of humility s15327752jpa4803_4.
and fierce resolve. Har Bus Rev. 2005;83:136–47. 18. Goleman D. Leadership that gets results. Harv Bus Rev.
12. Jackman JM, Strober MH. Fear of feedback. Harv Bus 2000;78(2):4–17.
Rev. 2003;81(4):101–8. 19. Kotter JP. Leading change: why transformation

28 13. Christensen CM, Allworth J, Dillon K. How will you
measure your life? New York: Harper Business; 2012.
efforts fail. Ottawa: Canada Communication Group;
1995.
397 29
Perioperative
Complications Chapter:
Shared Decision-Making
and Informed Consent
William K. Hart, Robert C. Macauley, Daniel A. Hansen,
and Mitchell H. Tsai
29.2 A History of Informed Consent – 398

29.2.1 Invasive Procedures Without Consent Is Assault – 398
29.2.2 Patients Should Be Informed of Risks – 398
29.2.3 How Much to Disclose? A Physician Standard
and a Patient Standard – 398
29.3 Further Clarifications of Disclosure – 400
29.4 Informed Consent in Practice – 400
29.5 Elements of Informed Consent – 401

29.5.1 Disclosure – 401
29.5.2 Capacity – 401
29.5.3 Voluntariness – 402
29.6 Shared Decision-Making – 402
29.7 Summary – 403
References – 405

https://doi.org/10.1007/978-3-319-96125-5_29
398 W. K. Hart et al.
29.1 Introduction Mary Scholendorff agreed to an ether exam

under anesthesia during a routine work-up for a
The relationship between the physician and patient is fibroid tumor. She declined a surgical operation,
especially unique among professional relationships. but while she was under anesthesia, the surgeon
Many professional and fiduciary responsibilities removed the tumor. Her recovery was compli-
involve trust, empathy, and nuanced communica- cated by gangrene and the subsequent amputa-
tion, but physician relationships are distinguished, tion of several fingers. In the appellate decision,
most importantly, by their care for human beings the judge argued that
and the attendant complexities. The trust and
faith extended in physician-patient relationships
»» Every human being of adult years and sound
mind has a right to determine what shall be
requires patients to have at least a basic understand- done with his own body; and a surgeon who
ing of risks and benefits inherent in the course of performs an operation without his patient’s
treatment. Although it may appear to be a simple consent commits an assault, for which he is
and straightforward process as a patient agrees to liable in damages.
undergo an anesthetic and surgery, it is only because
29 dramatic improvements in patient safety have been Further, the court emphasized that the case was not
so closely intertwined with the process of informed a simple matter of medical negligence, but rather
consent over the last century [1]. an assault. Prior to Scholendorff physicians made
Over the past few decades, medical paternalism many medical decisions for patients. Liability for
has yielded to a process of shared decision-making. assault or battery prompted a dramatic change in
Today, informed consent is a patient-centered physician practice patterns and began the modern
process based on the principle that autonomous era of patient-centered decision-making.
patients can make informed, rational decisions
when given the opportunity to do so. Shared
decision-making is an extension of informed con- 29.2.2 Patients Should Be Informed
sent and facilitates the complex process of medi- of Risks
cal decision-making. The stepwise exchange of
information between patient and physician occurs By the mid-twentieth century consent quickly
in accordance with individual patient preferences, evolved into informed consent. In Salgo v. Stanford
goals, and beliefs regarding their care. (1957) [3], the plaintiff agreed to undergo trans-
lumbar aortography but became permanently
paralyzed in his legs as a direct complication of the
29.2 A History of Informed Consent procedure. The defendant did not disclose to the
patient any risk of permanent neurologic damage.
When the American Medical Association pub- The court clarified that “a physician violates his
lished its first code of ethics in 1847, there was duty to his patient and subjects himself to liabil-
no mention of informed consent. The idea of an ity if he withholds any facts which are necessary
informed and autonomous patient would not be for the basis of an intelligent decision by a patient
developed for several decades. At this time, physi- to a proposed treatment.” They further noted that
cians elicited assent, or simple permission, from risks could not be minimized for the purposes of
patients prior to invasive procedures. By the early inducing consent. Hereafter, a physician could not
twentieth century, the concept of informed con- obtain consent for surgery (or procedures) with-
sent slowly began to emerge. It was guided in no out making the patient aware of any inherent risks.
small part by the US legal system and a series of The concept of an informed patient had emerged.
influential appellate decisions.
29.2.3 How Much to Disclose?

29.2.1 Invasive Procedures Without A Physician Standard
Consent Is Assault and a Patient Standard
The first major decision came in 1914 in Physicians now had a medicolegal responsibil-
Scholendorff v. Society of New York Hospital [2]. ity to appropriately inform patients of the risks
Perioperative Complications Chapter: Shared Decision-Making and Informed Consent
399 29
and benefits to a proposed treatment. Legal and cord. He was left partially paralyzed and inconti-
medical challenges continued regarding how and nent. In trial, the surgeon admitted to minimiz-
what to disclose. Two cases established the cur- ing the risk of paralysis though noted that his
rent general standards by which adequate disclo- discussion of risks was consistent with profes-
sure was measured. In Nathanson v. Kline (1960) sional custom. The District of Columbia Circuit
[4], a patient sued on the grounds that the risk Court of Appeals held in favor of the defendant
of injury was not adequately disclosed after she Canterbury and clarified several essential ele-
experienced severe burns secondary to radiation ments of informed consent:
therapy for cancer. The Supreme Court of Kansas 55 Physicians have a duty to disclose:
disagreed and established that 55 It is a duty to warn of the dangers lurking in
the proposed treatment, and that is surely a
»» The duty of the physician to disclose… is lim- facet of due care. It is too a duty to impart
ited to those disclosures which a reasonable information which the patient has every right
medical practitioner would make under the to expect. The patient’s reliance upon the
same or similar circumstances. How the phy- physician is a trust of the kind which tradi-
sician may best discharge his obligation to tionally has exacted obligations beyond those
the patient in this difficult situation involves associated with arms-length transactions. Just
primarily a question of medical judgment. So as plainly, due care normally demands that
long as the disclosure is sufficient to assure the physician warn the patient of any risks to
an informed consent, the physician’s choice his well-being which contemplated therapy
of plausible courses should not be called may involve.
into question if it appears, all circumstances 55 A reversal of the physician custom standard
considered, that the physician was motivated and creation of the “reasonable patient”
only by the patient’s best therapeutic inter- standard:
ests and he proceeded as competent medical 55 Respect for the patient’s right of self-
men would have done in a similar situation. determination on particular therapy demands
»» The primary basis of liability in a malpractice a standard set by law for physicians rather
than one which physicians may or may not
action is the deviation from the standard of
conduct of a reasonable and prudent medi- impose upon themselves.
cal doctor of the same school of practice as 55 A standard for the scope of how much to
the defendant under similar circumstances. disclose to patients:
Under such standard the patient is properly 55 A risk is thus material when a reasonable
protected by the medical profession’s own person… would be likely to attach signifi-
recognition of its obligations to maintain its cance to the risk or cluster or risks in
standards. deciding whether or not to forego the
proposed therapy… the topics importantly
Today, the medical profession’s obligations to demanding a communication of information
maintain transparency is known as the “rea- are the inherent and potential hazards of the
sonable physician” standard of disclosure and proposed treatment, the alternatives to that
is closely tied to professional self-regulation. treatment, if any, and the results likely if the
Establishing the adequacy of disclosure to a patient remains untreated.
patient can be determined during a jury trial with
expert physician testimony to explore what a dif- A large number of jurisdictions across the United
ferent physician would have done in the same or States have adopted the precedent established
similar circumstances. in Canterbury v. Spence. This landmark decision
Alternatively, Canterbury v. Spence (1972) [5] concisely affirmed the physician’s duty to disclose
established a patient-centered standard of disclo- risks, benefits, and alternatives, created a more
sure. In this case, the patient agreed to a lami- patient-centered “reasonable patient” standard
nectomy after suffering from years of back pain. for disclosure, and lastly, defined a measure of
While recovering he fell from his bed, reinjured disclosure commonly known as the “materiality
the surgical site, and underwent a second emer- clause.” The new disclosure standard also elimi-
gency operation to further decompress the spinal nated the need for expert physician testimony as
juries could now decide what a reasonable patient 29.4 Informed Consent in Practice
in the same or similar circumstances might have
decided. The case remains perhaps the most Today, adequately disclosure of risks, benefits,
thoughtful and elaborate discourse on the doc- and alternatives to proposed medical treatments
trine of informed consent to date. remains challenging. Many patients have a poor
understanding of their own medical conditions
or have significant deficits in the decision-making
29.3 Further Clarifications process around the time of surgery [9]. Physicians
of Disclosure should always adhere to their best judgment in
accordance with hospital policy, state law, pro-
Subsequent decisions clarified the adequacy of fessional custom, and guidelines. These general
disclosure. Cobbs v. Grant (1972) [6] echoed standards though may be inadequate to appropri-
Canterbury in that “the patient’s right of self- ately engage individual patients and physicians in
decision is the measure of the physician’s duty to complex healthcare discussions.
reveal.” However, they noted that all possible risks The American Society of Anesthesiologists
29 and complications need not be disclosed. Indeed, recommends that “the two most powerful protec-
“the patient’s interest in information does not tions available to anesthesiologists in the medico-
extend to a lengthy polysyllabic discourse on all legal context are (1) provision of a thorough and
possible complications… a mini-course in medi- compassionate discussion of the risks and ben-
cal science is not required.” This decision limited efits of the anesthetic procedures with the patient,
the scope of disclosure to material or realistic allowing time for all questions to be answered; and
risks. Kissinger and Lofgren (1987) [7] determined (2) meticulous documentation of said discussions
that physicians are also not obligated to disclose in the medical record” [10]. Hospital general legal
risks that are commonly known or of which counsels and ethics committees are often excel-
patients may already be aware. lent resources for physicians. . Table 29.1 high-

In Matthies v. Mastromonoco (1999) [8], the lights a number of common clinical scenarios and
plaintiff argued that consent to nontreatment and suggested legal precedent for reference.
its associated risks should also be disclosed. The A review of the American Society of
plaintiff, Matthies, agreed to bed rest as an alter- Anesthesiologists Closed Claims Database [20]
native to surgical fixation of a broken hip. The shows that of 4559 cases only 1% involved informed
surgeon had recommended against surgery given consent decisions. Generally, anesthesiologists and
the defendant’s age and comorbidities. She never hospitals have commonly paid for damages when
regained her independence and was permanently 55 Specific requests were ignored resulting in
bed-bound. The court held that personal injury (e.g., requests for no resident
involvement or requests to not be intubated).
»» For consent to be informed, the patient must 55 Informed consent occurred but a specific risk
know not only of alternatives that the physi- was not discussed.
cian recommends, but of medically reason- 55 There was no evidence of informed consent
able alternatives that the physician does not (e.g., failure to document).
recommend. Otherwise, the physician, by 55 Failure to adequately explain potential risks
not discussing these alternatives, effectively and complications.
makes the choice for the patient.
Even after an appropriate informed consent pro-
Restated, alternatives to treatment must also cess, injury to patients may still occur. Appropriate
be disclosed including the risks of nontreatment informed consent does not absolve physicians
or noninvasive treatment. For example, a patient of liability for medical negligence. For instance,
should be made aware that electing for medical disclosing a risk of stroke does not make a pro-
treatment of acute cholecystitis in lieu of surgery vider immune from failing to treat hypotension
carries its own set of risks including continued in a timely manner. Medical liability should be
pain and inflammation, ascending cholangitis, viewed as two separate liabilities—negligence and
sepsis, and the need for a more complex surgical informed consent—and both are the responsibil-
approach such as open cholecystectomy. ity of any practicing physician.
401 29
.. Table 29.1 Examples of legal precedent for common questions. It should be noted while these cases have
established some legal precedent, they are interpretations of existing laws and may not be recognized or
applied in all US jurisdictions. See also Ref. [11] for additional examples
How much detail is necessary The courts have generally held that statistical outcomes are not necessary
when disclosing risks? But an exception is noted in Johnson v. Kokemoor (1996) [12]: “When
different physicians have substantially different success rates with the same
procedure and a reasonable person … would consider such information
material, the court may admit this statistical evidence”
Is it necessary to disclose The courts are mixed

physician experience level? Avila v. Flangas (1996) [13]: surgeon experience is not relevant to informed
consent; it is not an actual risk of the procedure
Degennaro v. Tandom (2005) [14]: experience is material to decision-making
Does the involvement of Generally speaking, no:

mid-level providers or Zimmerman v. New York City Health and Hospital Corp (1983) [15] and Dingle v.
residents need to be Belin (2000) [16]; no obligation to disclose resident role
disclosed? Henry v. Bronx Lebanon Medical Center (1976) [17]: seeking care at a training
hospital implies consent to resident participation
Should research or financial Yes

interests be disclosed? Moore v. Regents of the Univ. of California (1990) [18]: disclose “personal
interests unrelated to the patient’s health, whether research or economic, that
may affect the physician’s professional judgement”
Generally, physician incentive schemes (surgical volume or HMOs) need not
be disclosed
Can a patient with decision- Yes. Any patient with capacity may refuse treatment regardless of risks of
making capacity refuse any or refusing to do so
all treatment regardless of Shine v. Vega (1999) [19]: “A competent patient’s refusal to consent to medial
medical advice? treatment cannot be overridden because the patient faces a life threatening
situation”
29.5 Elements of Informed Consent to a wide range of outcomes. Simply appending

a list of possible complications to consent forms
Informed consent and shared decision-making and discussions might offer some basic medico-
are processes that empower autonomous patients legal protection, but from an ethical perspective,
to make rational and informed decisions regard- it does little to empower the patient to make a
ing their medical and surgical care. To provide thoughtful decision about whether to proceed.
informed consent for treatment, three elements Physicians must strive to place relative risks into
must exist: context, so that the patient is able to grasp the
1. Disclosure of sufficient information by which implications of consenting to a given procedure
to make a decision. (including informed refusal or care). Medical eth-
2. The patient must have sufficient decision- icist Onora O’Neill argues that “genuine consent
making capacity to make that particular is apparent where patients can control the amount
decision. of information they receive, and what they allow
3. The decision must be voluntary. to be done” [21].
29.5.2 Capacity
29.5.1 Disclosure
A physician disclosing relevant information does
The first requirement is not as obvious as it may not guarantee that the patient comprehends that
first appear. Any invasive procedure—especially information or that the latter’s subsequent consent
one that requires general anesthesia—could lead is “informed.” The patient must possess sufficient
decision-making capacity, which is distinct from [28]. Rather than compromising the patient’s
“competence”. Whereas competence is a legal autonomy, a thoughtful recommendation—while
concept—and thus only a court has the power to accounting for the patient’s expressed goals and
declare a patient incompetent—capacity is a clini- values—is actually a component of “enhanced
cal determination. It is also decision-dependent, autonomy” [29]. As such, it is integral to the pro-
meaning that decisions that are especially serious cess of shared decision-making that is now recog-
or complex require a greater degree of capacity. nized as the ideal [30].
Decision-making capacity includes four Informed consent has been described as “the
basic elements [22, 23]: communicating a choice, modern clinical ritual of trust” [31]. It should be
understanding relevant information, appreciating viewed as an opportunity to engage patients in an
the consequences of a decision, and manipulating honest discussion regarding the risks, benefits,
information rationally. and alternatives to care rather than a bureaucratic
1. A patient with capacity must be able to nuisance. The precise balance of patient autonomy
express a decision either verbally or nonver- and physician disclosure or recommendations is
bally. unique to every patient. And though “one can-
29 2. A patient must have the ability to understand not know with certainty which medical consent
the relevant information provided, in terms is valid until a lawsuit is filed and resolved” [18],
of risks, benefits, and alternatives of various all efforts should be made to engage the patient
courses of action. Clinicians should attempt in a reasonable conversation. This should ide-
to avoid complex terminology and should ally satisfy the patient’s need for information and
provide the information in stages, allowing establish expectations in the perioperative period.
time for questions and clarification [24].
3. The patient must be able to appreciate on a
personal level the consequences of whatever 29.6 Shared Decision-Making
decision he makes.
4. Lastly, the patient must be able to reason While the volume of informed consent litigation
from the information to the conclusion. This remains small, the process of informed consent
requires the patient to apply their own values occurs prior to every anesthetic and is an integral
to a specific clinical situation. The decision part of the perioperative period. Patients today
need not be a “rational” decision as viewed are largely interested in participating in medical
in the eyes of an external observer who may decision-making [32]. Shared decision-making is
have different values and expectations. a collaborative decision-making process between
the patient and provider for preference-sensitive
healthcare-related decisions. Benefits of shared
29.5.3 Voluntariness decision-making include improved communica-
tion between patients and providers, increased
The third and final requirement of informed con- patient satisfaction, decreased perioperative
sent is that the patient’s decision be voluntary. This anxiety, cost savings, and decreased litigation
refers to protecting the patient from the improper [33]. While barriers to implementation of shared
external influence of friends, family, or healthcare decision-making processes exist, recent evidence
providers. Some physicians may be reluctant to demonstrates that the overall impact to the
offer their own opinions and perspective, for fear healthcare environment is positive.
of pressuring the patient into what they perceive The impact of shared decision-making in pre-
to be the best course of action [25]. In one mul- operative processes may be significant, especially
ticenter study, for instance, physicians refrained for patients with chronic conditions. Montori
from making a recommendation in 47% of cases, showed that diabetes management improved
including 50% of the time when specifically asked when patients were directly involved with the
to do so [26]. decision-making process [34]. Wilson showed
It is important to recognize that professional similar outcomes for patients with asthma [35].
recommendation is a crucial part of the informed Anesthesiologists should be encouraged to imple-
consent process [27], and that patients seek the ment shared decision-making as chronic diseases
physician’s perspective, not just the “bare facts” have significant implications in the perioperative
403 29
period and anesthesiologists are well positioned [40]. As outlined in their report, successful
to manage the patient throughout the entire peri- deployment of a shared decision-making process
operative process. Furthermore, shared decision- should include the following steps:
making can assist in the preoperative evaluation 1. Development and certification of shared
of higher-risk patients [36, 37]. decision-making aids
A fundamental concept underlying shared 2. Promotion of and training for competency in
decision-making is the recognition that each use of the tools and processes
patient is unique and has a right to select his or 3. Measurement and monitoring of the process
her preferred treatment options. The role of the 4. Development of a shared decision-making
physician is to provide his or her expert opinion culture
on the options available as well as demonstrate
the evidence for (and against) each. Charles [34] A 2017 Cochrane review [41] showed that among
suggested that shared decision-making processes 105 clinical trials patient decision aids improved
share the following characteristics: patient knowledge of options and outcomes,
1. Two (2) participants: the physician and patient knowledge of risks, and patients were also
patient. better able to articulate their values and beliefs.
2. Information is shared. The review also showed that patient decision aids
3. Consensus is built in a stepwise fashion. also reduced decisional conflict or uncertainty
4. An agreement is reached on the treatment plan. about the course of action to take [42].
As with all institutional changes, promoting
Together, the patient and physician can develop a the value of shared decision-making as a means
consensus and treatment plan consistent with the of improving both provider and patient satisfac-
patient’s goals of care. In practice, there are cir- tion will facilitate a cultural shift in the provider/
cumstances where the limits of shared decision- patient relationship [43]. This trend has been
making will be tested or when they are impractical ongoing for decades and with more recognition
(e.g., incapacitated patients, emergencies, or cir- of formalized shared decision-making tools and
cumstances where there is only one appropriate processes, providers and healthcare systems can
treatment option). expect patients to continue taking more active
Shared decision-making can also help reduce roles in the development of treatment plans.
bottlenecks which occur in operating rooms on
an operational level [38]. In the long run, anes-
thesiologists may be able to reduce the costs of 29.7 Summary
care by reducing rates of unnecessary surgery
or delaying such procedures. In 2012, Group Informed consent has evolved over the course of
Health in Washington State demonstrated that the twentieth century and now become the basis
a shared decision-making educational plat- of shared decision-making. Patient’s are largely
form reduced both surgery rates and costs for interested in engaging physicians in their care
total joint replacements [39]. The authors also and understanding the risks, benefits, and alterna-
advanced the discussion regarding an expanded tives to treatment. Any serious conversation must
role for the anesthesiologist in the perioperative incorporate the patients’ unique values, beliefs,
period. Anesthesiologists may facilitate conversa- and experiences that shape their expectations of
tions with surgeons, hospital administrators, and anesthesia, surgery, and medical treatment.
insurance companies to function more broadly as Case law may serve as a useful guide regarding
perioperative physicians. the informed consent process. Anesthesiologists
A growing body of evidence suggests that should also always be mindful of regional practice
development and implementation of shared patterns and relevant state laws or statute. Most
decision-making processes are most successful medical malpractice involves situations where
with standardized tools and physician training. patient expectations do not match the actual out-
The National Quality Forum has developed guide- comes. Shared decision-making and informed
lines for the creation of evidence-based shared consent will prove to be essential tools in ensuring
decision-making tools as well as metrics for mea- realistic expectations and outcomes that should
suring the impact and success of implementation lead to greater patient satisfaction.
zz Summary of Major Legal Decisions in Informed Consent

Case Key points of the decision
Scholendorff v. Society of New York Hospital (1914) Medical or surgical interventions without consent is
assault
Salgo v. Stanford (1957) Risks must be disclosed to inform the patient
Nathanson v. Kline (1960) Risks disclosed should be consistent with local or

regional physician custom
Canterbury v. Spence (1972) Physicians have a duty to disclose risks

Created the “reasonable or prudent patient” standard
of disclosure
Established a standard of how much information to
disclose (“materiality clause”)
Matthies v. Mastromonoco (1999) Alternatives to treatment must be disclosed including

reasonable treatment a physician does not recommend
29
zz The Four Basic Elements of Informed Consent
Communicating a choice The patient must be able to express a decision either

verbally or nonverbally
Understanding relevant information The patient must reasonably comprehend the risks,
benefits, and alternatives to treatment
Appreciating consequences The patient must acknowledge and appreciate the

consequences of any decision
Rational manipulation of information The patient demonstrates the ability to utilize

information received in the context of his or her own
values
Key Aspects of Shared Decision-Making
Definition Shared decision-making is a collaborative decision-

making process between the patient and provider for
preference-sensitive healthcare-related decisions
Key aspects of shared decision-making Two (2) participants: the physician and patient
Information and experience are shared
Consensus is built in a stepwise fashion
An agreement is reached on the treatment plan
Benefits of shared decision-making Improved communication between patients and

providers
Increased patient satisfaction
Decreased perioperative anxiety
Cost savings
Decreased litigation
Better patient comprehension of risks
Improved articulation of patient values and beliefs
405 29
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29
407
Supplementary
Information
Index – 409

https://doi.org/10.1007/978-3-319-96125-5
409 A
Index
A
Airway injuries, types of 172 –– psychiatric/psychological counseling
Airway management 230–232 and treatment 377
Airway obstruction 271 –– psychological disorders 377
Abbey Pain Scale 107
Albumin 142 –– randomized controlled trials 377
Abdominal injuries, perioperative
Alcohol-containing prep –– surgery for cesarean section 376
management of 236–238
solutions 180, 181 Anesthesia Closed Claims
Abnormal placentation,
Alcohol, substance abuse 34 database 306, 312
obstetrics 254, 255
Alert system protocol 344 Anesthesia delivery systems 306
Absolute hypovolemia 154
Allergic reactions 269, 270 Anesthesia equipment failure
Accreditation Association for
Alprazolam 35 –– management
Ambulatory Health Care 276
Amalgam 89 –– breathing circuit problems 312, 313
Acetaminophen 116
Ambulatory surgery 128, 129, 276 –– oxygen supply 313
Acid-base balance 143
–– analgesic agents 279 –– vaporizer 313
Acidosis 237
–– anesthetic technique 279, 280 –– ventilator 313
Acquired fibrinogen deficiency 137
–– ASA guidelines 276 –– PAC tasks 307, 314
Activated partial thromboplastin time
–– definition 276 –– prevention 314
(aPTT) 138, 139
–– facilities 276 Anesthesia machine breakdowns 311
Acute angle-closure glaucoma 205, 374
–– multimodal analgesia 279 Anesthesia machine checklist 306–308
Acute cardiac tamponade 235
–– patient discharge 281 Anesthesia Patient Safety
Acute compartment syndrome
–– patient selection 277 Foundation 341
(ACS) 239
–– postoperative nausea and Anesthesia-related cardiac arrest
Acute pain service (APS) 324
vomiting 281 associated with heart disease 384
Acute traumatic coagulopathy 135
–– postoperative pain management 281 Anesthesia-related medication errors,
Adjuncts 126
–– preoperative evaluation 278 taxonomy
Administration (delivery)-related
–– preoperative fasting 278 –– distribution/dispensing
medication error 323
–– recovery from anesthesia 280 (procurement/manipulation) 322
Advanced cardiac monitoring 330–333
–– regional anesthesia techniques 280 –– transcription (documentation) 323
Advanced trauma and life support
American Bar Association 358 Anesthesia-related mortality 271, 272
(ATLS) protocols 229, 237
American Society of Anesthesiologists Anesthetic breathing system (ABS) 310
Adverse respiratory events 273
(ASA) 348 Anesthetic technique 166
Afentanyl 126
ε-Aminocaproic acid 145 Anesthetized Patient Pain Scale
Agency for Healthcare Research and
Amniotic fluid embolus (AFE) 258 (APPS) 111
Quality (AHRQ) 319
Amphetamines 36, 37 Angiotensin-converting enzyme
Airway and respiratory system
Anaphylaxis 269 inhibitors (ACEI) 152
–– airway fires 169, 170
Anatomical crown 87 Anterior ischemic optic neuropathy
–– airway injuries, types of 172
Anesthesia (AION) 22, 204, 373
–– children 163, 164
–– dental fracture/avulsion during 93 Anterior optic nerve 21
–– components 169
–– for pregnant patients 251, 252 Antibiotics 270
–– legal issues 164, 165
–– risk factors associated with dental Anticholinergics 52
–– management 171, 173
injury during 93 Anticoagulation therapy 136
–– obesity 167
Anesthesia Awareness Registry 54, 373 Anticonvulsants 114
–– airway changes with 167
Anesthesia awareness under general Antihypertensives 39, 52
–– respiratory changes with 167, 169
anesthesia Anxiety reduction techniques 279
–– PACU, airway complications in
–– alcohol/drug abuse 376 Aortic injury 234
162, 163
–– American Society of Anesthesiology Apnea 2
–– prevention 172, 173
practice advisory 377, 378 Apnea hypopnea index (AHI) 14, 378
–– preventive measures 170, 171
–– anesthetic risk factors 376, 377 Aprotinin 145
–– risk factors 165–167, 172
–– cardiac surgery 376 Arrhythmias 241
–– trauma 171
–– history and physical assessment 377 Artificial conduits 221
Airway fires 169, 187
–– incidence 376 ASA Closed Claims database 53
–– algorithm 76
–– intraoperative and postoperative ASA difficult airway algorithm 70
–– management 171, 190
interventions 377 ASA preoperative fasting 279
–– precautions 189
–– intraoperative monitoring 377 ASA Task Force on Perioperative
–– predisposing risk factors for 170
–– neuromuscular blocking drugs 377 Management of Patients with
–– preparation 189
–– patient risk factors 376 Obstructive Sleep Apnea 380
–– prevention 189
–– pre-induction phase 377 Atrial fibrillation, modifiable risk factor 6
–– treatment 190
410
Index
Auditory evoked potential (AEP) 335 Bispectral index (BIS) 52, 124 –– burn injuries, perioperative
Auditory evoked potential index –– monitor, EEG 334 management of 236
(AAI) 125 Blood pressure (BP) 247 –– cardiac tamponade 235
Autoregulation 240 Blood transfusion, guidelines 140 –– hemorrhage 233
Awake fiber-optic intubation (AFOI) 71 Blunt cardiac injury (BCI) 233 –– PCI 233, 234
Awake paralysis 51 Body habitus extremes 214 –– tension pneumothorax 234
Awareness 267 Body mass index (BMI) 48, 135, 167 Cardiovascular procedures 128
Awareness under general anesthesia Bone cements, thermal injury 192 Cardiovascular system
(AAGA) 46 Brachial plexus injury 217 –– cardiac arrest 156
–– anesthesia related Bradycardia 6 –– chest pain 156
–– equipment failure, misuse, and Bradycardic dysrhythmias 100 –– complications, cardiac arrest and
mistakes 51 Bronchoscopy 75 local anesthetic toxicity 152
–– light depth of anesthesia 51 Burns –– hypertension
–– nitrous oxide 51 –– chemical 192, 193 –– postoperative 153
–– NMBD 50, 51 –– electrical –– preoperative 152, 153
–– premedication 52 –– electrocautery 194 –– hypotension
–– TIVA 50 –– ESU 193 –– history and physical
–– transport and remote –– faults 194 examination 153
locations 51, 52 –– magnetic resonance imaging 194 –– intraoperative 154
–– clinical signs 52 –– operating room –– postoperative 154, 155
–– evoked potential monitoring 53 –– airway fires 187, 189, 190 –– preoperative 153
–– incidence 46 –– fire 179 –– local anesthesia, cardiotoxicity and
–– intraoperative awareness –– fire, prevention of 180–183 comorbidities 156, 157
–– and medicolegal –– fire triad 179, 180 –– sinus tachycardia 155
consequences 53, 54 –– forced air warming 191 Catastrophic perioperative
–– monitoring for 52 –– heated materials 191 complications 106, 390
–– patient related –– intracavitary fires 190 Cementum 87
–– age 47 –– normothermia, maintenance Central hypoventilation syndrome
–– BMI 48 of 191 (CHS) 3
–– difficult airway 48 –– thermal injury 190–192 Central retinal artery occlusion
–– gender 46, 47 –– warming mattresses and (CRAO) 21, 23, 24, 204–208
–– medication and substance use, blankets 191 Central sensitization pathway 111
history of 47 –– perioperative management of 236 Central sleep apnea (CSA) 3, 379
–– previous history of 47 Burs 182, 183 –– due to heart failure 379
–– pysical condition and ASA physical –– with hypoventilation syndrome 379
status classification 48 –– with snoring 379
–– processed EEG 52, 53
–– psychological sequelae of 54
C Cerebral perfusion pressure (CPP) 240
Certificates of Merit/Good Faith 367
–– risk factors for 46 Cables sources 183 Cervical spine injuries 232
–– surgery related Calcium 249 Charlson risk index 24
–– cardiothoracic surgery 49 Cancer therapy 157 Chemical burns 192, 193
–– obstetric and gynecologic Capnography 77, 78 Chemotherapy 214
surgery 48, 49 Carbon dioxide laser 70 Chest injuries
–– surgery types 50 Cardiac abnormalities 241 –– aortic injury 234
–– trauma and emergency Cardiac arrest 152, 156, 242 –– BCI 233
surgery 49, 50 Cardiac complications 100, 101 –– burn injuries, perioperative
Axonal degeneration 219 Cardiac/major vascular surgery 135 management of 236
Cardiac obstetrics 246, 247 –– cardiac tamponade 235
Cardiac output (CO) 246, 330, 333 –– hemorrhage 233
B –– monitoring 335
Cardiac rhythm 247
–– PCI 233, 234
–– tension pneumothorax 234
Barotrauma 267 Cardiac tamponade 235 Chest pain 156
Basilar skull fractures 232 Cardiopulmonary bypass (CPB) 49 Chlorhexidine gluconate (CHG) 193
Benzodiazepines 52, 236 Cardiothoracic surgery, AAGA 49 Chlorpromazine 39
–– substance abuse 34, 35 Cardiovascular and chest injuries, Chronic kidney disease (CKD) 12
Berlin Questionnaire 10 perioperative management of 232 Chronic obstructive pulmonary disease
–– and ASA Checklist 378, 379 Cardiovascular causes of cardiac (COPD) 376
Beta-blockers (β-blockers) 114, 152 arrest 385 Citrate 139
Beta human chorionic gonadotropin Cardiovascular disease 277, 278 Clinical performance in healthcare 340
(BHCG) 246 Cardiovascular injuries Clonidine 39
Bilateral paralysis 77 –– aortic injury 234 Closed claims database 352
Biologic conduits 221 –– BCI 233 Closed Claims Project 26, 54
Index
411 A–E
–– anesthetic-related injury 373 –– preoperative exam 86, 87 Electrophysiology Lab/Cardiac
–– history of 373 –– proper technique 90, 91 Catheterization Lab 301, 302
Closed nerve injury 217 –– risk factors 86 Electrosurgical units (ESU) 184
Clotting factors deficiencies 135 –– treatment 91, 92 –– burns, operating room 182
Coagulation abnormalities 135, 136 Dental restorations 89 –– electrical burns 193
Coagulopathies 237 –– amalgam and resin-based composite –– thermal injury 192
Cocaine 36 fillings 89 Elevated intraocular pressures 374
Cognitive dysfunction 7 –– dental implants 90 Embolectomy 25
Coiling 194 –– fixed single-tooth restorations and Embolic phenomena 156
Collagen fibers 221 fixed multiunit restorations 89 Embryonic embolic event-associated
Collateral Source Rule 366 –– removable prosthesis 89 DIC 137
Colloids 142 Depth of general anesthesia (DGA) Emergency surgery, AAGA 49, 50
Conduit repair 221 monitoring 333–335 Emotional intelligence 391, 393, 394
Condylar fractures 232 Dereliction 349 Endocrine obstetrics 248, 249
Congenital bleeding disorder 135 Desflurane 266 Endogenous nerve healing,
Congenital central hypoventilation Desmopressin 144 PNI 219, 220
syndrome (CCHS) 3 Dexmedetomidine 126, 128–131 –– conduit repair 221
Congenital deficiency 135 Diathermy 182 –– direct nerve repair 220
Consumer Assessment of Healthcare Difficult tracheal intubation 97 –– nerve grafts 221
Providers and Systems (CAHPS) Difficulty airway algorithm 99 End-tidal carbon dioxide (ETCO2) 77
scores 344 Dilutional coagulopathy 137 End-to-end repair 220
Contingency fees 366 Direct-acting vasopressors 37 End-to-side repair 220
Continuous cardiac output Direct laryngoscopy, perioperative Entropy DGA monitor 334
(CCO) 331, 335 dental injury during 93 Epidural anesthesia 117
Continuous positive airway pressure Discharge from PACU, unmonitored Epineural sleeve repair 220
(CPAP) 11 setting 382 Equipment failure 51, 310, 312
Cornea 200 Disclosure clarifications 400 Esophageal intubation 97
Corneal abrasion 26, 198–200, 206 Disseminated intravascular coagulation Expert witness 367
Cornual ectopic pregnancy 253 (DIC) 135, 253 Eye anatomy
Coronary artery bypass grafting Disulfiram 158 –– structures 20, 21
(CABG) 49 Drug-induced acquired factor –– vasculature supplying 21
Cortical blindness (CB) 24, 25, 205, deficiency 136 Eye injury 198
206, 374 Drug overdose 36 –– acute angle-closure
Countersuits 352 Drug teratogen, resources 250 glaucoma 205
Cricothyroidotomy 72 Dyspnea 247 –– anesthesia, consent for 207, 208
Cryoprecipitation 141, 142 –– cornea, function of 200
Cuffed endotracheal tubes (ETTs) 164, –– neurovasculature of eye 204
170, 171
Cyber liability 367
E –– protection 200, 202
–– refraction 202
Cyber Liability Insurance 368 Eclampsia 258 –– transmission 202
Cyclooxygenase (COX) inhibitors 116 Ecstasy 40 –– corneal abrasions and mechanisms
Ectopic pregnancies, obstetrics 253, 254 of occurrence 199, 200
Edema 252 –– cortical blindness 205
D Education and information 343

Electrical blankets 191
–– CRAO 205
–– eye injuries and causes 203
Data collection approaches 373 Electrical burns –– eye surgery
Defective anesthesia systems 51 –– electrical faults 194 –– monitoring during 208
Defibrillator pads 184 –– electrocautery 194 –– positioning during 208
Demyelination 219 –– ESU 193 –– preparation for 207
Dental caries 88, 89 Electrical faults 194 –– hydrogel eye shields, comparative
Dental cavities 88 Electric stimulation 221 chart of 200
Dental implants 90 Electroacupuncture, PNI 222 –– incidence and amount of
Dental injury 84 Electrocautery 192 payment 198
–– burden 85 –– electrical burns 194 –– ION and OCS 205
–– causes 91 –– fires 75 –– mechanisms of 198
–– etiology 85 Electroconvulsive therapy for –– nasal side, vertical section of
–– medicolegal implications 85, 92 patients 296 right eye 201
–– prevention 86 Electrocution 242 –– patient movement 204
–– damage to restorations 90 –– injuries 241, 242 –– physiologic changes 204
–– dental anatomy 87 Electrolytes alterations 139 –– postoperative visual loss 205
–– dental restorations 89, 90 Electromyography (EM), PNI 219 –– POVL and malpractice claims 206
–– pathology 88, 89 Electronic medical record (EMR) 322 –– prevention of 208
412
Index
–– closed case claims 209

–– perioperative visual loss, practice
–– stroke 100
–– UAGA 98 I
advisory for 209 Gestational trophoblastic disease Ignition
–– prone position 204, 205 (GTD) 254 –– fire triad 180
–– simplified eye diagram 202 Gingival tissue 87 –– sources 180
Gingivitis 89 Iliohypogastric nerve block 127
Glasgow coma scale (GCS) score 240
F
Immediate extubation 171
GlideScope 71 Inadequate ventilation 97
Glue repair 222 Industrial quality systems 342
Feedback 390 Glycogen synthase kinase 3β Informed consent 351
Femoral nerve injury 218 inhibitors 222 –– elements of 401, 404
Fenproporex 37 Gowns 181 –– decision-making capacity 401, 402
Fentanyl 112 Gynecologic surgery, AAGA 49 –– disclosure 401
Fetal development 249, 250
–– voluntariness 402
H
Fetal monitoring, obstetrics 250, 251
–– invasive procedures 398
Fiber-optic-guided intubation 71, 72
–– Legal Decisions 404
Fiber optics 184
Hallucinogens, substance abuse 39 –– pain management 109, 110
–– light sources 183
Healthcare networks 341 –– physician standard and patient
–– thermal injury 192
Health Information Technology for standard 398–400
Fibrinogen 141
Economic and Clinical Health Act of –– in practice 400
Fibrinogen repletion strategy 141
2009 (HITECH) 367 –– and shared decision-making 401
Fifth National Audit Project (NAP-5) 46
Health Insurance Portability and –– translumbar aortography 398
Fire management
Accountability Act (HIPAA) Inguinal herniorrhaphy (IH) 127, 128
–– action plan 185, 186
standards 367–368 Institute for Safe Medication Practices
–– specific actions to take 187
Heart rate (HR) 246 (ISMP) 193, 342
Fire prevention algorithm 186
Heated materials 191 Insufflation/spontaneous
Fire triad 169
Hematologic, obstetrics 247, 248 respiration 66
Fixed multiunit restorations 89, 90
Hemolysis, elevated liver enzymes, and Intensive care unit (ICU) 323–325
Fixed single-tooth restorations 89, 90
low platelets (HELLP syndrome) 257 International Association for Ambulatory
FloTrac system 332
Hemopericardium 233 Surgery (IAAS) 276
Fluid resuscitation 236
Hemorrhage 232, 233, 236 International normalized ratio (INR) 136
Fluorouracil (5-FU) toxicity 158
–– vital sign changes, severity of 138 Interventional pain 128
Focused assessment with sonography
Hevea brasiliensis 270 Intra-abdominal compartment
for trauma (FAST) 237
High-voltage shocks 241 syndrome 237
Forced air ventilation 182
Hospital/clinical risk management Intracavitary fires 190
Forced air warming 191
personnel 351 Intraocular pressure (IOP) 205
Foreign body aspiration 74, 75
Hospital general legal counsels and Intraoperative awareness 53, 54
Fortwin 126
ethics committees 400, 401 –– monitoring for 52
Fractional area change (FAC) 333
Hydatidiform moles 254 Intraoperative blood salvage
Fresh frozen plasma (FFP) 141
Hydroxylethyl starch (HES) 142 technique 144
Fuel
Hyperbaric oxygen 222 Intraoperative hypertension (IH) 153
–– fire, prevention 180
Hypercapnia 4, 6 Intraoperative hypotension (IOH) 154
–– alcohol-containing prep
Hypercoagulability 252 Intraoperative normovolemic
solutions 180, 181
Hyperkalemia 139 hemodilution 144
–– surgical drapes and gowns 181
Hypertension 214, 277 Intravenous (IV) acetaminophen 113
–– fire triad 179, 180
–– with OSA 6 Intravenous conscious sedation
–– sources 179
–– postoperative 153 (IVCS) 64–66
–– preoperative 152, 153 Ischemic optic neuropathy 205, 206,
G Hypocalcemia 146
Hypokalemia 139, 146
208, 373, 374
–– risk factors 207
Gamma-aminobutyric acid (GABA) 114 Hypoperfusion/embolism, posterior
J
Gas delivery systems 308 cerebral artery 374
Gastroendoscopy 300 Hypotension 23
Gastrointestinal injuries, obstetrics 248 –– history and physical examination 153
Jet ventilation 67
–– perioperative management of 236–238 –– intraoperative 154
Joint and Several liability policies 366
General anesthesia 96 –– postoperative 154, 155
–– cardiac complications 100, 101 –– preoperative 153
–– death 96, 97
–– factors 96
Hypothermia 143
Hypovolemia 154, 155
K
–– limitations 96 Hypoxemia 6 Keratitis 200
–– respiratory complications 97, 98 –– in PACU 162 Keratopathy 208
–– Standard of Practice Parameters 96 Hypoxia 4, 13, 271 Keraunoparalysis 242
Index
413 E–M
Ketamine 39, 112, 126, 158 –– etiology 134 –– negligence in 367
Ketorolac 113, 126 –– trauma 134–137 –– noneconomic damages 365
Kidney enlargement 248 –– evaluation and diagnostic checklist –– pain versus anesthesiology 365
–– electrolytes alterations 139 –– payments 362
L
–– point-of-care testing 139 –– pre-suit requirements 359
–– prothrombin time and activated –– standard of care 349, 357
partial thromboplastin –– trial process
Lactobacilli 88
time 138, 139 –– appeals 361
Laryngeal mask airway (LMA) 67,
–– management strategies of 140 –– depositions 359, 360
69, 165
–– MTP 142, 143 –– expert witness 361, 362
Laryngospasm 73, 74, 271
–– acid-base balance 143 –– initial pleadings 359
Lasering vocal cord lesions 189
–– damage control resuscitation 144 –– legal fees 360
Laser-resistant endotracheal tubes 70, 71
–– intraoperative blood salvage –– litigation process 361
Lasers 184
technique 144 –– payment model criticisms 360
–– burns, operating room 183
–– intraoperative normovolemic –– plaintiffs and defendants
–– thermal injury 192
hemodilution 144 (discovery) 359, 360
Left ventricular end-diastolic area
–– low CVP level 144 –– settlement 361
(LVEDA) 333
–– patient positioning 143 –– standard of legal proof 360
Left ventricular end-systolic area
–– piggyback technique 144 –– verdicts 361
(LVESA) 333
–– temperature 143 Medical malpractice insurance
Left ventricular outflow tract (LVOT) 333
–– non-pharmacologic management, 364, 365
Legal responsibility for medical
transfusion 140–142 Medical malpractice lawsuit 351
wrongs 348
–– pharmacologic management Medical Malpractice Statistics 349
Life-threatening anaphylaxis 269
144, 145 Medical paternalism 398
Light sources 183
Massive transfusion protocol Medical records and documentation 351
Lipoprotein 137
(MTP) 142, 143 Medical responsibility 348
Lithium dilution cardiac output (LiDCO)
–– acid-base balance 143 Medication errors 319
system 331, 332
–– damage control resuscitation 144 –– adverse drug reactions 319
Lithium, role of 222
–– intraoperative blood salvage –– adverse events 319
Liver transplantation 134
technique 144 –– classification 319, 321
Local anesthetic systemic toxicity
–– intraoperative normovolemic –– medications 323
(LAST) 122
hemodilution 144 –– perioperative environment 319, 321
Lower extremity peripheral nerve injury
–– low CVP level 144 Medicolegal consequences 53, 54
–– clinical manifestations 218
–– patient positioning 143 Methamphetamine abuse 36
–– femoral nerve injury 218
–– piggyback technique 144 Microlaryngoscopy tubes 70
–– lithotomy position, nerve injuries
–– temperature 143 Midazolam 125, 126
in 218
McGill Pain Questionnaire 107 Middle latency auditory evoked
–– pudendal nerve injury 218, 219
MDMA/ecstasy 39, 40 potential (MLAEP) 335
Low-intensity ultrasound 222
Mean arterial pressure (MAP) 240, 247 Mid-latency auditory evoked potentials
Low-pressure cardiac tamponade 235
Mechanical protection 202 (MLAEP) 53
Low-voltage categories 241
Mechanical thrombectomy 25 Mixed sleep apnea 379
Lysergic acid diethylamide (LSD) 39
Mechanical ventilator 310 Molar pregnancy 254
Median nerve injury 217 Monitored anesthesia care (MAC) 64–66,
M Medical Errors reduction 350, 351

Medical malpractice 349, 357
97, 122, 123
–– ambulatory procedures 128, 129
Machine failure 313 –– apology/expression of –– cardiovascular procedures 128
Magnetic resonance imaging (MRI) sympathy 365 –– inguinal herniorrhaphy 127, 128
–– burns 194 –– at-risk specialty 362 –– interventional pain 128
–– PNI 219 –– adverse events 363 –– neurosurgical procedures 129
Major adverse cardiac event (MACE) 100 –– indemnity payments 362, 363 –– ophthalmologic procedures 127
Major joint dislocation 239 –– medical and anesthesia –– otolaryngologic procedures 127
Malignant hyperthermia (MH) 278, 283 records 363, 364 –– patient selection and
Mallampati class I airway 168 –– risk of liability 363 monitoring 123, 124
Management sciences 390 –– Breech of duty 357 –– pediatric procedures 129
Mandibular injuries 232 –– causation 357 –– systemic sedatives and
Marijuana, substance abuse 38, 39 –– cause of action 350 analgesics 125
Mask ventilation 65, 66, 268 –– damages 350, 358 –– adjuncts 126
Massive perioperative hemorrhage –– dereliction 349 –– dexmedetomidine 126
–– clinical manifestations –– doctor-patient relationship 357 –– ketamine 126
–– vital organ perfusion-related –– doctrine of res ipsa loquitur 358 –– midazolam 125, 126
presentations 138 –– legal duty 349 –– opioids 126
–– vital signs changes 137 –– Loss of Chance 367 –– propofol 125
414
Index
Morning sickness 248 Non-operating room anesthesia –– anesthetic management 10

Morton’s etherizer 309 (NORA) 63, 288 –– CPAP therapy, moderate-to-severe
Muffled roar 189 Non-opioid analgesia 116, 117 OSA on 10–12
Multimodal intraoperative monitoring Nonthermal laser amnion wrap 221 –– questionnaires 8–10
(MIOM) 241 Normothermia –– intraoperative management 380, 381
Multimodal pain control strategy 279 –– maintenance of 191 –– postoperative management 381, 382
Musculoskeletal injuries 238 Numbering system 87 –– preoperative evaluation 380
–– ACS 239 Numeric pain rating scale 107 –– renal, consequences of 12, 13
–– major hemorrhage 238 –– risk of 5, 14
–– major joint dislocation 239 –– and seizure disorder 7
–– open fracture 238, 239
–– pelvic injuries 239
O –– treatment 6
Obstructive Sleep Apnea (OSA) Death
Myocardial injury 242 Obesity 167 and Near Miss Registry 373, 380
–– airway changes with 167 Occult cardiac tamponade 235
–– respiratory changes with 167, 169 Ocular compression 23
N Obesity hypoventilation syndrome (OHS) 7

Observer’s Assessment of Alertness/
Ocular injury 374, 375
Office-based anesthesia 282
Narcotrend monitor, EEG 334, 335 Sedation (OAA/S) Scale 124 Office for Civil Rights within HHS 367
Nasal intubation 232 Obstetrical hemorrhage 253 Ohm’s law 329
Nasal RAE 70 Obstetric diseases 137 Open fracture 238, 239
Neck trauma 232 –– AAGA 49 Open nerve injury 217
Nefopam 113 Obstetrics Operating room (OR)
Negative pressure pulmonary edema –– fetal development and –– burns
(NPPE) 271 placenta 249, 250 –– airway fires 179, 187, 189, 190
Nerve allografts 221 –– fetal monitoring 250, 251 –– fire, prevention of 180–183
Nerve autografts 221 –– maternal physiology 246 –– fire triad 179, 180
Nerve blocks 109 –– cardiac 246, 247 –– forced air warming 191
Nerve conduction study (NCS),PNI 219 –– endocrine 248, 249 –– heated materials 191
Nerve grafting 221 –– gastrointestinal 248 –– intracavitary fires 190
Nerve regeneration 221 –– hematologic 247, 248 –– normothermia, maintenance
Nerve repair –– pregnancy, physiologic changes of 191
–– direct 220 in 249 –– thermal injury 190–192
–– timing of 220 –– respiratory 247 –– warming mattresses and
Network for Excellence in Healthcare –– skeletal 249 blankets 191
Innovation (NEHI) 318 –– urologic 248 –– fire algorithm 188
Neurogenic shock 241 –– obstetrical conditions –– fires, management
Neurological injuries 239 –– abnormal placentation 254, 255 –– action plan 185, 186
–– spinal cord injury and trauma 240, 241 –– AFE 258 –– specific next actions to take 187
–– TBI 240 –– eclampsia 258 –– preparation
Neurologic injury after non-supine –– ectopic pregnancies 253, 254 –– anatomic location 183, 184
shoulder surgery –– molar pregnancy 254 –– electrosurgical units, lasers and
–– blood pressure parameters 375 –– placental abruption 255 fiber optics 184
–– causes 375 –– postpartum hemorrhage 256, 257 –– fire contributors 184, 185
–– continuous CO2 monitoring 376 –– pregnancy-associated hyperten- –– flammable solutions 183
–– monitoring for ischemia 376 sion 257, 258 –– oxygen and nitrous oxide 184
–– NINS Registry 373 –– uterine atony 255, 256 –– personnel, process and
–– prevention 375 –– uterine inversion 255 teamwork 183
–– risk factors 375 –– perioperative care, obstetrical –– Silverstein Fire Risk Assessment
Neuromuscular blocking drugs physiologic changes affecting 252, 253 Tool 185
(NMBD) 50, 51, 166, 270 –– pregnant patients Ophthalmologic injuries
Neurosurgical procedures, MAC 129 –– anesthesia for 251, 252 –– anterior and posterior ischemic optic
Neurovasculature of eye 204 –– perioperative care for 252 neuropathy 21–23
Nicotine, substance abuse 38 Obstructive sleep apnea (OSA) 2, 3, 5, –– central retinal artery occlusion/retinal
Nicotine use disorder (NUD) 38 14, 169, 277, 282, 378, 379 vascular occlusion 23, 24
Nighttime snoring 2 –– atrial fibrillation, modifiable risk –– cortical blindness 24, 25
Nitroglycerin 37 factor for 6 Ophthalmologic procedures 127
Nitrous oxide 51, 108, 180, 184, 266 –– endocrine, consequences of 13 Opioid-induced hyperalgesia (OIH) 112
Non-amphetamine stimulants block 36 –– hypertension associated with 6 Opioids 8, 115, 116
Non-depolarizing paralytic (NDP) agent –– identifying patients 8 –– MAC 126
over succinylcholine 324 –– American Academy of Sleep –– substance abuse 35, 36
Noninvasive ventilation (NIV) 163 Medicine 10 Orbital apex congestion 205
Index
415 M–P
Orbital compartment syndrome (OCS) 205 –– constructive elements 394 Perioperative Sleep Apnea Prediction
Organization/department strategy 392, –– explicit inclusion 392 (P-SAP) 8
393, 395 –– fear and criticism 391 Perioperative stroke (PS) 100
Otolaryngologic procedures 127 –– and feedback 390, 395 Perioperative visual loss (POVL) 24, 207
Oxidizers –– individual’s performance 391 Peripheral nerve regeneration,
–– burns, operating room 182, 183 –– institutional environment 391 neurotrophic factors 220
–– fire triad 180 –– medical systems of care 391 Personal health information (PHI) 367
Oxygen 184, 190 –– peer review-friendly culture 394 Personal humility 391
–– consumption 268 –– professional performance 393 Personality traits 393–395
–– teaching tool 390 Phencyclidine (PCP) 39
Pelvic injuries 239 Phenergan 126
P Penetrating cardiac injuries (PCIs) 233, 234

Pentoxifylline 24
Physiologic monitoring
–– ASA monitors 329
Packed red blood cells (PRBC) 134, Perfusion monitoring, parameters 138 –– circulatory system 329
140, 141 Periodontal disease 88, 89 –– depth of general anesthesia 330
Pain management Perioperative anaphylaxis 267 –– indications 329
–– informed consent 109, 110 Perioperative care –– oxygenation 329
–– intraoperative pain 110–115 –– obstetrical physiologic changes –– perioperative and intraoperative
–– non-opioid analgesia 116, 117 affecting 252, 253 periods 328
–– opioids 115, 116 –– for pregnant patients 252 –– temperature 330
–– pain control 106 Perioperative medicine quality 340 –– ventilation 329
–– postoperative pain 106–109, 115 Perioperative MI (PMI) 101 Pickwickian syndrome 7
Partial denture 89 Perioperative nerve injuries (PNI) 214 Piggyback technique 144, 146
Patient-centered decision-making 398 –– classification 216 PION-induced blindness 373
Patient-centered standard of –– clinical manifestations of 215 Pituitary gland 248
disclosure 399 –– evaluation and diagnosis 219 Placenta 249, 250
Patient injuries 311, 312 –– electromyography 219 Placental abruption 255
Pediatric anesthesiology –– MRI 219 Placental anomalies 137
–– airway/cardiovascular –– NCS 219 Placenta previa 254
complications 263–265 –– lower extremity peripheral nerve Plasma 141
–– allergic reactions 269, 270 injury –– osmolality 248
–– anesthesia-related mortality 271, 272 –– femoral nerve injury 218 Point-of-care (POC) testing 139
–– complications 266, 267 –– lithotomy position, nerve injuries Polymethyl methacrylate 192
–– infant and adult respiratory in 218 Positive pressure-generating
physiology 262 –– pudendal nerve injury 218, 219 ventilator 306
–– pediatric patient, airway –– management of 219 Postanesthesia care unit (PACU), airway
complications 268 –– conduit repair 221 complications in 162, 163
–– postoperative complications 270, 271 –– direct nerve repair 220 Posterior ischemic optic neuropathy
–– practice of 262 –– electroacupuncture 222 (PION) 22, 23, 204, 207, 373, 374
–– subspecialty of 262 –– endogenous nerve Posterior reversible encephalopathy
Pediatric Perioperative Cardiac Arrest healing 219, 220 syndrome 28, 374
(POCA) Registry 373, 382, 383 –– hyperbaric oxygen 222 Post-extubation stridor 271
–– cardiac arrest 383 –– lithium, role of 222 Postoperative hypertension 153
–– anesthetic phase 384 –– low-intensity ultrasound 222 Postoperative hypotension
–– etiology of 384 –– nerve grafts 221 –– etiology 154
–– location 384 –– nerve repair, timing of 220 –– hypovolemia 154, 155
–– outcomes 384 –– nonsurgical methods 221, 222 –– treatment 155
–– risk factors 383 –– stem cells, role of 222 Postoperative nausea and vomiting
–– congenital/acquired disease 383 –– peripheral nerve regeneration, (PONV) 125, 270, 271
Pediatric procedures 129 neurotrophic factors 220 Postoperative visual loss (POVL) 26,
Peer review –– risk factors and causes of 214 205, 206, 208, 374
–– adaptive changes 391 –– anesthesia-related –– POVL Registry 373
–– toward feedback 391 factors 214, 215 Postpartum hemorrhage (PPH) 137,
–– barriers and incentives 392 –– patient-related factors 214 256, 257
–– catastrophic perioperative complica- –– surgery-related factors 215 Postsurgical inflammatory
tions 392 –– upper extremity peripheral nerve neuropathy 214
–– collaborative and peer review-friendly injury Pre-anesthesia checkout (PAC)
culture 392 –– brachial plexus injury 217 recommendation 306
–– of compliance 393 –– median nerve injury 217 Pre-check process 306
–– compliance with organization/ –– radial nerve injury 218 Preeclampsia 257
department strategy 393–395 –– ulnar nerve injury 217 Preexisting neurologic disease 214
416
Index
Pregnancy Recombinant activated factor VIIa 142 Respiratory system See Airway and
–– anesthesia for 251, 252 Refraction 202 respiratory system
–– obstetrics, physiologic changes in 249 Regional anesthesia (RA) 122, 127, Retinal ischemia 374
–– perioperative care for 252 214, 217 Retinal vascular occlusion 23, 24
Pregnancy-associated Regional cardiac tamponade 235 Revised cardiac risk index (RCRI) 100
hypertension 257, 258 Reinforced endotracheal tubes 71 Root fractures 91
Premature ventricular contractions Relative hypovolemia 154 Rotation thromboelastometry 137
(PVCs) 100 Remote anesthesia site
Preoperative hypertension 152–153 –– anesthesia care 289
Preoperative risk prediction score
(PRPS) 272
–– anesthesia types
–– general anesthesia 293, 294
S
Prescription (decision)-related –– MAC 293 Saws 182, 183
medication errors 322 –– regional anesthesia 294, 295 Sciatic nerve injury 218
Pre-tracheal auscultation 78 –– sedative-hypnotic drugs 295 Seat belt sign 237
Professional liability, field of –– total intravenous Sedation 65
anesthesiology 348 anesthesia 295, 296 Seizure disorder, OSA 7
Professional liability insurance –– ASA Closed Claims Database Seldinger technique 72
coverage 373 Analysis 297 Selective serotonin receptor inhibitor
Professional Liability Reform 365 –– ASA equipment requirements 291 (SSRI) 136
Professional performance 393–395 –– body temperature 293 Self-inflating manual ventilation device
Proof of Malpractice 357, 358 –– circulation 292 (SIMVD) 307
Propofol 50, 51, 124, 125, 127 –– classification 288, 289 Self-reporting 344
Prothrombin complex concentrate –– context-sensitive half-life of Sensory deficit 217
(PCC) 142, 146 intravenous opioids and sedative- Sevoflurane 266
Prothrombin time (PT) 138, 139 hypnotic drugs 294 Shared airway 63
P-SAP questionnaire 9 –– Dental Surgery Units 299 –– complications 73
Psychological Impact and Effect on –– diagnostic, therapeutic and –– capnography 77, 78
Practice 352 interventional procedures 288 –– endotracheal tube, suturing 78
Pudendal nerve injury 218, 219 –– endoscopy unit 301 –– failed intubation 73
Pulmonary edema 253 –– with Fixed Equipment 298 –– foreign body aspiration 74, 75
Pulmonary emboli 333 –– fluoroscopy safety 298 –– laryngospasm 73, 74
Pulse contour analysis 331, 335 –– JCAHO hospital requirements 293 –– pre-tracheal auscultation 78
Pulse index continuous cardiac output –– Location-Specific –– surgical fire 75
(PiCCO) system 331 Catastrophes 296, 298 –– throat pack 78
Pump effect 311 –– MRI scanners 298–300 –– vocal cord paralysis 77
Punitive damages 366 –– optimal environment for anesthesia –– intubation techniques 69
Pupillary aperture 20 delivery 290, 291 –– fiber-optic-guided
–– oversedation 296 intubation 71, 72
Q
–– oxygen supply 292 –– laser-resistant endotracheal
–– patient factors 290 tubes 70, 71
–– patient monitoring 289 –– microlaryngoscopy tubes 70
Quality management 344
–– perioperative complications 296 –– nasal RAE 70
–– measurement 344
–– postprocedure care in intensive care –– reinforced endotracheal tubes 71
–– program 343, 344
unit 288 –– standard endotracheal
–– team and officer 345
–– postprocedure recovery 303 tubes 69, 70
Quality of healthcare
–– preoperative evaluation 290 –– surgical airways 72
–– adverse events 342, 343
–– principles of 302, 303 –– videolaryngoscopy 71
–– collaborative efforts 340
–– procedure-related complications 302 –– open airway techniques
–– development 340
–– procedure requirement 290 –– insufflation/spontaneous
–– industrial quality improvement 340, 341
–– Psychiatry Wards and Procedure respiration 66
–– latent errors 342
Rooms 296, 298 –– jet ventilation 67
–– patient monitoring 341
–– radiology suite with fixed equip- –– LMA 67, 69
–– patient safety 340
ment 299 –– MAC and IVCS 64–66
–– protocols and evidence-based
–– sedation 294 –– mask ventilation 66
programs 340
–– standards of care 291, 292 –– patient evaluation 63, 64
–– quality improvement 340
–– Subspecialty-Specific Built Room 299 Shared decision-making 402–404
Quaternary compounds 193
–– three-step approach to Sheehan syndrome 248
anesthesia 289 Short-acting synthetic opioids 112
R –– ventilation 292
Respiratory arrest 242
Significant lordosis 249
Silverstein Fire Risk Assessment Tool 185
Radial nerve injury 218 Respiratory depression 97 Simplified PONV algorithm 281
Radiation (X-ray) therapy 157 Respiratory, obstetrics 247 Simulation training 314
Index
417 P–U
Sinus tachycardia 155 –– MDMA/ecstasy 39, 40 Trauma
Skeletal, obstetrics 249 –– nicotine 38 –– AAGA 49
Sleep apnea 2 –– opioids 35, 36 –– acute management
–– anesthesia preoperative –– perioperative considerations 33 –– pre-arrival and triage 229, 230
evaluations 5, 11 –– stimulants 36, 37 –– pre-arrival room preparation 230
–– CHS 3 –– SUDs 32 –– preparation for arrival 229
–– CSA 3 Succinylcholine 266, 273 –– airway and respiratory system 171
–– forms of 3 Sudden infant death syndrome (SIDS) 3 –– airway compression 232
–– identifying patients with OSA 8 Sufentanil 112 –– airway management 230–232
–– American Academy of Sleep Sugammadex 266 –– anesthesia 231
Medicine 10 Supplemental oxygen supply 311 –– cardiovascular and chest injuries,
–– anesthetic management 10 Surgical Care Improvement Project perioperative management of 232
–– CPAP therapy, moderate-to-severe (SCIP) scores 344 –– aortic injury 234
OSA on 10–12 Surgical drapes 181 –– BCI 233
–– questionnaires 8–10 Surgical drills 182, 183 –– burn injuries, perioperative
–– in middle-aged patients 13 Swiss cheese model 342 management of 236
–– nighttime snoring 2 Systemic vascular resistance (SVR) 247 –– cardiac tamponade 235
–– during non-rapid eye movement –– hemorrhage 232, 233
sleep 5 –– PCI 233, 234
–– OHS 7
–– opioids 8
T –– tension pneumothorax 234
–– electrocution injuries 241, 242
–– OSA 5–7 Tachycardic dysrhythmias 100 –– gastrointestinal and abdominal
–– endocrine, consequences of 13 Temporomandibular joint (TMJ) injuries, perioperative management
–– renal, consequences of 12, 13 injuries 172 of 236–238
–– and seizure disorder 7 Tension pneumothorax 156, 234 –– Glasgow coma scale 230
–– during rapid eye movement sleep 5 Tensor palatini muscle 4 –– massive perioperative
–– respiratory pause 2 Thermal injury 190 hemorrhage 134–137
–– sleep-related changes 4 –– bone cements 192 –– musculoskeletal injuries 238
–– structural risks 5 –– ESUs 192 –– ACS 239
–– symptom 2 –– fiber optics 192 –– major hemorrhage 238
–– treatment 3 –– lasers 192 –– major joint dislocation 239
–– upper airway narrowing 4 –– sterilized instruments 191 –– open fracture 238, 239
Social media liability 368, 369 Thermal laser welding 221 –– pelvic injuries 239
Society for Ambulatory Anesthesia Thermodilution 330 –– neurological injuries 239
(SAMBA) 276 Thoracotomy 233 –– spinal cord injury and 240, 241
–– consensus statement 381 Throat pack 78 –– TBI 240
Society of Anesthesia and Sleep Thromboelastography (TEG) 138 –– traumatic facial injury 232
Medicine (SASM) 8 Thromboelastometry (ROTEM) 138, 146 Traumatic brain injury (TBI) 239
Spinal anesthesia 117 Tiredness 2 –– trauma patient 240
Spinal cord injury and trauma 240, 241 Tobacco use 214 Traumatic facial injury 232
Spontaneous respiration 66 Tocolytics 255 Troponin testing 101
Standard endotracheal tubes 69, 70 Tonsillectomy 189
Standard for Flammability of Clothing Tooth decay 88
Textiles (SFCT) 181
State Patient Compensation Funds 366
Tort reform 365–367
Total Intravenous Anesthesia (TIVA) 50
U
Stem cell infusion 222 Tracheal injuries 172 Ulnar nerve injury 217
Stem cells, role of 222 Tracheostomy 189 Unintended awareness during a general
Steroids 114 Tranexamic acid 144, 145 anesthetic (UAGA) 98
Stimulants, substance abuse 36, 37 Transesophageal echocardiography University of Michigan Health System
STOP-Bang questionnaire 8, 9, 378 (TEE) 332, 333, 335 (UMHS) 54
Streptococcus mutans 88 Transfusion 140 Upper extremity peripheral nerve injury
Stroke, general anesthesia 100 –– albumin 142 –– brachial plexus injury 217
Stroke volume variation (SVV) 331 –– cryoprecipitate 141, 142 –– clinical manifestations 217
Subacute cardiac tamponade 235 –– fibrinogen 141 –– median nerve injury 217
Substance abuse –– packed RBCs 140, 141 –– radial nerve injury 218
–– acute and chronic 32 –– PCC 142 –– ulnar nerve injury 217
–– healthcare providers 32 –– plasma 141 Upper respiratory tract infection
–– screening for 32, 33 –– recombinant activated factor VIIa 142 (URI) 64
–– alcohol 34 Transmission 202 Urinalysis 237
–– benzodiazepines 34, 35 Transport protection 202 Urologic, obstetrics 248
–– hallucinogens 39 Transversus abdominis plane (TAP) Uterine atony 255, 256
–– marijuana 38, 39 block 117, 127 Uterine inversion 255
418
Index
V –– structures 20, 21
–– vasculature supplying 21
Vocal cord paralysis 77
Volutrauma 267
Vaporizer discrepancies 311 –– history of, postsurgical 20
W
Vascular injury 214 –– medicolegal issues 26, 27
Vascular ligation 255 –– ophthalmologic injuries
Vasopressors 145 –– anterior and posterior ischemic
Wallerian degeneration 221
Venous pressure 247 optic neuropathy 21–23
Warming mattresses 191
Venous thromboembolic events –– central retinal artery occlusion/
Wolff-Parkinson-White (WPW)
(VTE) 247 retinal vascular occlusion 23, 24
syndrome 101
Venous thrombotic event (VTE) 253 –– cortical blindness 24, 25
Wong-Baker Faces Pain Rating Scale 107
Ventilatory dysfunction 7 –– patient’s risk for 28
–– postoperative blindness, prevention
Z
Venturi effect 189
Videolaryngoscopy 71 of 25, 26
Visual loss –– after surgical procedure 373
Visual processing 20 Zygomatic arch injuries 232
–– eye anatomy

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Charles J.

ISBN 978-3-319-96124-8 ISBN 978-3-319-96125-5 (eBook)

Library of Congress Control Number: 2019930728

© Springer Nature Switzerland AG 2019

2 Postoperative Visual Loss: Anatomy, Pathogenesis,

5 Shared Airway: Techniques, Anesthesia Considerations,

6 Dental Injury: Anatomy, Pathogenesis, and Anesthesia

7 Complications of General Anesthesia............................................................................... 95

8 Pain Management......................................................................................................................... 105

9 Regional Anesthesia/MAC........................................................................................................ 121

10 Massive Perioperative Hemorrhage: Considerations

11 Cardiovascular System Damaging Events...................................................................... 151

12 Airway and Respiratory System Damaging Events................................................... 161

13 Burns in the Operating Room................................................................................................. 177

14 Eye Injury............................................................................................................................................ 197

15 Severe Peripheral Nerve Injury............................................................................................. 213

16 Catastrophic Perioperative Complications and Management

18 Catastrophic Complications in Pediatric Anesthesiology..................................... 261

19 Ambulatory and Office-Based Surgery............................................................................ 275

20 Remote Locations.......................................................................................................................... 287

21 Equipment Problems................................................................................................................... 305

22 Perioperative Medication Errors.......................................................................................... 317

23 Physiologic Monitoring: Technological Advances Improving

24 Quality of Care in Perioperative Medicine..................................................................... 339

25 Professional Liability................................................................................................................... 347

26 Medical Malpractice..................................................................................................................... 355

27 Closed Claims Project Overview........................................................................................... 371

28 Peer Review in Perioperative Medicine............................................................................ 389

29 Perioperative Complications Chapter: Shared Decision-Making

Gregory Allred, DO Jeffrey P. Cardinale, MD, PhD

Spencer Armuth, DMD, MD Tomas Carvajal, MD

R. Edward Betcher, MD, FACOG Robert Craft, MD

Steven Boggs, MD, FASA, MBA Nicholas Darensburg, MD

Andrew J. Brunk, MD Kraig S. de Lanzac, MD, FASA

Rebecca A. Moreci, BS, MA Joshua E. Dibble, DO

Ramla Farooq, MD Brendon M. Hart, DO

Farees S. Hyatali, MD Veerandra Koyyalamudi, MBBS

Usama Iqbal, MD Julia A. LeMense, JD, LLM, MPH

Andrew T. Meram, MD Jeffrey A. Planchard, MD, MBA

Mitchell H. Tsai, MD, MMM, FASA Marcus Zebrower, MD

1.1 Identifying Patients with OSA – 8

1.2 Consequences of Untreated OSA (Renal) – 12

1.3 Consequences of Untreated OSA (Endocrine) – 13

1.4 Review Questions – 13

© Springer Nature Switzerland AG 2019

.. Table 1.1 STOP-Bang questionnaire

Snoring (Do you snore loudly?) □ □

BMI (Is your body mass index >35 kg/m2?) □ □

Age (Are you older than 50 years?) □ □

Gender (Are you male?) □ □

Score 1 point for each positive response

.. Table 1.2 P-SAP questionnaire

Patient with presumptive

Optimized comorbid conditions

Not suitable for ambulatory

.. Fig. 1.1 Preoperative evaluation. (Adapted from Joshi et al. [46])

?? 4. In which patient might postoperative vv 1. B

?? 5. Which of the following makes smoking a vv 6. C

Postoperative Visual Loss:

1.1 Identifying Patients with OSA – 8

1.2 Consequences of Untreated OSA (Renal) – 12

1.3 Consequences of Untreated OSA (Endocrine) – 13

1.4 Review Questions – 13

?? 4. In which patient might postoperative vv 1. B

?? 5. Which of the following makes smoking a vv 6. C

2.1 Introduction and History of Postsurgical

2.2 Anatomy of the Eye – 20

2.3 Ophthalmologic Injuries – 21

2.4 Prevention of Postoperative Blindness – 25

2.5 Medicolegal Issues: Historic Considerations

2.7 Review Questions – 28

2.3 Ophthalmologic Injuries

3.2 Screening for Substance Use and Abuse – 32

3.4 Review Questions – 40

3.1 Introduction 3.2 creening for Substance Use

4.1 Awareness, Recall, and Dreams – 46

4.3 Risk Factors for Awareness – 46

4.4 Monitoring for Intraoperative Awareness – 52

4.5 Clinical Signs of Awareness – 52

4.6 Processed Electroencephalogram (EEG) – 52

4.7 Evoked Potential Monitoring – 53

4.8 Intraoperative Awareness and Medicolegal

4.9 Psychological Sequelae of Awareness Under

5.2 Patient Evaluation – 63

5.3 Open Airway Techniques – 64

5.4 Intubation Techniques – 69

5.7 Review Questions – 78

5.5.1 Failed Intubation

5.6.2 Pre-tracheal Auscultation

6.3 Risk Factors – 86

6.5 Dental Injury – 91

6.7 Medical Legal Implications – 92

6.9 Review Questions – 93