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Surgery_Schwartz_13202 | Surgery_Schwartz | women man-dates careful consideration of the impact of any breast surgery on cancer screening, diagnosis, and treatment. Preoperative breast cancer screening consistent with current American Can-cer Society guidelines should be performed for all patients undergoing elective breast reshaping surgery. After breast augmentation surgery, routine screening mammograms are no longer considered adequate. Patients with breast implants must have diagnostic mammograms where a radiologist studies the images at the time of the study to ensure they completely visual-ize the breast tissue.Gynecomastia is a condition of excess breast tissue in males. It can be caused by a wide range of medical disorders, including liver dysfunction, endocrine abnormalities, genetic syndromes (e.g., Klinefelter’s syndrome), renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast | Surgery_Schwartz. women man-dates careful consideration of the impact of any breast surgery on cancer screening, diagnosis, and treatment. Preoperative breast cancer screening consistent with current American Can-cer Society guidelines should be performed for all patients undergoing elective breast reshaping surgery. After breast augmentation surgery, routine screening mammograms are no longer considered adequate. Patients with breast implants must have diagnostic mammograms where a radiologist studies the images at the time of the study to ensure they completely visual-ize the breast tissue.Gynecomastia is a condition of excess breast tissue in males. It can be caused by a wide range of medical disorders, including liver dysfunction, endocrine abnormalities, genetic syndromes (e.g., Klinefelter’s syndrome), renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast |
Surgery_Schwartz_13203 | Surgery_Schwartz | renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast enlargement include marijuana use, digoxin, spironolactone, cimetidine, the-ophylline, diazepam, and reserpine. Although all of these pos-sible causes must be considered in any patient presenting with gynecomastia, the majority of patients have idiopathic enlarge-ment of the breast parenchyma, often occurring in teenagers. Surgical correction of this condition as often indicated.Aesthetic Surgery of the BodyAesthetic surgery may be applied to the torso and extremities. The most common circumstance is following massive weight loss, typically as a result of bariatric surgery. Morbid obesity stretches the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour | Surgery_Schwartz. renal disease, tes-ticular tumors, adrenal or pituitary adenomas, secreting lung carcinomas, and male breast cancer. Pharmacologic agents associated with the potential side effect of breast enlargement include marijuana use, digoxin, spironolactone, cimetidine, the-ophylline, diazepam, and reserpine. Although all of these pos-sible causes must be considered in any patient presenting with gynecomastia, the majority of patients have idiopathic enlarge-ment of the breast parenchyma, often occurring in teenagers. Surgical correction of this condition as often indicated.Aesthetic Surgery of the BodyAesthetic surgery may be applied to the torso and extremities. The most common circumstance is following massive weight loss, typically as a result of bariatric surgery. Morbid obesity stretches the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour |
Surgery_Schwartz_13204 | Surgery_Schwartz | the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour deformities. Improvement can be achieved only through skin excision. Therefore, all body-contouring surgery Brunicardi_Ch45_p1967-p2026.indd 201801/03/19 6:31 PM 2019PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ANaso-frontal angleNaso-labial angleTip-columellar angleLower lateral cartilageUpper lateral cartilageBCFigure 45-68. A. Rhinoplasty anatomy. B. Preoperative appear-ance. C. Postoperative appearance.Brunicardi_Ch45_p1967-p2026.indd 201901/03/19 6:31 PM 2020SPECIFIC CONSIDERATIONSPART IIFigure 45-69. Inferior pedicle reduction mammaplasty.De-epithelializedareaExcised arearepresents a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the | Surgery_Schwartz. the skin and supporting ligaments that tether it to the underlying fascial framework. Decreasing the amount of sub-cutaneous fat often results in significant skin laxity that creates body contour deformities. Improvement can be achieved only through skin excision. Therefore, all body-contouring surgery Brunicardi_Ch45_p1967-p2026.indd 201801/03/19 6:31 PM 2019PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ANaso-frontal angleNaso-labial angleTip-columellar angleLower lateral cartilageUpper lateral cartilageBCFigure 45-68. A. Rhinoplasty anatomy. B. Preoperative appear-ance. C. Postoperative appearance.Brunicardi_Ch45_p1967-p2026.indd 201901/03/19 6:31 PM 2020SPECIFIC CONSIDERATIONSPART IIFigure 45-69. Inferior pedicle reduction mammaplasty.De-epithelializedareaExcised arearepresents a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the |
Surgery_Schwartz_13205 | Surgery_Schwartz | a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the procedures. With the increased number of bar-iatric surgery procedures over the past decade, body-contouring surgery has become very popular and is emerging as a new sub-specialty of plastic surgery.Excess skin and subcutaneous tissue on the anterior abdominal wall creates a redundancy that can hang over the pubic area called an abdominal wall pannus. It can cause dif-ficulty dressing and maintaining proper personal hygiene. A panniculectomy is a procedure that removes the redundant skin and subcutaneous tissue of the pannus. If additional contouring of the abdominal wall is performed, the procedure is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires | Surgery_Schwartz. a trade of excess skin for scar, and this must be emphasized during patient consultation. The patient willing to accept scars in exchange for improved contour is likely to be satisfied with the procedures. With the increased number of bar-iatric surgery procedures over the past decade, body-contouring surgery has become very popular and is emerging as a new sub-specialty of plastic surgery.Excess skin and subcutaneous tissue on the anterior abdominal wall creates a redundancy that can hang over the pubic area called an abdominal wall pannus. It can cause dif-ficulty dressing and maintaining proper personal hygiene. A panniculectomy is a procedure that removes the redundant skin and subcutaneous tissue of the pannus. If additional contouring of the abdominal wall is performed, the procedure is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires |
Surgery_Schwartz_13206 | Surgery_Schwartz | is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires tightening of the underlying abdominal wall by suturing the midline and transposing the umbilicus as the upper abdominal skin is advanced inferiorly. At times additional skin must be excised transversely, requiring a concurrent vertical incision to remove skin in two vectors (Fig. 45-71). Possible complications include skin necrosis, persistent paresthesias of the abdominal wall, seroma, and wound separation. Necrosis of the umbili-cus may complicate preservation of that structure if the stalk is excessively long or an umbilical hernia is repaired. Adding a Brunicardi_Ch45_p1967-p2026.indd 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis | Surgery_Schwartz. is known as abdominoplasty. During this procedure, not only is the pannus excised but the maximum amount of skin is excised to tighten the abdominal wall. Optimum contouring typically requires tightening of the underlying abdominal wall by suturing the midline and transposing the umbilicus as the upper abdominal skin is advanced inferiorly. At times additional skin must be excised transversely, requiring a concurrent vertical incision to remove skin in two vectors (Fig. 45-71). Possible complications include skin necrosis, persistent paresthesias of the abdominal wall, seroma, and wound separation. Necrosis of the umbili-cus may complicate preservation of that structure if the stalk is excessively long or an umbilical hernia is repaired. Adding a Brunicardi_Ch45_p1967-p2026.indd 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis |
Surgery_Schwartz_13207 | Surgery_Schwartz | 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis majormusclevertical resection increases the incidence of skin necrosis, espe-cially at the confluence of scars in the lower abdomen.Brachioplasty, or arm lift, excises excess skin and subcu-taneous tissue from the arms. It results in improved contour but leaves a visible longitudinal scar on the medial aspect of the arm. Therefore, it is reserved for patients with excessive skin in that region. The patient willing to accept the scar can be happy with the results. Complications include distal seroma and wound separation. Paresthesias in the upper arm and forearm may occur secondary to injury of sensory nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh | Surgery_Schwartz. 202001/03/19 6:32 PM 2021PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-70. Placement of breast implant. A. Subglandular. B. Subpectoral.Figure 45-69. (Continued)ImplantBAPectoralis majormusclevertical resection increases the incidence of skin necrosis, espe-cially at the confluence of scars in the lower abdomen.Brachioplasty, or arm lift, excises excess skin and subcu-taneous tissue from the arms. It results in improved contour but leaves a visible longitudinal scar on the medial aspect of the arm. Therefore, it is reserved for patients with excessive skin in that region. The patient willing to accept the scar can be happy with the results. Complications include distal seroma and wound separation. Paresthesias in the upper arm and forearm may occur secondary to injury of sensory nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh |
Surgery_Schwartz_13208 | Surgery_Schwartz | nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh and buttock lifts treat loose skin on the thighs and buttocks. A variety of methods have been described, and applica-tion requires proper patient selection in order to obtain the best outcome. The lateral thighs can be lifted simultaneously during abdominoplasty with one scar along the belt line. If the lift is continued on the posterior torso, a buttocks lift can be performed as well. This procedure is referred to as a circumferential lower body lift. Contouring the medial thighs typically requires an inci-sion in the groin crease. Firmly anchoring the deep thigh fascia to Colles’ fascia is essential to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound | Surgery_Schwartz. nerves passing through the resec-tion area, though this rarely affects function. Incisions that cross the axilla must be designed to avoid axillary contractures that limit shoulder mobility.Thigh and buttock lifts treat loose skin on the thighs and buttocks. A variety of methods have been described, and applica-tion requires proper patient selection in order to obtain the best outcome. The lateral thighs can be lifted simultaneously during abdominoplasty with one scar along the belt line. If the lift is continued on the posterior torso, a buttocks lift can be performed as well. This procedure is referred to as a circumferential lower body lift. Contouring the medial thighs typically requires an inci-sion in the groin crease. Firmly anchoring the deep thigh fascia to Colles’ fascia is essential to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound |
Surgery_Schwartz_13209 | Surgery_Schwartz | to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound separation, skin necrosis, and change in the shape of the genital region (with possible sexual dysfunction).Brunicardi_Ch45_p1967-p2026.indd 202101/03/19 6:32 PM 2022SPECIFIC CONSIDERATIONSPART IIABFigure 45-71. A. Preoperative photo of 35-year-old woman after gastric bypass and massive weight loss. B. Patient 12 months after a fleurde-lis abdominoplasty.Suction LipectomyLiposuction is a technique that involves the removal of adipose tissue through minimal incisions using a hollow suction can-nula system. The key consideration in determining acceptable candidates for this body contouring technique directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin | Surgery_Schwartz. to help prevent spreading of the labia. In cases of severe excess skin on the inner thighs, a long verti-cal incision is necessary. Complications of thigh and buttock lift include seroma, wound separation, skin necrosis, and change in the shape of the genital region (with possible sexual dysfunction).Brunicardi_Ch45_p1967-p2026.indd 202101/03/19 6:32 PM 2022SPECIFIC CONSIDERATIONSPART IIABFigure 45-71. A. Preoperative photo of 35-year-old woman after gastric bypass and massive weight loss. B. Patient 12 months after a fleurde-lis abdominoplasty.Suction LipectomyLiposuction is a technique that involves the removal of adipose tissue through minimal incisions using a hollow suction can-nula system. The key consideration in determining acceptable candidates for this body contouring technique directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin |
Surgery_Schwartz_13210 | Surgery_Schwartz | directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin tone is a vital part of the preoperative patient evaluation. If there is excessive skin laxity in the body area to be treated, it may worsen after liposuction and contribute to contour irregularities, voids, and abnormal appearance.This technique can be highly effective in the correctly chosen patient as the access port sites provide minimally vis-ible scars and can remove significant amounts of fatty tissue to improve contour. However, it is worth mentioning that liposuc-tion is not considered a weight-loss treatment; rather, it is a tool for addressing unwanted and troublesome adipose depots. Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction | Surgery_Schwartz. directly relies on the patient’s inherent skin elasticity, which provides the sought-after retraction of skin over the lipoaspirated adipose depot to improve area contour. Thus, assessment of skin tone is a vital part of the preoperative patient evaluation. If there is excessive skin laxity in the body area to be treated, it may worsen after liposuction and contribute to contour irregularities, voids, and abnormal appearance.This technique can be highly effective in the correctly chosen patient as the access port sites provide minimally vis-ible scars and can remove significant amounts of fatty tissue to improve contour. However, it is worth mentioning that liposuc-tion is not considered a weight-loss treatment; rather, it is a tool for addressing unwanted and troublesome adipose depots. Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction |
Surgery_Schwartz_13211 | Surgery_Schwartz | Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction cannula system removes adipose tissue by avulsing fat into the small holes located within the cannula tip. As the cannula is repeatedly passed throughout the adipose planes to remove the fat, one can often visualize and feel the reduction in the fat depot area treated. In general, larger-diameter cannulas remove adi-pose tissue at a faster rate yet carry a higher risk of causing contour irregularities such as grooving and/or uneven removal of fat. Newer liposuction technologies employing ultrasonic or laser probes to heat and emulsify fat via cavitation before suc-tion are gaining increasing application because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat | Surgery_Schwartz. Typi-cally, the best candidates for liposuction are individuals who are close to their goal weight and have focal adipose deposits that are resistant to diet and exercise (Fig. 45-72). The suction cannula system removes adipose tissue by avulsing fat into the small holes located within the cannula tip. As the cannula is repeatedly passed throughout the adipose planes to remove the fat, one can often visualize and feel the reduction in the fat depot area treated. In general, larger-diameter cannulas remove adi-pose tissue at a faster rate yet carry a higher risk of causing contour irregularities such as grooving and/or uneven removal of fat. Newer liposuction technologies employing ultrasonic or laser probes to heat and emulsify fat via cavitation before suc-tion are gaining increasing application because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat |
Surgery_Schwartz_13212 | Surgery_Schwartz | because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat of the cannula and can cause burn injury to skin and underlying structures.A major advance in the field of liposuction involves appli-cation of tumescent local anesthesia. This method involves the infiltration of very dilute lidocaine and epinephrine (lidocaine 0.05% and epinephrine 1:1,000,000) in large volumes through-out the subcutaneous tissues prior to suction removal of fatty tissue. Tumescent volumes can range from one to three times the anticipated aspirate volume. The dilute lidocaine provides sufficient anesthesia to allow the liposuction to be performed without additional agents in some instances. However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent | Surgery_Schwartz. because they also aid in better tightening of the overlying skin envelope. However, use of these technologies also increases the chance and incidence of tissue damage and injury from the heat of the cannula and can cause burn injury to skin and underlying structures.A major advance in the field of liposuction involves appli-cation of tumescent local anesthesia. This method involves the infiltration of very dilute lidocaine and epinephrine (lidocaine 0.05% and epinephrine 1:1,000,000) in large volumes through-out the subcutaneous tissues prior to suction removal of fatty tissue. Tumescent volumes can range from one to three times the anticipated aspirate volume. The dilute lidocaine provides sufficient anesthesia to allow the liposuction to be performed without additional agents in some instances. However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent |
Surgery_Schwartz_13213 | Surgery_Schwartz | However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent anesthesia, the absorption of the dilute lidocaine from the subcutaneous tissue is very slow, with peak plasma concentrations occurring approx-imately 10 hours after the procedure. Therefore, the standard lidocaine dosing limit of 7 mg/kg may be safely exceeded. Cur-rent recommendations suggest a limit of 35 mg/kg of lidocaine with tumescent anesthesia. A very important component of the tumescent anesthetic solution is diluted epinephrine, which has proved to limit blood loss during the procedure.Safety issues are paramount for liposuction because of potential fluid shifts postoperatively and hypothermia. If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and | Surgery_Schwartz. However, in cases where large volumes of fat are to be removed or in cases where multiple sites are to be addressed, then sedation and/or general anesthesia is often preferred. With tumescent anesthesia, the absorption of the dilute lidocaine from the subcutaneous tissue is very slow, with peak plasma concentrations occurring approx-imately 10 hours after the procedure. Therefore, the standard lidocaine dosing limit of 7 mg/kg may be safely exceeded. Cur-rent recommendations suggest a limit of 35 mg/kg of lidocaine with tumescent anesthesia. A very important component of the tumescent anesthetic solution is diluted epinephrine, which has proved to limit blood loss during the procedure.Safety issues are paramount for liposuction because of potential fluid shifts postoperatively and hypothermia. If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and |
Surgery_Schwartz_13214 | Surgery_Schwartz | If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and B. Preoperative photos of a 22-year-old woman with focal adipose deposits on the trunk and extremities. C. Patient 3 months after surgery.Brunicardi_Ch45_p1967-p2026.indd 202301/03/19 6:32 PM 2024SPECIFIC CONSIDERATIONSPART IIperformed in an accredited acute care hospital facility. After the procedure, vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff familiar with perioperative care of the liposuction patient.Autologous Fat GraftingThe concept of reinjecting fat tissue harvested by liposuction has been put into practice for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by | Surgery_Schwartz. If ≥5000 mL of aspirate is to be removed, the procedure should be Brunicardi_Ch45_p1967-p2026.indd 202201/03/19 6:32 PM 2023PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45ABCFigure 45-72. A and B. Preoperative photos of a 22-year-old woman with focal adipose deposits on the trunk and extremities. C. Patient 3 months after surgery.Brunicardi_Ch45_p1967-p2026.indd 202301/03/19 6:32 PM 2024SPECIFIC CONSIDERATIONSPART IIperformed in an accredited acute care hospital facility. After the procedure, vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff familiar with perioperative care of the liposuction patient.Autologous Fat GraftingThe concept of reinjecting fat tissue harvested by liposuction has been put into practice for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by |
Surgery_Schwartz_13215 | Surgery_Schwartz | for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by centrifugation and/or filtering. Ideally, the prepared adipose grafts are then injected into the tissues using specially designed blunt-tipped cannulas that provide for micro-graft injection. Small aliquots of fat grafts are injected with each cannula pass to deposit the grafts within the vascularized tissues of the recipient bed. Autologous fat grafting has gained increased interest and has been applied to various areas of aesthetic and reconstructive surgery. Specific applications include fat grafting to augment areas where fat atrophy is commonplace (aging of the face or hands), to enhance breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital | Surgery_Schwartz. for decades. Key to the technique is a pro-cessing step in which the sterilely collected fat is separated from the aqueous (primarily tumescent fluid) and free lipid fractions. This can be done by centrifugation and/or filtering. Ideally, the prepared adipose grafts are then injected into the tissues using specially designed blunt-tipped cannulas that provide for micro-graft injection. Small aliquots of fat grafts are injected with each cannula pass to deposit the grafts within the vascularized tissues of the recipient bed. Autologous fat grafting has gained increased interest and has been applied to various areas of aesthetic and reconstructive surgery. Specific applications include fat grafting to augment areas where fat atrophy is commonplace (aging of the face or hands), to enhance breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital |
Surgery_Schwartz_13216 | Surgery_Schwartz | breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital processes.REFERENCESEntries highlighted in bright blue are key references. 1. Martin, Andrew J. (2005-07-27). “Academy Papyrus to be Exhibited at the Metropolitan Museum of Art” (Press release). The New York Academy of Medicine. Archived from the origi-nal on November 27, 2010. 2. Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plast Surg. 1962;15:242-254. 3. Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104:208-214. 4. Staylor A. Wound care devices: growth amid uncertainty. Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who | Surgery_Schwartz. breast aesthetics and/or other breast reconstruction techniques, gluteal augmentation, or to address contour deformities or irregularities caused by iatrogenic, trau-matic, oncologic, or congenital processes.REFERENCESEntries highlighted in bright blue are key references. 1. Martin, Andrew J. (2005-07-27). “Academy Papyrus to be Exhibited at the Metropolitan Museum of Art” (Press release). The New York Academy of Medicine. Archived from the origi-nal on November 27, 2010. 2. Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plast Surg. 1962;15:242-254. 3. Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104:208-214. 4. Staylor A. Wound care devices: growth amid uncertainty. Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who |
Surgery_Schwartz_13217 | Surgery_Schwartz | Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who studied skin grafting in animals. Baronio’s work represents the first preclinical animal study of a surgical procedure. The logo of the most important professional organization dedicated to plastic surgery research, the Plastic Surgery Research Council, is based on Baronio’s illustration of a sheep with multiple grafted areas of skin on the back. 6. Singh M, Nuutila K, Kruse C, Robson MC, Caterson E, Eriksson E. Challenging the conventional therapy: emerging skin graft techniques for wound healing. Plast Reconstruct Surg. 2015;136(4):524e-530e. 7. Sinha S, Schreiner AJ, Biernaskie J, Nickerson D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical | Surgery_Schwartz. Med Tech Insight. 2009;11(1):32-47. 5. Baronio G. On Grafting in Animals. Boston: Boston Medical Library; 1985. This is a modern publication of the classic 18th century work by Guiseppi Baronio who studied skin grafting in animals. Baronio’s work represents the first preclinical animal study of a surgical procedure. The logo of the most important professional organization dedicated to plastic surgery research, the Plastic Surgery Research Council, is based on Baronio’s illustration of a sheep with multiple grafted areas of skin on the back. 6. Singh M, Nuutila K, Kruse C, Robson MC, Caterson E, Eriksson E. Challenging the conventional therapy: emerging skin graft techniques for wound healing. Plast Reconstruct Surg. 2015;136(4):524e-530e. 7. Sinha S, Schreiner AJ, Biernaskie J, Nickerson D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical |
Surgery_Schwartz_13218 | Surgery_Schwartz | D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical manage-ment of the burn wound and use of skin substitutes: an expert panel white paper. J Burn Care Res. 2013;34(2):e60-e79. A variety of skin substitutes are available for repairing areas of skin loss from injuries such as deep partial-thickness or full-thickness burns. This article provides a nice summary of con-temporary options. 9. Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013;70(1):23-29. 10. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann | Surgery_Schwartz. D, Gabriel VA. Treating pain on skin graft donor sites: review and clini-cal recommendations. J Trauma Acute Care Surg. 2017;83(5): 954-964. 8. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical manage-ment of the burn wound and use of skin substitutes: an expert panel white paper. J Burn Care Res. 2013;34(2):e60-e79. A variety of skin substitutes are available for repairing areas of skin loss from injuries such as deep partial-thickness or full-thickness burns. This article provides a nice summary of con-temporary options. 9. Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013;70(1):23-29. 10. Maciel-Miranda A, Morris SF, Hallock GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann |
Surgery_Schwartz_13219 | Surgery_Schwartz | including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann Plast Surg. 1991;27(6):509-516; discussion 517-518. 12. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plastic Surg. 1973;26(3):202-213. 13. Rajabi A, Dolovich AT, Johnston JD. From the rhombic transpo-sition flap toward Z-plasty: an optimized design using the finite element method. J Biomech. 2015;48(13):3672-3678. 14. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg. 1971;24(2):174-183. 16. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evo-lution, classification, and applications. Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI, | Surgery_Schwartz. including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstruct Surg. 2013;131(6): 896e-911e. 11. Kunert P. Structure and construction: the system of skin flaps. Ann Plast Surg. 1991;27(6):509-516; discussion 517-518. 12. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plastic Surg. 1973;26(3):202-213. 13. Rajabi A, Dolovich AT, Johnston JD. From the rhombic transpo-sition flap toward Z-plasty: an optimized design using the finite element method. J Biomech. 2015;48(13):3672-3678. 14. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg. 1971;24(2):174-183. 16. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evo-lution, classification, and applications. Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI, |
Surgery_Schwartz_13220 | Surgery_Schwartz | Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-141. This is the classic article studying blood supply to the skin that introduced the angiosome concept and transformed our under-standing of the anatomic basis of surgical flap design. The blood supply was shown to be a continuous three-dimensional network of vessels in all tissue layers. The anatomical territory of a source artery corresponded in both the skin and deep tissues and gave rise to the angiosome concept. 19. Buchanan PJ, Kung TA, Cederna PS. Evidence-based medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale | Surgery_Schwartz. Ann Plast Surg. 2003;50(1):90-99. 17. Sinna R, Boloorchi A, Mahajan AL, Qassemyar Q, Robbe M. What should define a “perforator flap”? Plast Reconstr Surg. 2010;126(6):2258-2263. 18. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-141. This is the classic article studying blood supply to the skin that introduced the angiosome concept and transformed our under-standing of the anatomic basis of surgical flap design. The blood supply was shown to be a continuous three-dimensional network of vessels in all tissue layers. The anatomical territory of a source artery corresponded in both the skin and deep tissues and gave rise to the angiosome concept. 19. Buchanan PJ, Kung TA, Cederna PS. Evidence-based medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale |
Surgery_Schwartz_13221 | Surgery_Schwartz | medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale for vari-ous wound care methods, including dressings, negative pressure wound therapy, skin and dermal substitutes, and tissue expan-sion. This is basic knowledge that is important for all surgeons to understand. 20. Whitaker LA, Pashayan H, Reichman J. A proposed new classification of craniofacial anomalies. Cleft Palate J. 1981;18(3):161-176. 21. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip and nasal deformity. Plast Reconstr Surg. 2013;132(6): 1040e-1053e. 22. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & | Surgery_Schwartz. medicine: wound closure. Plast Reconstr Surg. 2014;134(6):1391-1404. This is an excellent summary of the basic principles of wound healing. It explains the physiologic basis and rationale for vari-ous wound care methods, including dressings, negative pressure wound therapy, skin and dermal substitutes, and tissue expan-sion. This is basic knowledge that is important for all surgeons to understand. 20. Whitaker LA, Pashayan H, Reichman J. A proposed new classification of craniofacial anomalies. Cleft Palate J. 1981;18(3):161-176. 21. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip and nasal deformity. Plast Reconstr Surg. 2013;132(6): 1040e-1053e. 22. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & |
Surgery_Schwartz_13222 | Surgery_Schwartz | Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016: 453-478. 24. van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg. 2008; 121(1 suppl):1-14. 25. Garfinkle JS, Grayson BH. Nasoalveolar molding and columella elongation in preparation for the primary repair of unilateral and bilateral cleft lip and palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadel-phia: Elsevier; 2013:1223-1251. 26. Kirschner REA, Losee JE. Lip adhesion. In: Losee J, Kirschner RE, eds. Comprehensive Cleft Care. Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial, | Surgery_Schwartz. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 23. Hoffman WY, Fisher DM. Unilateral cleft lip repair. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016: 453-478. 24. van Aalst JA, Kolappa KK, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate. Plast Reconstr Surg. 2008; 121(1 suppl):1-14. 25. Garfinkle JS, Grayson BH. Nasoalveolar molding and columella elongation in preparation for the primary repair of unilateral and bilateral cleft lip and palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadel-phia: Elsevier; 2013:1223-1251. 26. Kirschner REA, Losee JE. Lip adhesion. In: Losee J, Kirschner RE, eds. Comprehensive Cleft Care. Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial, |
Surgery_Schwartz_13223 | Surgery_Schwartz | Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadelphia: Elsevier; 2013:568-583.Brunicardi_Ch45_p1967-p2026.indd 202401/03/19 6:32 PM 2025PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45 28. Moe KS, Murr AH, Wester ST. Orbital Fractures. Facial Plast Surg Clin North Am. 2018 May;26(2):237-251. doi: 10.1016/j.fsc.2017.12.007. Review. PubMed PMID: 29636153. 29. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 30. Patel PK, Kawamoto HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical | Surgery_Schwartz. Boca Raton, FL: CRC Press; 2016:781-792. This is the definitive textbook on pediatric plastic surgery that covers each aspect in depth. 27. Hoffman WY. Cleft palate. In: Losee JE, ed. Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery. Philadelphia: Elsevier; 2013:568-583.Brunicardi_Ch45_p1967-p2026.indd 202401/03/19 6:32 PM 2025PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45 28. Moe KS, Murr AH, Wester ST. Orbital Fractures. Facial Plast Surg Clin North Am. 2018 May;26(2):237-251. doi: 10.1016/j.fsc.2017.12.007. Review. PubMed PMID: 29636153. 29. Fattah AY. Craniofacial syndromes: genetics, embryology, and clinical relevance. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:393-452. 30. Patel PK, Kawamoto HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical |
Surgery_Schwartz_13224 | Surgery_Schwartz | HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg. 1976;4(2):69-92. 32. Monasterio FO, Taylor JA. Major craniofacial clefts: case series and treatment philosophy. Plast Reconstr Surg. 2008;122(2):534-543. 33. Forrest CR, Nguyen PD, Smith DM. Craniosynostosis. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pedi-atric Plastic Surgery. Boca Raton: CRC Press; 2016:595-647. 34. Fearon JA. Evidence-based medicine: craniosynostosis. Plast Reconstr Surg. 2014;133(5):1261-1275. 35. Persing JA. MOC-PS(SM) CME article: management consider-ations in the treatment of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti | Surgery_Schwartz. HK, Jr. Atypical craniofacial clefts. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Prac-tice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:663-723. 31. Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg. 1976;4(2):69-92. 32. Monasterio FO, Taylor JA. Major craniofacial clefts: case series and treatment philosophy. Plast Reconstr Surg. 2008;122(2):534-543. 33. Forrest CR, Nguyen PD, Smith DM. Craniosynostosis. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pedi-atric Plastic Surgery. Boca Raton: CRC Press; 2016:595-647. 34. Fearon JA. Evidence-based medicine: craniosynostosis. Plast Reconstr Surg. 2014;133(5):1261-1275. 35. Persing JA. MOC-PS(SM) CME article: management consider-ations in the treatment of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti |
Surgery_Schwartz_13225 | Surgery_Schwartz | of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morphological resto-ration of hemifacial progressive atrophy. Plast Reconstr Surg. 2005;116(3):699-711. 38. Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunning-ham ML. Robin sequence: from diagnosis to development of an effective management plan. Pediatrics. 2011;127(5):936-948. 39. Kirschner RE, Low DW, Randall P, et al. Surgical airway man-agement in Pierre Robin sequence: is there a role for tongue-lip adhesion? Cleft Palate Craniofac J. 2003;40(1):13-18. 40. Overdiek A, Feifel H, Schaper J, Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous | Surgery_Schwartz. of craniosynostosis. Plast Reconstr Surg. 2008;121(4 suppl):1-11. 36. Taylor JA, Bartlett SP. What’s new in syndromic craniosynosto-sis surgery? Plast Reconstr Surg. 2017;140(1):82e-93e. 37. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morphological resto-ration of hemifacial progressive atrophy. Plast Reconstr Surg. 2005;116(3):699-711. 38. Evans KN, Sie KC, Hopper RA, Glass RP, Hing AV, Cunning-ham ML. Robin sequence: from diagnosis to development of an effective management plan. Pediatrics. 2011;127(5):936-948. 39. Kirschner RE, Low DW, Randall P, et al. Surgical airway man-agement in Pierre Robin sequence: is there a role for tongue-lip adhesion? Cleft Palate Craniofac J. 2003;40(1):13-18. 40. Overdiek A, Feifel H, Schaper J, Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous |
Surgery_Schwartz_13226 | Surgery_Schwartz | Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous dyspla-sia. Oral Maxillofac Surg Clin North Am. 2012;24(3):427-441. 42. Mulliken JB, Glowacki J. Hemangiomas and vascular malfor-mations in infants and children: a classification based on endo-thelial characteristics. Plast Reconstr Surg. 1982;69(3):412-422. 43. Greene AK, Phillips JH. Vascular anomalies. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:199-230. 44. Biswas A, Pan X, Meyer M, et al. Urinary excretion of microRNA-126 is a biomarker for hemangioma proliferation. Plast Reconstr Surg. 2017;139(6):1277e-1284e. 45. Iacobas I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5): | Surgery_Schwartz. Mayatepek E, Rosenbaum T. Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. Brain Dev. 2006;28(5):275-280. 41. Ricalde P, Magliocca KR, Lee JS. Craniofacial fibrous dyspla-sia. Oral Maxillofac Surg Clin North Am. 2012;24(3):427-441. 42. Mulliken JB, Glowacki J. Hemangiomas and vascular malfor-mations in infants and children: a classification based on endo-thelial characteristics. Plast Reconstr Surg. 1982;69(3):412-422. 43. Greene AK, Phillips JH. Vascular anomalies. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:199-230. 44. Biswas A, Pan X, Meyer M, et al. Urinary excretion of microRNA-126 is a biomarker for hemangioma proliferation. Plast Reconstr Surg. 2017;139(6):1277e-1284e. 45. Iacobas I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5): |
Surgery_Schwartz_13227 | Surgery_Schwartz | I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5): 795-801.e1-e7. 46. Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction. Breast. 2005 Apr;14(2):118-30. Review. PubMed PMID: 15767181. 47. Nicholas Zdenkowski, Butow P, Tesson S, Boyle F. A system-atic review of decision aids for patients making a decision about treatment for early breast cancer. Breast. 2016 Apr;26:31-45. doi: 10.1016/j.breast.2015.12.007. Epub 2016 Jan 8. Review. PubMed PMID: 27017240. 48. Cho BC, McCready DR. Oncologic principles in breast recon-struction. Clin Plast Surg. 2007 Jan;34(1):1-13; abstract v. Review. PubMed PMID: 17307067. 49. Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr | Surgery_Schwartz. I, Burrows PE, Frieden IJ, et al. LUMBAR: association between cutaneous infantile hemangiomas of the lower body and regional congenital anomalies. J Pediatr. 2010;157(5): 795-801.e1-e7. 46. Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction. Breast. 2005 Apr;14(2):118-30. Review. PubMed PMID: 15767181. 47. Nicholas Zdenkowski, Butow P, Tesson S, Boyle F. A system-atic review of decision aids for patients making a decision about treatment for early breast cancer. Breast. 2016 Apr;26:31-45. doi: 10.1016/j.breast.2015.12.007. Epub 2016 Jan 8. Review. PubMed PMID: 27017240. 48. Cho BC, McCready DR. Oncologic principles in breast recon-struction. Clin Plast Surg. 2007 Jan;34(1):1-13; abstract v. Review. PubMed PMID: 17307067. 49. Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr |
Surgery_Schwartz_13228 | Surgery_Schwartz | Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr Surg. 2009;124(1 suppl):1e-13e. 51. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: review and clinical appli-cations. Plast Reconstr Surg. 2014;133(2):367-376. 52. Millard DR. Principlization of Plastic Surgery. 1st ed. Boston/Toronto: Little, Brown; 1986. 53. Corcoran J, Bauer BS. Cutaneous lesions. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:453-478. 54. Bosse MJ et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and | Surgery_Schwartz. Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and man-agement. Mayo Clin Proc. 1998;73(1):28-36. 50. Arneja JS, Gosain AK. Giant congenital melanocytic nevi. Plast Reconstr Surg. 2009;124(1 suppl):1e-13e. 51. Arad E, Zuker RM. The shifting paradigm in the management of giant congenital melanocytic nevi: review and clinical appli-cations. Plast Reconstr Surg. 2014;133(2):367-376. 52. Millard DR. Principlization of Plastic Surgery. 1st ed. Boston/Toronto: Little, Brown; 1986. 53. Corcoran J, Bauer BS. Cutaneous lesions. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles & Practice of Pediatric Plastic Surgery. Boca Raton: CRC Press; 2016:453-478. 54. Bosse MJ et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and |
Surgery_Schwartz_13229 | Surgery_Schwartz | 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38(8):879-889. 57. Cho EH, Shammas RL, Carney MJ, et al. Muscle versus fascio-cutaneous free flaps in lower extremity traumatic reconstruc-tion: a multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191-199. 58. Yazar S, Lin CH, Wei FC. One-stage reconstruction of compos-ite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114(6):1457-1466. 59. Gurney JK(1), Stanley J(2), York S(3), Rosenbaum D(4), Sar-fati D(2). Risk of lower limb amputation in a national preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in | Surgery_Schwartz. 2002;347(24):1924-1931. 55. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72(2):299-304. 56. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38(8):879-889. 57. Cho EH, Shammas RL, Carney MJ, et al. Muscle versus fascio-cutaneous free flaps in lower extremity traumatic reconstruc-tion: a multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191-199. 58. Yazar S, Lin CH, Wei FC. One-stage reconstruction of compos-ite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114(6):1457-1466. 59. Gurney JK(1), Stanley J(2), York S(3), Rosenbaum D(4), Sar-fati D(2). Risk of lower limb amputation in a national preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in |
Surgery_Schwartz_13230 | Surgery_Schwartz | preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in Deciding on Limb Salvage versus Amputation in Patients With Diabetes? Plast Reconstr Surg. 2016 Sep;138(3 Suppl):188S-95S. doi: 10.1097/PRS.0000000000002713. Review. PubMed PMID: 27556759. 61. Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: an update. Plast Reconstr Surg. 2017;140:60S-68S. Radiation therapy has an adverse effect on all forms of breast reconstruction. The need for radiation therapy affects the opti-mal timing and technique for breast reconstructive surgery. It is helpful for all surgeons caring for breast cancer patients to have an understanding of the issues involved, and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic | Surgery_Schwartz. preva-lent cohort of patients with diabetes. Diabetologia. 2018 Mar;61(3):626-635. doi: 10.1007/s00125-017-4488-8. Epub 2017 Nov 3. 60. Wukich DK, Raspovic KM. What Role Does Function Play in Deciding on Limb Salvage versus Amputation in Patients With Diabetes? Plast Reconstr Surg. 2016 Sep;138(3 Suppl):188S-95S. doi: 10.1097/PRS.0000000000002713. Review. PubMed PMID: 27556759. 61. Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: an update. Plast Reconstr Surg. 2017;140:60S-68S. Radiation therapy has an adverse effect on all forms of breast reconstruction. The need for radiation therapy affects the opti-mal timing and technique for breast reconstructive surgery. It is helpful for all surgeons caring for breast cancer patients to have an understanding of the issues involved, and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic |
Surgery_Schwartz_13231 | Surgery_Schwartz | and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic defects. Plast Reconstr Surg. 2017;140(4):601e-612e. General surgeons often encounter problems in the perineum. This article offers an excellent summary of how to manage surgical problems in this region. It provides a review of anat-omy, the types of problems encountered, and appropriate local, regional, or free-flap options based on the location of the defect and donor-site characteristics. 63. Cushing CA, Phillips LG. Evidence-based medicine: pres-sure sores. Plast Reconstr Surg. 2013;132(6):1720-1732. Pressure sores are a common problem affecting surgical patients of all types, and it is important for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment | Surgery_Schwartz. and this paper provides an excellent summary of the issues surrounding breast reconstruction and radiation therapy. 62. Weichman KE, Matros E, Disa JJ. Reconstruction of peripelvic oncologic defects. Plast Reconstr Surg. 2017;140(4):601e-612e. General surgeons often encounter problems in the perineum. This article offers an excellent summary of how to manage surgical problems in this region. It provides a review of anat-omy, the types of problems encountered, and appropriate local, regional, or free-flap options based on the location of the defect and donor-site characteristics. 63. Cushing CA, Phillips LG. Evidence-based medicine: pres-sure sores. Plast Reconstr Surg. 2013;132(6):1720-1732. Pressure sores are a common problem affecting surgical patients of all types, and it is important for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment |
Surgery_Schwartz_13232 | Surgery_Schwartz | for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment options. Most impor-tantly, it reviews steps for the prevention of pressure sores.64. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. 65. Centers for Disease Control and Prevention. 2017 National Diabetes Statistics Report, 2017. Available at: https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed January 20, 2019.Brunicardi_Ch45_p1967-p2026.indd 202501/03/19 6:32 PM 2026SPECIFIC CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist | Surgery_Schwartz. for all surgeons to understand how to prevent and treat them. This paper provides an excellent overview of the problem, with emphasis on risk factors, patho-physiology, classification, and treatment options. Most impor-tantly, it reviews steps for the prevention of pressure sores.64. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. 65. Centers for Disease Control and Prevention. 2017 National Diabetes Statistics Report, 2017. Available at: https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed January 20, 2019.Brunicardi_Ch45_p1967-p2026.indd 202501/03/19 6:32 PM 2026SPECIFIC CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist |
Surgery_Schwartz_13233 | Surgery_Schwartz | CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28(suppl 1):179-217. 68. Johnson SK, Podratz KE, Dipboye RL, Gibbons E. Physi-cal attractiveness biases in ratings of employment suitability: tracking down the “beauty is beastly” effect. J Soc Psychol. 2010;150(3):301-318. 69. Jacono A, Chastant RP, Dibelius G. Association of patient self-esteem with perceived outcome after face-lift surgery. JAMA Facial Plast Surg. 2016;18(1):42-46. 70. Schwitzer JA, Sher SR, Fan KL, Scott AM, Gamble L, Baker SB. Assessing patient-reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg. | Surgery_Schwartz. CONSIDERATIONSPART II 66. Clemens MW, Attinger CE, Colen LB. Foot reconstruction. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia: Elsevier; 2006:1403. 67. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28(suppl 1):179-217. 68. Johnson SK, Podratz KE, Dipboye RL, Gibbons E. Physi-cal attractiveness biases in ratings of employment suitability: tracking down the “beauty is beastly” effect. J Soc Psychol. 2010;150(3):301-318. 69. Jacono A, Chastant RP, Dibelius G. Association of patient self-esteem with perceived outcome after face-lift surgery. JAMA Facial Plast Surg. 2016;18(1):42-46. 70. Schwitzer JA, Sher SR, Fan KL, Scott AM, Gamble L, Baker SB. Assessing patient-reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg. |
Surgery_Schwartz_13234 | Surgery_Schwartz | SR, Fan KL, Scott AM, Gamble L, Baker SB. Assessing patient-reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg. 2015;135(5):830e-837e. 71. Papadopulos NA, Niehaus R, Keller E, et al. The psychologic and psychosocial impact of otoplasty on children and adults. J Craniofac Surg. 2015;26(8):2309-2314. 72. McGrath MH. The psychological safety of breast implant sur-gery. Plast Reconstr Surg. 2007;120(7 suppl 1):103S-109S. 73. Papadopulos NA, Staffler V, Mirceva V, et al. Does abdomino-plasty have a positive influence on quality of life, self-esteem, and emotional stability? Plast Reconstr Surg. 2012;129(6):957e-962e. 74. Shridharani SM, Magarakis M, Manson PN, Rodriguez ED. Psychology of plastic and reconstructive surgery: a systematic clinical review. Plast Reconstr Surg. 2010;126(6):2243-2251. 75. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, | Surgery_Schwartz. SR, Fan KL, Scott AM, Gamble L, Baker SB. Assessing patient-reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg. 2015;135(5):830e-837e. 71. Papadopulos NA, Niehaus R, Keller E, et al. The psychologic and psychosocial impact of otoplasty on children and adults. J Craniofac Surg. 2015;26(8):2309-2314. 72. McGrath MH. The psychological safety of breast implant sur-gery. Plast Reconstr Surg. 2007;120(7 suppl 1):103S-109S. 73. Papadopulos NA, Staffler V, Mirceva V, et al. Does abdomino-plasty have a positive influence on quality of life, self-esteem, and emotional stability? Plast Reconstr Surg. 2012;129(6):957e-962e. 74. Shridharani SM, Magarakis M, Manson PN, Rodriguez ED. Psychology of plastic and reconstructive surgery: a systematic clinical review. Plast Reconstr Surg. 2010;126(6):2243-2251. 75. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, |
Surgery_Schwartz_13235 | Surgery_Schwartz | surgery: a systematic clinical review. Plast Reconstr Surg. 2010;126(6):2243-2251. 75. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.Brunicardi_Ch45_p1967-p2026.indd 202601/03/19 6:32 PM | Surgery_Schwartz. surgery: a systematic clinical review. Plast Reconstr Surg. 2010;126(6):2243-2251. 75. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.Brunicardi_Ch45_p1967-p2026.indd 202601/03/19 6:32 PM |
Surgery_Schwartz_13236 | Surgery_Schwartz | Anesthesia for Surgical PatientsJunaid Nizamuddin and Michael O’Connor 46chapterBRIEF HISTORY OF ANESTHESIAThe discovery of anesthesia is one of the seminal American con-tributions to the world. Along with infection control and blood transfusion, anesthesia has enabled surgery to occupy its fundamental place in medicine. Before the advent of anes-thesia in the 1840s, many substances and methods had been tried in the search for pain relief and better operating conditions. Patients were typically restrained by several attendants, and only the most stoic could tolerate the screams heard in the oper-ating theater.BeginningsHorace Wells (1815–1848), a dentist, first pursued using nitrous oxide for the relief of pain in surgical procedures in 1844.1 After experimenting on himself, Wells attempted to demonstrate the analgesic effects of nitrous oxide for a dental procedure at Harvard Medical School in 1845. The public demonstration was a failure, at least partially, due to improper | Surgery_Schwartz. Anesthesia for Surgical PatientsJunaid Nizamuddin and Michael O’Connor 46chapterBRIEF HISTORY OF ANESTHESIAThe discovery of anesthesia is one of the seminal American con-tributions to the world. Along with infection control and blood transfusion, anesthesia has enabled surgery to occupy its fundamental place in medicine. Before the advent of anes-thesia in the 1840s, many substances and methods had been tried in the search for pain relief and better operating conditions. Patients were typically restrained by several attendants, and only the most stoic could tolerate the screams heard in the oper-ating theater.BeginningsHorace Wells (1815–1848), a dentist, first pursued using nitrous oxide for the relief of pain in surgical procedures in 1844.1 After experimenting on himself, Wells attempted to demonstrate the analgesic effects of nitrous oxide for a dental procedure at Harvard Medical School in 1845. The public demonstration was a failure, at least partially, due to improper |
Surgery_Schwartz_13237 | Surgery_Schwartz | attempted to demonstrate the analgesic effects of nitrous oxide for a dental procedure at Harvard Medical School in 1845. The public demonstration was a failure, at least partially, due to improper administration of the gas. Wells never recovered from his humiliating experience and eventually committed suicide. However, he does hold a place in history as the first person to recognize and use the only anesthetic from the 1800s that is still in use today—nitrous oxide.Ether DayWilliam Morton (1819–1868) was a dentist and partner of Horace Wells. After taking a course in anesthesia from Wells, Morton left the partnership in Hartford, Connecticut, and established himself in Boston. He continued his interest in anesthesia, but using diethyl ether instead of nitrous oxide. Ether proved a good choice. He practiced the administration of ether on a 11dog and then used it when extracting teeth from patients in his office. On October 16, 1846, Morton gave the first pub-lic demonstration of ether | Surgery_Schwartz. attempted to demonstrate the analgesic effects of nitrous oxide for a dental procedure at Harvard Medical School in 1845. The public demonstration was a failure, at least partially, due to improper administration of the gas. Wells never recovered from his humiliating experience and eventually committed suicide. However, he does hold a place in history as the first person to recognize and use the only anesthetic from the 1800s that is still in use today—nitrous oxide.Ether DayWilliam Morton (1819–1868) was a dentist and partner of Horace Wells. After taking a course in anesthesia from Wells, Morton left the partnership in Hartford, Connecticut, and established himself in Boston. He continued his interest in anesthesia, but using diethyl ether instead of nitrous oxide. Ether proved a good choice. He practiced the administration of ether on a 11dog and then used it when extracting teeth from patients in his office. On October 16, 1846, Morton gave the first pub-lic demonstration of ether |
Surgery_Schwartz_13238 | Surgery_Schwartz | He practiced the administration of ether on a 11dog and then used it when extracting teeth from patients in his office. On October 16, 1846, Morton gave the first pub-lic demonstration of ether as an anesthetic for Johns Collins Warren, a distinguished surgeon and one of the founders of Massachusetts General Hospital. In attendance in the surgi-cal amphitheater were several surgeons, medical students, and a newspaper reporter. After induction of anesthesia, Warren successfully removed a vascular mass from the patient’s neck with no ill effects (Fig. 46-1). The description of this public demonstration of ether was published in the Boston Medical and Surgical Journal (now The New England Journal of Medicine).2 The stature of Warren lent considerable credence to the advent of surgical anesthesia. The news spread rapidly, and surgeons around the world were quick to adopt this new invention. Massachusetts General Hospital has restored and preserved the original amphi-theater where the | Surgery_Schwartz. He practiced the administration of ether on a 11dog and then used it when extracting teeth from patients in his office. On October 16, 1846, Morton gave the first pub-lic demonstration of ether as an anesthetic for Johns Collins Warren, a distinguished surgeon and one of the founders of Massachusetts General Hospital. In attendance in the surgi-cal amphitheater were several surgeons, medical students, and a newspaper reporter. After induction of anesthesia, Warren successfully removed a vascular mass from the patient’s neck with no ill effects (Fig. 46-1). The description of this public demonstration of ether was published in the Boston Medical and Surgical Journal (now The New England Journal of Medicine).2 The stature of Warren lent considerable credence to the advent of surgical anesthesia. The news spread rapidly, and surgeons around the world were quick to adopt this new invention. Massachusetts General Hospital has restored and preserved the original amphi-theater where the |
Surgery_Schwartz_13239 | Surgery_Schwartz | The news spread rapidly, and surgeons around the world were quick to adopt this new invention. Massachusetts General Hospital has restored and preserved the original amphi-theater where the demonstration took place, now called the Ether Dome. The description of the public demonstration of ether was voted as the most important article published in the history of The New England Journal of Medicine in its first 200 years.3The Modern EraAnesthesia has developed rapidly over the past century. Inhaled anesthetics, initially discovered fortuitously by observation, have been synthetically produced and remain the mainstay of anesthetic maintenance. The advent of the hollow syringe and needle and discovery of rapidly acting of intravenous anesthet-ics allowed for rapid induction of anesthesia. Development of endotracheal intubation and mechanical ventilation revolution-ized the delivery of inhaled anesthetics. The discovery of local anesthetics led to the development of peripheral nerve blocks | Surgery_Schwartz. The news spread rapidly, and surgeons around the world were quick to adopt this new invention. Massachusetts General Hospital has restored and preserved the original amphi-theater where the demonstration took place, now called the Ether Dome. The description of the public demonstration of ether was voted as the most important article published in the history of The New England Journal of Medicine in its first 200 years.3The Modern EraAnesthesia has developed rapidly over the past century. Inhaled anesthetics, initially discovered fortuitously by observation, have been synthetically produced and remain the mainstay of anesthetic maintenance. The advent of the hollow syringe and needle and discovery of rapidly acting of intravenous anesthet-ics allowed for rapid induction of anesthesia. Development of endotracheal intubation and mechanical ventilation revolution-ized the delivery of inhaled anesthetics. The discovery of local anesthetics led to the development of peripheral nerve blocks |
Surgery_Schwartz_13240 | Surgery_Schwartz | of endotracheal intubation and mechanical ventilation revolution-ized the delivery of inhaled anesthetics. The discovery of local anesthetics led to the development of peripheral nerve blocks Brief History of Anesthesia 2027Beginnings / 2027Ether Day / 2027The Modern Era / 2027Basic Pharmacology 2028Pharmacokinetics and Pharmacodynamics / 2028Administration, Distribution, Metabolism, and Elimination / 2029Pharmacodynamics / 2029Potency, Efficacy, Lethal Dose, and Therapeutic Index / 2029Anesthetic Agents 2029Inhaled Anesthetics / 2029Local Anesthetics / 2031Neuromuscular Blockers / 2031Anesthetic Monitoring 2032Perioperative Evaluation and Preparation 2033ASA Physical Status Assessment / 2034Airway Evaluation / 2034Cardiovascular Disease / 2034Pulmonary Disease / 2035Renal Disease / 2036Hepatic Disease / 2036Endocrine Disease / 2036Preoperative Fasting / 2036Patients With Advanced Directives / 2036Risk Estimation / 2036Intraoperative Management 2036General Anesthesia / | Surgery_Schwartz. of endotracheal intubation and mechanical ventilation revolution-ized the delivery of inhaled anesthetics. The discovery of local anesthetics led to the development of peripheral nerve blocks Brief History of Anesthesia 2027Beginnings / 2027Ether Day / 2027The Modern Era / 2027Basic Pharmacology 2028Pharmacokinetics and Pharmacodynamics / 2028Administration, Distribution, Metabolism, and Elimination / 2029Pharmacodynamics / 2029Potency, Efficacy, Lethal Dose, and Therapeutic Index / 2029Anesthetic Agents 2029Inhaled Anesthetics / 2029Local Anesthetics / 2031Neuromuscular Blockers / 2031Anesthetic Monitoring 2032Perioperative Evaluation and Preparation 2033ASA Physical Status Assessment / 2034Airway Evaluation / 2034Cardiovascular Disease / 2034Pulmonary Disease / 2035Renal Disease / 2036Hepatic Disease / 2036Endocrine Disease / 2036Preoperative Fasting / 2036Patients With Advanced Directives / 2036Risk Estimation / 2036Intraoperative Management 2036General Anesthesia / |
Surgery_Schwartz_13241 | Surgery_Schwartz | / 2036Hepatic Disease / 2036Endocrine Disease / 2036Preoperative Fasting / 2036Patients With Advanced Directives / 2036Risk Estimation / 2036Intraoperative Management 2036General Anesthesia / 2036Monitored Anesthesia Care / 2039Regional Anesthesia/Acute Pain / 2039Recovery And Complications 2039The Postanesthesia Care Unit / 2039Enhanced Recovery After Surgery Pathways / 2039Acute Postoperative Pain / 2039Malignant Hyperthermia / 2040Cardiovascular Complications / 2040Respiratory Failure / 2040Neurologic and Psychiatric Complications / 2040Conclusion 2040Brunicardi_Ch46_p2027-p2044.indd 202701/03/19 11:03 AM 2028Figure 46-1. Robert Cutler Hinckley, The First Operation with Ether. (Reproduced with permission from Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Massachusetts.)Key Points1 The discovery of anesthesia was one of the most important advances and has enabled surgery to occupy its fundamental place in medicine.2 Advances in anesthetic | Surgery_Schwartz. / 2036Hepatic Disease / 2036Endocrine Disease / 2036Preoperative Fasting / 2036Patients With Advanced Directives / 2036Risk Estimation / 2036Intraoperative Management 2036General Anesthesia / 2036Monitored Anesthesia Care / 2039Regional Anesthesia/Acute Pain / 2039Recovery And Complications 2039The Postanesthesia Care Unit / 2039Enhanced Recovery After Surgery Pathways / 2039Acute Postoperative Pain / 2039Malignant Hyperthermia / 2040Cardiovascular Complications / 2040Respiratory Failure / 2040Neurologic and Psychiatric Complications / 2040Conclusion 2040Brunicardi_Ch46_p2027-p2044.indd 202701/03/19 11:03 AM 2028Figure 46-1. Robert Cutler Hinckley, The First Operation with Ether. (Reproduced with permission from Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Massachusetts.)Key Points1 The discovery of anesthesia was one of the most important advances and has enabled surgery to occupy its fundamental place in medicine.2 Advances in anesthetic |
Surgery_Schwartz_13242 | Surgery_Schwartz | Boston, Massachusetts.)Key Points1 The discovery of anesthesia was one of the most important advances and has enabled surgery to occupy its fundamental place in medicine.2 Advances in anesthetic monitoring have made the admin-istration of anesthesia safer than ever. Types of cardiovas-cular monitors include arterial catheters, central venous and pulmonary artery catheters, and transesophageal echocardiography.3 A detailed preoperative evaluation should be performed on each patient when circumstances allow, with special atten-tion devoted to functional status. The American College of Cardiology/American Heart Association guidelines for pre-operative evaluation can guide workup.4 The American Society of Anesthesiologists has developed specific guidelines for preoperative fasting to mitigate the risk of aspiration of gastric contents; individual patients may need more stringent preoperative fasting periods and/or rapid sequence inductions.5 The American Society of Anesthesiologists has | Surgery_Schwartz. Boston, Massachusetts.)Key Points1 The discovery of anesthesia was one of the most important advances and has enabled surgery to occupy its fundamental place in medicine.2 Advances in anesthetic monitoring have made the admin-istration of anesthesia safer than ever. Types of cardiovas-cular monitors include arterial catheters, central venous and pulmonary artery catheters, and transesophageal echocardiography.3 A detailed preoperative evaluation should be performed on each patient when circumstances allow, with special atten-tion devoted to functional status. The American College of Cardiology/American Heart Association guidelines for pre-operative evaluation can guide workup.4 The American Society of Anesthesiologists has developed specific guidelines for preoperative fasting to mitigate the risk of aspiration of gastric contents; individual patients may need more stringent preoperative fasting periods and/or rapid sequence inductions.5 The American Society of Anesthesiologists has |
Surgery_Schwartz_13243 | Surgery_Schwartz | the risk of aspiration of gastric contents; individual patients may need more stringent preoperative fasting periods and/or rapid sequence inductions.5 The American Society of Anesthesiologists has developed an algorithm for management of the difficult airway. Nota-bly, in patients in whom both intubation and ventilation are impossible, the algorithm calls for placement of a laryngeal mask airway as the next step.and spinal anesthesia. Concurrently, physiologic monitoring techniques have advanced to make the administration of anes-thesia safer than ever.Initially, anesthesia was given by medical students, nurses, and dentists, but eventually became a physician specialty of medicine of its own. The American Board of Anesthesiology was formed in 1938. Over the past 50 years, anesthesiology has increasingly specialized and also spread outside the operating room into critical care, pain management, and perioperative medicine.BASIC PHARMACOLOGYPharmacokinetics and | Surgery_Schwartz. the risk of aspiration of gastric contents; individual patients may need more stringent preoperative fasting periods and/or rapid sequence inductions.5 The American Society of Anesthesiologists has developed an algorithm for management of the difficult airway. Nota-bly, in patients in whom both intubation and ventilation are impossible, the algorithm calls for placement of a laryngeal mask airway as the next step.and spinal anesthesia. Concurrently, physiologic monitoring techniques have advanced to make the administration of anes-thesia safer than ever.Initially, anesthesia was given by medical students, nurses, and dentists, but eventually became a physician specialty of medicine of its own. The American Board of Anesthesiology was formed in 1938. Over the past 50 years, anesthesiology has increasingly specialized and also spread outside the operating room into critical care, pain management, and perioperative medicine.BASIC PHARMACOLOGYPharmacokinetics and |
Surgery_Schwartz_13244 | Surgery_Schwartz | 50 years, anesthesiology has increasingly specialized and also spread outside the operating room into critical care, pain management, and perioperative medicine.BASIC PHARMACOLOGYPharmacokinetics and PharmacodynamicsPharmacodynamics is the study of what a drug does to the body; pharmacokinetics is the study of what the body does to a drug. Brunicardi_Ch46_p2027-p2044.indd 202801/03/19 11:04 AM 2029ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46The conduct of anesthesia is predicated upon the pharmacody-namics and pharmacokinetics of the drugs used.4Administration, Distribution, Metabolism, and EliminationAdministration of a drug affects its pharmacokinetics, as there will be different rates of drug entry into the circulation. For example, medications administered via the oral route are subject to first-pass effect of the portal circulation; this can be bypassed with the IV, nasal, or sublingual route. Other routes of drug administration include transdermal, intramuscular, subcutaneous, | Surgery_Schwartz. 50 years, anesthesiology has increasingly specialized and also spread outside the operating room into critical care, pain management, and perioperative medicine.BASIC PHARMACOLOGYPharmacokinetics and PharmacodynamicsPharmacodynamics is the study of what a drug does to the body; pharmacokinetics is the study of what the body does to a drug. Brunicardi_Ch46_p2027-p2044.indd 202801/03/19 11:04 AM 2029ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46The conduct of anesthesia is predicated upon the pharmacody-namics and pharmacokinetics of the drugs used.4Administration, Distribution, Metabolism, and EliminationAdministration of a drug affects its pharmacokinetics, as there will be different rates of drug entry into the circulation. For example, medications administered via the oral route are subject to first-pass effect of the portal circulation; this can be bypassed with the IV, nasal, or sublingual route. Other routes of drug administration include transdermal, intramuscular, subcutaneous, |
Surgery_Schwartz_13245 | Surgery_Schwartz | to first-pass effect of the portal circulation; this can be bypassed with the IV, nasal, or sublingual route. Other routes of drug administration include transdermal, intramuscular, subcutaneous, or inhalation.Distribution is the delivery of a drug from the systemic circulation to the tissues. Once a drug has entered the systemic circulation, the rate at which it will enter the tissues depends on the blood flow into that tissue, as well as the molecular size of the drug, lipid solubility, capillary permeability, polarity, plasma protein and tissue binding, and volume of distribution, the fluid volume in which the drug distributes. The distribution or redis-tribution of drugs can play a critical role in shaping their clinical use. For instance, clinically, the effect of propofol is terminated by its redistribution into fatty tissues and not metabolism of the drug.Metabolism is the permanent breakdown of original compounds into smaller metabolites. Drug elimination varies widely; some | Surgery_Schwartz. to first-pass effect of the portal circulation; this can be bypassed with the IV, nasal, or sublingual route. Other routes of drug administration include transdermal, intramuscular, subcutaneous, or inhalation.Distribution is the delivery of a drug from the systemic circulation to the tissues. Once a drug has entered the systemic circulation, the rate at which it will enter the tissues depends on the blood flow into that tissue, as well as the molecular size of the drug, lipid solubility, capillary permeability, polarity, plasma protein and tissue binding, and volume of distribution, the fluid volume in which the drug distributes. The distribution or redis-tribution of drugs can play a critical role in shaping their clinical use. For instance, clinically, the effect of propofol is terminated by its redistribution into fatty tissues and not metabolism of the drug.Metabolism is the permanent breakdown of original compounds into smaller metabolites. Drug elimination varies widely; some |
Surgery_Schwartz_13246 | Surgery_Schwartz | by its redistribution into fatty tissues and not metabolism of the drug.Metabolism is the permanent breakdown of original compounds into smaller metabolites. Drug elimination varies widely; some drugs are excreted unchanged by the body, some decompose via plasma enzymes, and some are degraded in the liver. Many drugs rely on multiple pathways for metabolism and elimination (i.e., metabolized by liver enzymes and then excreted by the kidney).Context-sensitive half time is the time required for blood concentrations of a drug to decrease by 50% after its discontinu-ation, which is determined by the interaction of the duration of administration, distribution and accumulation, and metabolism and excretion. Fig. 46-2 illustrates the context sensitive half-time for commonly used anesthetics and opioids.4PharmacodynamicsPharmacodynamics, or how the plasma concentration of a drug translates into its effect on the body, depends on biologic vari-ability, receptor physiology, and clinical | Surgery_Schwartz. by its redistribution into fatty tissues and not metabolism of the drug.Metabolism is the permanent breakdown of original compounds into smaller metabolites. Drug elimination varies widely; some drugs are excreted unchanged by the body, some decompose via plasma enzymes, and some are degraded in the liver. Many drugs rely on multiple pathways for metabolism and elimination (i.e., metabolized by liver enzymes and then excreted by the kidney).Context-sensitive half time is the time required for blood concentrations of a drug to decrease by 50% after its discontinu-ation, which is determined by the interaction of the duration of administration, distribution and accumulation, and metabolism and excretion. Fig. 46-2 illustrates the context sensitive half-time for commonly used anesthetics and opioids.4PharmacodynamicsPharmacodynamics, or how the plasma concentration of a drug translates into its effect on the body, depends on biologic vari-ability, receptor physiology, and clinical |
Surgery_Schwartz_13247 | Surgery_Schwartz | and opioids.4PharmacodynamicsPharmacodynamics, or how the plasma concentration of a drug translates into its effect on the body, depends on biologic vari-ability, receptor physiology, and clinical evaluations of the actual drug. An agonist is a drug that causes a response (acti-vates a receptor). A full agonist produces the full receptor/tissue response, and a partial agonist elicits less than the maximum response induced by a full agonist. An antagonist is a drug that blocks agonist mediated responses. An additive effect means that a second drug acts with the first drug and will produce an effect that is equal to the algebraic summation of both drugs. A synergistic effect means that two drugs interact to produce an effect that is greater than expected from the two drugs’ alge-braic summation. Tolerance, desensitization, or tachyphylaxis occurs when a larger than expected dose is required to produce a response. Tolerance usually results from chronic drug exposure, either through | Surgery_Schwartz. and opioids.4PharmacodynamicsPharmacodynamics, or how the plasma concentration of a drug translates into its effect on the body, depends on biologic vari-ability, receptor physiology, and clinical evaluations of the actual drug. An agonist is a drug that causes a response (acti-vates a receptor). A full agonist produces the full receptor/tissue response, and a partial agonist elicits less than the maximum response induced by a full agonist. An antagonist is a drug that blocks agonist mediated responses. An additive effect means that a second drug acts with the first drug and will produce an effect that is equal to the algebraic summation of both drugs. A synergistic effect means that two drugs interact to produce an effect that is greater than expected from the two drugs’ alge-braic summation. Tolerance, desensitization, or tachyphylaxis occurs when a larger than expected dose is required to produce a response. Tolerance usually results from chronic drug exposure, either through |
Surgery_Schwartz_13248 | Surgery_Schwartz | summation. Tolerance, desensitization, or tachyphylaxis occurs when a larger than expected dose is required to produce a response. Tolerance usually results from chronic drug exposure, either through enzyme induction (e.g., alcohol) or depletion of neurotransmitters (e.g., cocaine).4Potency, Efficacy, Lethal Dose, and Therapeutic IndexThe potency of a drug is the dose required to produce a given effect, such as pain relief or a change in heart rate. The aver-age sensitivity to a particular drug can be expressed through the calculation of the effective dose; ED50 would have the desired effect in 50% of the general population. The efficacy of any therapeutic agent is its power to produce a desired effect. Two drugs may have the same efficacy but different potencies. Dose-response curves show the relationship between the dose of a drug administered (or the resulting plasma concentration) and the pharmacologic effect of the drug. The lethal dose (LD50) of a drug produces death in 50% of | Surgery_Schwartz. summation. Tolerance, desensitization, or tachyphylaxis occurs when a larger than expected dose is required to produce a response. Tolerance usually results from chronic drug exposure, either through enzyme induction (e.g., alcohol) or depletion of neurotransmitters (e.g., cocaine).4Potency, Efficacy, Lethal Dose, and Therapeutic IndexThe potency of a drug is the dose required to produce a given effect, such as pain relief or a change in heart rate. The aver-age sensitivity to a particular drug can be expressed through the calculation of the effective dose; ED50 would have the desired effect in 50% of the general population. The efficacy of any therapeutic agent is its power to produce a desired effect. Two drugs may have the same efficacy but different potencies. Dose-response curves show the relationship between the dose of a drug administered (or the resulting plasma concentration) and the pharmacologic effect of the drug. The lethal dose (LD50) of a drug produces death in 50% of |
Surgery_Schwartz_13249 | Surgery_Schwartz | the relationship between the dose of a drug administered (or the resulting plasma concentration) and the pharmacologic effect of the drug. The lethal dose (LD50) of a drug produces death in 50% of animals to which it is given, and the toxic dose (TD50) is the dose that elicits a toxicity in 50% of humans to which it is given. The ratio of the toxic dose and effective dose, TD50/ED50, is the therapeutic index. A drug with a high therapeutic index is safer than a drug with a low or narrow therapeutic index.4ANESTHETIC AGENTSInhaled AnestheticsInhaled anesthetics have greatly advanced since the original dem-onstration with ether. Modern agents provide faster induction and emergence and provide all of the major characteristics of general anesthesia: unconsciousness, analgesia, and muscle relaxation.Minimum alveolar concentration (MAC) is a measure of anesthetic potency. It is the ED50 of an inhaled agent (i.e., the dose required to prevent movement in response to skin incision in 50% of | Surgery_Schwartz. the relationship between the dose of a drug administered (or the resulting plasma concentration) and the pharmacologic effect of the drug. The lethal dose (LD50) of a drug produces death in 50% of animals to which it is given, and the toxic dose (TD50) is the dose that elicits a toxicity in 50% of humans to which it is given. The ratio of the toxic dose and effective dose, TD50/ED50, is the therapeutic index. A drug with a high therapeutic index is safer than a drug with a low or narrow therapeutic index.4ANESTHETIC AGENTSInhaled AnestheticsInhaled anesthetics have greatly advanced since the original dem-onstration with ether. Modern agents provide faster induction and emergence and provide all of the major characteristics of general anesthesia: unconsciousness, analgesia, and muscle relaxation.Minimum alveolar concentration (MAC) is a measure of anesthetic potency. It is the ED50 of an inhaled agent (i.e., the dose required to prevent movement in response to skin incision in 50% of |
Surgery_Schwartz_13250 | Surgery_Schwartz | alveolar concentration (MAC) is a measure of anesthetic potency. It is the ED50 of an inhaled agent (i.e., the dose required to prevent movement in response to skin incision in 50% of patients). The higher the MAC, the less potent an agent is. Advantages and disadvantages of inhaled anesthetics are shown in Table 46-1.5Nitrous Oxide. Nitrous oxide has a low solubility and is a weak anesthetic agent, but it has the most rapid onset and offset. Because 600500400300Duration of infusion (min)2001000020406080100120140Time required for plasmalevels to drop by 50% (min)AEtomidateMidazolamPropofolSufentanilFentanylRemifentanil600500400300Duration of infusion (min)2001000020406080100120140Time required for plasmalevels to drop by 50% (min)BFigure 46-2. Context-sensitive half time for commonly used anesthetics (A) and opioids (B). The vertical axis represents the half-time, or the time required for plasma concentrations of the drug to drop by 50%. The horizontal axis represents the duration of | Surgery_Schwartz. alveolar concentration (MAC) is a measure of anesthetic potency. It is the ED50 of an inhaled agent (i.e., the dose required to prevent movement in response to skin incision in 50% of patients). The higher the MAC, the less potent an agent is. Advantages and disadvantages of inhaled anesthetics are shown in Table 46-1.5Nitrous Oxide. Nitrous oxide has a low solubility and is a weak anesthetic agent, but it has the most rapid onset and offset. Because 600500400300Duration of infusion (min)2001000020406080100120140Time required for plasmalevels to drop by 50% (min)AEtomidateMidazolamPropofolSufentanilFentanylRemifentanil600500400300Duration of infusion (min)2001000020406080100120140Time required for plasmalevels to drop by 50% (min)BFigure 46-2. Context-sensitive half time for commonly used anesthetics (A) and opioids (B). The vertical axis represents the half-time, or the time required for plasma concentrations of the drug to drop by 50%. The horizontal axis represents the duration of |
Surgery_Schwartz_13251 | Surgery_Schwartz | anesthetics (A) and opioids (B). The vertical axis represents the half-time, or the time required for plasma concentrations of the drug to drop by 50%. The horizontal axis represents the duration of a continuous infusion. (Reproduced with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.)Brunicardi_Ch46_p2027-p2044.indd 202901/03/19 11:04 AM 2030SPECIFIC CONSIDERATIONSPART IITable 46-1Advantages and disadvantages of inhaled anestheticsANESTHETICADVANTAGESDISADVANTAGESNitrous OxideNo odor, taste, or pungencyRapid uptake and eliminationAnalgesic effectMinimal cardiovascular depressionMinimal biotransformationInexpensiveAirspace expansionIncreased nausea and vomitingInhibits methionine synthaseEnvironmental pollutantSupports combustionIsofluraneGood muscle relaxationBronchodilationStable heart rateInexpensiveSlow uptake and eliminationSevoflurane Rapid uptake and eliminationNot pungentBreakdown to compound A | Surgery_Schwartz. anesthetics (A) and opioids (B). The vertical axis represents the half-time, or the time required for plasma concentrations of the drug to drop by 50%. The horizontal axis represents the duration of a continuous infusion. (Reproduced with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.)Brunicardi_Ch46_p2027-p2044.indd 202901/03/19 11:04 AM 2030SPECIFIC CONSIDERATIONSPART IITable 46-1Advantages and disadvantages of inhaled anestheticsANESTHETICADVANTAGESDISADVANTAGESNitrous OxideNo odor, taste, or pungencyRapid uptake and eliminationAnalgesic effectMinimal cardiovascular depressionMinimal biotransformationInexpensiveAirspace expansionIncreased nausea and vomitingInhibits methionine synthaseEnvironmental pollutantSupports combustionIsofluraneGood muscle relaxationBronchodilationStable heart rateInexpensiveSlow uptake and eliminationSevoflurane Rapid uptake and eliminationNot pungentBreakdown to compound A |
Surgery_Schwartz_13252 | Surgery_Schwartz | combustionIsofluraneGood muscle relaxationBronchodilationStable heart rateInexpensiveSlow uptake and eliminationSevoflurane Rapid uptake and eliminationNot pungentBreakdown to compound A in circuitMore expensive than isofluraneDesflurane Rapid uptake and eliminationVery low biotransformationAirway irritantRequires electric/heated vaporizerExpensiveData from Longnecker DE, Brown DL, Newman MF, et al: Anesthesiology, 2nd ed. New York, NY: McGraw-Hill Ediucation; 2012.its MAC is 104%, it must be combined with other agents to pro-vide general anesthesia. A recent randomized controlled trial demonstrated that use of 70% nitrous oxide, given as part of a general anesthetic, did not increase the risk of death or major adverse cardiovascular events.6 Nitrous oxide has been shown to increase the rate of postoperative nausea and vomiting (PONV).Volatile Agents. The volatile inhaled anesthetics are gener-ally more soluble in blood than nitrous oxide, are more potent, and thus require lower | Surgery_Schwartz. combustionIsofluraneGood muscle relaxationBronchodilationStable heart rateInexpensiveSlow uptake and eliminationSevoflurane Rapid uptake and eliminationNot pungentBreakdown to compound A in circuitMore expensive than isofluraneDesflurane Rapid uptake and eliminationVery low biotransformationAirway irritantRequires electric/heated vaporizerExpensiveData from Longnecker DE, Brown DL, Newman MF, et al: Anesthesiology, 2nd ed. New York, NY: McGraw-Hill Ediucation; 2012.its MAC is 104%, it must be combined with other agents to pro-vide general anesthesia. A recent randomized controlled trial demonstrated that use of 70% nitrous oxide, given as part of a general anesthetic, did not increase the risk of death or major adverse cardiovascular events.6 Nitrous oxide has been shown to increase the rate of postoperative nausea and vomiting (PONV).Volatile Agents. The volatile inhaled anesthetics are gener-ally more soluble in blood than nitrous oxide, are more potent, and thus require lower |
Surgery_Schwartz_13253 | Surgery_Schwartz | the rate of postoperative nausea and vomiting (PONV).Volatile Agents. The volatile inhaled anesthetics are gener-ally more soluble in blood than nitrous oxide, are more potent, and thus require lower inspired concentrations. Currently, iso-flurane, sevoflurane, and desflurane are the agents that are most commonly used. Older agents, including halothane, which was associated with hepatotoxicity, are no longer widely used.Isoflurane is the most inexpensive and widely available of the agents currently used. Sevoflurane has relatively rapid uptake and elimination. It is also not pungent and is therefore commonly used for inhalational induction. Desflurane has the most rapid uptake and elimination of the three most commonly used volatile agents. It is also the most expensive, requires a heated-electric vaporizer, and is an airway irritant. All of the volatile inhalational agents as well as the depolarizing neu-romuscular blocker succinylcholine are triggering agents for malignant | Surgery_Schwartz. the rate of postoperative nausea and vomiting (PONV).Volatile Agents. The volatile inhaled anesthetics are gener-ally more soluble in blood than nitrous oxide, are more potent, and thus require lower inspired concentrations. Currently, iso-flurane, sevoflurane, and desflurane are the agents that are most commonly used. Older agents, including halothane, which was associated with hepatotoxicity, are no longer widely used.Isoflurane is the most inexpensive and widely available of the agents currently used. Sevoflurane has relatively rapid uptake and elimination. It is also not pungent and is therefore commonly used for inhalational induction. Desflurane has the most rapid uptake and elimination of the three most commonly used volatile agents. It is also the most expensive, requires a heated-electric vaporizer, and is an airway irritant. All of the volatile inhalational agents as well as the depolarizing neu-romuscular blocker succinylcholine are triggering agents for malignant |
Surgery_Schwartz_13254 | Surgery_Schwartz | a heated-electric vaporizer, and is an airway irritant. All of the volatile inhalational agents as well as the depolarizing neu-romuscular blocker succinylcholine are triggering agents for malignant hyperthermia.5Intravenous Agents. Intravenous agents are used to produce unconsciousness, analgesia, muscle relaxation, and/or amnesia. They include barbiturates, propofol, benzodiazepines, ketamine, etomidate, opioids, and nonopioid analgesics.7Barbiturates Barbiturates used in anesthesia include thio-pental and methohexital. These drugs act as agonists at the γ-aminobutyric acid (GABA) receptor, which inhibit excitatory synaptic transmission. Clinically, they produce a rapid, smooth induction of general anesthesia and wear off quickly. They cause hypotension and myocardial depression in a dose-dependent manner. Barbiturates are seldom used in modern anesthesia, with the exception of methohexital, which is still commonly used dur-ing electroconvulsive therapy.Propofol Propofol is an | Surgery_Schwartz. a heated-electric vaporizer, and is an airway irritant. All of the volatile inhalational agents as well as the depolarizing neu-romuscular blocker succinylcholine are triggering agents for malignant hyperthermia.5Intravenous Agents. Intravenous agents are used to produce unconsciousness, analgesia, muscle relaxation, and/or amnesia. They include barbiturates, propofol, benzodiazepines, ketamine, etomidate, opioids, and nonopioid analgesics.7Barbiturates Barbiturates used in anesthesia include thio-pental and methohexital. These drugs act as agonists at the γ-aminobutyric acid (GABA) receptor, which inhibit excitatory synaptic transmission. Clinically, they produce a rapid, smooth induction of general anesthesia and wear off quickly. They cause hypotension and myocardial depression in a dose-dependent manner. Barbiturates are seldom used in modern anesthesia, with the exception of methohexital, which is still commonly used dur-ing electroconvulsive therapy.Propofol Propofol is an |
Surgery_Schwartz_13255 | Surgery_Schwartz | a dose-dependent manner. Barbiturates are seldom used in modern anesthesia, with the exception of methohexital, which is still commonly used dur-ing electroconvulsive therapy.Propofol Propofol is an alkylated phenol that inhibits synaptic transmission through its effects at the GABA receptor. It has a short duration, rapid recovery, and low incidence of nausea and vomiting. Consequently, it is the induction agent of choice. Propofol causes hypotension in a dose-dependent manner, and it should be used cautiously in patients with cardiac disease or hypovolemia. Continuous infusion of propofol is commonly used for sedation in the intensive care unit setting. Continuous infusions of propofol are also used for moderate-to-deep seda-tion for many procedures and are also commonly incorporated into total intravenous anesthetics (TIVA), most commonly for neurosurgical procedures. Propofol is an irritant and frequently causes pain on injection. Propofol also has anticonvulsant | Surgery_Schwartz. a dose-dependent manner. Barbiturates are seldom used in modern anesthesia, with the exception of methohexital, which is still commonly used dur-ing electroconvulsive therapy.Propofol Propofol is an alkylated phenol that inhibits synaptic transmission through its effects at the GABA receptor. It has a short duration, rapid recovery, and low incidence of nausea and vomiting. Consequently, it is the induction agent of choice. Propofol causes hypotension in a dose-dependent manner, and it should be used cautiously in patients with cardiac disease or hypovolemia. Continuous infusion of propofol is commonly used for sedation in the intensive care unit setting. Continuous infusions of propofol are also used for moderate-to-deep seda-tion for many procedures and are also commonly incorporated into total intravenous anesthetics (TIVA), most commonly for neurosurgical procedures. Propofol is an irritant and frequently causes pain on injection. Propofol also has anticonvulsant |
Surgery_Schwartz_13256 | Surgery_Schwartz | incorporated into total intravenous anesthetics (TIVA), most commonly for neurosurgical procedures. Propofol is an irritant and frequently causes pain on injection. Propofol also has anticonvulsant properties.Benzodiazepines Benzodiazepines are most commonly used to reduce anxiety and produce amnesia. Midazolam, which has a rapid onset and relatively short duration of action, is by far the most commonly used benzodiazepine in anesthesia. Lorazepam and diazepam are still sometimes used as anxiolytics or amnes-tics. Benzodiazepines act as agonists at the GABAA receptor. They produce sedation, vasodilation, and respiratory depres-sion in a dose-dependent manner. They should be used with caution when given with opioids because a synergistic reaction causing respiratory depression is common. Oral midazolam is commonly used for anxiolysis in children. Benzodiazepines are excellent anticonvulsants and only rarely cause allergic reac-tions. Benzodiazepines should be administered cautiously in | Surgery_Schwartz. incorporated into total intravenous anesthetics (TIVA), most commonly for neurosurgical procedures. Propofol is an irritant and frequently causes pain on injection. Propofol also has anticonvulsant properties.Benzodiazepines Benzodiazepines are most commonly used to reduce anxiety and produce amnesia. Midazolam, which has a rapid onset and relatively short duration of action, is by far the most commonly used benzodiazepine in anesthesia. Lorazepam and diazepam are still sometimes used as anxiolytics or amnes-tics. Benzodiazepines act as agonists at the GABAA receptor. They produce sedation, vasodilation, and respiratory depres-sion in a dose-dependent manner. They should be used with caution when given with opioids because a synergistic reaction causing respiratory depression is common. Oral midazolam is commonly used for anxiolysis in children. Benzodiazepines are excellent anticonvulsants and only rarely cause allergic reac-tions. Benzodiazepines should be administered cautiously in |
Surgery_Schwartz_13257 | Surgery_Schwartz | midazolam is commonly used for anxiolysis in children. Benzodiazepines are excellent anticonvulsants and only rarely cause allergic reac-tions. Benzodiazepines should be administered cautiously in older adult patients due to the heightened risk of delayed awak-ening and postoperative delirium.Etomidate Etomidate is an imidazole derivative used for IV induction. Its rapid and almost complete hydrolysis to inactive metabolites results in rapid offset. Like the IV agents mentioned earlier, etomidate acts on the GABA receptor. Etomidate has little direct effect on cardiac output and heart rate; induction doses thus cause less reduction in blood pressure than seen with propofol. Etomidate is associated with pain on injection. Nota-bly, etomidate causes adrenal suppression,8,9 although whether a single dose of etomidate given at induction causes clinically relevant adrenal suppression remains controversial.10-13Dexmedetomidine Dexmedetomidine is an IV α2-adrenergic agonist, administered as | Surgery_Schwartz. midazolam is commonly used for anxiolysis in children. Benzodiazepines are excellent anticonvulsants and only rarely cause allergic reac-tions. Benzodiazepines should be administered cautiously in older adult patients due to the heightened risk of delayed awak-ening and postoperative delirium.Etomidate Etomidate is an imidazole derivative used for IV induction. Its rapid and almost complete hydrolysis to inactive metabolites results in rapid offset. Like the IV agents mentioned earlier, etomidate acts on the GABA receptor. Etomidate has little direct effect on cardiac output and heart rate; induction doses thus cause less reduction in blood pressure than seen with propofol. Etomidate is associated with pain on injection. Nota-bly, etomidate causes adrenal suppression,8,9 although whether a single dose of etomidate given at induction causes clinically relevant adrenal suppression remains controversial.10-13Dexmedetomidine Dexmedetomidine is an IV α2-adrenergic agonist, administered as |
Surgery_Schwartz_13258 | Surgery_Schwartz | a single dose of etomidate given at induction causes clinically relevant adrenal suppression remains controversial.10-13Dexmedetomidine Dexmedetomidine is an IV α2-adrenergic agonist, administered as a continuous infusion, and has both sedative and analgesic properties. It is useful for sedation in an intensive care unit setting and as an adjunct to general anes-thesia, especially as part of a total intravenous anesthetic. Side effects include hypotension and bradycardia in a dose-dependent manner. It does not cause respiratory depression at commonly used doses and is thus particularly useful for procedural seda-tion for patients at high risk of respiratory complications. It is synergistic with opiates and thus can be used to facilitate an opiate-sparing anesthetic.14,15Ketamine Ketamine differs from the aforementioned IV agents in that it produces analgesia as well as amnesia. Its principal Brunicardi_Ch46_p2027-p2044.indd 203001/03/19 11:04 AM 2031ANESTHESIA FOR SURGICAL | Surgery_Schwartz. a single dose of etomidate given at induction causes clinically relevant adrenal suppression remains controversial.10-13Dexmedetomidine Dexmedetomidine is an IV α2-adrenergic agonist, administered as a continuous infusion, and has both sedative and analgesic properties. It is useful for sedation in an intensive care unit setting and as an adjunct to general anes-thesia, especially as part of a total intravenous anesthetic. Side effects include hypotension and bradycardia in a dose-dependent manner. It does not cause respiratory depression at commonly used doses and is thus particularly useful for procedural seda-tion for patients at high risk of respiratory complications. It is synergistic with opiates and thus can be used to facilitate an opiate-sparing anesthetic.14,15Ketamine Ketamine differs from the aforementioned IV agents in that it produces analgesia as well as amnesia. Its principal Brunicardi_Ch46_p2027-p2044.indd 203001/03/19 11:04 AM 2031ANESTHESIA FOR SURGICAL |
Surgery_Schwartz_13259 | Surgery_Schwartz | differs from the aforementioned IV agents in that it produces analgesia as well as amnesia. Its principal Brunicardi_Ch46_p2027-p2044.indd 203001/03/19 11:04 AM 2031ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46action is on the N-methyl-d-aspartate (NMDA) receptor. It is a dissociative anesthetic, producing a cataleptic gaze with nystag-mus. Patients may experience delirium and hallucinations while regaining consciousness. The addition of benzodiazepines has been shown to reduce the incidence of these side effects. Ket-amine typically increases heart rate and blood pressure, which may cause myocardial ischemia in patients with coronary dis-ease. Ketamine is often used in acutely hypovolemic patients to maintain blood pressure via sympathetic stimulation. Impor-tantly, ketamine is a direct myocardial depressant in patients who are catecholamine depleted, and it can produce profound hypotension and low cardiac output in such patients. Ketamine is a bronchodilator and is sometimes used | Surgery_Schwartz. differs from the aforementioned IV agents in that it produces analgesia as well as amnesia. Its principal Brunicardi_Ch46_p2027-p2044.indd 203001/03/19 11:04 AM 2031ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46action is on the N-methyl-d-aspartate (NMDA) receptor. It is a dissociative anesthetic, producing a cataleptic gaze with nystag-mus. Patients may experience delirium and hallucinations while regaining consciousness. The addition of benzodiazepines has been shown to reduce the incidence of these side effects. Ket-amine typically increases heart rate and blood pressure, which may cause myocardial ischemia in patients with coronary dis-ease. Ketamine is often used in acutely hypovolemic patients to maintain blood pressure via sympathetic stimulation. Impor-tantly, ketamine is a direct myocardial depressant in patients who are catecholamine depleted, and it can produce profound hypotension and low cardiac output in such patients. Ketamine is a bronchodilator and is sometimes used |
Surgery_Schwartz_13260 | Surgery_Schwartz | myocardial depressant in patients who are catecholamine depleted, and it can produce profound hypotension and low cardiac output in such patients. Ketamine is a bronchodilator and is sometimes used as an induction agent in asthmatic patients. It can increase intracranial pressure and intraocular pressure, and thus its use in patients with trauma to the head and neck is controversial. Ketamine can be admin-istered intramuscularly to induce anesthesia in patients who would not tolerate an inhalational induction or IV placement, such as patients with developmental delay.Opioid Analgesics The commonly used opioids—morphine, codeine, hydromorphone, meperidine, and the fentanyl-based compounds—act on µ-receptors in the brain and spinal cord. The main side effects of opioids are euphoria, sedation, con-stipation, and respiratory depression, which also are mediated by µ-receptors in a dose-dependent fashion. Although opioids have differing potencies required for effective analgesia, | Surgery_Schwartz. myocardial depressant in patients who are catecholamine depleted, and it can produce profound hypotension and low cardiac output in such patients. Ketamine is a bronchodilator and is sometimes used as an induction agent in asthmatic patients. It can increase intracranial pressure and intraocular pressure, and thus its use in patients with trauma to the head and neck is controversial. Ketamine can be admin-istered intramuscularly to induce anesthesia in patients who would not tolerate an inhalational induction or IV placement, such as patients with developmental delay.Opioid Analgesics The commonly used opioids—morphine, codeine, hydromorphone, meperidine, and the fentanyl-based compounds—act on µ-receptors in the brain and spinal cord. The main side effects of opioids are euphoria, sedation, con-stipation, and respiratory depression, which also are mediated by µ-receptors in a dose-dependent fashion. Although opioids have differing potencies required for effective analgesia, |
Surgery_Schwartz_13261 | Surgery_Schwartz | sedation, con-stipation, and respiratory depression, which also are mediated by µ-receptors in a dose-dependent fashion. Although opioids have differing potencies required for effective analgesia, equi-analgesic doses of opioids result in equal degrees of respiratory depression. Thus, there is no completely safe opioid analgesic, and no reason to suppose that one opioid is safer than another. The synthetic opioid fentanyl and its analogues sufentanil, alfentanil, and remifentanil are used in the operating room. They differ pharmacokinetically in their lipid solubility, tissue binding, and elimination profiles and thus have differing poten-cies and durations of action. Fentanyl, which is highly lipid-soluble, accumulates in tissues and exhibits a steep increase in its context-sensitive half-time with infusions. Remifentanil is remarkable in that it undergoes rapid hydrolysis that is unaf-fected by sex, age, weight, or renal or hepatic function, even after prolonged infusion. Alfentanil | Surgery_Schwartz. sedation, con-stipation, and respiratory depression, which also are mediated by µ-receptors in a dose-dependent fashion. Although opioids have differing potencies required for effective analgesia, equi-analgesic doses of opioids result in equal degrees of respiratory depression. Thus, there is no completely safe opioid analgesic, and no reason to suppose that one opioid is safer than another. The synthetic opioid fentanyl and its analogues sufentanil, alfentanil, and remifentanil are used in the operating room. They differ pharmacokinetically in their lipid solubility, tissue binding, and elimination profiles and thus have differing poten-cies and durations of action. Fentanyl, which is highly lipid-soluble, accumulates in tissues and exhibits a steep increase in its context-sensitive half-time with infusions. Remifentanil is remarkable in that it undergoes rapid hydrolysis that is unaf-fected by sex, age, weight, or renal or hepatic function, even after prolonged infusion. Alfentanil |
Surgery_Schwartz_13262 | Surgery_Schwartz | with infusions. Remifentanil is remarkable in that it undergoes rapid hydrolysis that is unaf-fected by sex, age, weight, or renal or hepatic function, even after prolonged infusion. Alfentanil and sufentanil are seldom used, having largely been replaced by remifentanil in the mod-ern era. Morphine and meperidine have active metabolites that are renally excreted and thus should be used with caution or avoided in patients with renal insufficiency.Naloxone, an opioid antagonist, can be used to rapidly reverse the effects of opioids, and is commonly used to rescue patients from opioid-associated respiratory depression. Nalox-one is poorly absorbed orally and is also often combined with oral opioids to prevent abuse by injection use of the combined drug. Methylnaltrexone and alvimopan are both peripheral opi-oid antagonists and can reverse the opioid side effect of consti-pation without affecting analgesia.16,17Nonopioid Analgesics Ketorolac is a parenteral nonsteroidal anti-inflammatory | Surgery_Schwartz. with infusions. Remifentanil is remarkable in that it undergoes rapid hydrolysis that is unaf-fected by sex, age, weight, or renal or hepatic function, even after prolonged infusion. Alfentanil and sufentanil are seldom used, having largely been replaced by remifentanil in the mod-ern era. Morphine and meperidine have active metabolites that are renally excreted and thus should be used with caution or avoided in patients with renal insufficiency.Naloxone, an opioid antagonist, can be used to rapidly reverse the effects of opioids, and is commonly used to rescue patients from opioid-associated respiratory depression. Nalox-one is poorly absorbed orally and is also often combined with oral opioids to prevent abuse by injection use of the combined drug. Methylnaltrexone and alvimopan are both peripheral opi-oid antagonists and can reverse the opioid side effect of consti-pation without affecting analgesia.16,17Nonopioid Analgesics Ketorolac is a parenteral nonsteroidal anti-inflammatory |
Surgery_Schwartz_13263 | Surgery_Schwartz | peripheral opi-oid antagonists and can reverse the opioid side effect of consti-pation without affecting analgesia.16,17Nonopioid Analgesics Ketorolac is a parenteral nonsteroidal anti-inflammatory drug (NSAID) that produces analgesia by reducing prostaglandin formation via inhibition of the enzyme cyclooxygenase (COX). Intraoperative use of ketorolac reduces postoperative need for opioids. Ketorolac along with other NSAIDs can cause major side effects, including bleeding, plate-let dysfunction, and acute kidney injury and should be used cau-tiously in elderly patients or patients with renal insufficiency.Acetaminophen is an analgesic drug and antipyretic; its site of action is in the central nervous system. Use of acetaminophen has been shown to reduce opioid requirements postoperatively. Long available in an orally administered form as well as a rec-tal suppository, an intravenous formulation of acetaminophen is now available which has become widely used in the postopera-tive | Surgery_Schwartz. peripheral opi-oid antagonists and can reverse the opioid side effect of consti-pation without affecting analgesia.16,17Nonopioid Analgesics Ketorolac is a parenteral nonsteroidal anti-inflammatory drug (NSAID) that produces analgesia by reducing prostaglandin formation via inhibition of the enzyme cyclooxygenase (COX). Intraoperative use of ketorolac reduces postoperative need for opioids. Ketorolac along with other NSAIDs can cause major side effects, including bleeding, plate-let dysfunction, and acute kidney injury and should be used cau-tiously in elderly patients or patients with renal insufficiency.Acetaminophen is an analgesic drug and antipyretic; its site of action is in the central nervous system. Use of acetaminophen has been shown to reduce opioid requirements postoperatively. Long available in an orally administered form as well as a rec-tal suppository, an intravenous formulation of acetaminophen is now available which has become widely used in the postopera-tive |
Surgery_Schwartz_13264 | Surgery_Schwartz | Long available in an orally administered form as well as a rec-tal suppository, an intravenous formulation of acetaminophen is now available which has become widely used in the postopera-tive setting.18Lidocaine is a local anesthetic commonly used for local infiltration, nerve blocks, or epidural infusions. Recently, intra-venous infusions of lidocaine have been shown to be beneficial in the perioperative period. A large meta-analysis of 42 trials with 2800 patients showed that intravenous lidocaine infusions modestly reduced postoperative pain, reduced opioid require-ments, and shortened time to recovery of bowel function for patients undergoing abdominal surgery.19Local AnestheticsLocal anesthetics act on sodium channels to block transmission of neural impulses. They are divided into two groups based on their chemical structure: the amides and the esters. In general, the amides are metabolized in the liver, and the esters are metabo-lized by plasma cholinesterases, which yield | Surgery_Schwartz. Long available in an orally administered form as well as a rec-tal suppository, an intravenous formulation of acetaminophen is now available which has become widely used in the postopera-tive setting.18Lidocaine is a local anesthetic commonly used for local infiltration, nerve blocks, or epidural infusions. Recently, intra-venous infusions of lidocaine have been shown to be beneficial in the perioperative period. A large meta-analysis of 42 trials with 2800 patients showed that intravenous lidocaine infusions modestly reduced postoperative pain, reduced opioid require-ments, and shortened time to recovery of bowel function for patients undergoing abdominal surgery.19Local AnestheticsLocal anesthetics act on sodium channels to block transmission of neural impulses. They are divided into two groups based on their chemical structure: the amides and the esters. In general, the amides are metabolized in the liver, and the esters are metabo-lized by plasma cholinesterases, which yield |
Surgery_Schwartz_13265 | Surgery_Schwartz | two groups based on their chemical structure: the amides and the esters. In general, the amides are metabolized in the liver, and the esters are metabo-lized by plasma cholinesterases, which yield metabolites with slightly higher allergic potential than the amides. Amides include lidocaine, bupivacaine, mepivicaine, prilocaine, and ropivicaine. Lidocaine has a fairly rapid onset and is shorter acting. Ropivic-aine and bupivacaine have a slower onset and are longer lasting. All three are commonly used for local infiltration and regional nerve blocks. Amides are 95% metabolized in the liver, with a minority excreted unchanged in the kidneys. Prilocaine and mepivicaine are seldom used in anesthesia at present. Esters include cocaine, procaine, chloroprocaine, tetracaine, and ben-zocaine. Esters are hydrolyzed in the blood by plasma esterases.When used in large quantities over a short period of time, local anesthetic levels can rise in the blood and cause central nervous system (CNS) | Surgery_Schwartz. two groups based on their chemical structure: the amides and the esters. In general, the amides are metabolized in the liver, and the esters are metabo-lized by plasma cholinesterases, which yield metabolites with slightly higher allergic potential than the amides. Amides include lidocaine, bupivacaine, mepivicaine, prilocaine, and ropivicaine. Lidocaine has a fairly rapid onset and is shorter acting. Ropivic-aine and bupivacaine have a slower onset and are longer lasting. All three are commonly used for local infiltration and regional nerve blocks. Amides are 95% metabolized in the liver, with a minority excreted unchanged in the kidneys. Prilocaine and mepivicaine are seldom used in anesthesia at present. Esters include cocaine, procaine, chloroprocaine, tetracaine, and ben-zocaine. Esters are hydrolyzed in the blood by plasma esterases.When used in large quantities over a short period of time, local anesthetic levels can rise in the blood and cause central nervous system (CNS) |
Surgery_Schwartz_13266 | Surgery_Schwartz | Esters are hydrolyzed in the blood by plasma esterases.When used in large quantities over a short period of time, local anesthetic levels can rise in the blood and cause central nervous system (CNS) toxicity and cardiovascular toxicity. Symptoms of CNS toxicity include restlessness, tinnitus, and slurred speech and can progress to seizures and coma. Car-diovascular toxicity may manifest as hypotension, conduction abnormalities leading to heart block, and ventricular arrhyth-mias, and it may lead to cardiac arrest. The type of local anes-thetic used affects the risk of developing toxicity; bupivicaine is most often associated with cardiovascular toxicity. Other risk factors for local anesthetic systemic toxicity include cumulative dose, site of injection, and preexisting renal, hepatic, or cardiac disease in the patient.20 In addition to treating symptomatology, local anesthetic systemic toxicity can be treated with intrave-nous administration of lipid emulsion.21Neuromuscular | Surgery_Schwartz. Esters are hydrolyzed in the blood by plasma esterases.When used in large quantities over a short period of time, local anesthetic levels can rise in the blood and cause central nervous system (CNS) toxicity and cardiovascular toxicity. Symptoms of CNS toxicity include restlessness, tinnitus, and slurred speech and can progress to seizures and coma. Car-diovascular toxicity may manifest as hypotension, conduction abnormalities leading to heart block, and ventricular arrhyth-mias, and it may lead to cardiac arrest. The type of local anes-thetic used affects the risk of developing toxicity; bupivicaine is most often associated with cardiovascular toxicity. Other risk factors for local anesthetic systemic toxicity include cumulative dose, site of injection, and preexisting renal, hepatic, or cardiac disease in the patient.20 In addition to treating symptomatology, local anesthetic systemic toxicity can be treated with intrave-nous administration of lipid emulsion.21Neuromuscular |
Surgery_Schwartz_13267 | Surgery_Schwartz | or cardiac disease in the patient.20 In addition to treating symptomatology, local anesthetic systemic toxicity can be treated with intrave-nous administration of lipid emulsion.21Neuromuscular BlockersWhile general anesthetics provide muscle relaxation, they usu-ally do so at a much deeper anesthetic depth than required for amnesia and hypnosis. For this reason, neuromuscular blockers are commonly administered to attain adequate relaxation at lev-els of anesthesia sufficient to produce hypnosis, amnesia, and analgesia. Neuromuscular blockers block conduction at the neu-romuscular junction of skeletal muscle.22The two categories of neuromuscular blockers in use are depolarizing and nondepolarizing blockers. Character-istics of neuromuscular blockers currently used are summa-rized in Table 46-2. Succinylcholine is the only depolarizing agent used currently. It binds to acetylcholine receptors on the postjunctional membrane in the neuromuscular junction and causes depolarization of | Surgery_Schwartz. or cardiac disease in the patient.20 In addition to treating symptomatology, local anesthetic systemic toxicity can be treated with intrave-nous administration of lipid emulsion.21Neuromuscular BlockersWhile general anesthetics provide muscle relaxation, they usu-ally do so at a much deeper anesthetic depth than required for amnesia and hypnosis. For this reason, neuromuscular blockers are commonly administered to attain adequate relaxation at lev-els of anesthesia sufficient to produce hypnosis, amnesia, and analgesia. Neuromuscular blockers block conduction at the neu-romuscular junction of skeletal muscle.22The two categories of neuromuscular blockers in use are depolarizing and nondepolarizing blockers. Character-istics of neuromuscular blockers currently used are summa-rized in Table 46-2. Succinylcholine is the only depolarizing agent used currently. It binds to acetylcholine receptors on the postjunctional membrane in the neuromuscular junction and causes depolarization of |
Surgery_Schwartz_13268 | Surgery_Schwartz | 46-2. Succinylcholine is the only depolarizing agent used currently. It binds to acetylcholine receptors on the postjunctional membrane in the neuromuscular junction and causes depolarization of muscle fibers. The rapid onset (less than 60 seconds) and rapid offset (5–8 minutes) of succinyl-choline make it ideal for management of the airway in certain Brunicardi_Ch46_p2027-p2044.indd 203101/03/19 11:04 AM 2032SPECIFIC CONSIDERATIONSPART IITable 46-2Commonly used neuromuscular blockersAGENTTYPEINTUBATING DOSECONSIDERATIONSSuccinylcholineDepolarizer1 mg/kgCan cause severe hyperkalemiaContraindicated in burns, denervating conditionsExcessive or prolonged use can lead to phase II blockRocuroniumNondepolarizer0.6 mg/kg1.2 mg/kg for RSIPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorVecuroniumNondepolarizer0.1 mg/kgPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorCisatracuriumNondepolarizer0.1 | Surgery_Schwartz. 46-2. Succinylcholine is the only depolarizing agent used currently. It binds to acetylcholine receptors on the postjunctional membrane in the neuromuscular junction and causes depolarization of muscle fibers. The rapid onset (less than 60 seconds) and rapid offset (5–8 minutes) of succinyl-choline make it ideal for management of the airway in certain Brunicardi_Ch46_p2027-p2044.indd 203101/03/19 11:04 AM 2032SPECIFIC CONSIDERATIONSPART IITable 46-2Commonly used neuromuscular blockersAGENTTYPEINTUBATING DOSECONSIDERATIONSSuccinylcholineDepolarizer1 mg/kgCan cause severe hyperkalemiaContraindicated in burns, denervating conditionsExcessive or prolonged use can lead to phase II blockRocuroniumNondepolarizer0.6 mg/kg1.2 mg/kg for RSIPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorVecuroniumNondepolarizer0.1 mg/kgPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorCisatracuriumNondepolarizer0.1 |
Surgery_Schwartz_13269 | Surgery_Schwartz | or acetylcholinesterase inhibitorVecuroniumNondepolarizer0.1 mg/kgPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorCisatracuriumNondepolarizer0.1 mg/kgHoffman degradationCan be reversed with an acetylcholinesterase inhibitorRSI = rapid sequence inductionsituations.23 Succinylcholine has several adverse effects includ-ing transient hyperkalemia, which can be severe or even fatal for patients with burns and denervating injuries. Succinylcholine can cause bradycardia, which can be severe in children. It is also associated with transient increases in intracranial and intraocular pressure. The depolarization caused by succinylcholine causes skeletal muscles to fasciculate, which in turn, can result in post-operative myalgias. Succinylcholine is a known trigger of malig-nant hyperthermia in susceptible individuals. Succinylcholine is broken down by psuedocholinesterase; patients who are homo-zygous for pseudocholinestrase deficiency will have | Surgery_Schwartz. or acetylcholinesterase inhibitorVecuroniumNondepolarizer0.1 mg/kgPrimarily hepatic metabolismCan be reversed with suggamadex or acetylcholinesterase inhibitorCisatracuriumNondepolarizer0.1 mg/kgHoffman degradationCan be reversed with an acetylcholinesterase inhibitorRSI = rapid sequence inductionsituations.23 Succinylcholine has several adverse effects includ-ing transient hyperkalemia, which can be severe or even fatal for patients with burns and denervating injuries. Succinylcholine can cause bradycardia, which can be severe in children. It is also associated with transient increases in intracranial and intraocular pressure. The depolarization caused by succinylcholine causes skeletal muscles to fasciculate, which in turn, can result in post-operative myalgias. Succinylcholine is a known trigger of malig-nant hyperthermia in susceptible individuals. Succinylcholine is broken down by psuedocholinesterase; patients who are homo-zygous for pseudocholinestrase deficiency will have |
Surgery_Schwartz_13270 | Surgery_Schwartz | known trigger of malig-nant hyperthermia in susceptible individuals. Succinylcholine is broken down by psuedocholinesterase; patients who are homo-zygous for pseudocholinestrase deficiency will have prolonged neuromuscular blockade, typically lasting for several hours.There are several nondepolarizing neuromuscular block-ing agents in clinical use. Long-acting agents including pan-curonium are no longer widely used. Intermediate-duration neuromuscular blockers include the steroid-based drugs vecuronium and rocuronium, which are metabolized by the liver as well as by the kidney, and the benzylisoquinolone drugs atra-curium and cisatracurium, which undergo breakdown in plasma known as Hofmann elimination. All nondepolarizers reversibly bind to the postsynaptic terminal in the neuromuscular junc-tion and prevent acetylcholine from depolarizing the muscle. Muscle blockade occurs without fasciculation and without the subsequent side effects seen with succinylcholine. Neuromus-cular | Surgery_Schwartz. known trigger of malig-nant hyperthermia in susceptible individuals. Succinylcholine is broken down by psuedocholinesterase; patients who are homo-zygous for pseudocholinestrase deficiency will have prolonged neuromuscular blockade, typically lasting for several hours.There are several nondepolarizing neuromuscular block-ing agents in clinical use. Long-acting agents including pan-curonium are no longer widely used. Intermediate-duration neuromuscular blockers include the steroid-based drugs vecuronium and rocuronium, which are metabolized by the liver as well as by the kidney, and the benzylisoquinolone drugs atra-curium and cisatracurium, which undergo breakdown in plasma known as Hofmann elimination. All nondepolarizers reversibly bind to the postsynaptic terminal in the neuromuscular junc-tion and prevent acetylcholine from depolarizing the muscle. Muscle blockade occurs without fasciculation and without the subsequent side effects seen with succinylcholine. Neuromus-cular |
Surgery_Schwartz_13271 | Surgery_Schwartz | junc-tion and prevent acetylcholine from depolarizing the muscle. Muscle blockade occurs without fasciculation and without the subsequent side effects seen with succinylcholine. Neuromus-cular blockade with nondepolarizing drugs is typically reversed. Failure to adequately reverse neuromuscular blockade is associ-ated with an increased risk of perioperative respiratory failure and death. Reversal agents include acetylcholinesterase inhibi-tors including neostigmine, edrophonium, or pyridostigmine that are given concurrently with muscarinic-anticholinergics, almost always atropine or glycopyrrolate. Recently, suggama-dex, a chelating agent, has been approved for use as a reversal agent for reversal of neuromuscular blockade by the steroid paralytics rocuronium and vecuronium. When given at a very high dose, suggamadex can even rapidly reverse the effect of an intubating dose of a steroid neuromuscular blocker.ANESTHETIC MONITORINGOver the past several decades, advancement in anesthetic | Surgery_Schwartz. junc-tion and prevent acetylcholine from depolarizing the muscle. Muscle blockade occurs without fasciculation and without the subsequent side effects seen with succinylcholine. Neuromus-cular blockade with nondepolarizing drugs is typically reversed. Failure to adequately reverse neuromuscular blockade is associ-ated with an increased risk of perioperative respiratory failure and death. Reversal agents include acetylcholinesterase inhibi-tors including neostigmine, edrophonium, or pyridostigmine that are given concurrently with muscarinic-anticholinergics, almost always atropine or glycopyrrolate. Recently, suggama-dex, a chelating agent, has been approved for use as a reversal agent for reversal of neuromuscular blockade by the steroid paralytics rocuronium and vecuronium. When given at a very high dose, suggamadex can even rapidly reverse the effect of an intubating dose of a steroid neuromuscular blocker.ANESTHETIC MONITORINGOver the past several decades, advancement in anesthetic |
Surgery_Schwartz_13272 | Surgery_Schwartz | a very high dose, suggamadex can even rapidly reverse the effect of an intubating dose of a steroid neuromuscular blocker.ANESTHETIC MONITORINGOver the past several decades, advancement in anesthetic moni-toring has made administration of anesthesia safer than ever. The goal of anesthetic monitoring is to continuously moni-tor the patients’ cardiovascular status, pulmonary status, respiratory physiology, anesthetic depth, concentration of gases administered, and temperature. The American Society of Anesthesiology (ASA) has established standards for basic intra-operative monitoring that are listed in Table 46-3. Types of anesthetic monitoring are listed in Table 46-4.Cardiovascular monitoring includes continuous ECG monitoring as well as blood pressure monitoring, which is to be measured and recorded at least every 5 minutes. Blood pressure monitoring can be done using noninvasive blood pressure cuff measurements or invasively using an arterial catheter. Other car-diovascular monitors | Surgery_Schwartz. a very high dose, suggamadex can even rapidly reverse the effect of an intubating dose of a steroid neuromuscular blocker.ANESTHETIC MONITORINGOver the past several decades, advancement in anesthetic moni-toring has made administration of anesthesia safer than ever. The goal of anesthetic monitoring is to continuously moni-tor the patients’ cardiovascular status, pulmonary status, respiratory physiology, anesthetic depth, concentration of gases administered, and temperature. The American Society of Anesthesiology (ASA) has established standards for basic intra-operative monitoring that are listed in Table 46-3. Types of anesthetic monitoring are listed in Table 46-4.Cardiovascular monitoring includes continuous ECG monitoring as well as blood pressure monitoring, which is to be measured and recorded at least every 5 minutes. Blood pressure monitoring can be done using noninvasive blood pressure cuff measurements or invasively using an arterial catheter. Other car-diovascular monitors |
Surgery_Schwartz_13273 | Surgery_Schwartz | recorded at least every 5 minutes. Blood pressure monitoring can be done using noninvasive blood pressure cuff measurements or invasively using an arterial catheter. Other car-diovascular monitors include monitoring of central venous pres-sure, pulmonary artery pressure, and cardiac output. In high-risk 22Table 46-3American Society of Anesthesiologists standards for basic intraoperative monitoringStandardsStandard 1: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics and regional and monitored anesthesia care.Standard 2: Oxygenation, ventilation, circulation, and temperature shall be continually evaluated Oxygenation Inspired gas oxygen analyzer Pulse oximetry Monitoring of patient clinical status Ventilation Auscultation Observation of the patient Observation of reservoir bag End-tidal carbon dioxide analysis Circulation Continuous electrocardiogram display Heart rate and blood pressure recorded at least every 5 | Surgery_Schwartz. recorded at least every 5 minutes. Blood pressure monitoring can be done using noninvasive blood pressure cuff measurements or invasively using an arterial catheter. Other car-diovascular monitors include monitoring of central venous pres-sure, pulmonary artery pressure, and cardiac output. In high-risk 22Table 46-3American Society of Anesthesiologists standards for basic intraoperative monitoringStandardsStandard 1: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics and regional and monitored anesthesia care.Standard 2: Oxygenation, ventilation, circulation, and temperature shall be continually evaluated Oxygenation Inspired gas oxygen analyzer Pulse oximetry Monitoring of patient clinical status Ventilation Auscultation Observation of the patient Observation of reservoir bag End-tidal carbon dioxide analysis Circulation Continuous electrocardiogram display Heart rate and blood pressure recorded at least every 5 |
Surgery_Schwartz_13274 | Surgery_Schwartz | of the patient Observation of reservoir bag End-tidal carbon dioxide analysis Circulation Continuous electrocardiogram display Heart rate and blood pressure recorded at least every 5 minutes Evaluation of circulation: auscultation of heart sounds, palpation of pulse, pulse oximetry, blood pressure monitoring with noninvasive means or intra-arterial catheter pressure measurement Temperature Core and/or skin temperatureReproduced with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.Brunicardi_Ch46_p2027-p2044.indd 203201/03/19 11:04 AM 2033ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46Table 46-4Types of anesthesia monitors and their propertiesTYPE OF MONITORWHAT IS MEASUREDINVASIVENESSPOTENTIAL FOR COMPLICATIONSPhysical examinationHeart sounds, breath sounds, pulse, color, mental status, etcNoninvasive–Pulse oximetryArterial oxygen saturationNoninvasive–Arterial catheterBlood pressure, acid/base | Surgery_Schwartz. of the patient Observation of reservoir bag End-tidal carbon dioxide analysis Circulation Continuous electrocardiogram display Heart rate and blood pressure recorded at least every 5 minutes Evaluation of circulation: auscultation of heart sounds, palpation of pulse, pulse oximetry, blood pressure monitoring with noninvasive means or intra-arterial catheter pressure measurement Temperature Core and/or skin temperatureReproduced with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.Brunicardi_Ch46_p2027-p2044.indd 203201/03/19 11:04 AM 2033ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46Table 46-4Types of anesthesia monitors and their propertiesTYPE OF MONITORWHAT IS MEASUREDINVASIVENESSPOTENTIAL FOR COMPLICATIONSPhysical examinationHeart sounds, breath sounds, pulse, color, mental status, etcNoninvasive–Pulse oximetryArterial oxygen saturationNoninvasive–Arterial catheterBlood pressure, acid/base |
Surgery_Schwartz_13275 | Surgery_Schwartz | examinationHeart sounds, breath sounds, pulse, color, mental status, etcNoninvasive–Pulse oximetryArterial oxygen saturationNoninvasive–Arterial catheterBlood pressure, acid/base statusInvasive++Noninvasive blood pressure measurementBlood pressureNoninvasive+/–ElectrocardiographyCardiac rhythm, rate, ST segmentsNoninvasive–CapnographyVentilatory, circulatory statusNoninvasive–Electroenceophalogram, bispectral index, etcBrain function, depth of anesthesiaNoninvasive+/–Temperature probeBody temperatureNoninvasive to invasive+/–Central venous pressure, pulmonary artery pressureCardiac function, volume statusInvasive+++Transesophageal echocardiogramCardiac function, volume statusInvasive+++Adapted with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.anesthetics such as liver transplantation and cardiac surgery, transesophageal echocardiography (TEE) is employed to moni-tor myocardial function and volume status. | Surgery_Schwartz. examinationHeart sounds, breath sounds, pulse, color, mental status, etcNoninvasive–Pulse oximetryArterial oxygen saturationNoninvasive–Arterial catheterBlood pressure, acid/base statusInvasive++Noninvasive blood pressure measurementBlood pressureNoninvasive+/–ElectrocardiographyCardiac rhythm, rate, ST segmentsNoninvasive–CapnographyVentilatory, circulatory statusNoninvasive–Electroenceophalogram, bispectral index, etcBrain function, depth of anesthesiaNoninvasive+/–Temperature probeBody temperatureNoninvasive to invasive+/–Central venous pressure, pulmonary artery pressureCardiac function, volume statusInvasive+++Transesophageal echocardiogramCardiac function, volume statusInvasive+++Adapted with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.anesthetics such as liver transplantation and cardiac surgery, transesophageal echocardiography (TEE) is employed to moni-tor myocardial function and volume status. |
Surgery_Schwartz_13276 | Surgery_Schwartz | NY: McGraw-Hill Education; 2018.anesthetics such as liver transplantation and cardiac surgery, transesophageal echocardiography (TEE) is employed to moni-tor myocardial function and volume status. Intraoperative TEE can also be used to guide surgeons when performing complex cardiac surgeries, including cardiac valve replacements.Monitoring of oxygenation and ventilation includes use of continuous pulse oximetry, monitoring of exhaled end-tidal carbon dioxide (ETCO2), and monitoring of fraction of inspired oxygen. End tidal CO2 monitoring also provides important infor-mation about systemic perfusion. During cardiac arrest, there is no delivery of CO2 to the lungs, and the end-tidal CO2 is thus very low or zero; a sudden spike in end tidal CO2 during cardio-pulmonary resuscitation correlates with return of spontaneous circulation.24 Modern ventilators also measure peak and plateau inspiratory airway pressure and minute ventilation. Adequacy of oxygenation and ventilation can also be | Surgery_Schwartz. NY: McGraw-Hill Education; 2018.anesthetics such as liver transplantation and cardiac surgery, transesophageal echocardiography (TEE) is employed to moni-tor myocardial function and volume status. Intraoperative TEE can also be used to guide surgeons when performing complex cardiac surgeries, including cardiac valve replacements.Monitoring of oxygenation and ventilation includes use of continuous pulse oximetry, monitoring of exhaled end-tidal carbon dioxide (ETCO2), and monitoring of fraction of inspired oxygen. End tidal CO2 monitoring also provides important infor-mation about systemic perfusion. During cardiac arrest, there is no delivery of CO2 to the lungs, and the end-tidal CO2 is thus very low or zero; a sudden spike in end tidal CO2 during cardio-pulmonary resuscitation correlates with return of spontaneous circulation.24 Modern ventilators also measure peak and plateau inspiratory airway pressure and minute ventilation. Adequacy of oxygenation and ventilation can also be |
Surgery_Schwartz_13277 | Surgery_Schwartz | with return of spontaneous circulation.24 Modern ventilators also measure peak and plateau inspiratory airway pressure and minute ventilation. Adequacy of oxygenation and ventilation can also be confirmed by arterial blood gas analysis.Temperature monitoring is performed using a temperature probe, usually inserted in the esophagus or nasopharynx. Core body temperature can be measured with temperature sensing Foley catheters. Temperature can also be measured at the skin.Several monitors exist that measure depth of anesthesia, including the bispectral index (BIS) monitor and the SedLine monitor. While these monitors were designed to prevent aware-ness under anesthesia, a multicenter trial of over 6000 patients showed that titrating anesthetic concentration to the BIS moni-tor was not superior to titrating anesthetic depth to end-tidal anesthetic concentration with goal MAC greater than 0.7.25Peripheral nerve stimulators should be used to moni-tor depth of neuromuscular blockade. A | Surgery_Schwartz. with return of spontaneous circulation.24 Modern ventilators also measure peak and plateau inspiratory airway pressure and minute ventilation. Adequacy of oxygenation and ventilation can also be confirmed by arterial blood gas analysis.Temperature monitoring is performed using a temperature probe, usually inserted in the esophagus or nasopharynx. Core body temperature can be measured with temperature sensing Foley catheters. Temperature can also be measured at the skin.Several monitors exist that measure depth of anesthesia, including the bispectral index (BIS) monitor and the SedLine monitor. While these monitors were designed to prevent aware-ness under anesthesia, a multicenter trial of over 6000 patients showed that titrating anesthetic concentration to the BIS moni-tor was not superior to titrating anesthetic depth to end-tidal anesthetic concentration with goal MAC greater than 0.7.25Peripheral nerve stimulators should be used to moni-tor depth of neuromuscular blockade. A |
Surgery_Schwartz_13278 | Surgery_Schwartz | to titrating anesthetic depth to end-tidal anesthetic concentration with goal MAC greater than 0.7.25Peripheral nerve stimulators should be used to moni-tor depth of neuromuscular blockade. A train-of-four monitor delivers four successive stimuli over 2 seconds. Presence of four twitches without fade with a ratio of the height of the first twitch to the height of the fourth twitch at least 0.9 suggests adequate reversal of neuromuscular blockade.26 The presence of one or two twitches (absence of the last two or three) is generally suffi-cient for the relaxation required for almost any kind of abdomi-nal or thoracic operation.PERIOPERATIVE EVALUATION AND PREPARATIONThe ASA has adopted basic standards for the evaluation of patients before surgery. These standards require the anesthe-siologist to evaluate the medical status of the patient, develop a plan of anesthetic care, and discuss this plan with the patient and/or the patient’s legal guardian.A preoperative evaluation includes an | Surgery_Schwartz. to titrating anesthetic depth to end-tidal anesthetic concentration with goal MAC greater than 0.7.25Peripheral nerve stimulators should be used to moni-tor depth of neuromuscular blockade. A train-of-four monitor delivers four successive stimuli over 2 seconds. Presence of four twitches without fade with a ratio of the height of the first twitch to the height of the fourth twitch at least 0.9 suggests adequate reversal of neuromuscular blockade.26 The presence of one or two twitches (absence of the last two or three) is generally suffi-cient for the relaxation required for almost any kind of abdomi-nal or thoracic operation.PERIOPERATIVE EVALUATION AND PREPARATIONThe ASA has adopted basic standards for the evaluation of patients before surgery. These standards require the anesthe-siologist to evaluate the medical status of the patient, develop a plan of anesthetic care, and discuss this plan with the patient and/or the patient’s legal guardian.A preoperative evaluation includes an |
Surgery_Schwartz_13279 | Surgery_Schwartz | to evaluate the medical status of the patient, develop a plan of anesthetic care, and discuss this plan with the patient and/or the patient’s legal guardian.A preoperative evaluation includes an appropriately detailed medical history, current drug therapy, appropriate physical examination, and review of laboratory and specific testing results. Based on these findings, the anesthesiologist may conclude that a patient is not in optimal medical condition to undergo elective surgery. These findings and opinions are then discussed with the patient’s primary physician or surgeon, and the surgery may be delayed (or cancelled) until the patient’s medical condition is further evaluated and optimized.The medical history obtained at the preoperative visit should include the patient’s previous exposure and experi-ence with anesthesia, as well as any family history of problems with anesthesia. History of atopy is an important aspect of this evaluation in that it may predispose patients to form | Surgery_Schwartz. to evaluate the medical status of the patient, develop a plan of anesthetic care, and discuss this plan with the patient and/or the patient’s legal guardian.A preoperative evaluation includes an appropriately detailed medical history, current drug therapy, appropriate physical examination, and review of laboratory and specific testing results. Based on these findings, the anesthesiologist may conclude that a patient is not in optimal medical condition to undergo elective surgery. These findings and opinions are then discussed with the patient’s primary physician or surgeon, and the surgery may be delayed (or cancelled) until the patient’s medical condition is further evaluated and optimized.The medical history obtained at the preoperative visit should include the patient’s previous exposure and experi-ence with anesthesia, as well as any family history of problems with anesthesia. History of atopy is an important aspect of this evaluation in that it may predispose patients to form |
Surgery_Schwartz_13280 | Surgery_Schwartz | and experi-ence with anesthesia, as well as any family history of problems with anesthesia. History of atopy is an important aspect of this evaluation in that it may predispose patients to form antibodies against antigens that may be represented by agents administered during the perioperative period. Concurrent medications should be fully evaluated when circumstances allow, and adverse inter-actions with agents administered during the perioperative period need to be considered. A review of the function of major organ systems should also be performed. The physical examination is targeted primarily at the central nervous system, cardiovascular system, lungs, and airway.Laboratory testing should be based on the patient’s con-dition and the proposed procedure. Otherwise healthy patients usually do not need laboratory testing for minor procedures. Preoperative testing may be necessitated by findings on physi-cal examination; for example, an electrocardiogram should be obtained if an | Surgery_Schwartz. and experi-ence with anesthesia, as well as any family history of problems with anesthesia. History of atopy is an important aspect of this evaluation in that it may predispose patients to form antibodies against antigens that may be represented by agents administered during the perioperative period. Concurrent medications should be fully evaluated when circumstances allow, and adverse inter-actions with agents administered during the perioperative period need to be considered. A review of the function of major organ systems should also be performed. The physical examination is targeted primarily at the central nervous system, cardiovascular system, lungs, and airway.Laboratory testing should be based on the patient’s con-dition and the proposed procedure. Otherwise healthy patients usually do not need laboratory testing for minor procedures. Preoperative testing may be necessitated by findings on physi-cal examination; for example, an electrocardiogram should be obtained if an |
Surgery_Schwartz_13281 | Surgery_Schwartz | usually do not need laboratory testing for minor procedures. Preoperative testing may be necessitated by findings on physi-cal examination; for example, an electrocardiogram should be obtained if an irregular heart rhythm is noted, and an echo-cardiogram may be indicated if a new murmur is observed on Brunicardi_Ch46_p2027-p2044.indd 203301/03/19 11:04 AM 2034SPECIFIC CONSIDERATIONSPART IIauscultation. Chest imaging or pulmonary function testing may be indicated if abnormalities are noted on pulmonary examina-tion and may be pertinent to the administration of the anesthetic or the recovery from anesthesia and surgery. Urine pregnancy testing is typically performed on the day of surgery in women of childbearing age.ASA Physical Status AssessmentThe ASA classification system is a scale used to risk-stratify patients for anesthesia and surgery. The scale, ranging from physical status I to VI, is shown in Table 46-5. Patients under-going emergent surgery are denoted by an “E”; for | Surgery_Schwartz. usually do not need laboratory testing for minor procedures. Preoperative testing may be necessitated by findings on physi-cal examination; for example, an electrocardiogram should be obtained if an irregular heart rhythm is noted, and an echo-cardiogram may be indicated if a new murmur is observed on Brunicardi_Ch46_p2027-p2044.indd 203301/03/19 11:04 AM 2034SPECIFIC CONSIDERATIONSPART IIauscultation. Chest imaging or pulmonary function testing may be indicated if abnormalities are noted on pulmonary examina-tion and may be pertinent to the administration of the anesthetic or the recovery from anesthesia and surgery. Urine pregnancy testing is typically performed on the day of surgery in women of childbearing age.ASA Physical Status AssessmentThe ASA classification system is a scale used to risk-stratify patients for anesthesia and surgery. The scale, ranging from physical status I to VI, is shown in Table 46-5. Patients under-going emergent surgery are denoted by an “E”; for |
Surgery_Schwartz_13282 | Surgery_Schwartz | used to risk-stratify patients for anesthesia and surgery. The scale, ranging from physical status I to VI, is shown in Table 46-5. Patients under-going emergent surgery are denoted by an “E”; for example, an otherwise healthy patient undergoing an appendectomy for appendicitis would be classified as ASA IE. Mortality has shown to increase with increasing ASA physical status, and it has been shown to be higher for patients undergoing emergency surgery.27Airway EvaluationAirway examination can identify most patients in whom management of the airway and conventional endotracheal CLASS 1: Soft palate, fauces, uvula, pillarsCLASS 2: Soft palate, fauces, portion of uvulaCLASS 3: Soft palate, base of uvulaCLASS 4: Hard palate onlyMALLAMPATI CLASSIFICATIONCLASS 1CLASS 2CLASS 3CLASS 4Figure 46-3. The Mallampati classification.Table 46-5American Society of Anesthesiologists physical status classificationASA PHYSICAL STATUSDESCRIPTIONIA healthy patient without systemic diseaseIIA patient with | Surgery_Schwartz. used to risk-stratify patients for anesthesia and surgery. The scale, ranging from physical status I to VI, is shown in Table 46-5. Patients under-going emergent surgery are denoted by an “E”; for example, an otherwise healthy patient undergoing an appendectomy for appendicitis would be classified as ASA IE. Mortality has shown to increase with increasing ASA physical status, and it has been shown to be higher for patients undergoing emergency surgery.27Airway EvaluationAirway examination can identify most patients in whom management of the airway and conventional endotracheal CLASS 1: Soft palate, fauces, uvula, pillarsCLASS 2: Soft palate, fauces, portion of uvulaCLASS 3: Soft palate, base of uvulaCLASS 4: Hard palate onlyMALLAMPATI CLASSIFICATIONCLASS 1CLASS 2CLASS 3CLASS 4Figure 46-3. The Mallampati classification.Table 46-5American Society of Anesthesiologists physical status classificationASA PHYSICAL STATUSDESCRIPTIONIA healthy patient without systemic diseaseIIA patient with |
Surgery_Schwartz_13283 | Surgery_Schwartz | Mallampati classification.Table 46-5American Society of Anesthesiologists physical status classificationASA PHYSICAL STATUSDESCRIPTIONIA healthy patient without systemic diseaseIIA patient with mild systemic diseaseIIIA patient with severe systemic diseaseIVA patient with severe systemic disease that is a constant threat to lifeVA moribund patient not expected to survive without the operationVIA declared brain-dead patient whose organs are being removed for donationData from American Society of Anesthesiologists: ASA Physical Status Classification System Developed. ASA House of Delegates/Executive Committee. Amended: October 15, 2014.intubation may be difficult. It is vitally important to recognize such patients before administering medications that induce apnea. The Mallampati classification (Fig. 46-3) is based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position.28 Patients with higher Mallampati classification, in combination with | Surgery_Schwartz. Mallampati classification.Table 46-5American Society of Anesthesiologists physical status classificationASA PHYSICAL STATUSDESCRIPTIONIA healthy patient without systemic diseaseIIA patient with mild systemic diseaseIIIA patient with severe systemic diseaseIVA patient with severe systemic disease that is a constant threat to lifeVA moribund patient not expected to survive without the operationVIA declared brain-dead patient whose organs are being removed for donationData from American Society of Anesthesiologists: ASA Physical Status Classification System Developed. ASA House of Delegates/Executive Committee. Amended: October 15, 2014.intubation may be difficult. It is vitally important to recognize such patients before administering medications that induce apnea. The Mallampati classification (Fig. 46-3) is based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position.28 Patients with higher Mallampati classification, in combination with |
Surgery_Schwartz_13284 | Surgery_Schwartz | (Fig. 46-3) is based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position.28 Patients with higher Mallampati classification, in combination with other airway abnormalities, can be difficult to intubate. Other predictors of difficult intubation include short neck, immobility of the neck,29 a large overbite, a small mandible, or the inability to shift the lower incisors in front of the upper incisors. The thyromental distance, the distance from the thyroid cartilage to the tip of the chin should be greater than 6 cm; thyromental distance of less than 6 cm has been associated with difficult intubation.30 Obesity is also a risk factor for difficult intubation, and neck circumference has been identified as a risk factor for both dif-ficult intubation as well as difficult mask ventilation.31Cardiovascular DiseaseCardiac risk is widely regarded as the most important risk associated with anesthesia and surgery, and it has been the focus of an | Surgery_Schwartz. (Fig. 46-3) is based on the structures visualized with maximal mouth opening and tongue protrusion in the sitting position.28 Patients with higher Mallampati classification, in combination with other airway abnormalities, can be difficult to intubate. Other predictors of difficult intubation include short neck, immobility of the neck,29 a large overbite, a small mandible, or the inability to shift the lower incisors in front of the upper incisors. The thyromental distance, the distance from the thyroid cartilage to the tip of the chin should be greater than 6 cm; thyromental distance of less than 6 cm has been associated with difficult intubation.30 Obesity is also a risk factor for difficult intubation, and neck circumference has been identified as a risk factor for both dif-ficult intubation as well as difficult mask ventilation.31Cardiovascular DiseaseCardiac risk is widely regarded as the most important risk associated with anesthesia and surgery, and it has been the focus of an |
Surgery_Schwartz_13285 | Surgery_Schwartz | as well as difficult mask ventilation.31Cardiovascular DiseaseCardiac risk is widely regarded as the most important risk associated with anesthesia and surgery, and it has been the focus of an enormous amount of scholarship over the past four decades. The revised cardiac risk index incorporates six patient and surgical factors to assess a patient’s risk of major adverse cardiac events in the perioperative period: history of ischemic heart disease, congestive heart failure, cerebrovascular dis-ease, diabetes requiring insulin, chronic kidney disease with baseline creatinine greater than 2, and whether the surgery is in a high-risk area, namely major vascular, intraperitoneal, or intrathoracic. In 2014, the American College of Cardiology and the American Heart Association published guidelines for perioperative workup and management of patients with cardio-vascular disease; a simplified version is seen in Fig. 46-4 . Notably, this guideline stresses the importance of func-tional status | Surgery_Schwartz. as well as difficult mask ventilation.31Cardiovascular DiseaseCardiac risk is widely regarded as the most important risk associated with anesthesia and surgery, and it has been the focus of an enormous amount of scholarship over the past four decades. The revised cardiac risk index incorporates six patient and surgical factors to assess a patient’s risk of major adverse cardiac events in the perioperative period: history of ischemic heart disease, congestive heart failure, cerebrovascular dis-ease, diabetes requiring insulin, chronic kidney disease with baseline creatinine greater than 2, and whether the surgery is in a high-risk area, namely major vascular, intraperitoneal, or intrathoracic. In 2014, the American College of Cardiology and the American Heart Association published guidelines for perioperative workup and management of patients with cardio-vascular disease; a simplified version is seen in Fig. 46-4 . Notably, this guideline stresses the importance of func-tional status |
Surgery_Schwartz_13286 | Surgery_Schwartz | for perioperative workup and management of patients with cardio-vascular disease; a simplified version is seen in Fig. 46-4 . Notably, this guideline stresses the importance of func-tional status in determining need for further evaluation; patients with good functional status can typically proceed to surgery without additional evaluation. Functional capacity is measured in metabolic equivalents (METs), with patients unable to attain 4 METs considered to have poor functional status. Activities representing 4 METs including walking up a flight of stairs, climbing a hill, or walking on level ground at 3 to 4 miles per hour.3233Brunicardi_Ch46_p2027-p2044.indd 203401/03/19 11:04 AM 2035ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46These recent guidelines have minimized the role of routine screening. Preoperative electrocardiograms and stress testing are unnecessary for asymptomatic patients undergoing low-risk surgery.Special attention is required for patients with coronary stents. | Surgery_Schwartz. for perioperative workup and management of patients with cardio-vascular disease; a simplified version is seen in Fig. 46-4 . Notably, this guideline stresses the importance of func-tional status in determining need for further evaluation; patients with good functional status can typically proceed to surgery without additional evaluation. Functional capacity is measured in metabolic equivalents (METs), with patients unable to attain 4 METs considered to have poor functional status. Activities representing 4 METs including walking up a flight of stairs, climbing a hill, or walking on level ground at 3 to 4 miles per hour.3233Brunicardi_Ch46_p2027-p2044.indd 203401/03/19 11:04 AM 2035ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46These recent guidelines have minimized the role of routine screening. Preoperative electrocardiograms and stress testing are unnecessary for asymptomatic patients undergoing low-risk surgery.Special attention is required for patients with coronary stents. |
Surgery_Schwartz_13287 | Surgery_Schwartz | screening. Preoperative electrocardiograms and stress testing are unnecessary for asymptomatic patients undergoing low-risk surgery.Special attention is required for patients with coronary stents. Elective surgery should be delayed a stent has been inserted, which allows time for it to stabilize and the risk of in-stent thrombosis to decrease. The ACC/AHA guidelines rec-ommend delaying elective surgery for 30 days after bare metal stent placement and for 1 year after drug eluting stent place-ment. Dual antiplatelet therapy should be continued for urgent or emergent procedures that take place before the minimum recommended waiting period.32 For semi-elective surgeries in patients with drug-eluting stents, where the risk of delaying sur-gery is greater than the risk of in-stent thrombosis, ACC/AHA guidelines recommend surgery be delayed for 180 days.Current recommendation is that β-blockers and statins should be continued in patients who are on them chronically. β-Blockers may be | Surgery_Schwartz. screening. Preoperative electrocardiograms and stress testing are unnecessary for asymptomatic patients undergoing low-risk surgery.Special attention is required for patients with coronary stents. Elective surgery should be delayed a stent has been inserted, which allows time for it to stabilize and the risk of in-stent thrombosis to decrease. The ACC/AHA guidelines rec-ommend delaying elective surgery for 30 days after bare metal stent placement and for 1 year after drug eluting stent place-ment. Dual antiplatelet therapy should be continued for urgent or emergent procedures that take place before the minimum recommended waiting period.32 For semi-elective surgeries in patients with drug-eluting stents, where the risk of delaying sur-gery is greater than the risk of in-stent thrombosis, ACC/AHA guidelines recommend surgery be delayed for 180 days.Current recommendation is that β-blockers and statins should be continued in patients who are on them chronically. β-Blockers may be |
Surgery_Schwartz_13288 | Surgery_Schwartz | ACC/AHA guidelines recommend surgery be delayed for 180 days.Current recommendation is that β-blockers and statins should be continued in patients who are on them chronically. β-Blockers may be started in the perioperative period for patients with multiple RCRI risk factors or who are at intermediate or high risk for myocardial ischemia. If started in the perioperative period, β-blockers should be started long enough before sur-gery to ascertain their safety, and not on the day of surgery.32,33 Recent large randomized trials have demonstrated excess risk of mortality and stroke simultaneously with decreased risk of myocardial events in moderateand high-risk patients who are newly treated with β-blockers in the periprocedural setting.34,35Implanted cardiac devices including pacemakers and implantable cardioverter-defibrillators also have important peri-operative implications. A 2011 ASA practice advisory stressed the importance of determining whether electromagnetic interfer-ence is | Surgery_Schwartz. ACC/AHA guidelines recommend surgery be delayed for 180 days.Current recommendation is that β-blockers and statins should be continued in patients who are on them chronically. β-Blockers may be started in the perioperative period for patients with multiple RCRI risk factors or who are at intermediate or high risk for myocardial ischemia. If started in the perioperative period, β-blockers should be started long enough before sur-gery to ascertain their safety, and not on the day of surgery.32,33 Recent large randomized trials have demonstrated excess risk of mortality and stroke simultaneously with decreased risk of myocardial events in moderateand high-risk patients who are newly treated with β-blockers in the periprocedural setting.34,35Implanted cardiac devices including pacemakers and implantable cardioverter-defibrillators also have important peri-operative implications. A 2011 ASA practice advisory stressed the importance of determining whether electromagnetic interfer-ence is |
Surgery_Schwartz_13289 | Surgery_Schwartz | implantable cardioverter-defibrillators also have important peri-operative implications. A 2011 ASA practice advisory stressed the importance of determining whether electromagnetic interfer-ence is likely to occur during the planned procedure, determin-ing the current function and necessity of the implanted device, determining whether reprogramming or temporary disabling of the device is advantageous, having alternative therapy available for the time that the device is unavailable, and restoring device function in the postoperative period.36Pulmonary DiseaseChronic pulmonary disease is an increasingly recognized cause of morbidity and mortality in surgical patients. For patients with asthma or chronic obstructive pulmonary disease, exercise toler-ance and the frequency and severity of exacerbations should be evaluated. A focused history, including prior admissions and intubations for exacerbations, should be obtained. Treatment with bronchodilators in the perioperative setting is | Surgery_Schwartz. implantable cardioverter-defibrillators also have important peri-operative implications. A 2011 ASA practice advisory stressed the importance of determining whether electromagnetic interfer-ence is likely to occur during the planned procedure, determin-ing the current function and necessity of the implanted device, determining whether reprogramming or temporary disabling of the device is advantageous, having alternative therapy available for the time that the device is unavailable, and restoring device function in the postoperative period.36Pulmonary DiseaseChronic pulmonary disease is an increasingly recognized cause of morbidity and mortality in surgical patients. For patients with asthma or chronic obstructive pulmonary disease, exercise toler-ance and the frequency and severity of exacerbations should be evaluated. A focused history, including prior admissions and intubations for exacerbations, should be obtained. Treatment with bronchodilators in the perioperative setting is |
Surgery_Schwartz_13290 | Surgery_Schwartz | exacerbations should be evaluated. A focused history, including prior admissions and intubations for exacerbations, should be obtained. Treatment with bronchodilators in the perioperative setting is appropri-ate, although there is no literature to either guide this care or to document a benefit from it. Most inhaled anesthetics act as bronchodilators.37 Desflurane can be an airway irritant, and it is often avoided in patients with reactive airway disease.The incidence of obstructive sleep apnea (OSA) has risen with the incidence of obesity. In 2014 the ASA published guide-lines for perioperative management of patients with OSA. These guidelines highlight the importance of identifying patients with obstructive sleep apnea during preoperative evaluation and obtaining a sleep study if appropriate. They also highlight the importance of the development of protocols by anesthesiologists and surgeons to manage OSA in the perioperative setting. There is consensus that these patients should | Surgery_Schwartz. exacerbations should be evaluated. A focused history, including prior admissions and intubations for exacerbations, should be obtained. Treatment with bronchodilators in the perioperative setting is appropri-ate, although there is no literature to either guide this care or to document a benefit from it. Most inhaled anesthetics act as bronchodilators.37 Desflurane can be an airway irritant, and it is often avoided in patients with reactive airway disease.The incidence of obstructive sleep apnea (OSA) has risen with the incidence of obesity. In 2014 the ASA published guide-lines for perioperative management of patients with OSA. These guidelines highlight the importance of identifying patients with obstructive sleep apnea during preoperative evaluation and obtaining a sleep study if appropriate. They also highlight the importance of the development of protocols by anesthesiologists and surgeons to manage OSA in the perioperative setting. There is consensus that these patients should |
Surgery_Schwartz_13291 | Surgery_Schwartz | They also highlight the importance of the development of protocols by anesthesiologists and surgeons to manage OSA in the perioperative setting. There is consensus that these patients should not be extubated until they are completely awake, and that they should be treated with ACC/AHA algorithm of cardiac evaluation for noncardiac surgeryProceed to surgery with medical riskreduction and perioperative surveillancePostpone surgery until stabilized or correctedNo clinicalpredictorsProceed with surgeryProceed with surgery˜1 clinicalpredictorsIntermediate riskor vascular surgeryProceed with surgeryProceed to surgery with heart ratecontrol or consider noninvasive testingif it will change managementEmergency surgeryActive cardiac conditions• Unstable coronary syndromes (unstable or severe angina, recent MI)• Decompensated heart failure (HF; new onset, NYHA class IV)• Significant arrhythmias (Mobitz ll or third-degree heart block, supraventricular tachycardia or atrial fibrillation with | Surgery_Schwartz. They also highlight the importance of the development of protocols by anesthesiologists and surgeons to manage OSA in the perioperative setting. There is consensus that these patients should not be extubated until they are completely awake, and that they should be treated with ACC/AHA algorithm of cardiac evaluation for noncardiac surgeryProceed to surgery with medical riskreduction and perioperative surveillancePostpone surgery until stabilized or correctedNo clinicalpredictorsProceed with surgeryProceed with surgery˜1 clinicalpredictorsIntermediate riskor vascular surgeryProceed with surgeryProceed to surgery with heart ratecontrol or consider noninvasive testingif it will change managementEmergency surgeryActive cardiac conditions• Unstable coronary syndromes (unstable or severe angina, recent MI)• Decompensated heart failure (HF; new onset, NYHA class IV)• Significant arrhythmias (Mobitz ll or third-degree heart block, supraventricular tachycardia or atrial fibrillation with |
Surgery_Schwartz_13292 | Surgery_Schwartz | recent MI)• Decompensated heart failure (HF; new onset, NYHA class IV)• Significant arrhythmias (Mobitz ll or third-degree heart block, supraventricular tachycardia or atrial fibrillation with rapid ventricular rate (>100), symptomatic ventricular arrhythmia or bradycardia, new ventricular tachycardia)• Severe valvular disease (severe aortic or mitral stenosis)Step 1Step 2Low-risk surgery (risk <1%)• Superficial or endoscopic• Cataract, breast• Ambulatory surgeryStep 3Functional capacityGood; ≥4 METS (can walk flight of stairs without symptoms)Step 4Clinical predictors• Ischemic heart disease• Compensated or prior HF• Cerebrovascular disease (stroke, TIA)• Diabetes mellitus• Renal insufficiencyStep 5Figure 46-4. Simplified cardiac evaluation for noncardiac surgery. (Data from Eagle KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery–executive summary: a report of the American College of Cardiology/American | Surgery_Schwartz. recent MI)• Decompensated heart failure (HF; new onset, NYHA class IV)• Significant arrhythmias (Mobitz ll or third-degree heart block, supraventricular tachycardia or atrial fibrillation with rapid ventricular rate (>100), symptomatic ventricular arrhythmia or bradycardia, new ventricular tachycardia)• Severe valvular disease (severe aortic or mitral stenosis)Step 1Step 2Low-risk surgery (risk <1%)• Superficial or endoscopic• Cataract, breast• Ambulatory surgeryStep 3Functional capacityGood; ≥4 METS (can walk flight of stairs without symptoms)Step 4Clinical predictors• Ischemic heart disease• Compensated or prior HF• Cerebrovascular disease (stroke, TIA)• Diabetes mellitus• Renal insufficiencyStep 5Figure 46-4. Simplified cardiac evaluation for noncardiac surgery. (Data from Eagle KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery–executive summary: a report of the American College of Cardiology/American |
Surgery_Schwartz_13293 | Surgery_Schwartz | KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery), J Am Coll Cardiol. 2002 Feb 6;39(3):542-553.)Brunicardi_Ch46_p2027-p2044.indd 203501/03/19 11:04 AM 2036SPECIFIC CONSIDERATIONSPART IInoninvasive positive pressure ventilation in the postoperative period as indicated.38Renal DiseaseManagement of anesthesia in patients with chronic renal insuf-ficiency requires close attention to perioperative fluid man-agement and acid-base and electrolyte homeostasis. Doses of opioids and neuromuscular agents are typically reduced and dosing intervals increased to compensate for decreased renal excretion. Cisatracurium is often chosen as the muscle relax-ant in patients with severe renal | Surgery_Schwartz. KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery), J Am Coll Cardiol. 2002 Feb 6;39(3):542-553.)Brunicardi_Ch46_p2027-p2044.indd 203501/03/19 11:04 AM 2036SPECIFIC CONSIDERATIONSPART IInoninvasive positive pressure ventilation in the postoperative period as indicated.38Renal DiseaseManagement of anesthesia in patients with chronic renal insuf-ficiency requires close attention to perioperative fluid man-agement and acid-base and electrolyte homeostasis. Doses of opioids and neuromuscular agents are typically reduced and dosing intervals increased to compensate for decreased renal excretion. Cisatracurium is often chosen as the muscle relax-ant in patients with severe renal |
Surgery_Schwartz_13294 | Surgery_Schwartz | agents are typically reduced and dosing intervals increased to compensate for decreased renal excretion. Cisatracurium is often chosen as the muscle relax-ant in patients with severe renal insufficiency because its elimi-nation is unchanged by renal failure. Sugammadex, a reversal agent for steroid-based neuromuscular blockers, is not currently recommended for use in patients with advanced chronic kidney disease or end-stage renal disease.Hepatic DiseaseHepatic dysfunction has many causes, and it can compel significant changes in anesthetic care. First, anesthetic agents metabolized in the liver can accumulate in these patients and may have a longer duration of effect. To mitigate this, short-acting agents are strongly preferred in these patients. Hypoalbuminemia can paradoxically increase the free plasma levels of drugs, which can also exagger-ate their effects. In patients with substantial ascites, high intra-abdominal pressure may increase the risk of passive gastric reflux, and | Surgery_Schwartz. agents are typically reduced and dosing intervals increased to compensate for decreased renal excretion. Cisatracurium is often chosen as the muscle relax-ant in patients with severe renal insufficiency because its elimi-nation is unchanged by renal failure. Sugammadex, a reversal agent for steroid-based neuromuscular blockers, is not currently recommended for use in patients with advanced chronic kidney disease or end-stage renal disease.Hepatic DiseaseHepatic dysfunction has many causes, and it can compel significant changes in anesthetic care. First, anesthetic agents metabolized in the liver can accumulate in these patients and may have a longer duration of effect. To mitigate this, short-acting agents are strongly preferred in these patients. Hypoalbuminemia can paradoxically increase the free plasma levels of drugs, which can also exagger-ate their effects. In patients with substantial ascites, high intra-abdominal pressure may increase the risk of passive gastric reflux, and |
Surgery_Schwartz_13295 | Surgery_Schwartz | the free plasma levels of drugs, which can also exagger-ate their effects. In patients with substantial ascites, high intra-abdominal pressure may increase the risk of passive gastric reflux, and thus many such patients are managed as if they have a full stomach, regardless of how long they have been NPO. In patients with significant hepatocellular dysfunction and/or portal hyperten-sion, the combination of thrombocytopenia and coagulation factor deficiency not only increase the risk of bleeding associated with surgery, they also are relative or absolute contraindications to a variety of anesthetic techniques, such as subarachnoid blocks and epidural anesthesia. Presence of esophageal varices increases the risk of gastric tubes and transesophageal echocardiography.Endocrine DiseasePerioperative management of the diabetic patient can be espe-cially challenging. A hemoglobin A1c level should be obtained if a recent level is not available, as an increased A1c level is asso-ciated with an | Surgery_Schwartz. the free plasma levels of drugs, which can also exagger-ate their effects. In patients with substantial ascites, high intra-abdominal pressure may increase the risk of passive gastric reflux, and thus many such patients are managed as if they have a full stomach, regardless of how long they have been NPO. In patients with significant hepatocellular dysfunction and/or portal hyperten-sion, the combination of thrombocytopenia and coagulation factor deficiency not only increase the risk of bleeding associated with surgery, they also are relative or absolute contraindications to a variety of anesthetic techniques, such as subarachnoid blocks and epidural anesthesia. Presence of esophageal varices increases the risk of gastric tubes and transesophageal echocardiography.Endocrine DiseasePerioperative management of the diabetic patient can be espe-cially challenging. A hemoglobin A1c level should be obtained if a recent level is not available, as an increased A1c level is asso-ciated with an |
Surgery_Schwartz_13296 | Surgery_Schwartz | management of the diabetic patient can be espe-cially challenging. A hemoglobin A1c level should be obtained if a recent level is not available, as an increased A1c level is asso-ciated with an increase in perioperative complications including wound infections.39-41 Several institutions have implemented pro-tocols for glucose management for diabetic patients undergoing surgery, although recommendations differ on appropriate target glucose levels.39,42,43 Perhaps the most important thing for a prac-titioner to know and remember is that the difference between type 1 and type 2 diabetes is important, and that these two differ-ent diseases require different approaches to their management. In general, patients with type 2 diabetes have a lower risk of becom-ing hypoglycemic, tend to have higher blood sugars at baseline, and tolerate higher levels of serum glucose without significant acute hazard. Patients with type 1 diabetes, who are deficient in insulin production and thus require | Surgery_Schwartz. management of the diabetic patient can be espe-cially challenging. A hemoglobin A1c level should be obtained if a recent level is not available, as an increased A1c level is asso-ciated with an increase in perioperative complications including wound infections.39-41 Several institutions have implemented pro-tocols for glucose management for diabetic patients undergoing surgery, although recommendations differ on appropriate target glucose levels.39,42,43 Perhaps the most important thing for a prac-titioner to know and remember is that the difference between type 1 and type 2 diabetes is important, and that these two differ-ent diseases require different approaches to their management. In general, patients with type 2 diabetes have a lower risk of becom-ing hypoglycemic, tend to have higher blood sugars at baseline, and tolerate higher levels of serum glucose without significant acute hazard. Patients with type 1 diabetes, who are deficient in insulin production and thus require |
Surgery_Schwartz_13297 | Surgery_Schwartz | higher blood sugars at baseline, and tolerate higher levels of serum glucose without significant acute hazard. Patients with type 1 diabetes, who are deficient in insulin production and thus require insulin administration to pre-vent ketosis, are far more likely to become hypoglycemic when subjected to stress, and they are also at risk for developing keto-acidosis with hyperglycemia. Patients with type 1 diabetes merit more careful monitoring of their blood sugars in the periopera-tive setting than patients with type 2 diabetes.44-47Preoperative FastingThe ASA has developed specific guidelines for preoperative fasting to mitigate the risk of aspiration of gastric contents. Table 46-6 shows guidelines for preoperative food and fluid intake for elective procedures. Individual patients may need lengthier fasting times than the guidelines indicate. Notably, a rapid sequence induction and intubation should be considered in patients who are at higher risk for aspiration such as those with | Surgery_Schwartz. higher blood sugars at baseline, and tolerate higher levels of serum glucose without significant acute hazard. Patients with type 1 diabetes, who are deficient in insulin production and thus require insulin administration to pre-vent ketosis, are far more likely to become hypoglycemic when subjected to stress, and they are also at risk for developing keto-acidosis with hyperglycemia. Patients with type 1 diabetes merit more careful monitoring of their blood sugars in the periopera-tive setting than patients with type 2 diabetes.44-47Preoperative FastingThe ASA has developed specific guidelines for preoperative fasting to mitigate the risk of aspiration of gastric contents. Table 46-6 shows guidelines for preoperative food and fluid intake for elective procedures. Individual patients may need lengthier fasting times than the guidelines indicate. Notably, a rapid sequence induction and intubation should be considered in patients who are at higher risk for aspiration such as those with |
Surgery_Schwartz_13298 | Surgery_Schwartz | need lengthier fasting times than the guidelines indicate. Notably, a rapid sequence induction and intubation should be considered in patients who are at higher risk for aspiration such as those with very symptomatic gastroesophageal reflux, achala-sia, gastroparesis, or dysmotility, regardless of fasting status.48Patients With Advanced DirectivesPatients with do not resuscitate (DNR) and/or do not intu-bate (DNI) orders present a unique challenge. Patients or their power-of-attorney may choose to rescind these directives in the perioperative period, maintain them as originally ordered, or modify them to allow for a limited resuscitation. Both the ASA and the American College of Surgeons recommend that preoperative discussions with the patient and their family clarify the patient’s wishes, and both societies emphasize that policies that mandate uniform enforcement or disregarding of all DNR orders take away patients’ right to self-determination.49,50Risk EstimationSeveral risk | Surgery_Schwartz. need lengthier fasting times than the guidelines indicate. Notably, a rapid sequence induction and intubation should be considered in patients who are at higher risk for aspiration such as those with very symptomatic gastroesophageal reflux, achala-sia, gastroparesis, or dysmotility, regardless of fasting status.48Patients With Advanced DirectivesPatients with do not resuscitate (DNR) and/or do not intu-bate (DNI) orders present a unique challenge. Patients or their power-of-attorney may choose to rescind these directives in the perioperative period, maintain them as originally ordered, or modify them to allow for a limited resuscitation. Both the ASA and the American College of Surgeons recommend that preoperative discussions with the patient and their family clarify the patient’s wishes, and both societies emphasize that policies that mandate uniform enforcement or disregarding of all DNR orders take away patients’ right to self-determination.49,50Risk EstimationSeveral risk |
Surgery_Schwartz_13299 | Surgery_Schwartz | wishes, and both societies emphasize that policies that mandate uniform enforcement or disregarding of all DNR orders take away patients’ right to self-determination.49,50Risk EstimationSeveral risk calculators have been developed to estimate peri-operative morbidity and mortality. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical risk calculator allows for estimation of risk of eight different adverse outcomes, including mortality.51 The Society of Thoracic Surgeons risk calculator estimates risk of morbidity and mortality after cardiac surgical procedures.52 While such risk estimators can provide widely differing esti-mates or may be inaccurate in certain situations,53 they are still invaluable aids for discussions with patients and their families about high-risk surgery.INTRAOPERATIVE MANAGEMENTGeneral AnesthesiaGeneral anesthesia remains the cornerstone of anesthesia prac-tice; many surgical procedures cannot be done under regional | Surgery_Schwartz. wishes, and both societies emphasize that policies that mandate uniform enforcement or disregarding of all DNR orders take away patients’ right to self-determination.49,50Risk EstimationSeveral risk calculators have been developed to estimate peri-operative morbidity and mortality. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical risk calculator allows for estimation of risk of eight different adverse outcomes, including mortality.51 The Society of Thoracic Surgeons risk calculator estimates risk of morbidity and mortality after cardiac surgical procedures.52 While such risk estimators can provide widely differing esti-mates or may be inaccurate in certain situations,53 they are still invaluable aids for discussions with patients and their families about high-risk surgery.INTRAOPERATIVE MANAGEMENTGeneral AnesthesiaGeneral anesthesia remains the cornerstone of anesthesia prac-tice; many surgical procedures cannot be done under regional |
Surgery_Schwartz_13300 | Surgery_Schwartz | families about high-risk surgery.INTRAOPERATIVE MANAGEMENTGeneral AnesthesiaGeneral anesthesia remains the cornerstone of anesthesia prac-tice; many surgical procedures cannot be done under regional techniques or monitored anesthesia care with sedation.The induction of general anesthesia can precipitate cata-strophic anesthetic complications. Many different techniques can be used to induce general anesthesia, each with significant advantages and disadvantages.Intravenous induction, used primarily in adults, quickly produces unconsciousness, and depending on the agent used, apnea as well. Propofol, the most common induction agent currently used, can cause hypotension due to its myocardial depressing and vasodilatory properties. Hypertension and 4Table 46-6Guidelines for food and fluid intake before elective surgeryTIME BEFORE SURGERYFOOD OR FLUID INTAKEUp to 8 hoursFood and fluids as desiredUp to 6 hoursaLight meal, infant formulaUp to 4 hoursBreast milkUp to 2 hoursClear liquids | Surgery_Schwartz. families about high-risk surgery.INTRAOPERATIVE MANAGEMENTGeneral AnesthesiaGeneral anesthesia remains the cornerstone of anesthesia prac-tice; many surgical procedures cannot be done under regional techniques or monitored anesthesia care with sedation.The induction of general anesthesia can precipitate cata-strophic anesthetic complications. Many different techniques can be used to induce general anesthesia, each with significant advantages and disadvantages.Intravenous induction, used primarily in adults, quickly produces unconsciousness, and depending on the agent used, apnea as well. Propofol, the most common induction agent currently used, can cause hypotension due to its myocardial depressing and vasodilatory properties. Hypertension and 4Table 46-6Guidelines for food and fluid intake before elective surgeryTIME BEFORE SURGERYFOOD OR FLUID INTAKEUp to 8 hoursFood and fluids as desiredUp to 6 hoursaLight meal, infant formulaUp to 4 hoursBreast milkUp to 2 hoursClear liquids |
Surgery_Schwartz_13301 | Surgery_Schwartz | intake before elective surgeryTIME BEFORE SURGERYFOOD OR FLUID INTAKEUp to 8 hoursFood and fluids as desiredUp to 6 hoursaLight meal, infant formulaUp to 4 hoursBreast milkUp to 2 hoursClear liquids onlyaLight meal refers to a limited amount of easily digestible food, such as toast or crackers. Individual patients may need lengthier fasting times than these guidelines indicate.Adapted with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.Brunicardi_Ch46_p2027-p2044.indd 203601/03/19 11:04 AM 2037ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46tachycardia commonly occur during laryngoscopy or other sig-nificant airway stimulation.The goal of a rapid sequence induction (RSI) is to achieve secure protection of the airway with a cuffed endotracheal tube without ever mask ventilating a patient. It is intended to prevent vomiting and aspiration, and it is routinely employed in patients at heightened risk for | Surgery_Schwartz. intake before elective surgeryTIME BEFORE SURGERYFOOD OR FLUID INTAKEUp to 8 hoursFood and fluids as desiredUp to 6 hoursaLight meal, infant formulaUp to 4 hoursBreast milkUp to 2 hoursClear liquids onlyaLight meal refers to a limited amount of easily digestible food, such as toast or crackers. Individual patients may need lengthier fasting times than these guidelines indicate.Adapted with permission from Longnecker DE, Mackey SC, Newman MF, et al: Anesthesiology, 3rd ed. New York, NY: McGraw-Hill Education; 2018.Brunicardi_Ch46_p2027-p2044.indd 203601/03/19 11:04 AM 2037ANESTHESIA FOR SURGICAL PATIENTSCHAPTER 46tachycardia commonly occur during laryngoscopy or other sig-nificant airway stimulation.The goal of a rapid sequence induction (RSI) is to achieve secure protection of the airway with a cuffed endotracheal tube without ever mask ventilating a patient. It is intended to prevent vomiting and aspiration, and it is routinely employed in patients at heightened risk for |
Subsets and Splits