Questions and Answers
What is the primary aim when mechanically ventilating?
What is a common intraoperative challenge specific to LVAD patients?
Suction events, power failure, and LVAD pump thrombosis
LVAD pump thrombosis rarely occurs intraoperatively.
True
Which treatments may be used for suction events in LVAD patients?
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Hypertrophic cardiomyopathy is characterized by asymmetric LV ______.
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What should be maintained to avoid worsening outflow obstruction in hypertrophic cardiomyopathy?
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Which of the following factors can worsen outflow obstruction in hypertrophic cardiomyopathy?
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Dysrhythmias in patients with congenital heart disease are uncommon.
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What is a potential risk for cyanotic congenital heart disease patients?
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In what circumstances should infective endocarditis prophylaxis be considered for congenital heart disease patients?
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What was Dr. Richard Kitz's vision for the manual of anesthetic practice?
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The chapters of the manual were passed on from generation to generation without updates.
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What significant global event influenced the writing of the 10th edition of the manual?
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The manual is designed to be a source of information for practicing anesthesiologists, CRNAs, and other __________ professionals.
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What is noted as essential for maintaining normalcy during the writing of the book?
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Match the following components of preoperative evaluation:
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True allergic reactions are considered common in patients.
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What kinds of medications are particularly important to review during preoperative evaluations?
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What is defined as an emergency procedure according to ACC/AHA guidelines?
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What are the clinical risk factors for major adverse cardiac events (MACE)?
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Cardiac catheterization is not considered the gold standard for evaluating coronary artery disease (CAD).
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Which medication is generally recommended to be continued in the perioperative period for patients already taking it?
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The risk of ischemic events is greatest within _____ days of PCI.
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What is myocardial ischemia?
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What is the primary treatment goal for managing ischemic heart disease (IHD)?
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Tachycardia is well tolerated in patients with atherosclerotic coronary arteries.
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Patients with heart failure manifest symptoms such as ______, fatigue, and pulmonary edema.
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What type of heart failure is characterized by reduced ejection fraction?
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Patients with LVADs are typically good candidates for regional anesthesia techniques.
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Which of the following are common symptoms of an allergic reaction?
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90% to 99% of patients who self-report a penicillin allergy have a negative skin test.
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What is the primary determinant of immunological reaction to a cephalosporin in patients with a penicillin allergy?
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Patients with a documented reaction to __________ are at risk if exposed to the same agent.
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What percentage of individuals with banana or avocado allergies may have cross-reactive allergies to latex?
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An allergy to amide-type local anesthetics is exceedingly common.
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What should be established for patients with poorly controlled hypertension before surgery?
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Which of the following describes a high likelihood of fluid responsiveness in a patient?
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The diameter of the IVC indicates filling pressures when it is less than _______ cm and collapses more than 50% with sniff.
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Match the following allergies with their characteristic risks:
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Study Notes
Handbook of Clinical Anesthesia Procedures
- The 10th edition of the Handbook of Clinical Anesthesia Procedures of the Massachusetts General Hospital was published in 2022.
- It is edited by Richard M. Pino, MD, PhD, FCCM with associate editors Edward A. Bittner, MD, PhD, FCCM, Hovig V. Chitilian, MD, Wilton C. Levine, MD, and Susan A. Vassallo, MD.
Contributors
- The handbook has contributions from over 100 authors, including anesthesiologists, residents, and certified registered nurse anesthetists from Massachusetts General Hospital and other institutions.
- The contributors come from various departments, including the Department of Anesthesia, Critical Care, and Pain Medicine at Massachusetts General Hospital.
Copyright and Publishing Information
- The handbook is published by Wolters Kluwer and copyrighted in 2022, 2016, 2010, 2007, 2002, and 1998 by Wolters Kluwer or its predecessors.
- The publication is protected by copyright, and no part of it may be reproduced or transmitted without written permission from the copyright owner.
Disclaimer and Medical Liability
- The handbook is provided "as is" without warranties of any kind, and the publisher disclaims any liability for damages or injuries resulting from its use.
- The handbook is not a substitute for individual patient assessment and medical judgment, and healthcare professionals are solely responsible for using the information provided.
- The publisher does not provide medical advice or guidance, and healthcare professionals should consult multiple sources and verify information before making medical decisions.### Evaluating the Patient Before Anesthesia
I. Introduction
- The clinic model for anesthesiologists' preoperative evaluation of patients is evolving
- The approach is being modified to include telemedicine consults, electronic consults (eConsults), and deferring the entire evaluation to the day of surgery
- The basic tenets of preoperative evaluation remain the same
II. History
- Relevant information is obtained through chart review and patient interview
- The anesthesiologist should review:
- History of presenting illness
- Medications (including dosing and schedules)
- Allergies and drug reactions
- True allergic reactions vs. adverse reactions
- Specific examples: antibiotic allergy, soybean oil and/or egg yolk allergy, inhalational agent or succinylcholine "allergy", local anesthetic allergy, shellfish or seafood allergy, latex allergy
- Anesthetic history
- Prior experience with anesthesia
- Response to medications (e.g., sedative, analgesic, anesthetic agents)
- Vascular access and invasive monitoring (e.g., ultrasound-guided IV placement, central access)
- Airway management (e.g., ease of mask ventilation, view obtained on direct laryngoscopy)
- Perianesthetic complications (e.g., adverse drug reactions, dental injury, PONV, hemodynamic instability)
- Family history of adverse anesthetic outcomes
- Social history and habits
- Smoking (cessation counseling and support)
- Drug and alcohol use (type, routes, frequency, and timing of use)
III. Review of Systems
- The purpose of review of systems (ROS) is to elicit symptoms of occult disease and determine the stability of current disease
- The ROS should include:
- Cardiovascular system
- Coronary artery disease (CAD) and its implications (e.g., spontaneous myocardial ischemia, demand ischemia, ventricular dysfunction)
- Pacemakers (permanent pacemaker, PPM) and implanted cardioverter-defibrillators (ICD)### HTN and Cardiovascular Disease
- Cardiovascular system
- Poorly controlled HTN is associated with marked preoperative HTN and labile intraoperative pressures.
- Patients with DOE should be evaluated and referred for appropriate testing to determine etiology and treatment.
- Assessment of functional capacity helps in risk stratification for predicting perioperative cardiac events.
Right Ventricular Function and Assessment
- Right ventricular wall thickness can be measured by TTE using the subcostal four-chamber view.
- Normal right ventricular wall thickness is less than 5 mm.
- Right ventricular dilation can be evaluated in the apical four-chamber view, with a normal value of less than 4.2 cm.
IVC and Hemodynamic Measurements
- IVC diameter can be assessed by surface ultrasound and correlates with central venous pressure (CVP).
- IVC diameter less than 2.1 cm with collapse more than 50% indicates normal filling pressures, CVP < 5 mm Hg.
- IVC diameter greater than 2.1 cm with collapse less than 50% indicates elevated filling pressures, CVP > 15 mm Hg.
Doppler Ultrasound
- Doppler ultrasound can measure velocity and infer pressure and flow.
- There are three main modes of Doppler: continuous wave, pulse wave, and color.
- Continuous wave Doppler measures the highest velocity of blood flow along the path of the beam.
- Pulse wave Doppler measures velocity at a specific location, but is limited by the Nyquist limit.
- Color Doppler allows visualization of flow overlaid on the 2D image, but is also limited to accurate measurement of lower velocities.
Fluid Responsiveness
- Fluid responsiveness is defined by a 10% to 15% increase in stroke volume after receiving a 500 mL fluid bolus over 10 to 15 minutes.
- Dynamic echocardiographic parameters, such as SVV, IVC variation, passive leg raise testing, and fluid challenge, are more evidence-supported indices for determining fluid responsiveness.
- Static echocardiographic parameters, such as LVEDA and LVESA, are poor predictors of volume responsiveness.
Conclusion
- Point-of-care cardiac ultrasound is a powerful tool for the bedside clinician.
- Echocardiography allows for rapid and repeated evaluation of patients, supplementing physical examination and obviating the potential risk involved in waiting for, or transporting an unstable patient for, additional forms of diagnostic testing.
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Description
This quiz is based on the 10th edition of the Handbook of Clinical Anesthesia Procedures of the Massachusetts General Hospital. It covers anesthesia procedures and techniques in critical care and pain medicine. Test your knowledge on anesthesia procedures and medical concepts.
