Decision Making in Anesthesiology. An Algorithmic Approach

599 Pages·15.758 MB·English

by  Lois L. Bready, MD, Dawn Dillman, MD, and Susan H. Noorily, MD (Eds.)

Decision
Making in
Anesthesiology
An Algorithmic Approach
4th Edition
Lois L. Bready, MD
Associate Dean for Graduate Medical Education
Professor and Vice Chair
Department of Anesthesiology
University of Texas Health Sciences Center in San Antonio
San Antonio, Texas
Dawn Dillman, MD
Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University
Portland, Oregon
Susan H. Noorily, MD
Clinical Professor
Department of Anesthesiology
University of Texas Health Sciences Center in San Antonio
San Antonio, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
DECISION MAKING IN ANESTHESIOLOGY:
AN ALGORITHMIC APPROACH, FOURTH EDITION ISBN: 978-0-323-03938-3
Copyright © 2007 by Mosby, Inc., an imprint of Elsevier Inc.
All rights reserved.No part of this publication may be reproduced or transmitted in any form or by
any means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher.
Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia,
PA, USA: phone: [phone], fax: [phone], e-mail: [email protected].
You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com) by
selecting ‘Customer Support’ and then ‘Obtaining Permissions’.
Notice
Neither the Publisher nor the Authors assume any responsibility for any loss or injury and/or damage
to persons or property arising out of or related to any use of the material contained in this book. It is
the responsibility of the treating practitioner, relying on independent expertise and knowledge of the
patient, to determine the best treatment and method of application for the patient.
The Publisher
Previous editions copyrighted 1987, 1992, 2007
Library of Congress Cataloging-in-Publication Data
Decision making in anesthesiology : an algorithmic approach / [edited by] Lois L. Bready, Susan H.
Noorily, Dawn Dillman. — 4th ed.
p. ; cm
Includes bibliographical references and index.
ISBN 978-0-323-03938-3
1. Anesthesia—Decision making. 2. Algorithms. I. Bready, Lois L. II. Noorily, Susan H. (Susan Helene)
III. Dillman, Dawn.
[DNLM: 1. Anesthesia—methods. 2. Decision Trees. 3. Perioperative Case—methods.
WO 200 D294 2007]
RD82.D43 2007
617.9’6–dc22
2007018660
Acquisitions Editor: Natasha Andjelkovic
Editorial Assistant: Isabel Trudeau
Project Manager: David Salzberg
Design Direction: Ellen Zanolle
Printed in the United States of America
9 8 7 6 5 4 3 2 1
CONTRIBUTORS
Stacey Allen, MD Daniel Martin Bitner, MD, MS
Department of Anesthesiology Department of Anesthesiology
University of Texas Health Sciences Center University of Texas Health Sciences Center
in San Antonio, in San Antonio
San Antonio, Texas San Antonio, Texas
D.M. Anderson, MD Mary Blanchette, MD
Department of Anesthesiology Department of Anesthesiology and Perioperative
University of Texas Health Sciences Center Medicine
in San Antonio Oregon Health Sciences University
San Antonio, Texas Portland, Oregon
Franklin L. Anderson, MD Erik A. Boatman, MD
Department of Anesthesiology San Antonio Uniformed Services Health Education
University of Texas Health Sciences Center Consortium
in San Antonio San Antonio, Texas
San Antonio, Texas
Gwendolyn L. Boyd, MD
J. Jeff Andrews, MD Department of Anesthesiology
Department of Anesthesiology University of Alabama at Birmingham School
University of Texas Health Sciences Center of Medicine
in San Antonio Birmingham, Alabama
San Antonio, Texas
Christopher A. Bracken, MD, PhD
William P. Arnold III, MD Department of Anesthesiology
Department of Anesthesia University of Texas Health Sciences Center
University of Virginia in San Antonio
Charlottesville, Virginia San Antonio, Texas
Patrick Bakke, MD Carol R. Bradford, MD
Department of Anesthesiology and Perioperative Medicine Department of Otolaryngology
Oregon Health Sciences University University of Michigan Medical Center
Portland, Oregon Ann Arbor, Michigan
Joanne Baust, MD Kevin M. Brady, MD
Department of Anesthesiology Department of Anesthesiology and Critical Care
University of Texas Health Sciences Center Medicine
in San Antonio The Johns Hopkins Medical Institutions
San Antonio, Texas Baltimore, Maryland
Jonathan L. Benumof, MD Ansgar M. Brambrink, MD, PhD
Department of Anesthesia Department of Anesthesiology and Perioperative
University of California at San Diego Medicine
San Diego, California Oregon Health Sciences University
Portland, Oregon
Lauren Berkow, MD
Department of Anesthesiology and Critical Care Darin Brandt, DO
Medicine Department of Anesthesiology and Perioperative Medicine
The Johns Hopkins Medical Institutions Oregon Health Sciences University
Baltimore, Maryland Portland, Oregon
Arnold J. Berry, MD, MPH Lois L. Bready, MD
Department of Anesthesiology Department of Anesthesiology
Emory University School of Medicine University of Texas Health Sciences Center
Atlanta, Georgia in San Antonio
San Antonio, Texas
iii
iv CONTRIBUTORS
Russell C. Brockwell, MD John A. Dilger, MD
Department of Anesthesiology Department of Anesthesiology
University of Alabama at Birmingham Mayo Clinic
Birmingham, Alabama Rochester, Maryland
David M. Broussard, MD Dawn Dillman, MD
Department of Anesthesiology Department of Anesthesiology and Perioperative Medicine
Ochsner Clinical Foundation Oregon Health Sciences University
New Orleans, Louisiana Portland, Oregon
Allan C.D. Brown, MD Stephen Donahue, MD
Department of Anesthesiology Anesthesiologists for Children
University of Michigan Medical Center Dallas, Texas
Ann Arbor, Michigan
Nivine H. Doran, MD
Carol E. Campbell, MD Department of Anesthesiology and Critical Care
Department of Anesthesiology Medicine
University of Texas Health Sciences Center University of New Mexico
in San Antonio Albuquerque, New Mexico
San Antonio, Texas
M. Joanne Douglas, MD
A. Sue Carlisle, MD, PhD Department of Anesthesia
University of British Columbia
Department of Anesthesia and Perioperative Care
Vancouver, British Columbia, Canada
University of California San Francisco and San Francisco
General Hospital
George A. Dumitrascu, MD
San Francisco, California
Ottawa, Ontario, Canada
Bonny Carter, MD
Lynn A. Fenton, MD
Department of Anesthesiology
Department of Anesthesiology and Perioperative Medicine
University of Texas Health Sciences Center
Oregon Health Sciences University
in San Antonio
Portland, Oregon
San Antonio, Texas
Juergen Fleisch, MD
Lydia Cassorla, MD, MBA
Department of Anesthesiology and Perioperative Medicine
Department of Anesthesia and Perioperative Care
Oregon Health Sciences University
University of California San Francisco
Portland, Oregon
San Francisco, California
Judith A. Freeman, MD, CHB
Harold D. Cline, MD
Department of Anesthesiology and Perioperative Medicine
Department of Anesthesiology Oregon Health Sciences University
University of Maryland Medical Center Portland, Oregon
Baltimore, Maryland
Thomas Frietsch, MD
Corey Collins, DO
Department of Anesthesiology and Perioperative Medicine
Medford, Massachusetts Oregon Health Sciences University
Portland, Oregon
Sally Combest, MD
Department of Anesthesiology William R. Furman, MD
University of Texas Health Sciences Center Department of Anesthesiology
in San Antonio University of North Carolina
San Antonio, Texas Chapel Hill, North Carolina
Saundra E. Curry, MD Susan Garwood, MD, ChB, BSc, FRCA
Department of Anesthesiology Department of Anesthesiology
Columbia University College of Physicians and Yale School of Medicine
Surgeons Yale-New Haven Hospital
New York, New York New Haven, Connecticut
Myrdalis Diaz-Ramirez, MD Ethan Gaumond, MD
Department of Anesthesiology and Perioperative Care Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University Oregon Health Sciences University
Portland, Oregon Portland, Oregon
CONTRIBUTORS v
Kevin B. Gerold, DO, JD Vivian Hou, MD
Department of Anesthesiology and Critical Care Department of Anesthesiology and Perioperative Medicine
Medicine Oregon Health Sciences University
The Johns Hopkins Medical Institutions Portland, Oregon
Johns Hopkins Bayview Medical Center
Baltimore, Maryland Michael P. Hutchens, MD, MA
Department of Anesthesiology and Perioperative Medicine
James D. Griffin, MD Oregon Health Sciences University
Department of Anesthesiology and Pain Management Portland, Oregon
University of Texas Southwestern Medical Center at
Dallas Per-Olof Jarnberg, MD, PhD
Dallas, Texas Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University
Mary Ann Gurkowski, MD Portland, Oregon
Department of Anesthesiology
University of Texas Health Sciences Center Wendy B. Kang, MD, JD
in San Antonio Department of Anesthesiology
San Antonio, Texas University of Texas Health Sciences Center in San Antonio
San Antonio, Texas
Charles B. Hantler, MD
Department of Anesthesiology Suzanne B. Karan, MD
Washington University Department of Anesthesiology
St. Louis, Missouri University of Rochester School of Medicine
and Dentistry
Jinny Kim Hartman, MD Rochester, New York
Department of Anesthesiology
Dartmouth-Hitchcock Medical Center Celia I. Kaye, MD, PhD
Lebanon, New Hampshire Department of Pediatrics
University of Colorado Health Sciences Center
Joy L. Hawkins, MD Denver, Colorado
Department of Anesthesia
University of Colorado Health Sciences Center Angela Kendrick, MD
Denver, Colorado Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University
Eugenie Heitmiller, MD Portland, Oregon
Department of Anesthesiology and Critical Care
Medicine Jeffrey R. Kirsch, MD
The Johns Hopkins Medical Institutions Department of Anesthesiology and Perioperative Medicine
Baltimore, Maryland Oregon Health Sciences University
Portland, Oregon
Antonio Hernandez, MD
Department of Anesthesiology Kevin K. Klein, MD
University of Texas Health Sciences Center Department of Anesthesiology and Pain Management
in San Antonio University of Texas Southwestern Medical Center at
San Antonio, Texas Dallas
Dallas, Texas
Rosemary Hickey, MD
Department of Anesthesiology Ines P. Koerner, MD
University of Texas Health Sciences Center Department of Anesthesiology and Perioperative
in San Antonio Medicine
San Antonio, Texas Oregon Health Sciences University
Portland, Oregon
Joseph R. Holahan, MD
South Texas Oncology and Hematology PA Hector LaCassie, MD
San Antonio, Texas Department of Anesthesiology
Duke University Health System
W. Corbett Holmgreen, MD, DDS Durham, North Carolina
Department of Anesthesiology
University of Texas Health Sciences Center Kirk Lalwani, MD
in San Antonio Department of Anesthesiology and Perioperative Medicine
San Antonio, Texas Oregon Health Sciences University
Portland, Oregon
vi CONTRIBUTORS
Marilyn Green Larach, MD, FAAP Kimberly D. Milhoan, MD
Owing Mills, Maryland Department of Anesthesiology
University of Texas Health Sciences Center in San Antonio
Catherine K. Lineberger, MD San Antonio, Texas
Department of Anesthesiology
Duke University Health System Tobias Moeller-Bertram, MD
Durham, North Carolina Department of Anesthesiology
University of California at San Diego
John J. Liszka-Hackzell, MD, PhD
San Diego, California
Department of Anesthesiology
University of Arizona College of Medicine Joseph J. Naples, MD
Tucson, Arizona
Department of Anesthesiology
The Methodist Hospital
Robert Loeb, MD
Houston, Texas
Department of Anesthesiology
University of Arizona College of Medicine
David V. Nelson, PhD
Tucson, Arizona
Department of Psychology and Philosophy
Sam Houston State University
Gaelan B. Luhn, MD
Huntsville, Texas
Department of Anesthesiology
University of Texas Health Sciences Center
Christopher D. Newell, MD
in San Antonio
Department of Anesthesiology and Perioperative Medicine
San Antonio, Texas
Oregon Health Sciences University
Colin F. Mackenzie, MD, ChB, FCCM Portland, Oregon
Department of Anesthesiology
Victor Ng, MD
University of Maryland Medical Center
Baltimore, Maryland Department of Anesthesia and Perioperative Care
University of California San Francisco
T. Philip Malan, Jr., MD, PhD San Francisco, California
Department of Anesthesiology
University of Arizona College of Medicine Dolores B. Njoku, MD
Tucson, Arizona Department of Anesthesiology and Critical Care Medicine
The Johns Hopkins Medical Institutions
Vinod Malhotra, MD Baltimore, Maryland
Department of Anesthesiology
Weill Medical College of Cornell University Susan H. Noorily, MD
New York, New York Department of Anesthesiology
University of Texas Health Sciences Center
David C. Mayer, MD
in San Antonio
Department of Anesthesiology San Antonio, Texas
University of North Carolina
Chapel Hill, North Carolina J. Russell Norton, MD
Department of Anesthesiology
Kathryn E. McGoldrick, MD
University of Rochester School of Medicine and
Department of Anesthesiology
Dentistry
New York Medical College
Rochester, New York
Valhalla, New York
Steven C. Onstad
Katherine R. McGuire, MD
Department of Anesthesiology and Perioperative Medicine
Department of Anesthesiology
Oregon Health Sciences University
University of Texas Health Sciences Center in San Antonio
Portland, Oregon
San Antonio, Texas
William T. Merritt, MD, MBA James C. Opton, MD
Department of Anesthesiology and Critical Care Medicine Department of Anesthesiology and Perioperative Medicine
The Johns Hopkins Medical Institutions Oregon Health Sciences University
Baltimore, Maryland Portland, Oregon
Sara M. Metcalf, MD Malcolm D. Orr, MD, PhD
Department of Anesthesiology and Perioperative Medicine Department of Anesthesiology
Oregon Health Sciences University University of Texas Health Sciences Center in San Antonio
Portland, Oregon San Antonio, Texas
CONTRIBUTORS vii
Robert H. Overbaugh, MD Marco S. Robin, DO
Department of Anesthesiology Department of Anesthesiology and Perioperative Medicine
Penn State Milton S. Hershey Medical Center Oregon Health Sciences University
Hershey, Pennsylvania Portland, Oregon
Fred G. Panico, MD Stephen T. Robinson, MD
Seaford, Delaware Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University
Cathleen L. Peterson-Layne, MD, PhD
Portland, Oregon
Department of Anesthesiology
Duke University Health System James N. Rogers, MD
Durham, North Carolina Department of Anesthesiology
University of Texas Health Sciences Center
Michael G. Phillips, BHS, PA-C
in San Antonio
University of Alabama at Birmingham San Antonio, Texas
School of Medicine
Birmingham, Alabama Mark A. Rosen, MD
Department of Anesthesia and Perioperative Care
Jorge Pineda, MD
University of California San Francisco
Department of Anesthesiology and Perioperative
San Francisco, California
Medicine
Oregon Health Sciences University Renata Rusa, MD
Portland, Oregon
Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University
Anthony S. Poon, MD, DDS, PhD
Portland, Oregon
Department of Oral and Maxillofacial Surgery
University of Texas Health Sciences Center
Andrew S. Rushton, MD
in San Antonio
Department of Anesthesiology and Perioperative
San Antonio, Texas
Medicine
Oregon Health Sciences University
Marcelo Quezado, MD
Portland, Oregon
Department of Anesthesiology and Critical Care
Medicine
Susan M. Ryan, MD
The Johns Hopkins Medical Institutions
Department of Anesthesia and Perioperative Care
Baltimore, Maryland
University of California San Francisco
Rajam S. Ramamurthy, MD San Francisco, California
Department of Anesthesiology
Lauren L. Salgado, MD
University of Texas Health Sciences Center
Department of Anesthesiology
in San Antonio
University of Texas Health Sciences Center in San Antonio
San Antonio, Texas
San Antonio, Texas
Somayaji Ramamurthy, MD
Jamie McElrath Schwartz, MD
Department of Anesthesiology
University of Texas Health Sciences Center Department of Anesthesiology and Critical Care Medicine
in San Antonio The Johns Hopkins Medical Institutions
San Antonio, Texas Baltimore, Maryland
Deborah K. Rasch, MD Jaydeep S. Shah, MD
Department of Anesthesiology Department of Anesthesiology
University of Texas Health Sciences Center University of Texas Health Sciences Center
in San Antonio in San Antonio
San Antonio, Texas San Antonio, Texas
Jeffrey M. Richman, MD David I. Shapiro, MD
Department of Anesthesiology and Critical Care Medicine Department of Anesthesiology
The Johns Hopkins Medical Institutions Erie County Medical Center
Baltimore, Maryland Buffalo, New York
Kerri M. Robertson, MD Aarti Sharma, MD
Department of Anesthesiology Department of Anesthesiology
Duke University Health System Weill Medical College of Cornell University
Durham, North Carolina New York, New York
viii CONTRIBUTORS
Nicholas R. Simmons, MD Michael Verber, MD
Department of Anesthesiology Department of Anesthesiology
Washington University University of Texas Health Sciences Center
St. Louis, Missouri in San Antonio
San Antonio, Texas
Gary D. Skrivanek, MD
Department of Anesthesiology and Pain Management Jennifer F. Vookles, MD
University of Texas Southwestern Medical Center at Department of Anesthesiology and Perioperative
Dallas Medicine
Dallas, Texas Oregon Health Sciences University
Portland, Oregon
Tod B. Sloan, MD, PhD
Department of Anesthesiology David B. Waisel, MD
University of Colorado Health Sciences Center Department of Anesthesiology
Denver, Colorado Boston Children’s Hospital
Boston, Massachusetts
Fred J. Spielman, MD
Department of Anesthesiology Tessa L. Walters, MD
University of North Carolina Burlingame, California
Chapel Hill, North Carolina
Denham S. Ward, MD, PhD
Louis A. Stool, MD Department of Anesthesiology
Department of Anesthesiology and Pain Management University of Rochester School of Medicine and
University of Texas Southwestern Medical Center at Dentistry
Dallas Rochester, New York
Dallas, Texas
Leila G. Welborn, MD
Vijayendra Sudheendra, MD Department of Anesthesiology
Department of Surgery Children’s National Medical Center
Brown University Washington, DC
Providence, Rhode Isaland
Gary Welch, MD
Melba W.G. Swafford, MD Mico, Texas
Department of Anesthesiology
Baylor College of Medicine Lynda T. Wells, MD
Houston, Texas Department of Anesthesiology
University of Virginia Health System
Veronica C. Swanson, MD Charlottesville, Virginia
Department of Anesthesiology and Perioperative Medicine
Oregon Health Sciences University James R. Zaidan, MD, MBA
Portland, Oregon Department of Anesthesiology
Emory University School of Medicine
Jeffrey E. Terrell, MD Atlanta, Georgia
Department of Anesthesiology
University of Michigan Medical Center Angela Zimmerman, MD
Ann Arbor, Michigan Department of Anesthesiology and Perioperative
Medicine
John E. Tetzlaff, MD Oregon Health Sciences University
Division of Anesthesiology Portland, Oregon
Cleveland Clinic
Cleveland, Ohio Marcos A. Zuazu, MD
Department of Anesthesiology
Mohamed Tiouririne, MD University of Texas Health Sciences Center
Department of Anesthesiology in San Antonio
University of Virginia Health System San Antonio, Texas
Charlottesville, Virginia
Irena Vaitkeviciute, MD
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut
PREFACE
The purpose of Decision Making in Anesthesiology is to anesthesiology residents. In learning the practice of
present the process of anesthetic management during anesthesiology or reviewing an unfamiliar procedure, it is
the perioperative period in a decision-tree format. Thus, very helpful to have immediate access to an experienced
this work is not intended to replace major anesthesia consultant who can suggest a reasonable approach and
textbooks but rather to illustrate how to employ the review special surgical requirements (and potential
information they contain. This format encourages the pitfalls). That is what is proposed in our book—to suggest
reader to think systematically and to follow a logical reasonable anesthetic management schemes and to
sequence through preoperative evaluation and prepara- serve as a clinical reference. Just as advice rendered
tion, intraoperative management, and postoperative by the experienced consultant must be individualized
considerations. Our goal was to construct decision trees for the patient in question, so must our suggestions be
that were easy to follow, demonstrated decision points considered in light of special patient needs. We hope
clearly, and were simple but not simplistic. The com- that anesthesia providers and others involved in the
ments are keyed to designated decision points for further perioperative care of surgical patients may also find this
information, supported by references. It has been most a refreshing method of review. Feedback from those who
interesting to reformulate and reorganize our knowledge have used the book has been very helpful, and we
and clinical experiences in order to construct these encourage you to communicate your concerns to us.
algorithms. Many thanks to our authors, who shared their clinical
Although we would like to suppose that our practices expertise generously and enthusiastically tackled this
are evidence-based, many decisions in the "real world" rather unusual format. Thanks to Natasha Andjelkovic
are influenced by patient preferences, availability of for her help and support, without which this book would
equipment or supplies, and medicolegal considerations, have been impossible. Special thanks to Katharine
as well as the current limitations of the science of Holahan, editorial assistant extraordinaire, who coordi-
anesthesia. Despite these constraints, we all strive daily nated the editorial processes for the manuscript and
for precision in our decision making and for optimal kept everything organized. And as always, our profound
outcomes in our patient care. We have attempted to gratitude to the many anesthesiology residents with
ensure that the algorithms are accurate and realistic. whom we have worked and learned over the years—you
In controversial areas, they may reflect the preferences make us proud.
and thinking of the individual contributors. In some cases
there may be valid alternative techniques that are not Lois L. Bready, MD
described. Dawn Dillman, MD
As educators involved in university training Susan H. Noorily, MD
programs, we have consciously targeted the work for
ix
General Anesthesia
DAWN DILLMAN, M.D.
General anesthesia is defined by the American Society of responses and potential morbidity (e.g., the use of
Anesthesiologists (ASA): barbiturates in the patient with acute intermittent por-
General anesthesia is a drug-induced loss of con- phyria and propofol in the patient with egg allergy).
sciousness during which patients are not able to be D. The necessity for tracheal intubation should be assessed.
aroused, even by painful stimulation. The patient’s abil- If intubation is not required, a facemask or extraglottic
ity to independently maintain ventilatory function is often device, such as a laryngeal mask airway, may be used.
impaired. Patients often require assistance in maintaining However,the adequacy of ventilation must constantly
a patent airway, and positive pressure ventilation may be be assessed. If problems arise (airway obstruction,
required because of depressed spontaneous ventilation hypoventilation, or aspiration), tracheal intubation
or drug-induced depression of neuromuscular function. should be performed.
Cardiovascular function may be impaired.1 E. Maintenance of a stable course of anesthesia with
Drugs are administered to produce a patient who is minimal alteration in physiological status requires
unconscious to the point of being nonresponsive to painful constant assessment of the adequacy of anesthesia
stimulus. Amnesia is expected. Unfortunately, the drugs for the level of consciousness, muscle relaxation, and
used to induce and maintain general anesthesia almost hemodynamic stability. Adjustment of the anesthetic
always cause profound physiological effects on the body, dose (inhalational or intravenously) and the addition of
including cardiovascular, respiratory, and by definition, an analgesic agent (inhalational or intravenously) or a
neurological depression. For this reason, many investiga- neuromuscular blocking agent (depolarizing or non-
tors have hypothesized that regional anesthesia should depolarizing) ensure this stable course. If additional
be associated with less serious morbidity and mortality, amnestic agents are required, benzodiazepines or
although there has been little evidence to support that scopolamine can be added.
claim across broad populations. F. The postoperative course after the use of general
A. Because of the physiological changes anticipated with anesthesia is related to the operative procedure and
general anesthesia, any patient for whom deep seda- the technique and agents used to manage the associ-
tion or general anesthesia is planned should have a ated anesthesia. After any general anesthetic, the
preoperative evaluation, including a review of his or patient will be transported to either a PACU or its
her medical record, medical history including previous equivalent by a member of the anesthesia team, who
anesthetic exposures, last oral intake, physical exami- will report to the accepting care team. Monitoring of
nation (with emphasis on the airway, the cardiopul- cardiovascular status and respiration is essential,
monary system, and neurological status), and especially in patients who were given muscle relax-
appropriate laboratory tests and studies. It is also ants or narcotics during the surgery.4
essential that informed consent is obtained and that
documentation of this process occurs.2 REFERENCES
B. Preparation and monitoring should be consistent with 1. American Society of Anesthesiologists: Continuum of depth of
sedation: definition of general anesthesia and levels of
the amount of information required to ensure cardio-
sedation/analgesia, available at: http://www.asahq.org/publications
vascular and respiratory stability during the surgery.
andservices/standards/20.pdf, 2004.
The standards of the ASA for basic monitoring include 2. American Society of Anesthesiologist Task Force on Preanesthesia
cardiovascular function by continuous ECG monitor- Evaluation: Practice advisory for preanesthesia evaluation: a report
ing; arterial pressure and pulse monitoring; level of by the American Society of Anesthesiologists Task Force on
Preanesthesia Evaluation, Anesthesiology96 (2):485-496, 2002.
oxygenation and ventilation via pulse oximetry; cap-
3. American Society of Anesthesiologists: Standards for basic anesthetic
nometry or capnography; and for general anesthetics monitoring, available at: http://www.asahq.org/publicationsand
utilizing an anesthesia machine, an oxygen analyzer services/standards/02.pdf, 2005.
and disconnect sensor.3 4. American Society of Anesthesiologist Task Force on Postanesthetic
Care: Practice guidelines for postanesthetic care: a report by the
C. The type of induction of anesthesia will be influenced
American Society of Anesthesiologists Task Force on Postanesthetic
by the age and physical status of the patient, the NPO
Care, Anesthesiology96 (3):742–752, 2002.
status of the patient, the general anesthetic agent(s) to
be used, and whether intubation of the trachea is
required. Although IV and mask inductions are most
common, anesthesia may also be induced via IM injec-
tion for an uncooperative patient. Unique aspects of
each agent should be considered to avoid deleterious
2