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PhysioloGy And AnesthesiA for GenerAl And BAriAtriC surGery ● 339 anesthetic plan, you may choose to use a consciousness monitor such as BIS, particularly if you choose to use TIVA during any part of the case. Temperature monitoring availability is an ASA standard, and morbidly obese patients generally do not lose heat as quickly as thin patients in the OR. However, a large portion of the body will be exposed and the insufflating gas is relatively cool, so she may become hypothermic. Since this is a risk factor for wound infection, you should monitor temperature continuously. How will you induce and maintain anesthesia? Although any combination of general anesthetics are possible, you may consider short acting, nonlipophilic drugs to avoid excessive somnolence and respiratory problems at the end of the case. You may choose to avoid nitrous oxide to maximize oxygen delivery, but, conversely, it is rapidly eliminated and thus may facilitate a rapid wakeup. You will have to weigh its use against other adverse effects such as bowel distention in laparoscopic surgery. Some anesthesiologists have advocated TIVA at least at the end of the procedure to allow you to fully wash out inhalation anesthetics. Dexmedetomidine and remifentanil can provide excellent analgesia and sedation with minimal postoperative respiratory depression and is one attractive option. You should avoid large doses of long-acting opioids until her respiratory status can be assessed postoperatively. You will fully reverse neuromuscular blockade prior to emergence to avoid hypoventilation due to even subtle weakness. How will you manage postoperative pain? Would your plan differ if the procedure were an open Roux-en-Y? It is important to have good pain control but not oversedate the patient. Pain control is important to avoid splinting and hypoventilation that can cause atelectasis and hypoxemia. Patient-controlled analgesia has been successfully used following bariatric surgery. Some advocate increased vigilance for hypoventilation such as continuous pulse oximetry or frequent respiratory rate monitoring. The surgeon can also infiltrate the laparoscopy incisions with long-acting local anesthetic such as bupivacaine with epinephrine to augment the analgesia. If the procedure were an open laparotomy, placement of a thoracic epidural for postoperative pain control should be strongly considered. This technique allows minimization of systemic opioids and may improve pulmonary outcomes.
340 ● AnesthesiA student survivAl Guide Suggested Further Reading Bray GA (1992) Pathophysiology of obesity. Am J Clin Nutr 55:488S–94S Brodsky JB (2008) Perioperative management of the obese patient. Conferencias Magistrales 31(1):S85–S89 Poirier P et al (2006) Obesity and cardiovascular disease, pathophysiology, evaluation, and effect of weight loss. Circulation 113:898–918 Paulain M et al (2006) The effect of obesity on chronic respiratory diseases: pathophysiology and therapeutic strategies. CMAJ 174(9). doi:10.1503/ cmaj.051299 Grundy SM et al (2004) Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation 109:433–438 Sprung J et al (1992) The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy. Anesth Analg 94:1345–1350 Strollo PJ, Rogers RM (1996) Obstructive sleep apnea. N Eng J Med 334 99–104 Joshi GP (2002) Anesthesia for laparoscopic surgery. Can J Anaesth 49:R11 Redai I et al (2004) Anesthetic considerations during liver surgery. Surg Clin North Am 84:401–411 Ogunnaike BO et al (2002) Anesthetic considerations for bariatric surgery. Anesth Analg 95:1793–1805 Jaffe RA, Samuels SI (2004) Anesthesiologist’s manual of surgical procedures, 3rd edn. Lippincott, Williams & Wilkins, Philadelphia Wheatley RG et al (2001) Safety and efficacy of postoperative epidural analgesia. Br J Anaesth 87(1):47–61
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Table 14.6 Advantages, disadvantage
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Table 14.11 Transfusion of bloodpro
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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