Clinical Anesthesia Procedures of the Massachusetts General Hospital-10판

Written by residents and attendings at the world-renowned Massachusetts General Hospital Department of
Anesthesia, Clinical Anesthesia Procedures of the Massachusetts General Hospital, Tenth Edition, offers
current, comprehensive, and concise guidelines on all facets of anesthesia, perioperative care, critical
care, and pain management.

Emphasizing the clinical fundamentals necessary for patient safety and optimal outcomes, this trusted
guide provides fast answers to the most frequent problems encountered in daily anesthetic practice, making
it an invaluable resource for practicing anesthesiologists and residents as well as nurse anesthetist
trainees and practitioners.

● Focuses on the clinical fundamentals needed for the safe delivery of anesthesia and perioperative care
in day-to-day practice.

● Uses an easy-to-scan outline format that progresses intuitively from preoperative evaluation through
administration of anesthesia to perioperative issues for each subject.


● Updated and reorganized table of contents in addition to chapters on evaluating the patient, anesthesia
for pediatric surgery and care of the neonate, non-operating room anesthesia and pain management.


● Includes new chapters on the basics of echocardiography, anesthesia for orthopedic surgery, anesthesia
for transplant surgery and vascular access. Features appendices covering drugs and intravenous
antibiotics.

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● Read directly on your preferred device(s), such as computer, tablet, or smartphone.

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Table of Contents

PART I: EVALUATING THE PATIENT BEFORE ANESTHESIA

1 Evaluating the Patient Before Anesthesia

I. INTRODUCTION
II. HISTORY
III. REVIEW OF SYSTEMS
IV. THE PHYSICAL EXAMINATION
V. LABORATORY STUDIES
VI. PREOPERATIVE MEDICAL OPTIMIZATION
VII. ANESTHETIC ASSESSMENT AND PLAN
VIII. PATIENT DISCUSSION
IX. INFORMED CONSENT
X. DAY OF SURGERY PREMEDICATION
XI. DELAYING SURGICAL PROCEDURES
XII. ETHICAL CONSIDERATIONS IN PATIENT CARE

2 Basics of Echocardiography

I. TRANSTHORACIC IMAGE ACQUISITION
II. TRANSESOPHAGEAL IMAGE ACQUISITION
III. ECHOCARDIOGRAPHIC ASSESSMENT
IV. HEMODYNAMIC MEASUREMENTS AND FLUID RESPONSIVENESS
V. CONCLUSION

3 Specific Considerations With Cardiac Disease

I. GENERAL CONSIDERATIONS
II. CORONARY ANATOMY
III. PREOPERATIVE CARDIOVASCULAR EVALUATION FOR NONCARDIAC SURGERY
IV. PREANESTHETIC CONSIDERATIONS
V. ISCHEMIC HEART DISEASE
VI. VALVULAR HEART DISEASE
VII. CONGESTIVE HEART FAILURE
VIII. HYPERTROPHIC CARDIOMYOPATHY
IX. CONGENITAL HEART DISEASE
X. CARDIAC TRANSPLANT PATIENT
XI. CARDIAC IMPLANTABLE ELECTRONIC DEVICES: PACEMAKERS AND IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS

4 Specific Considerations With Pulmonary Disease

I. OVERVIEW
II. PULMONARY FUNCTION
III. ASTHMA
IV. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
V. OBESITY
VI. ACUTE RESPIRATORY DISTRESS SYNDROME

5 Specific Considerations With Renal Disease

I. GENERAL CONSIDERATIONS
II. PHYSIOLOGY
III. RENAL FAILURE
IV. ANESTHETIC MANAGEMENT
V. PHARMACOLOGY AND THE KIDNEY
VI. PHARMACOLOGY AND RENAL FAILURE
VII. FUTURE CONSIDERATIONS FOR IDENTIFICATION OF PATIENTS AT RISK OF PERIOPERATIVE AKI

6 Specific Considerations With Liver Disease

I. HEPATIC ANATOMY
II. HEPATIC FUNCTION
III. METABOLISM OF ANESTHETICS
IV. LIVER DISEASE
V. SURGICAL RISK IN PATIENTS WITH LIVER DISEASE
VI. ANESTHESIA IN PATIENTS WITH LIVER DISEASE
VII. POSTOPERATIVE LIVER DYSFUNCTION

7 Specific Considerations With Endocrine Disease

I. DIABETES MELLITUS
II. HYPOGLYCEMIA
III. THYROID DISEASE
IV. CALCIUM METABOLISM AND PARATHYROID DISEASE
V. ADRENAL CORTICAL DISEASE
VI. ADRENAL MEDULLARY DISEASE
VII. PITUITARY DISEASE
VIII. CARCINOID

8 Infectious Diseases and Infection Control in Anesthesia

I. INTRODUCTION
II. INFECTION CONTROL IN THE OR
III. PERIOPERATIVE ANTIBIOTICS
IV. PATHOGENIC ORGANISMS OF ANESTHETIC CONCERN
V. OCCUPATIONAL EXPOSURE TO INFECTIOUS DISEASE
VI. IMMUNOCOMPROMISED PATIENTS

PART II: ADMINISTRATION OF ANESTHESIA

9 Safety in Anesthesia

I. OVERVIEW OF SAFETY IN ANESTHESIA
II. STANDARDS FOR SAFE ANESTHESIA CARE
III. TYPES OF ERRORS
IV. GENERAL SAFETY STRATEGIES
V. QUALITY ASSURANCE AND SAFETY IMPROVEMENT PROGRAMS

10 The Anesthesia Machine

I. OVERVIEW
II. THE GAS DELIVERY SYSTEM (FIGURE 10.1)
III. BREATHING SYSTEMS
IV. ANESTHESIA VENTILATORS
V. SAFETY FEATURES
VI. SCAVENGING
VII. GAS ANALYSIS
VIII. EMERGENCY EQUIPMENT
IX. ANESTHESIA MACHINE CHECKOUT RECOMMENDATIONS

11 Administration of General Anesthesia

I. INDICATIONS
II. PRE-­OP EVALUATION AND PLANNING
III. INDUCTION OF ANESTHESIA
IV. AIRWAY MANAGEMENT
V. MAINTENANCE OF ANESTHESIA
VI. EMERGENCE AND EXTUBATION
VII. TRANSPORT AND DISPOSITION
VIII. INTRAOPERATIVE ADVERSE EFFECTS RELATED TO GENERAL ANESTHESIA AND MANAGEMENT
IX. POSTOPERATIVE ADVERSE EFFECTS RELATED TO GENERAL ANESTHESIA

12 Intravenous and Inhalation Anesthetics

I. PHARMACOLOGY OF INTRAVENOUS ANESTHETICS
II. PHARMACOLOGY OF INHALATION ANESTHETICS

13 Airway Evaluation and Management

I. APPLIED ANATOMY
II. EVALUATION
III. MASK AIRWAY
IV. LARYNGEAL MASK AIRWAY
V. ENDOTRACHEAL INTUBATION
VI. THE DIFFICULT AIRWAY AND EMERGENCY AIRWAY TECHNIQUES
VII. SPECIAL CONSIDERATIONS

14 Neuromuscular Blockade

I. NEUROMUSCULAR JUNCTION
II. GENERAL PHARMACOLOGY
III. NEUROMUSCULAR BLOCKADE
IV. MONITORING OF NEUROMUSCULAR FUNCTION
V. REVERSAL OF NMB
VI. EFFECTS OF NMB
VII. DISORDERS THAT INFLUENCE THE RESPONSE TO NMBDS

15 Monitoring

I. STANDARD MONITORING
II. CARDIOVASCULAR SYSTEM
III. CVP AND CARDIAC OUTPUT
IV. RESPIRATORY SYSTEM
V. TEMPERATURE MONITORING

16 Monitoring Anesthetic Brain States

I. GENERAL CONSIDERATIONS
II. ELECTROENCEPHALOGRAM-BASED INDICES OF LEVEL OF CONSCIOUSNESS
III. END-TIDAL ANESTHETIC CONCENTRATION
IV. THE SPECTRAL ANALYSIS OF THE EEG
V. EFFECTS OF DIFFERENT ANESTHETICS ON THE BRAIN
VI. AGE-RELATED CHANGES IN ANESTHETIC-INDUCED EEG SIGNATURES
VII. CLINICAL MONITORING OF ANESTHETIC STATES
VIII. CONCLUSION

17 Intra-anesthetic Problems

I. HYPOTENSION
II. HYPERTENSION
III. DYSRHYTHMIAS
IV. HYPOXEMIA
V. HYPERCARBIA
VI. ABNORMAL URINE OUTPUT
VII. HYPOTHERMIA
VIII. HYPERTHERMIA
IX. DIAPHORESIS (SWEATING)
X. LARYNGOSPASM
XI. BRONCHOSPASM
XII. ASPIRATION
XIII. PNEUMOTHORAX
XIV. MYOCARDIAL ISCHEMIA
XV. PULMONARY EMBOLISM
XVI. CARDIAC TAMPONADE
XVII. MALIGNANT HYPERTHERMIA
XVIII. ANAPHYLACTIC AND ANAPHYLACTOID REACTIONS
XIX. FIRE AND ELECTRICAL HAZARDS IN THE OPERATING ROOM
XX. EQUIPMENT MALFUNCTIONS

18 Perioperative Hemodynamic Control

I. BLOOD PRESSURE
II. AUTOREGULATION
III. ADRENERGIC RECEPTOR PHYSIOLOGY (TABLE 18.1)
IV. ADRENERGIC AGONISTS (TABLE 18.2)
V. NONADRENERGIC AGENTS
VI. β-Adrenergic Antagonists (Table 18.3)
VII. VASODILATORS (TABLE 18.4)
VIII. CONTROLLED HYPOTENSION
IX. DRUG DOSAGE CALCULATIONS

19 Local Anesthetics

I. General Principles
II. Clinical Uses of Local Anesthetics
III. Toxicity
IV. Novel Developments

20 Spinal, Epidural, and Caudal Anesthesia

I. GENERAL CONSIDERATIONS
II. SEGMENTAL LEVEL REQUIRED FOR SURGERY
III. CONTRAINDICATIONS TO NEURAXIAL ANESTHESIA
IV. SPINAL ANESTHESIA
V. EPIDURAL ANESTHESIA
VI. COMBINED SPINAL-EPIDURAL ANESTHESIA
VII. CAUDAL ANESTHESIA
VIII. ANTICOAGULATION AND NEURAXIAL BLOCKADE

21 Regional Anesthesia

I. GENERAL CONSIDERATIONS
II. GENERAL CONTRAINDICATIONS
III. COMPLICATIONS COMMON TO ALL NERVE BLOCKS
IV. EQUIPMENT
V. NERVE LOCALIZATION TECHNIQUES
VI. REGIONAL ANESTHESIA OF THE NECK
VII. REGIONAL ANESTHESIA OF THE UPPER EXTREMITY
VIII. REGIONAL ANESTHESIA OF THE LOWER EXTREMITY
IX. REGIONAL ANESTHESIA OF THE TRUNK

22 Anesthesia for Orthopedic Surgery

I. GENERAL CONSIDERATION
II. ANESTHESIA FOR TOTAL HIP AND KNEE ARTHROPLASTY
III. ANESTHESIA FOR SHOULDER SURGERY
IV. ANESTHESIA FOR FOOT AND ANKLE SURGERY
V. ANESTHESIA FOR ELBOW, ARM, AND HAND SURGERY
VI. ANESTHESIA FOR ORTHOPEDIC ONCOLOGY
VII. ANESTHESIA FOR ORTHOPEDIC TRAUMA
VIII. ANESTHESIA FOR SPINE SURGERY

23 Anesthesia for Neurosurgery

I. PHYSIOLOGY
II. PHARMACOLOGY
III. ELECTROPHYSIOLOGIC MONITORING
IV. PREOPERATIVE CONSIDERATIONS FOR NEUROSURGICAL PROCEDURES
V. INTRAOPERATIVE MANAGEMENT
VI. SPECIFIC NEUROSURGICAL PROCEDURES
VII. SURGERY ON THE SPINE AND SPINAL CORD

24 Anesthesia for Spine Surgery

I. BLOOD LOSS
II. SPINAL CORD PERFUSION
III. DISPOSITION
IV. POSTOPERATIVE PAIN MANAGEMENT

25 Anesthesia for Transplant Surgery

I. HISTORY AND ETHICAL CONSIDERATIONS
II. ANESTHESIA FOR KIDNEY TRANSPLANTATION
III. ANESTHESIA FOR PANCREAS TRANSPLANTATION
IV. ANESTHESIA FOR LIVER TRANSPLANTATION
V. ANESTHESIA FOR ORGAN PROCUREMENT

26 Anesthesia for Abdominal Surgery

I. PREANESTHETIC CONSIDERATIONS
II. ANESTHETIC TECHNIQUES
III. MANAGEMENT OF ANESTHESIA
IV. ANESTHETIC CONSIDERATIONS FOR SPECIFIC ABDOMINAL PROCEDURES

27 Anesthesia for Thoracic Surgery

I. PREOPERATIVE EVALUATION
II. PREOPERATIVE PREPARATION
III. MONITORING
IV. ENDOSCOPIC PROCEDURES
V. MEDIASTINAL OPERATIONS
VI. PULMONARY RESECTION
VII. TRACHEAL RESECTION AND RECONSTRUCTION
VIII. INTRAPULMONARY HEMORRHAGE
IX. BRONCHOPLEURAL FISTULA
X. ESOPHAGEAL SURGERY

28 Anesthesia for Vascular Surgery

I. PREOPERATIVE ASSESSMENT AND MANAGEMENT
II. PERIPHERAL ARTERIAL SURGERY
III. CAROTID REVASCULARIZATION
IV. ABDOMINAL AORTIC REPAIR
V. THORACOABDOMINAL AORTIC ANEURYSM REPAIR
VI. AMPUTATIONS

29 Anesthesia for Cardiac Surgery

I. CARDIOPULMONARY BYPASS
II. PREOPERATIVE ASSESSMENT FOR CARDIAC SURGERY
III. ANESTHETIC MANAGEMENT
IV. INDUCTION
V. Postoperative Care
VI. Pediatric Cardiac Anesthesia
VII. Other Cardiac Procedures
VIII. ANESTHESIA FOR “OFF-SITE” CARDIAC PROCEDURES

30 Anesthesia for Head and Neck Surgery

I. Anesthesia for Ophthalmic Surgery
II. ANESTHESIA FOR OTORHINOLARYNGOLOGIC PROCEDURES
III. ANESTHESIA FOR PROCEDURES OF THE NECK
IV. ANESTHESIA FOR DENTISTRY AND ORAL AND MAXILLOFACIAL SURGERY

31 Anesthesia for Urologic Surgery

I. ANESTHESIA FOR SPECIFIC UROLOGIC PROCEDURES
II. LITHOTRIPSY
III. PATIENTS WITH SPINAL CORD PATHOLOGY

32 Anesthesia for Obstetrics and Gynecology

I. MATERNAL PHYSIOLOGY IN PREGNANCY (TABLE 32.1)
II. LABOR AND DELIVERY
III. MEDICATIONS COMMONLY USED FOR LABOR AND DELIVERY
IV. PLACENTAL TRANSFER OF DRUGS
V. ANALGESIA FOR LABOR AND VAGINAL DELIVERY
VI. ANESTHESIA FOR CESAREAN DELIVERY
VII. PREECLAMPSIA
VIII. PERIPARTUM HEMORRHAGE
IX. AMNIOTIC FLUID EMBOLISM
X. ANESTHESIA FOR NONOBSTETRIC SURGERY DURING PREGNANCY
XI. CPR DURING PREGNANCY
XII. ANESTHESIA FOR GYNECOLOGIC SURGERY
XIII. ANESTHESIA FOR OOCYTE RETRIEVAL

33 Anesthesia for Pediatric Surgery and Care of the Neonate

I. Development
II. GENERAL ASSESSMENT
III. COMMON NEONATAL PROBLEMS PERTINENT TO ANESTHESIA
IV. ANATOMY AND PHYSIOLOGY
V. THE PREANESTHETIC VISIT
VI. PERIPROCEDURAL CONSIDERATIONS AND FASTING GUIDELINES
VII. PREPARATION OF THE OR
VIII. INDUCTION TECHNIQUES
IX. ENDOTRACHEAL INTUBATION
X. ANALGESIA
XI. PHARMACOTHERAPY
XII. FLUID MANAGEMENT
XIII. EMERGENCE AND POST-ANESTHESIA CARE
XIV. SPECIFIC PEDIATRIC ANESTHESIA PROBLEMS

34 Non-Operating Room Anesthesia

I. General Considerations
II. ANESTHESIA TECHNIQUES
III. CONTRAST MEDIA
IV. ANESTHESIA FOR DIAGNOSTIC RADIOLOGY
V. ANESTHESIA FOR CT-GUIDED THERMAL ABLATIONS
VI. ANESTHESIA FOR NEUROINTERVENTIONS
VII. ANESTHESIA FOR GASTROINTESTINAL/GENITOURINARY AND VASCULAR RADIOLOGY PROCEDURES
VIII. ANESTHESIA FOR PROTON BEAM THERAPY AND RADIATION THERAPY
IX. ANESTHESIA FOR ELECTROCONVULSIVE THERAPY
X. ANESTHESIA FOR GASTROINTESTINAL PROCEDURES

35 Anesthesia for Trauma and Burns

I. INITIAL EVALUATION OF THE TRAUMA PATIENT
II. SPECIFIC INJURIES
III. THE PEDIATRIC TRAUMA PATIENT
IV. THE PREGNANT TRAUMA PATIENT
V. MAJOR BURN INJURIES

36 Transfusion Therapy

I. THE DECISION TO TRANSFUSE
II. COAGULATION STUDIES
III. BLOOD TYPING AND CROSS-MATCHING
IV. BLOOD COMPONENT THERAPY
V. PLASMA SUBSTITUTES
VI. PHARMACOLOGIC THERAPY
VII. CONSERVATION AND SALVAGE TECHNIQUES
VIII. COMPLICATIONS OF BLOOD TRANSFUSION THERAPY
IX. PERIOPERATIVE COAGULOPATHY
X. SPECIAL CONSIDERATIONS
XI. Acknowledgment

PART III: PERIOPERATIVE ISSUES

37 The Post-anesthesia Care Unit

I. GENERAL CONSIDERATIONS
II. ADMISSION TO THE PACU
III. MONITORING
IV. GENERAL COMPLICATIONS
V. EFFECTS OF ANESTHETICS AND SEDATIVES
VI. RESPIRATORY AND AIRWAY COMPLICATIONS
VII. HEMODYNAMIC AND CARDIOVASCULAR COMPLICATIONS
VIII. RENAL COMPLICATIONS
IX. NEUROLOGIC COMPLICATIONS
X. POSTOPERATIVE NAUSEA AND VOMITING
XI. PRINCIPLES OF PAIN MANAGEMENT
XII. BODY TEMPERATURE CHANGES
XIII. RECOVERY FROM REGIONAL AND NEURAXIAL ANESTHESIA
XIV. CRITERIA FOR DISCHARGE
XV. ENHANCED RECOVERY AFTER SURGERY
XVI. CONSIDERATIONS FOR PEDIATRIC RECOVERY
XVII. CRITICAL CARE IN THE POST-ANESTHESIA RECOVERY UNIT

38 Pain Management

I. DEFINITION AND TERMINOLOGY
II. TREATMENT OF ACUTE PAIN IN THE PERIOPERATIVE SETTING
III. COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PAIN MANAGEMENT

39 Adult, Pediatric, and Newborn Resuscitation

I. OVERVIEW
II. CARDIAC ARREST
III. ADULT RESUSCITATION
IV. PEDIATRIC RESUSCITATION
V. NEONATAL RESUSCITATION

40 Vascular Access

I. OVERVIEW
II. APPLIED VASCULAR ANATOMY
III. VASCULAR ACCESS DEVICES
IV. PRINCIPLES OF IMAGE-GUIDED VASCULAR ACCESS
V. COMMON ISSUES AND TROUBLESHOOTING
Appendix I: Drugs With Narrow Therapeutic Ranges and Potential for Harm
Appendix II: Commonly Used Drugs
Appendix III: Common Intravenous Antibiotics
Index