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Chapter 13

Anesthesiology and Pain Management

Sachin Kheterpal and Michael R. Mathis

Key Points

1 Anesthetics are generalized depressants of consciousness, pain, cardiopulmonary function, motor

function, and recall.

2 To prevent movement and to facilitate the surgical exposure, neuromuscular blocking agents are

generally used. These drugs are competitive or noncompetitive inhibitors of the neurotransmitter

acetylcholine at the neuromuscular junction.

3 Residual neuromuscular blockade is a common and underappreciated phenomenon that impacts

postoperative adverse events such as hypoxemia, pneumonia, reintubation, and prolonged recovery

room stay. Suggamadex, a novel medication capable of reversing deep neuromuscular blockade, may

revolutionize perioperative care for high-risk patients.

4 Opioids produce profound analgesia and respiratory depression. They have no amnesic properties,

minimal direct myocardial depressive effects, and no muscle-relaxant properties.

5 Propofol is unique because it is rapidly cleared through hepatic metabolism to inactive metabolites

in a way that the patient becomes alert soon after cessation of the infusion. However, as the

duration and dose of the maintenance infusion is increased, the time to return of consciousness is

also significantly increased.

6 Although neuraxial techniques may decrease pulmonary complications, they are associated with

hemodynamic instability and are contraindicated in patients with severe flow-dependent

cardiovascular diseases.

7 Peripheral nerve blockade can be used in lieu of general anesthesia as a primary anesthetic for

surgery, or in conjunction with general anesthesia to serve as a postoperative pain management

technique. Use of long-acting local anesthetics or placement of an indwelling continuous catheter

provides long-term (16 hours to several days) pain relief.

8 The concept of airway management should be focused on not just endotracheal intubation, but also

mask ventilation. Until the airway can be secured via intubation, the patient must be supported

through mask ventilation. The key elements of an airway examination are an assessment of obesity,

mouth opening, neck flexion and extension, Mallampati oropharyngeal classification, presence of

beard, and mandibular protrusion ability.

9 Laryngeal mask airways offer an alternative to endotracheal intubation for general anesthesia

airway management in selected patients and procedures.

10 More than 8% of patients undergoing major noncardiac surgery will experience postoperative

myocardial ischemia, elevating their risk of 30-day mortality. Benefits must be weighed against risk

of initiating preoperative beta-blockers, alpha-blockers, and aspirin.

11 The appropriate duration to defer elective surgery after coronary stenting remains controversial, but

recent guidelines from the American College of Cardiology/American Heart Association recommend

365 days for drug-eluting stents and 30 days for bare-metal stents. The role for antiplatelet therapy

remains a major question, but data suggest that cessation of recommended antiplatelet therapy in

the perioperative period may have significant coronary thrombotic risks without major

improvement in bleeding adverse events.

12 The three goals of the preoperative evaluation are (a) to develop an anesthetic plan that considers

the patient’s medical condition, the requirements of the surgical procedure, and the patient’s

preferences; (b) to ensure that the patient’s chronic disease is under appropriate medical therapy

before an elective procedure; and (c) to gain rapport with and the confidence of the patient, answer

any questions, and allay fears.

13 Patients receiving chronic pain or opioid addiction therapy with buprenorphine (Subutex, Suboxone)

can be particularly challenging to manage in the postoperative period and should be immediately

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