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 Cambridge
Handbook of
Anesthesiology

Published online by Cambridge University Press

Published online by Cambridge University Press
 Cambridge
Handbook of
Anesthesiology
Edited by
Richard D. Urman, MD, MBA
Jay J. Jacoby Professor and Chair, Department of Anesthesiology, The Ohio State University
and Wexner Medical Center, Columbus, OH

Alan David Kaye, MD PhD, DABA, DABPM,

DABIPP, FASA
Professor of Anesthesiology and Pharmacology, Toxicology, and Neurosciences; Vice
Chairman of Research, Pain Fellowship Director, Provost, Chief Academic Officer and Vice
Chancellor, Louisiana State University Health Sciences Center, Ochsner-LSU Hospital System,
Shreveport, Louisiana

Published online by Cambridge University Press

 Shaftesbury Road, Cambridge CB2 8EA, United Kingdom
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Cambridge University Press is part of Cambridge University Press & Assessment,

a department of the University of Cambridge.
We share the University’s mission to contribute to society through the pursuit of
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www.cambridge.org
Information on this title: www.cambridge.org/9781108947657
DOI: 10.1017/9781108936941
© Cambridge University Press & Assessment 2023
This publication is in copyright. Subject to statutory exception and to the provisions
of relevant collective licensing agreements, no reproduction of any part may take
place without the written permission of Cambridge University Press & Assessment.
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..................................................................................................................................................

Every effort has been made in preparing this book to provide accurate and up-to-date information
that is in accord with accepted standards and practice at the time of publication. Although case
histories are drawn from actual cases, every effort has been made to disguise the identities of the
individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that
the information contained herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors, editors, and publishers therefore
disclaim all liability for direct or consequential damages resulting from the use of material contained
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Published online by Cambridge University Press

 I would like to dedicate this book to my colleagues, men-
tors and patients from whom I learn something new every
day. I also would like to dedicate this book to my wife Dr.
Zina Matlyuk and my two children and thank them for
their patience and support during my work on this impor-
tant project.
Richard D. Urman
-To my wife Dr. Kim Kaye for being the best spouse a man
could ask for in his life.
-To my mother Florence Feldman who taught me tremen-
dous things about life, to accomplish tasks with the highest
of quality, and to reach my dreams and goals.
-To my good friend James V. Johnson, for his loving
support and help over the past 45 plus years.
-To all my teachers and colleagues at the University of
Arizona in Tucson, Ochsner Clinic in New Orleans,
Massachusetts General Hospital/Harvard School of
Medicine in Boston, Tulane School of Medicine in New
Orleans, Texas Tech Health Sciences Center in Lubbock,
LSU School of Medicine in New Orleans, and LSU School
of Medicine in Shreveport.
Alan David Kaye

Published online by Cambridge University Press

Published online by Cambridge University Press
 Contents

List of Contributors x

Introduction 1 6. Intravenous Anesthetics and

Douglas R. Bacon Adjunctive Agents 86
Matthew M. Colontonio,
1. Preoperative Evaluation and Mitchell C. Fuller,
Coexisting Disease 4 Harish Bangalore
Matthew Sherrer, Siddaiah, Shilpa Patil,
Sher-Lu Pai, and Jeffrey and Alan David Kaye
Dobyns
7. Pharmacology of Local
2. Airway Management 23 Anesthetics 106
Chikezie N. Okeagu, Chang H. Park and
Madelyn K. Craig, Brook Garrett W. Burnett
Girma, Sumitra Miriyala,
Meeta M. Sheth, Sridhar 8. Anesthesia Techniques: Mild,
R. Tirumala, Rhian E. Moderate, and Deep
Germany, and Alan David Sedation in Clinical
Kaye Practice 119
Mark R. Jones, Boris C.
3. Anesthesia Equipment: Anyama, Chikezie N.
Clinical Considerations 41 Okeagu, Meredith K.
George Mychaskiw, Shaw, Madelyn K. Craig,
Eric Ly, Austin Ly, and Alan David Kaye
Kelsey Rooney, Leah A.
Kaplan, Stephen Patin, 9. Anesthesia Techniques:
Victoria L. Lassiegne, General Anesthesia
Katherine C. Babin, Techniques in Clinical
George Thomas, Elyse Practice 131
M. Cornett, and Alan Mark R. Jones, Edward
David Kaye S. Alpaugh, Boris C.
Anyama, Chikezie N.
4. Patient Monitoring 60 Okeagu, Meredith K.
William Lee, Nihir Patel, Shaw, Madelyn K. Craig,
and Christina Jeng and Alan David Kaye
5. Inhalational Anesthetics 75 10. Postanesthesia Care Unit 151
Ricardo Diaz Milian Iliana Ramirez-Saldana
vii

Published online by Cambridge University Press

 viii Contents

11a. Regional Anesthesia: Blocks 16. Thoracic Anesthesia 246

of the Upper and Lower Kimberley C. Brondeel,
Extremities 161 Frederick R. Ditmars,
Peter Amato, Brittany and Alan David Kaye
Deiling, Erik Helander,
Jinlei Li, Chikezie N. 17. Neuroanesthesia 273
Okeagu, Michael Lakshmi N. Kurnutala
McManus, Annemarie and Vishal Yajnik
Senekal, Christopher M. 18. Renal Anesthesiology in
Sharrow, Ashley Clinical Practice 287
Shilling, Alan David Pankaj Thakur, Harish
Kaye, and Michael P. Bangalore Siddaiah,
Webb Vijay Kata, Shilpadevi S.
11b. Regional Anesthesia: Chest Patil, Naina Singh, and
and Abdominal Plane Alan David Kaye
Blocks 173 19. Anesthesia for General
Jinlei Li, Annemarie Surgical Procedures 302
Senekal, Michael P. Julie A. Gayle and Alan
Webb, Alan David Kaye, David Kaye
and Erik Helander
20. Anesthesia for Endocrine
12. Fluid and Electrolyte Diseases 314
Balance 182
Alex D. Pham, James L.
Ryan J. Kline, John A. Dillon, Gregory M.
Helmstetter, and Tortorich, Stuart H.
Bethany L. Menard Brown, Gopal Kodumudi,
13. Blood Transfusion Oren Cohen, Joshua J.
Components and Hurley, Brittni M.
Complications in Lanoux, Elyse M. Cornett,
Anesthesiology 200 and Alan David Kaye
Christine T. Vo and 21. Anesthesia for
Pamela R. Roberts Neuromuscular and Collagen
14. Cardiac Anesthesiology 217 Vascular Diseases 338
Alan M. Smeltz, Logan Erin Yen and Timothy
Gray, Austin Erney, Julia Martin
Kendrick, and Matthew 22. Anesthesia for Ocular, Ear,
Graves and Throat Diseases 354
15. Vascular Anesthesia 234 Sheriza L. Hussain and
Jeffrey Park Graham T. Lubinsky

Published online by Cambridge University Press

 Contents ix

23. Orthopedic Anesthesia 369 31. Trauma Anesthesia 472

Adrienne Mejia, Paul C. Amanda Frantz,
DeMarco, Erik Meghan Brennan, and
Helander, and Jinlei Li Corey Scher
24. Obstetric and Gynecologic 32. Perioperative Cognitive
Anesthesia 385 Disorders 485
Ankit Bhatia and Reine Catherine Price, Sarah
Zbeidy McCraney, Margaret E.
Wiggins, Carlos Hernaiz
25. Pediatric Anesthesia 399 Alonso, Catherine Dion,
Elyse M. Cornett, Alan Franchesca Arias,
David Kaye, and Sonja Kristin Hamlet, and
A. Gennuso Patrick Tighe
26. Geriatric Anesthesia 411 33. Acute Pain Management in
Zhuo Sun and the ICU 497
Anterpreet Dua Farees Hyatali,
27. Anesthesia for Ambulatory Franciscka Macieiski,
Surgical Procedures 423 Harish Bangalore
Sandra N. Gonzalez, Siddaiah, and Alan
Olga C. Nin, and Sonia David Kaye
D. Mehta 34. Infection Control for the
28. Chronic Pain Medicine 439 Anesthesia Provider 503
Ken P. Ehrhardt, Devin Tamara Lawson
S. Reed, Mark 35. Coagulation 521
Motejunas, and Ken Kenneth Flax and Erica
Candido Fagelman
29. Acute Pain
Management 448
Farees Hyatali, Karina
Gritsenko, and Kay Lee Index 532
30. Anesthetic
Emergencies 460
Eric Fried and Aaron
Reagan

Published online by Cambridge University Press

 Contributors

Edward S. Alpaugh MD Meghan Brennan MD

Department of Anesthesiology, Department of Anesthesiology,
Louisiana State University Health University of Florida College of
Sciences Center, New Orleans, Medicine, Gainesville, FL, USA
LA, USA
Kimberley C. Brondeel BS
Peter Amato MD University of Texas Medical Branch,
Department of Anesthesiology, Galveston, TX, USA
University of Virginia,
Charlottesville, VA, USA Stuart H. Brown MD MD
Department of Anesthesiology,
Boris C. Anyama MD Louisiana State University Health
Department of Anesthesiology and Sciences Center, New Orleans,
Perioperative Medicine, University LA, USA
of Pittsburgh Medical Center,
Pittsburgh, PA, USA Garrett W. Burnett MD
Department of Anesthesiology,
Franchesca Arias PhD Perioperative and Pain Medicine,
Perioperative Cognitive Anesthesia Icahn School of Medicine at Mount
Network (PeCAN), University of Sinai, New York, NY, USA
Florida, Gainesville, FL, USA; Aging
Brain Center, Hebrew SeniorLife, Ken Candido MD
Beth Israel Deaconess Medical UCLA Health, Santa Monica,
Center, Harvard Medical School, CA, USA
Boston, MA, USA
Oren Cohen MD
Katherine C. Babin Department of Anesthesiology,
Louisiana State University Health Louisiana State University Health
Shreveport, Shreveport, Sciences Center, New Orleans,
LA, USA LA, USA

Ankit Bhatia DO Matthew M. Colontonio MD

Jackson Memorial Hospital, Department of Anesthesiology,
University of Miami, Miller School Louisiana State University Health
of Medicine, Miami, FL, USA Shreveport, Shreveport, LA, USA

Published online by Cambridge University Press

 List of Contributors xi

Elyse M. Cornett PhD Medicine, Department of

Department of Anesthesiology, Anesthesiology and Perioperative
Louisiana State University Health Medicine, Birmingham,
Shreveport, Shreveport, LA, USA AL, USA

Madelyn K. Craig MD Anterpreet Dua

Department of Anesthesiology, Department of Anesthesiology and
Louisiana State University Health Perioperative Medicine, Augusta
Sciences Center, New Orleans, University Medical Center,
LA, USA Medical College of Georgia at
Augusta University,
Brittany Deiling MD Augusta, GA, USA
Department of Anesthesiology,
University of Virginia, Ken P. Ehrhardt MD
Charlottesville, VA, USA Beth Israel Deaconess Medical
Center, Harvard Medical School,
Paul C. DeMarco MD Boston, MA, USA
Department of Anesthesiology,
UVA Health System, Charlottesville, Austin Erney DO
VA, USA University of North Carolina,
Chapel Hill, NC, USA
Ricardo Diaz Milian MD, FASE
Mayo Clinic, Jacksonville, FL, USA Erica Fagelman MD
Department of Anesthesiology,
James L. Dillon MD Icahn School of Medicine at Mount
Department of Anesthesiology, Sinai, New York, NY, USA
Louisiana State University Health
Sciences Center, New Orleans, Kenneth Flax MD
LA, USA Mount Sinai Queens, The Mount
Sinai Hospital Mount Sinai
Catherine Dion MS Morningside and Mount Sinai West,
Clinical and Health Psychology, New York, NY, USA
Perioperative Cognitive Anesthesia
Network (PeCAN), Anesthesiology, Amanda Frantz MD
University of Florida College of Department of Anesthesiology,
Medicine, Gainesville, FL, USA University of Florida College of
Medicine, Gainesville,
Frederick R. Ditmars BA FL, USA
University of Texas Medical Branch,
Galveston, TX, USA Eric Fried MD
Department of Anesthesiology,
Jeffrey Dobyns DO MSHA MSHQS FASA Perioperative, and Pain Medicine,
University of Alabama at Icahn School of Medicine at Mount
Birmingham, Heersink School of Sinai, New York, NY, USA

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 xii List of Contributors

Mitchell C. Fuller BS Kristin Hamlet PhD

Medical College of Wisconsin, Clinical and Health Psychology,
Wauwatosa, WI, USA Perioperative Cognitive Anesthesia
Network (PeCAN), Anesthesiology,
Julie A. Gayle MD University of Florida, Gainesville,
Louisiana State University Health FL, USA
Sciences Center, School of Medicine,
New Orleans, LA, USA Erik Helander MBBS
US Anesthesia Partners, Denver,
Sonja A. Gennuso MD CO, USA
Department of Anesthesiology,
Louisiana State University Health John Helmstetter MD DABA
Shreveport, Shreveport, Louisiana State University Health
LA, USA Sciences Center, New Orleans,
LA, USA
Rhian E. Germany BS MS
Louisiana State University Health Carlos Hernaiz Alonso BS
Shreveport, Shreveport, Clinical and Health Psychology,
LA, USA Perioperative Cognitive Anesthesia
Network (PeCAN), Anesthesiology,
Brook Girma MD University of Florida, Gainesville,
Department of Anesthesiology, FL, USA
Louisiana State University Health
Shreveport, Shreveport, LA, USA Joshua J. Hurley MD
Department of Anesthesiology,
Sandra N. Gonzalez MD Louisiana State University Health
Department of Anesthesiology, Sciences Center, New Orleans,
University of Florida College of LA, USA
Medicine, Gainesville, FL, USA
Sheriza L. Hussain MD MS
Matthew Graves MD MedStar Georgetown University
Department of Anesthesia and Hospital, Washington, DC, USA
Perioperative Medicine, Medical
University of South Carolina, Farees Hyatali MD
Charleston, SC, USA Montefiore Medical Center, Bronx,
NY, USA
Logan Gray DO
Department of Anesthesiology, Christina Jeng MD FASA
University of North Carolina, Department of Anesthesiology,
Chapel Hill, NC, USA Perioperative and Pain Medicine;
Department of Orthopaedics;
Karina Gritsenko MD Department of Medical Education,
Montefiore Medical Center, Bronx, Icahn School of Medicine at Mount
NY, USA Sinai, New York, NY, USA

Published online by Cambridge University Press

 List of Contributors xiii

Mark R. Jones MD Brittni M. Lanoux MD

Department of Anesthesia, Weill Department of Anesthesiology,
Cornell Medical School, New York, Louisiana State University Health
NY, USA Sciences Center, New Orleans,
LA, USA
Leah A. Kaplan BFA
Louisiana State University Health Victoria L. Lassiegne MD (expected)
Shreveport, Shreveport, Louisiana State University Health
LA, USA Sciences Center, School of Medicine,
New Orleans, LA, USA
Vijay Kata MD (expected)
Department of Anesthesiology, Tamara Lawson MD MPH
Louisiana State University Health Virginia Commonwealth University
Shreveport, Shreveport, Health System, Richmond, VA, USA
LA, USA
Kay Lee MD
Alan David Kaye MD PhD Montefiore Medical Center, Bronx,
Department of Anesthesiology, NY, USA
Louisiana State University Health
Shreveport, Shreveport, William Lee MD
LA, USA Department of Anesthesiology,
Perioperative and Pain Medicine;
Julia Kendrick MD Icahn School of Medicine at Mount
Department of Adult Sinai, New York, NY, USA
Cardiothoracic Anesthesiology,
Medical University of South Jinlei Li MD PhD FASA
Carolina, Charleston, Department of Anesthesiology, Yale
SC, USA University, New Haven, CT

Ryan J. Kline MD Graham T. Lubinsky MD

Department of Anesthesiology, Anesthesiology and Critical Care
Louisiana State University Health Medicine, MedStar Georgetown
Sciences Center, New Orleans, University Hospital, Washington,
LA, USA DC, USA

Gopal Kodumudi MD Austin Ly BS

Department of Anesthesiology, University of Tennessee Health
Louisiana State University Health Science Center College of Medicine,
Sciences Center, New Orleans, Memphis, TN, USA
LA, USA
Eric Ly MD
Lakshmi N. Kurnutala MD MSc University of Tennessee Health
University of Mississippi Medical Science Center College of Medicine,
Center, Jackson, MS, USA Memphis, TN, USA

Published online by Cambridge University Press

 xiv List of Contributors

Franciscka Macieiski MD George Mychaskiw DO

Louisiana State University Health Department of Anesthesiology,
Shreveport Medical Center, Louisiana State University Health
Shreveport, LA, USA Shreveport, Shreveport, LA, USA

Timothy Martin MD MBA FASA Olga C. Nin MD

Division of Pediatric Anesthesia, University of Florida College of
University of Florida College of Medicine, Gainesville, FL, USA
Medicine, Gainesville, FL, USA
Chikezie N. Okeagu MD
Sarah McCraney MD Department of Anesthesiology,
Anesthesiology, University of Louisiana State University Health
Florida, Gainesville, FL, USA Sciences Center, New Orleans,
LA, USA
Michael McManus MD
Department of Anesthesiology, Sher-Lu Pai MD
University of Virginia, Department of Anesthesiology and
Charlottesville, VA, USA Perioperative Medicine, Mayo
Clinic College of Medicine,
Sonia D. Mehta MD Jacksonville, FL, USA
Department of Anesthesiology,
University of Florida College of Chang H. Park MD
Medicine, Gainesville, FL, USA Department of Anesthesiology,
Perioperative and Pain Medicine,
Adrienne Mejia MD Icahn School of Medicine at Mount
Department of Anesthesiology, Sinai, New York, NY, USA
Yale University, New Haven,
CT, USA Jeffrey Park MD
Department of Anesthesiology,
Bethany Menard MD University of North Carolina at
Louisiana State University Health Chapel Hill, Chapel Hill, NC, USA
Sciences Center, New Orleans,
LA, USA Nihir Patel MD
Department of Anesthesiology,
Sumitra Miriyala PhD Perioperative and Pain Medicine;
Department of Cellular Biology and Icahn School of Medicine at Mount
Anatomy, Louisiana State Sinai, New York, NY, USA
University Health Shreveport,
Shreveport, LA, USA Shilpa Patil MD
Department of Anesthesiology,
Mark Motejunas MD Louisiana State University Health
UCLA Health, Santa Monica, Shreveport, Shreveport,
CA, USA LA, USA

Published online by Cambridge University Press

 List of Contributors xv

Shilpadevi S. Patil MD Kelsey Rooney BS

Department of Anesthesiology Louisiana State University Health
Louisiana State University Health Shreveport, Shreveport, LA, USA
Sciences Center, New Orleans,
LA, USA Corey Scher MD
Department of Anesthesiology,
Stephen Patin MPH MD (expected) Perioperative Care, and Pain
Louisiana State University Health Medicine, NYU Grossman School of
Shreveport, Shreveport, LA, USA Medicine, New York, NY, USA

Alex D. Pham MD Annemarie Senekal MBChB MMed FCA

Department of Anesthesiology, Department of Anesthesiology and
Louisiana State University Health Critical Care, University of
Sciences Center, New Orleans, Stellenbosch, Tygerberg
LA, USA Hospital, Cape Town, South Africa

Catherine Price PhD Christopher M. Sharrow MD

Clinical and Health Psychology, Department of Anesthesiology,
Perioperative Cognitive Anesthesia University of Virginia,
Network (PeCAN), Anesthesiology, Charlottesville, VA, USA
University of Florida, Gainesville,
FL, USA Meredith K. Shaw MD
Department of Anesthesiology,
Iliana Ramirez-Saldana MD Louisiana State University Health
University of Mississippi Medical Sciences Center, New Orleans,
Center, Jackson, MS, USA LA, USA

Aaron Reagan MD Matthew Sherrer MD MBA FASA

Department of Anesthesiology and University of Alabama at
Perioperative Pain Medicine, The Birmingham, Heersink School of
Mount Sinai Hospital, New York, Medicine, Department of
NY, USA Anesthesiology and Perioperative
Medicine, Birmingham, AL, USA
Devin S. Reed MD
Louisiana State University Health Meeta M. Sheth MD
Sciences Center, New Orleans, Department of Anesthesiology,
LA, USA Louisiana State University Health
Shreveport, Shreveport, LA, USA
Pamela R. Roberts MD FCCM FCCP
Department of Anesthesiology, Ashley Shilling MD
University of Oklahoma College of Department of Anesthesiology,
Medicine, Oklahoma City, University of Virginia,
OK, USA Charlottesville, VA, USA

Published online by Cambridge University Press

 xvi List of Contributors

Naina Singh MD Sridhar R. Tirumala MD

Department of Anesthesiology, Department of Anesthesiology,
Louisiana State University Louisiana State University Health
Health Shreveport, Shreveport, Shreveport, Shreveport, LA, USA
LA, USA
Gregory M. Tortorich MD
Harish Bangalore Siddaiah MD Department of Anesthesiology,
Department of Anesthesiology Louisiana State University Health
Louisiana State University Health Sciences Center, New Orleans,
Sciences Center, Shreveport, LA, USA
LA, USA
Christine T. Vo MD
Alan M. Smeltz MD Department of Anesthesiology,
University of North Carolina University of Oklahoma College of
Hospital, Chapel Hill, NC, Medicine, Oklahoma City, OK, USA
USA
Michael P. Webb MBChB MSc
Zhuo Sun Counties Manukau Health
Department of Anesthesiology and Department of Anaesthesia and Pain
Perioperative Medicine, Augusta Medicine, Auckland, New Zealand
University Medical Center,
Medical College of Georgia at Margaret E. Wiggins MS
Augusta University, Augusta, Clinical and Health Psychology,
GA, USA Perioperative Cognitive Anesthesia
Network (PeCAN), Anesthesiology,
Pankaj Thakur MD University of Florida, Gainesville,
Department of Anesthesiology, FL, USA
Louisiana State University Health
Sciences Center, Shreveport, Vishal Yajnik MD MS
LA, USA Anesthesiology Division of Critical
Care, Virginia Commonwealth
George Thomas BS University, Richmond, VA, USA
George Washington School of
Medicine and Health Sciences, Erin Yen DO
Washington, DC, USA University of Florida College of
Medicine, Gainesville, FL, USA
Patrick Tighe MD
Clinical and Health Psychology, Reine Zbeidy MD
Perioperative Cognitive Anesthesia Division of Obstetric
Network (PeCAN), Anesthesiology, Anesthesiology, University of
University of Florida, Gainesville, Miami, Miller School of Medicine,
FL, USA Miami, FL, USA

Published online by Cambridge University Press

 Introduction
Douglas R. Bacon

The pages that unfold behind this introduction are full of information for
providers of anesthesia services. In some ways, this is a “how to” manual for
one of the most misunderstood and difficult practices in medicine. For some,
this book will unlock new knowledge and improve clinical practice. For others,
it will confirm already acquired information or update knowledge to ensure
practice at the forefront of anesthesiology. The transfer of the expertise is
seamless, simple, and, by the nature of the publication, created and reviewed
by experts.
It was not always so straightforward to find this information in one
place. Think for a moment about how the information about the discovery
of the anesthetic properties of diethyl ether spread across the world. On
October 16, 1846, William Thomas Green Morton anesthetized Gilbert
Abbott for the removal of a tumor of the jaw at the Massachusetts
General Hospital by the surgeon John Collins Warren. By December,
1846, ether anesthesia was being used in London, several thousand miles
across the Atlantic Ocean [1]. The question of how this knowledge crossed
the ocean in a time when electronic communication did not exist continues
to fascinate historians of medicine.
A letter from Jacob Bigelow, a physician and botanist to Francis Boot,
and an expatriate American physician practicing in London, conveyed news
of Morton’s work. Boot proceeded to anesthetize Miss Lonsdale for the
extraction of a tooth by Mr. James Robinson, a dentist, on December 19,
1846. Two days later, Dr. Boot would anesthetize Frederick Churchill for the
amputation of his leg by the famous surgeon Robert Liston [1]. All of this
occurred due a letter from one physician to another, carried by steamship
across the Atlantic! Gwen Wilson has likewise chronicled the arrival of the
news of surgical anesthesia in Australia, half a world away from Boston. On
June 7, 1847, just shy of eight months later, ether anesthesia was given in
Sydney, Australia [2]. Almost a full year later, on October 4, 1847, the
physician and missionary Peter Parker gave the first ether anesthetics in
China [3].
It would be almost another thirty-five years before a textbook of anesthesia
would be published. Henry M. Lyman, Professor of Physiology and Diseases of
1

https://doi.org/10.1017/9781108936941.001 Published online by Cambridge University Press

 2 Douglas R. Bacon

the Nervous System at Rush Medical College and Professor of Theory and
Practice of Medicine at the Woman’s College, both in Chicago, would be the
sole author of a book entitled Artificial Anaesthesia and Anaesthetics [4]. It is
a comprehensive text, with many subjects that are recognizable today.
Dr. Lyman wrote about medical legal considerations, administration of anes-
thetics, and several chapters on anesthetic agents. Two things stand out in the
book. First, in the chapter on the history of anesthesia is the first recitation of
the anesthetic given by William E. Clarke in January, 1842. The other is his
section on local anesthesia before the discovery of the anesthetic properties of
cocaine by Carl Koller in 1884.
One of the next major and popular textbooks prior to World War
I was written by New York City physician James Tayloe Gwathmey.
Published in 1914, Anesthesia [5], with almost 950 pages, is a summary
of anesthetic knowledge of the time. The book may well have been
published in response to the need of members of the newly established
American Association of Anesthetists, the first truly national association of
physician specialists in the United States. Both the textbook and the
Association demonstrate the slow-growing trend of physician specializa-
tion in anesthesia. The textbook especially demonstrates the growth in
knowledge of anesthetics and the techniques for administration in the
thirty-three years since Lyman’s book was published.
Shortly thereafter, textbooks of anesthesia proliferated. One interest-
ing text was published by Paluel Flagg. In the preface to the second
edition [6] in 1919, Flagg wrote that the “purpose of this little volume
‘as a groundwork upon which the student, interne, and general practi-
tioner may acquire a more comprehensive knowledge of the Art of
Anaesthesia’ has been strictly adhered to . . .” in the almost 370 pages.
A scant three years later, Gaston Labat would publish one of the first
comprehensive American textbooks on an anesthetic subspecialty with
Regional Anesthesia [7]. The book is based largely on the much smaller
and less comprehensive text produced by Victor Pauchet, Paul Sourdat,
and Gaston Labat entitled L’Anesthésie Régionale. In point of fact, much
of the text and many of the illustrations are taken almost directly from
Pauchet’s work, except for a long section on techniques that emphasized
the anesthetist’s interaction with and approach to the patient [8].
While the emergence of textbooks on the subject of anesthesia, essentially
in the early years of the twentieth century, may seem unimportant to the
modern reader used to the massive thousand-page or multivolume tome, it
remains interesting to understand the growth of information in these books.
For the development of the specialty, the core knowledge that constitutes
anesthesiology is defined within the bindery of the edition. Reading through
the following pages of this volume reconstructs what students of the art and
science of anesthesiology have been doing for more than a century. May the

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 Introduction 3

insights gained within this book allow the reader to improve care for the most
important aspect of our shared specialty – the patient.

References
1. Rushman GB, Davies NJH, Atkinson RS. A Short History of Anaesthesia. Oxford:
Butterworth-Heinemann; 1996.
2. Wilson G. One Grand Chain, Vol. I. Melbourne: The Australian and New Zealand
College of Anaesthetists; 1995.
3. Sim P, Du B, Bacon DR. Pioneer Chinese anesthesiologists: American influence on
the development of anesthesiology in China. Anesthesiology. 2000;93:256–64.
4. Lyman HM. Artificial Anaesthesia and Anaesthetics. New York, NY: William Wood
and Company; 1881.
5. Gwathmey JT. Anesthesia. New York, NY: D. Appleton and Company; 1914.
6. Flagg PJ. The Art of Anaesthesia. Philadelphia, PA: J. B. Lippincott Company; 1919.
7. Labat G. Regional Anesthesia Its Technic and Clinical Application. Philadelphia, PA:
W. B. Saunders Company; 1922.
8. Cote AV, Vachon CA, Horlocker TT, Bacon DR. From Victor Pauchet to Gaston
Labat: the transformation of regional anesthesia from a surgeon’s practice to the
physician anesthetist. Anesth Analg. 2003;96:1193–200.

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 Chapter
Preoperative Evaluation

1 and Coexisting Disease

Matthew Sherrer, Sher-Lu Pai, and Jeffrey
Dobyns

Preoperative Evaluation
The preoperative evaluation is a review of a patient’s physical condition in
preparation for surgery. The history and physical examination are the
foundation of this assessment and focus on identifying predisposing factors
for cardiac and pulmonary complications and on determining a patient’s
functional capacity to define fitness for surgery. The history and physical
examination findings determine the need for additional laboratory or
diagnostic testing if such evaluation changes the course of action or
improves patient health and outcomes. Presurgical medical optimization,
including proper subspecialty consultation, improves surgical outcomes in
patients with coexisting diseases. Preoperative preparation and optimiza-
tion efforts focus on identifying and mitigating modifiable risk factors to
improve surgical and longitudinal outcomes while reducing healthcare
costs.

Elements of Preoperative Evaluation

The essential component of the preoperative evaluation is the history, which
details past and current medical and surgical status, family and genetic
history, and documentation of tobacco, alcohol, and substance use.
A detailed list of allergies and reactions, as well as previous anesthetic
experiences, helps formulate the anesthetic plan. A complete 12-point
review of systems identifies any undiagnosed or inadequately optimized
disease. Cardiovascular and pulmonary diseases are the primary drivers of
adverse perioperative outcomes and are the most relevant in determining
fitness for anesthesia and surgery [1].
A focused preoperative physical examination includes, at a minimum,
documentation of vital signs, including height and weight, with body mass
index (BMI) calculation, and an assessment of the airway, lungs, and
heart, and a basic neurologic examination. Unexpected abnormal findings
on the physical examination, such as a new heart murmur or an unex-
plained decline in functional capacity, compel investigation before elective
surgery.

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 Preoperative Evaluation and Coexisting Disease 5

Medication Reconciliation
A complete medication history, including current and new drug therapy and
unusual reactions or responses to drugs, ensures safe perioperative care.
Medications that provide physiologic homeostasis should be continued pre-
operatively. The decision to continue, discontinue, or modify chronic medica-
tion regimens requires thoughtful risk–benefit analysis. Polypharmacy is
common in elderly patients, and the preoperative evaluation is an opportunity
to identify and mitigate duplicated medications and those with cross-
reactivity. This encounter is also an opportunity to ensure that appropriate
stroke and cardiovascular risk reduction strategies, such as statin therapy, are
in place.

Risk Stratification
Perioperative risk is determined by healthcare, patient, and socio-economic
factors [2]. Healthcare factors include elements specific to the type and
magnitude of the surgical procedure and those encompassing anesthesia
type and management techniques employed, such as goal-directed fluid
therapy. Patient characteristics include fixed risk factors, such as age and
genetics, and modifiable risk factors, such as smoking, nutrition status, and
anemia. Perioperative outcomes are directly affected by social determinants
of health, such as economic stability, physical environment, and level of
education.
Deciding to have surgery is a complex consideration of risks, short- and
long-term benefits, alternatives, and effects on longitudinal health. A primary
goal of the preoperative evaluation is to make surgery safer by estimating the
total risk relative to the benefits of proceeding with surgery and reducing
modifiable risk. Communicating the risk to the patient, along with risk
reduction strategies in the interest of shared decision-making, affects whether
or not to proceed with surgery.

ASA Physical Status Classification

Originally intended to assess and communicate a patient’s preanesthesia
medical comorbidities, the American Society of Anesthesiologists (ASA) phy-
sical status classification is a current standard of risk assessment and
a mandated element of the preanesthetic evaluation by the Joint
Commission. The ASA scoring system alone does not predict perioperative
risks. When combined with other factors such as frailty and functional status,
it demonstrates excellent risk prediction, and higher scores correlate with
increased postoperative morbidity and mortality [3]. This scale is based solely
on the presence of existing disease and does not consider the risk of the
surgical procedure.

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 6 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

Cardiac
Cardiac functional status or capacity, expressed as metabolic equivalents
(METs), is determined subjectively by assessment with a brief set of questions
and has been thought to be positively associated with postoperative outcomes.
Many risk models rely on this assessment. Achieving four METs of activity
without symptoms is a good prognostic indicator of perioperative outcomes
[4]. A subjective assessment of functional status does not accurately identify
patients with inadequate functional capacity or predict postoperative morbid-
ity or mortality [5]. The Duke Activity Status Index (DASI) provides an
objective assessment of functional capacity. Compared with cardiopulmonary
exercise testing and subjective assessment of functional capacity, only DASI
scores successfully predicted the primary outcomes of myocardial injury or
death at 30 days. A DASI score of <34 is associated with an increased risk of
30-day death, myocardial infarction (MI), and moderate to severe complica-
tions [6].
All patients scheduled for noncardiac surgery should have an initial
assessment of the percentage risk of a major adverse cardiac event (MACE)
using validated models that include information from the history and
physical examination, objective functional capacity score, electrocardio-
gram, laboratory studies, and planned procedure. The calculated risk aids
the patient and perioperative specialists in weighing the risks and benefits
and determining the optimal timing of surgery. The risk score guides
decision-making as to whether the planned surgery should proceed without
further preoperative cardiovascular testing or whether postponement for
additional testing is indicated. Preoperative risk stratification is also instru-
mental in determining if a patient would benefit from preoperative coron-
ary revascularization or consideration of a lesser-risk or nonsurgical
alternative. The risk assessment occasionally uncovers undiagnosed pro-
blems or inadequately managed chronic conditions requiring optimization.
The decision to pursue further cardiovascular testing considers both short-
and long-term risk reductions.
The Revised Cardiac Risk Index (RCRI) or the American College of
Surgeons National Surgical Quality Improvement Program (NSQIP) risk
prediction tool are two commonly used risk indices. The RCRI is simpler
and has been widely used and validated for many years. The NSQIP
calculator is more complex, requiring calculation through an online algo-
rithm. A more straightforward tool derived from the NSQIP database is the
Gupta myocardial infarction or cardiac arrest (MICA) calculator. The
newer Cardiovascular Risk Index (CVRI) is a validated model with higher
discriminatory power than the RCRI [7]. For patients at low MACE risk
(<1%), no further testing is indicated. For patients with higher MACE risk
(>1%) and inadequate functional capacity (<4 METs), the question

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 Preoperative Evaluation and Coexisting Disease 7

becomes whether further cardiovascular testing will change management

and improve the outcome.

Pulmonary
Postoperative pulmonary complications adversely influence a patient’s post-
operative course. They are a significant source of postoperative morbidity and
mortality, resulting in substantial increases in healthcare resource utilization.
Table 1.1 details the patient and surgical risk factors associated with post-
operative pulmonary complications. The ARISCAT Risk Index is a commonly
used risk prediction tool to identify patients at risk of postoperative pulmon-
ary complications and likely to benefit from presurgical risk reduction inter-
ventions, such as increased physical activity and preoperative incentive
spirometry. All available risk indices provide a reliable estimation of post-
operative pulmonary complication risk, but the ARISCAT Risk Index is the
most practical for preoperative assessment. The strongest predictor for post-
operative pulmonary complications is poor functional capacity. Any history
suggesting unrecognized chronic lung disease or heart failure, such as reduced
functional capacity, unexplained dyspnea, or cough, requires further evalua-
tion. Pulmonary function tests and routine chest X-rays do not appreciably
add to risk stratification.

Table 1.1 Predictive risk factors for postoperative pulmonary complications

Patient risk factors Surgical risk factors

• Age >50 yearsa • Upper abdominal or thoracic

• Preexisting pulmonary disease surgerya
• Obstructive sleep apnea • Emergency surgerya
• ASA physical status of 3 or higher • Surgery lasting longer than
• Current smoking 2 hoursa
• Heart failure • General versus combined gen-
• Poor functional capacity/frailty eral and regional anesthesia
• Malnutrition • Intraoperative fluid manage-
• Diabetes with hyperglycemia/ele- ment strategy
vated hemoglobin A1c • Blood transfusion
• Preoperative anemiaa • Neuromuscular blockade
• Morbid obesity
• Preoperative oxygen saturation
below 95%a
• Respiratory infection within preced-
ing montha
a
Factors assessed by the ARISCAT Risk Index.

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 8 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

Preoperative Optimization and Prehabilitation

Safe and efficient surgical and anesthesia practice requires a fit and medically
optimized patient. Numerous epidemiological studies indicate that inadequate
preoperative preparation is a significant contributory factor to the primary
causes of perioperative morbidity and mortality. Postoperative morbidity is
a significant surgical outcome in terms of economic consequences to health-
care institutions. Preoperative comorbidities, coupled with surgical complex-
ity, predict adverse outcomes and increased healthcare resource utilization.
Given preoperative time and resource limitations, it is reasonable to focus
these efforts on patients at high risk of postoperative morbidity and mortality.
Preoperative optimization and prehabilitation represent prudent economic
strategies for reducing short- and long-term healthcare expenses and improv-
ing longitudinal population health.
Preoperative optimization is a process of clinician-managed interventions
not directly involving patient effort or behavior modification, such as medica-
tion adjustment, glucose management, or anemia correction, designed to
prepare the patient psychologically and physiologically to handle the stress
of surgery. Prehabilitation differs from optimization and is the active pre-
operative process of enhancing a patient’s functional capacity to allow better
tolerance of the stressors of surgery and recovery. Prehabilitation efforts
implemented to improve postoperative outcomes involve lifestyle interven-
tions, such as nutritional supplementation, physical exercise, stress reduction,
and smoking cessation.

Coexisting Disease
Cardiac
Ischemic Heart Disease
Patients with coronary stents undergoing noncardiac surgery are at high MACE
risk even when receiving perioperative antiplatelet therapy, and withholding
one or both antiplatelet medications increases the risk of thrombosis. They are
also at high risk of significant bleeding when one or both medications are
continued. MACEs, including stroke, are mainly related to previous medical
conditions and perioperative blood loss, and not to the surgery itself. In patients
undergoing noncardiac surgery after a percutaneous coronary intervention
(PCI) with second-generation drug-eluting stents, the incidence of MACEs,
including death, MI, stent thrombosis, and the need for repeat revasculariza-
tion, was highest in the first 6 months after the PCI [8]. Elective procedures
should be delayed for at least 6 months in patients with drug-eluting stents, at
least 30 days for those with bare-metal stents, and 14 days following balloon
angioplasty to allow for uninterrupted dual antiplatelet therapy.

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 Preoperative Evaluation and Coexisting Disease 9

Hypertension
Perioperative hypertension is primarily a manifestation of acute or acute-on-
chronic hypertension. Perioperative hypertension occurs mainly for two rea-
sons: (1) worsening of chronic hypertension; or (2) a response to transient
factors, such as pain, anxiety, or withholding of blood pressure medications.
Hypertension is not a significant factor for determining perioperative cardiac
risk, but it does contribute to several conditions that are, such as chronic renal
disease and diastolic dysfunction. In the absence of acute end-organ dysfunc-
tion, there is little justification for case cancellation for blood pressures below
180/110 mmHg.
Isolated systolic hypertension (ISH) is the most common type of hyper-
tension in the elderly. It is associated with a two- to fourfold increase in the
risk of MI, left ventricular hypertrophy (LVH), renal dysfunction, stroke, and
cardiovascular mortality. Characteristics of ISH include a widened pulse
pressure and a systolic blood pressure of ≥140 mmHg, with a diastolic blood
pressure of <90 mmHg. Elderly patients benefit significantly from therapies to
reduce systolic blood pressure. The preoperative treatment of ISH risks dia-
stolic hypotension and compromise of perfusion to vascular beds, and
requires careful consideration.

Bioprosthetic and Mechanical Heart Valves

Anticoagulation management in the patient with a bioprosthetic or mechan-
ical valve undergoing surgery considers the type, location, and number of
prosthetic heart valves, planned surgical procedure and bleeding risk, and
other patient risk factors for thromboembolism, and the planned procedure.
The primary concern with interrupting anticoagulation is thromboembolism,
which carries a 20% mortality rate and a 40% rate of significant disability [9].
The decision to interrupt anticoagulation and whether or not to bridge with
low-molecular-weight heparin requires stratification of a patient’s risk of
thromboembolism versus significant bleeding. Thromboembolism risk strati-
fication tools, such as the BleedMAP and HAS-BLED scores, are useful in
clinical decision-making. Patients undergoing procedures with associated low
bleeding risk should be continued on their regular anticoagulation regimen.
The thromboembolic risk is highest within the first three months of biopros-
thetic or mechanical mitral valve replacement or repair. Noncardiac surgery
should be deferred to avoid interruption of anticoagulation.

Heart Failure
Heart failure represents a spectrum of disease, and perioperative risk varies
depending on where the patient is along the continuum. Risk is lowest for those
patients with asymptomatic diastolic dysfunction where ejection fraction is
preserved, and highest for those at the end-stage with reduced ejection fraction.

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 10 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

The postoperative mortality risk is higher in patients with heart failure than in
those with coronary artery disease, and elderly patients with heart failure have
substantially higher risks of postoperative mortality and hospital readmission.
The preoperative assessment goals for heart failure patients before noncardiac
surgery include: assessing functional status; identifying asymptomatic patients
who are at risk of developing heart failure in the postoperative period; deter-
mining whether heart failure patients are stable and optimally managed or
showing signs and symptoms of decompensation; recognizing high-risk heart
failure syndromes, including new-onset heart failure; and identifying comor-
bidities that impact the stability of heart failure in the postoperative period. The
inability to achieve 4 METs functional capacity by walking four average-length
city blocks and climbing two flights of stairs without experiencing symptomatic
limitation was 71% sensitive and 47% specific for predicting severe postopera-
tive complications. Given the critical prognostic implications of functional
capacity to surgical outcomes, the New York Heart Association (NYHA) func-
tional classification (see Table 1.2) categorizes heart failure patients based on
functional capacity limitations and symptom development. Postoperative mor-
tality increases with severity of the preoperative functional impairment, from
4% in NYHA class 1 to 67% in class IV.
Asymptomatic diastolic dysfunction is common in elderly and hyperten-
sive patients and presents considerable perioperative challenges. Diastolic
dysfunction is an underestimated disease and is independently associated
with major adverse outcomes in patients undergoing both cardiac or non-
cardiac surgery. The most straightforward approach to recognizing asympto-
matic left ventricular dysfunction is maintaining a high index of suspicion

Table 1.2 New York Heart Association functional classification

NYHA Symptoms
class

I No limitations of physical activity. Ordinary activity does not cause

dyspnea, palpitations, or fatigue

II Slight limitation of physical activity. Comfortable at rest, but

ordinary physical activity results in dyspnea, palpitations, or fatigue

III Pronounced limitation of physical activity. Comfortable at rest, but

less-than-ordinary physical activity results in dyspnea, palpitations,
or fatigue

IV Unable to carry on any physical activity without discomfort.

Symptoms of heart failure at rest. Discomfort increases with any
physical activity

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 Preoperative Evaluation and Coexisting Disease 11

when a patient provides a history of risk factors or presents with particular

physical signs, such as resting tachycardia or the presence of a fourth heart
sound. Identification of suspicious signs and symptoms warrants prompt
cardiology referral. A risk stratification model, such as the RCRI or NSQIP
calculator, including heart failure as a procedural risk factor provides an
accurate MACE risk assessment. Both models offer an estimation of
MACEs, but the NSQIP calculator also provides estimates of several other
adverse outcomes, such as postoperative pulmonary complications (PPCs)
and expected length of stay.

Pulmonary
The ARISCAT index identifies patients at risk of PPC and guides preopera-
tive optimization strategies, as described in Table 1.3. Those at low risk of
PPCs benefit from simple recommendations, such as practicing good oral
hygiene and early mobilization. Those patients at intermediate and high
risk of PPCs benefit from preoperative incentive spirometry and increased
activity and advanced lung-protective ventilation maneuvers. All patients
undergoing general anesthesia benefit from low-tidal-volume ventilation
strategies. The use of inhaled bronchodilators more than three times
a day in patients with chronic lung disease warrants the preoperative
addition of maintenance medications.

Table 1.3 Perioperative pulmonary risk mitigation strategies

Low risk of PPC Intermediate risk of PPC High risk of PPC

Early mobilization All of low maneuvers, plus: All of low and intermediate
maneuvers, plus:

Good oral hygiene Postoperative incentive 1–2 weeks of preoperative

spirometry incentive spirometry

Optimization of Identification and commu- Increased postoperative

chronic lung nication of “increased risk” surveillance
disease status

Smoking cessation Regional anesthesia/

counseling and analgesia, if applicable
resources

Lung-protective ventilation
Source: Used with permission from Pfeifer, K. Guide to Preoperative Evaluation. www
.preopevalguide.com, 2020.

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 12 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

Tobacco, Marijuana, and Vaping Use

Smoking within 1 year of surgery is associated with increased postoperative
complications, including poor wound healing, increased healthcare costs,
increased hospitalization, and higher utilization of healthcare resources.
Preoperative smoking cessation reduces the incidence of these complications
and, when maintained long term, improves population health in general. Each
week of smoking cessation before surgery decreases the complication risk by
19%, and cessation of one year or more reduces PPC risk to that of
a nonsmoker [10]. Preoperative smoking cessation counseling and nicotine
replacement therapy increase the likelihood of long-term abstinence. Like the
use of traditional tobacco, chronic marijuana use results in similar long-term
effects to cigarette use. Preoperative abstinence, comparable to that seen with
smoking cessation, leads to a reduction in the risk of adverse outcomes.
There has been an increase in the usage of electronic (e-)cigarettes in
recent years. While e-cigarettes do not contain the harmful combustion by-
products of traditional cigarettes, they contain toxic solvents, such as glycerol
and propylene glycol, and chemical flavorings. Vaping by patients undergoing
plastic surgery exhibited an increased risk of skin flap necrosis and death.
Perioperative vaping instructions and cessation efforts are identical to those
for tobacco users.

Pulmonary Hypertension
The preoperative preparation of patients with pulmonary hypertension is
a multidisciplinary effort critical to a good outcome for these patients. It focuses
on determining the severity of the disease and the adequacy of physiologic and
pharmacologic compensation. All pulmonary hypertension medications continue
throughout the day of surgery, including diuretics, angiotensin-converting
enzyme inhibitors (ACEIs), and sildenafil, to prevent acute decompensation.
Laboratory studies are indicated, based on patient physical status and medication
management. An electrocardiogram identifies right ventricular hypertrophy and
evidence of right heart strain, and recent echocardiography assesses right ven-
tricular function and pulmonary artery pressures. Evidence of right ventricular
failure warrants case delay for further medical management.

Obstructive Sleep Apnea

Patients with obstructive sleep apnea (OSA) have a two- to fourfold higher risk
of perioperative complications than patients without OSA. Respiratory com-
plications, such as desaturation and respiratory failure, are the most common.
Undiagnosed severe OSA is significantly associated with an increased risk of
30-day postoperative cardiovascular complications [11]. Other perioperative
complications include difficulty with airway management, cardiovascular
complications, and postoperative delirium, all leading to higher resource

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 Preoperative Evaluation and Coexisting Disease 13

utilization. Given the increasing prevalence and associated perioperative risks

of OSA, the Society of Anesthesia and Sleep Medicine recommends screening
all presurgical patients for OSA.
The STOP-Bang questionnaire is the best-validated tool for preoperative
screening for OSA. Patients with zero to two positive responses are considered
low risk; those with three or four are at intermediate risk, and those with ≥5
positive responses are at high risk of having OSA. An elevated serum bicarbo-
nate increases the specificity of intermediate STOP-Bang scores. A high risk
score of 5–8 was associated with an increased cardiovascular risk following
surgery and intensive care unit (ICU) readmission. In contrast, a moderate
risk score of 3 or 4 was associated with an increased risk of ICU readmission
and wound infection. Most patients with known or suspected OSA may
proceed to surgery without additional testing or treatment for OSA.
However, select patients benefit from surgical delay for formal diagnosis by
sleep study and for initiation of therapy or treatment optimization. Patients
requiring further testing or treatment optimization are delayed at least one
week for acclimation to the continuous positive airway pressure (CPAP)
device or adjusted settings. Patients on CPAP therapy for OSA should con-
tinue treatment up to the day of surgery and bring their CPAP or other
treatment devices on the day of surgery, including controllers for hypoglossal
nerve stimulators.

Frailty
Although frailty is independent of chronological age, it is more prevalent in
the geriatric population. Frailty is defined as a decrease in physiologic
reserve exceeding that expected from advanced age alone and presents
with an increased vulnerability to stressors. Sarcopenia, characterized by
a decline in functional capacity with low muscle mass and strength, is
a significant component of frailty. Sarcopenia measurement by preoperative
grip strength, gait speed, or chair stand test provides an accurate diagnosis of
the severity of frailty [12]. Frailty predicts postoperative mortality and
morbidity, including delirium, increased hospital stay, discharge to
a skilled nursing facility, cognitive impairment, and functional decline
[13]. The preoperative evaluation of elderly patients requiring elective
major surgery should include a frailty screen. Most assessment tools involve
scoring based on specific comorbidities, dependence on others for daily
living activities, malnutrition, and dementia, rather than on physical assess-
ment alone. There are several validated frailty screening tools, such as the
FRAIL scale (detailed in Table 1.4), but few methods of objective measure-
ment. FRAIL scale scores range from zero to 5, and a score of zero represents
robust health status and 1–2 a prefrail state, and 3–5 is consistent with frailty.
A positive frailty screen is an indication for a comprehensive evaluation and

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 14 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

Table 1.4 The FRAIL scale

Description Question Score

Fatigue “Have you felt fatigued for most or all of the Yes = 1
time over the past month?” No = 0

Resistance “Do you have difficulty climbing a flight of Yes = 1

stairs?” No = 0

Ambulation “Do you have difficulty walking one block?” Yes = 1

No = 0

Illness “Do you have any of these illnesses: hyperten- ≥5 illnesses

sion, diabetes, cancer, chronic lung disease, =1
heart attack, congestive heart failure, angina, <5 illnesses
asthma, arthritis, stroke, and kidney disease?” =0

Loss of “Have you lost more than 5% of your weight in Yes = 1

weight the past year?” No = 0

Source: Morely, JE, Malmstrom, TK, Miller, DK. A simple frailty questionnaire (FRAIL)
predicted outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):-
601–8.

intervention by a geriatric medicine specialist. Identification of preoperative

frailty informs patient and family discussions and decision-making regard-
ing surgical techniques and alternative treatments, postoperative recovery
strategies, and expected outcomes. The prognosis of frail patients improves
with shared decision-making, prehabilitation, and interdisciplinary geriatric
co-management [14].

Malnutrition
Preoperative malnutrition leads to immune system dysfunction and contri-
butes to several adverse surgical outcomes, including increased susceptibility
to wound infection, cognitive dysfunction, and poor wound healing. Patients
with preoperative hypoalbuminemia, either alone or associated with chronic
liver disease or congestive heart failure, are more likely to have postoperative
complications such as infections, organ dysfunction, increased duration of
mechanical ventilation and ICU stay, and mortality. BMI is not an accurate
assessment of nutritional status.
Various screening tools exist to identify malnutrition preoperatively. The
Nestlé Mini Nutritional Assessment Short Form (MNA-SF) is a validated
screening tool which evaluates predictive parameters such as recent oral
intake, weight loss, mobility, psychological stress, and neuropsychological

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 Preoperative Evaluation and Coexisting Disease 15

problems, in addition to BMI or calf circumference. The sensitivity and

specificity of the MNA-SF is 97.9% and 100%, with a diagnostic accuracy
of 99% for predicting undernutrition [15]. The MNA-SF is easy to use and
efficient, and minimally impacts workflow. A numerical score identifies
patients as malnourished, at risk of malnutrition, or of normal nutritional
status. Preoperative nutritional optimization includes supplementation with
protein or immunonutrient solutions containing arginine and omega fatty
acids. Benefits of preoperative dietary supplementation include reduced
hospital stays, reduced need for critical care, and reduced postoperative
infections, including pulmonary and surgical site infections in patients
undergoing gastrointestinal cancer surgery [16]. The Enhanced Recovery
After Surgery (ERAS) Society strongly encourages complex carbohydrate
loading before surgery, which reduces postoperative insulin resistance and
length of stay.

Anemia
Anemia is not merely an independent predictor of adverse perioperative
outcomes; it is a potent risk multiplier. The preoperative presence of
anemia augments the inherent mortality risk of coexisting diseases, such
as chronic kidney disease (CKD) and congestive heart failure. Anemia is
widespread in surgical patients, with a reported incidence of up to 76%.
Frequently, the anemia is undiagnosed. Consequently, anemia identified on
preoperative evaluation is often ignored and accepted as a harmless devia-
tion. Not only is anemia a modifiable preoperative condition, but it is also
associated with decreased survival and higher rates of hospitalization, and
is one of the strongest predictors of perioperative blood transfusions, an
individual risk profile. A preoperative hemoglobin level <6 g/dL increases
the risk of death at 30 days 26-fold, compared to a hemoglobin level of
12 g/dL [17].
Iron deficiency is the most common cause of anemia and results from
malabsorption or nutritional deficiency, or is medication-related. Oral iron
supplementation initiated 4–6 weeks before a scheduled surgery generally
results in an increase in reticulocyte count within 7–14 days and an increase
in hemoglobin level of about 2 g/dL within 3 weeks. Patients who do not
respond to oral iron or who are noncompliant due to gastrointestinal distur-
bance are candidates for intravenous iron therapy. Intravenous iron results in
hemoglobin increases of 0.5–1.0 g dL−1 per week. The use of erythrocyte-
stimulating factors concurrently with intravenous iron results in an even greater
response, but has an increased incidence of venous thromboembolism. Other
nutritional causes of anemia, such as vitamin B12 and folate deficiencies, are
easily correctable with over-the-counter supplementation. Preoperative consul-
tation with a hematologist helps manage other identified forms of anemia, such

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 16 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

as hemolytic or anemia of chronic inflammation. Intravenous iron initiated

after surgery does not reduce the incidence of a perioperative blood transfusion
but does reduce the 30-day transfusion incidence.

Cognitive Dysfunction
Many geriatric patients present for surgery with cognitive impairment pre-
disposing them to preventable adverse outcomes, such as delirium, falls,
pneumonia, urinary tract infections, functional decline, and increased mor-
tality. Cognitive impairment describes a patient’s current state, and usually
presents as confusion, memory loss, decreased attention, disorientation, and
mood changes. Dementia and delirium are the two most common forms of
cognitive impairment, and Table 1.5 differentiates one from the other.
Patients with preexisting dementia have an increased incidence of early
postoperative mortality.
Approximately one-third of hospitalized elderly patients experience delir-
ium. Routine preoperative screening for cognitive impairment identifies at-
risk patients and allows appropriate referral to a neurologist or geriatric
medicine specialist. The six-item screen, noted in Table 1.6, is a brief screening
tool for identifying patients with cognitive impairment by testing attention,
short-term memory, and orientation. Its reliability is comparable to the full
Mini-Mental State Examination. A score of 2 or higher suggests cognitive
impairment and the need for further evaluation.

Table 1.5 Characteristics of dementia and delirium

Dementia Delirium

Duration Chronic, progressive Hours to weeks

condition

Onset Chronic onset Acute onset

Attention Generally normal Impaired or fluctuating

Memory Long- and short-term Recent and immediate mem-

memory impairment ory impairment

Alertness Generally normal Lethargic to hypervigilant

Thought Word-finding difficulty; Disorganized thinking; slow or

pattern poor judgment accelerated thoughts
Source: Adapted from: Agency for Clinical Innovation 2018. www.ausmed.com/cpd/arti
cles/cognitive-impairment.

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 Preoperative Evaluation and Coexisting Disease 17

Table 1.6 Six-item screen for cognitive impairment

Did the patient correctly answer the questions Yes No

below?
Correct Incorrect

What year is this? 0 1

What month is this? 0 1

What day of the week is this? 0 1

What were the three objects you were asked to

remember?

Apple 0 1

Table 0 1

Car 0 1

Total

Diabetes
An overwhelming quantity of literature establishes a clear correlation between
perioperative hyperglycemia and adverse surgical outcomes, including increased
surgical site infections and mortality. The risk of postoperative complications and
death is a function of both long-term glycemic control and the short-term severity
of hyperglycemia on admission. Diabetic patients, particularly those requiring
insulin management, undergoing major vascular surgery have a higher incidence
of perioperative death and cardiovascular complications. Neither diabetes man-
aged with insulin nor that managed with oral medications independently predicts
mortality. Significant risk factors for death include several diabetes comorbidities,
such as proteinuria, elevated creatinine level, history of congestive heart failure,
and stroke. After adjusting for comorbidities, diabetic patients have a 38% or
higher increase in hospital length of stay [18]. Preoperative risk stratification
involves a basic metabolic panel within 6 months of the scheduled surgery, or
more recent, depending on patient status. A hemoglobin A1c (Hgb A1c) level
indicates long-term glucose control over the preceding 2–3 months, but there is
no clear delineation of the level above which elective surgery should not occur.
The ability of a preoperative Hgb A1c to predict surgical site infections remains
controversial, but many orthopedic departments utilize a 7.0–8.5% range, above
which elective surgery is delayed. Fructosamine levels are an alternative to Hgb
A1c and provide an indication of glucose control over the past 2–3 weeks. Some

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 18 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

literature suggests that fructosamine levels are a more significant predictor of

adverse outcomes in orthopedic surgery than Hgb A1c. Fructosamine is useful for
assessing glucose control in conditions where Hgb A1c is unreliable, such as end-
stage renal disease (ESRD) and chronic hemolytic anemia.

Chronic Kidney Disease

The preoperative management of the spectrum of CKD, further detailed
in Table 1.7, requires consideration of the disease process and comorbid-
ities, such as cardiovascular dysfunction, anemia, and electrolyte disor-
ders. These coexisting diseases confer significant perioperative risk. Of
primary concern is the independent association with underlying coronary
artery disease. Objective assessment of functional capacity with DASI
and adherence to the American College of Cardiology (ACC)/American
Heart Association (AHA) perioperative guidelines aid in risk assessment.
ACEIs, angiotensin receptor blockers (ARBs), and diuretics are customa-
rily held before surgery unless indicated for heart failure or volume

Table 1.7 Stages of chronic kidney disease

Stage of Signs and symptoms Percentage of

chronic normal kidney
kidney function
disease (estimated GFR)

1 No symptoms, but coexisting dis- ≥90% (normal or

ease present (diabetes, hyperten- increased GFR)
sion, obesity)

2 No symptoms, but proteinuria 60–89% (mildly

present reduced GFR)

3 Edema, fatigue, microalbuminuria, 30–59% (moder-

back pain ately reduced GFR)

4 Stage 3 symptoms plus nausea, 15–29% (severely

vomiting, neuropathy, and loss of reduced GFR)
appetite

5 Stage 4 symptoms plus fatigue, <15% (kidney fail-

weakness, anemia, thirst, cramps, ure; dialysis
skin discoloration, little to no urine dependent)
output, and easy bruising/
bleeding
GFR, glomerular filtration rate.

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 Preoperative Evaluation and Coexisting Disease 19

overload. All other cardiovascular medications should continue as usual.

ESRD patients have a high incidence of coexisting structural heart disease,
and both right and left ventricular dysfunction are associated with poor
outcomes and death. An echocardiogram obtained within the previous year
is useful for risk stratification. Despite a high prevalence of coronary artery
disease, many CKD patients are asymptomatic and have adequate functional
capacity. An objective assessment of cardiac function, such as dobutamine
stress echocardiography, identifies undiagnosed cardiovascular disease and
allows for preoperative risk mitigation. CKD is associated with excess surgical
morbidity, including acute renal failure, hyperkalemia, volume overload, and
infections. Patients with ESRD have an adjusted all-cause mortality rate at
least 10-fold higher than that of nonESRD patients.
Decreased renal production of erythropoietin leads to anemia. The
National Kidney Foundation suggests optimizing preoperative hemoglo-
bin level to 11–12 g dL−1 with oral or intravenous iron and erythropoie-
tin-stimulating agents. Hemodialysis, preferably on the day before
surgery, corrects electrolyte abnormalities and platelet dysfunction.
While there is no established upper limit for hyperkalemia, with differ-
ences in institutional policy and patient tolerance, a preoperative basic or
comprehensive metabolic profile detects potassium and other electrolyte
abnormalities.

Summary and Conclusion

Preoperative evaluation and optimization are an opportunity for anesthesia
providers to enhance patient safety and outcomes and to create value in
healthcare through the identification, risk stratification, and mitigation of
modifiable risk factors. A systems-based, collaborative approach and applica-
tion of high-yield preoperative interventions on modifiable risk factors inte-
grate the quadruple aim of improved outcomes, improved clinical and patient
experiences, and reduction in healthcare costs.

Review Questions
1. Which New York Heart Association (NYHA) class is assigned a patient
with a history of heart failure who has slight limitation of physical activity
and is comfortable at rest, but experiences dyspnea, palpitations, or fatigue
with ordinary physical activity?
(a) Class I
(b) Class II
(c) Class III
(d) Class IV

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 20 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

2. Which of the following is a risk prediction tool commonly used to identify

patients at risk of postoperative pulmonary complications?
(a) Six-item screen
(b) NSQIP surgical risk calculator
(c) ARISCAT Risk Index
(d) FRAIL scale

3. Which of the following is a patient risk factor for the development of

postoperative pulmonary complications?
(a) Poor functional capacity/frailty
(b) Emergency surgical procedure
(c) Surgery lasting >2 hours
(d) Receipt of a perioperative blood transfusion

4. Which of the following laboratory tests is useful for assessing glycemic control
over the preceding 2–3 weeks in end-stage renal disease (ESRD) patients?
(a) Hemoglobin A1c
(b) Comprehensive metabolic profile
(c) Fructosamine
(d) Phenylpropanolamine

Answers
1 (b) A patient with a history of heart failure who experiences slight limita-
tion of physical activity with dyspnea, palpitations, or fatigue on
ordinary activity is assigned NYHA class II.
2 (c) The ARISCAT Risk Index is a risk prediction tool used to identify
patients at risk of postoperative pulmonary complications and to guide
perioperative optimization strategies.
3 (a) Poor functional capacity/frailty is a patient risk factor for postopera-
tive pulmonary complications. The other choices are surgical risk
factors.
4 (c) Fructosamine levels assess glycemic control over the preceding 2–3 weeks,
whereas hemoglobin A1c assesses glycemic control over the previous 2–
3 months. Fructosamine levels give a more reliable estimation in patients
with conditions such as ESRD and chronic hemolytic anemia.

References
1. Gupta S, Fernandes RJ, Rao JS, Dhanpal R. Perioperative risk factors for pulmonary
complications after non-cardiac surgery. J Anaesthesiol Clin Pharmacol. 2020;36
(1):88–93.

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 Preoperative Evaluation and Coexisting Disease 21

2. Aronson S, Murray S, Martin G, et al. Roadmap for transforming preoperative

assessment to preoperative optimization. Anes Analg. 2020;130(4):811–19.
3. Knuf KM, Maani CV, Cummings AK. Clinical agreement in the American Society
of Anesthesiologists physical status classification. Perioper Med. 2018;7(14):1–6.
4. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on
perioperative cardiovascular evaluation and management of patients undergoing
noncardiac surgery: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):
e278.
5. Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional
capacity before major non-cardiac surgery: an international, prospective cohort
study. Lancet. 2018;391(10140):2631.
6. Wijeysundera DN, Beattie WS, Hillis GS, et al. Integration of the Duke Activity
Status Index into preoperative risk evaluation: a multicentre prospective cohort
study. Br J Anaesth. 2020;124(3):261.
7. Dakik HA, Chehab O, Eldirani M, et al. A new index for preoperative cardiovas-
cular evaluation. J Am Coll Cardiol. 2019;73(24):3067–78.
8. Smith BB, Warner MA, Warner NS, et al. Cardiac risk of noncardiac surgery after
percutaneous coronary intervention with second-generation drug-eluting stents.
Anesth Analg. 2019;128(4):621.
9. Tan CW, Wall M, Rosengart TK, et al. How to bridge? Management of anti-
coagulation in patients with mechanical heart valves undergoing noncardiac
surgical procedures. J Thorac Cardiovasc Surg.2019;158:200–3.
10. Quan H, Ouyang L, Zhou H, et al. The effect of preoperative smoking cessation and
smoking dose on postoperative complications following radical gastrectomy for gastric
cancer: a retrospective study of 2469 patients. World J Surg Oncol. 2019;17(61):1–11.
11. Chan MTV, Wang CY, Seet E, et al. Association of unrecognized obstructive sleep
apnea with postoperative cardiovascular events in patients undergoing major
noncardiac surgery. JAMA. 2019;321(18):1788–98.
12. Dalton A, Zafirova Z. Preoperative management of the geriatric patient: frailty and
cognitive impairment assessment. Anesthesiol Clin. 2018;36(4):599–614.
13. Kim SW, Han HS, Jung HW, et al. Multidimensional frailty score for the prediction
of postoperative mortality risk. JAMA Surg. 2014;149(7):633–40.
14. Alvarez-Nebreda ML, Bentov N, Urman RD, et al. Recommendations for preo-
perative management of frailty from the Society for Perioperative Assessment and
Quality Improvement (SPAQI). J Clin Anesth. 2018;47:33–42.
15. Mays LC, Drummonds JW, Powers S, et al. Identifying geriatric patients at risk for
malnutrition: a quality improvement project. J Nutr Gerontol Geriatr. 2019;38
(2):115–29.

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 22 Matthew Sherrer, Sher-Lu Pai, and Jeffrey Dobyns

16. Zhang B, Najarali Z, Ruo L, et al. Effect of perioperative nutritional supplementa-

tion on postoperative complications – systematic review and meta-analysis.
J Gastrointest Surg. 2019;23:1682–93.
17. Kumar A. Perioperative management of anemia: limits of blood transfusion and
alternatives. Cleve Clin J Med. 2009;76(4):S112–18.
18. Axelrod DA, Upchurch GA, DeMonner S, et al. Perioperative cardiovascular risk
stratification of patients with diabetes who undergo elective major vascular surgery.
J Vasc Surg. 2002;35:894–901.

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 Chapter
Airway Management

2
Chikezie N. Okeagu, Madelyn K. Craig,
Brook Girma, Sumitra Miriyala, Meeta
M. Sheth, Sridhar R. Tirumala, Rhian E.
Germany, and Alan David Kaye

Introduction
Airway management is a vital component of administering anesthesia,
allowing for the exchange of gases between the patient and the surrounding
atmosphere. Difficult or unsuccessful management of the airway is
a significant source of anesthesia-related morbidity and mortality [1]. As
such, it is important for anesthesia providers to be adept at all aspects of
managing the airway. A thorough understanding of the pertinent anatomy
and physiology, the ability to use clinical evaluation to identify potential
difficulties, and a mastery of interventional techniques and procedures are
crucial to safe and effective airway management. This chapter presents
a comprehensive overview of the elements related to effective airway
management.

Airway Anatomy
Respiration is a complex process that involves the exchange of gases and the
breakdown of glucose to yield energy [1]. Understanding the anatomy of the
airway is important when performing intubation. The airway can be divided
into multiple subsections: the nasal cavity, oral cavity, and pharynx. The
pharynx is further divided into the nasopharynx, oral pharynx, and hypophar-
ynx, running from superior to inferior. The nasal cavity consists of the nares,
septum, and turbinates (superior, middle, and cheap). It is bound superiorly
by the ethmoid bone. It is continuous posteriorly with the nasopharynx (the
most prominent portion of the pharynx). The oral cavity consists of the upper/
lower rows of teeth, the tongue, hard palate, and soft palate, and is continuous
posteriorly with the oropharynx. The oropharynx stretches down to the
epiglottis (the cartilaginous structure that serves as a flap to cover the trachea
or esophagus). The hypopharynx runs from the epiglottis down to the superior
edge of the trachea. This is the region where the vocal cords will be visualized
(along with the larynx region). These lie at around the level of the thyroid
cartilage. Breathing, or ventilation, is the process of conducting air to and
from the lungs. Simultaneously, gaseous exchange is the diffusion of oxygen
23

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 24 C. N. Okeagu, M. K. Craig, B. Girma, et al.

into the blood vessels and the removal of carbon dioxide and other gases into
the air [2]. The respiratory tract organs form a continuous passage for air, and
they are divided into upper and lower airways.
The lower airways include the trachea, bronchi, bronchioles, and alveoli.
Their primary function is to facilitate the movement of air between the lungs
and the atmosphere. The trachea is a hollow tube supported by cartilage. It
begins from the larynx and branches into the bronchi. The cartilage helps to
ensure that it does not collapse or overexpand. The bronchi branch from the
trachea and subdivide into bronchioles. They serve as passages for bringing air
in and out of the lungs. Unlike the trachea and bronchi, the bronchioles do not
have cartilage and their diameter is much smaller [3]. They are ciliated and
have a simple epithelium with mucus-secreting cells. The final portion of the
lower airway is made of the alveoli, single-cell layered and near the capillaries.
They facilitate the actual exchange of gases in the lungs. The general function
of the airway is to allow for airflow to facilitate gaseous exchange, which is
essential for respiration. However, they perform other functions to maintain
adequate protection and homeostasis. They serve as moisture barriers to
prevent loss of excessive moisture through humidification of air. They work
as temperature barriers by warming the air from the environment as it gets
into the airways. Finally, they work as barriers to infection, primarily through
the mucosa-associated lymphoid tissue (MALT).
From the base of the trachea, the airways branch into the right and left
sides. Two bronchi further divide into lobar (secondary) bronchi, which in
turn divide into segmental (tertiary) bronchi that eventually form the bronch-
ioles [4]. The right- and left-sided airways connect to the respective lungs. The
branching of the airways into the left and right sides forms an extensive
pulmonary tree. The right lung is broader and shorter, whereas the left lung
is thinner and longer. The reason why the right lung is shorter is because the
liver rests beneath it. On the other hand, the left lung has to make room for the
heart, hence is narrower.
The right lung refers to the right side of the pair of lungs at the front of the
thoracic cavity, whereas the left side is known as the left lung. One of the key
differences is the number of lobes, with the right lung having three (superior,
middle, and inferior). By contrast, the left lung has only two lobes (upper and
lower). There is a thick cardiac notch at the left lung, making it distinct,
although it does not serve any role in the right lung. Finally, the left lung has
a horizontal and an oblique fissure, whereas the left has only the oblique fissure.
These different upper airway areas are innervated differently by branches
and terminal ends of some cranial nerves. The primary nerves that give
sensation to the airway are the trigeminal nerve (CN V), the glossophar-
yngeal nerve (CN IX), and the vagus nerve (CN X). The trigeminal nerve is
almost exclusively a cranial sensory nerve and gives off three main branches:
ophthalmic (V1), maxillary (V2), and mandibular (V3). The ophthalmic

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 Airway Management 25

nerve and its smaller branches provide sensory innervation to the superior
region of the internal nasal cavity. Many internal components supply the
medial and lateral parts of the ethmoidal area and the superior nares. The
maxillary nerve provides sensory innervation to the inferior nasal region,
nasal septum, and soft palate in the oral cavity. It also provides some
innervation to the external nasal area via the infraorbital nerve (one of the
terminal branches of the maxillary nerve). The pterygopalatine ganglion lies
in between the palatine and maxilla bones, receives fibers from the maxillary
nerve, and then sends smaller components out (nasopalatine, greater/lesser
palatine, etc.). Remember, the nasopalatine nerve comes from the pterygo-
palatine ganglion, runs along inside the nasal septum mucosa, dives through
the incisive canal, and terminates in the anterior hard palate. Finally, the
mandibular nerve gives sensation to the anterior two-thirds via the lingual
nerve [5].
The posterior one-third of the tongue and posterior pharyngeal mucosa
(down to the aryepiglottic fold level) receive sensory innervation from the
glossopharyngeal nerve. This nerve also provides fibers to the dense pharyn-
geal nerve plexus, which innervates the palatopharyngeal arch. The pharyn-
geal nerve plexus receives some glossopharyngeal nerve fibers. However, the
plexus is mainly made up of motor fibers from the vagus nerve. The vagus
nerve mediates sensory innervation to the larynx and laryngopharynx, and
gives rise to the superior laryngeal nerve. The superior laryngeal nerve
branches into the internal and external. The inner laryngeal nerves provide
sensory innervation to the epiglottic region’s mucosa, extending to the level of
the vocal folds. Below the vocal folds, sensory and motor innervation is
supplied by the left and right recurrent laryngeal nerves (also branches of
the vagus). Therefore, they innervate all the larynx’s intrinsic muscles (sparing
the cricothyroid muscle, which is innervated by the external laryngeal nerve).
All of these innervations are important for airway management when per-
forming intubation because the endotracheal (ET) tube will pass through
most, if not all, of these regions to end up in the trachea to provide oxygena-
tion to the lungs [5].
During routine intubation, the blade should move the patient’s tongue out
of the visual field to directly see the vocal cords. The vocal cords are the most
medial. They connect to the cricoid cartilage anteriorly, and posteriorly to the
arytenoid cartilage on the larynx’s posterior edge. Visualization of the ET tube
moving midline through the cords should give successful intubation. The ET
tube was kept in place just superior to the carina level (e.g., bifurcation of the
trachea into the two primary bronchi). Although adult and pediatric patients
have all of the same airway structures, there can be differences in length, size,
and width. In pediatric patients, note the prominent occiput will cause neck
flexion in the supine position, so a towel should be placed under the shoulders
to keep a direct airway ready for intubation. The hypopharynx will also be

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 26 C. N. Okeagu, M. K. Craig, B. Girma, et al.

shorter and narrower than in an adult – the cricoid cartilage resting higher at
the C4 vertebra (the adult cricoid cartilage is at C6).
Additionally, the pediatric vocal cords are not at a 90-degree angle to the
larynx wall as the adult vocal cords are. The pediatric cords slope downwards
anteriorly, providing difficulty with the tube rubbing against the cords and
possibly causing trauma. Lastly, the epiglottis in a pediatric patient is not as
flat as in an adult, presenting problems with using a Macintosh blade instead
of a Miller blade. Some physicians prefer the Miller blade during pediatric
intubation because it has a better shape to move the pediatric epiglottis out of
the visual field, compared to a curved Macintosh blade [5].

Airway Assessment
Airway Assessment
A thorough assessment of the patient’s airway should be conducted in the
preoperative setting. This consists of obtaining a history of any previous
airway instrumentation, reviewing the patient’s medical record, with parti-
cular attention to previous anesthesia and/or intubations, and noting any
disease states that may have implications on airway management. Typically,
patients who have presented difficulties with airway management have been
informed of this and/or documentation of such can be found in the
patient’s medical record. The medical record may also contain information
regarding which techniques were used in order to successfully manage the
airway [6].
A comprehensive history should be accompanied by a physical examina-
tion, with the aim of identifying features that may portend difficulty with
airway management. Examination of the mouth opening, dentition, oro-
pharyngeal space, submandibular compliance, cervical spine mobility, and
body habitus can all help stratify the risk of difficult airway management, and
several tools exist to assist in this assessment. The sensitivity and specificity
of any single one of these tools are low. However, when used in combination,
they can be helpful in predicting which patients may present difficulty in
airway management. The Mallampati test is used to evaluate the orophar-
yngeal space. It consists of visual examination of the oropharyngeal space.
A “Mallampati score” is derived based upon which structures are visible in
the patient’s mouth. To properly administer the test, the observer should be
at eye level, with the patient holding the head in a neutral position, opening
the mouth maximally, and protruding the tongue without phonating. The
Mallampati classification is as follows:
• I: The soft palate, fauces, uvula, and tonsillar pillars are visible.
• II: The soft palate, fauces, and uvula are visible.

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 Airway Management 27

• III: The soft palate and base of the uvula are visible.
• IV: The soft palate is not visible [6].
The mnemonic PUSH (tonsillar Pillars, Uvula, Soft palate, Hard palate) is
often used to remember the Mallampati score. A patient with a Mallampati
score of I has all four elements of PUSH visible on examination, whereas
a patient with a Mallampati score of IV has only the hard palate visible.
A Mallampati score of III or IV correlates with difficult laryngoscopy.
Mouth opening is assessed by measurement of the interincisor distance –
that is, the distance between the upper and lower incisors. An interincisor
distance of <3–4.5 cm correlates with difficult laryngoscopy. Patients with
overbites have a reduced effective interincisor distance and therefore may
present difficulties with laryngoscopy. The upper lip bite test (ULBT) is also
used to predict ease of laryngoscopy and intubation. The ULBT assesses an
individual’s mandibular prognathic ability. The ULBT is broken down into
three classes. Patients who fall in Class III of the ULBT may present difficulty
with laryngoscopy and intubation:
• Class I: The lower incisors can bite above the vermilion border of the
upper lip.
• Class II: The lower incisors cannot reach the vermilion border.
• Class III: The lower incisors cannot bite the upper lip.
As the soft tissues of the pharynx are displaced into the submandib-
ular space during laryngoscopy, anything that limits the size or compli-
ance of the submandibular space can make laryngoscopy and intubation
more challenging. The thyromental distance, which is the distance
between the tip of the jaw and the thyroid cartilage, can also be infor-
mative. A distance less than three fingerbreadths or of 6–7 cm correlates
with difficult laryngoscopy. Difficulty with neck extension and certain
physical features, such as obesity and increased neck circumference, also
indicate a potential difficult airway [6].

Predictors of Difficult Intubation/Ventilation

The purpose of conducting a thorough preoperative history and physical
examination is to identify patients with potential difficult airways and
formulate a plan for successful management. The unanticipated difficult
airway must be avoided at all costs. A number of congenital and acquired
conditions are associated with difficult airway management. Table 2.1
outlines factors that are associated with difficult ventilation and/or intu-
bation. It should be noted that factors that are associated with difficult
intubation are not always also associated with difficult ventilation. The
reverse is also true.

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 28 C. N. Okeagu, M. K. Craig, B. Girma, et al.

Table 2.1 Factors associated with difficult ventilation and intubation

Predictors of difficult ventilation Predictors of difficult intubation

Edentulous History of difficult intubation

History of snoring Prognathic inability

Macroglossia Limited neck range of motion

Micrognathia Long incisors

Uvula not visible Mallampati class III or IV

Obesity Mandibular space stiff, indurated, or

occupied

Obstructive sleep apnea Mouth opening <3–4 cm

Presence of beard Uvula not visible

Short neck Obesity

Thick neck Prominent overbite

Thyromental distance <6 cm

Short neck

Thick neck

Physiology of Airway Management

Preoxygenation
Prior to any intubation, it is important to practice clinical fundamentals of
management of the airway with preoxygenation. If possible, preoxygenation
with oxygen via face mask should be initiated prior to all airway management
interventions or anesthetic induction. Nitrogen makes up about 80% of the
concentration in the lung. During preoxygenation, or denitrogenation, the func-
tional residual capacity (FRC) is purged of nitrogen and filled with oxygen,
increasing the duration of apnea without desaturation. The four maximal breath
technique of preoxygenation was found to be associated with a statistically sig-
nificant shorter time to onset of oxygen desaturation of blood, when compared to
normal breathing of 100% oxygen for 3 minutes [7]. A healthy patient breathing
room air will experience desaturation of <90%, with apnea within 1–2 minutes
versus up to 8 minutes following preoxygenation. Goals for preoxygenation

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 Airway Management 29

include: bringing the patient’s saturation as close to 100% as possible; denitro-

genating the residual capacity of the lungs (maximizing oxygen storage in the
lungs); and denitrogenating and maximally oxygenating the bloodstream [8].
Utilizing this technique to achieve the goals mentioned will increase the duration
of safe apnea, as oxygen is poorly soluble, and can provide preferable conditions
for intubation.

Apneic Preoxygenation
The process by which gases are entrained into the alveolar space during
apnea is referred to as apneic preoxygenation. Since oxygen enters blood
from the alveoli at a faster rate than carbon dioxide leaving blood, a negative
pressure is generated in the alveolus, driving oxygen into the lungs. This
method extends the duration of safe apnea after the use of sedatives and
muscle relaxants.

Airway Reflexes
Laryngoscopy and tracheal intubation directly stimulate airway reflexes that
may elicit protective responses to this stimulation, leading to hypertension
and tachycardia. This is commonly seen in a pediatric setting or “light” planes
of anesthesia. In the larynx, glottic stimulation, innervated by the superior
laryngeal nerve, causes closure of the distal airways, leading to glottic closure
to prevent aspiration. When exaggerated, this response can lead to complete
glottic closure, and consequently impending respiratory collapse. If laryngo-
spasm occurs and persists, positive pressure ventilation or small doses of
succinylcholine may be required to abate this response. However, in certain
cases, the spasm is sustained as long as the stimulus continues, and morbidity,
such as cardiac arrest, arrhythmia, pulmonary edema, bronchospasm, or
gastric aspiration, may occur [9]. Bronchospasm, a reflex more commonly
seen in asthmatics, tends to also occur in pediatric patients and those under
“light” planes of anesthesia. This response may also be an indicator of bron-
chial intubation. Aside from respiratory reflexes, intubation may cause an
increase in intracranial or intraocular pressure, primarily due to a sympathetic
surge.

Aspiration Risk and Ways to Minimize the Risk

Intraoperative pulmonary aspiration, a rare anesthesia-related complication,
is associated with potentially fatal complications with significant associated
morbidity. Awareness of the risk factors, predisposing conditions, maneuvers
to decrease risk, and immediate management options by both the surgeon and
the anesthesia team is imperative to reducing risk and optimizing patient
outcomes associated with acute intraoperative pulmonary aspiration [10].

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 30 C. N. Okeagu, M. K. Craig, B. Girma, et al.

Risk factors include, but are not limited to: obesity; medications that reduce
lower esophageal tone; gastrointestinal (GI) obstruction; need for emergency
surgery; nasogastric tube placement; meal within 8 hours prior to surgery;
previous esophageal surgery; lack of coordination of swallowing or respira-
tion; esophageal cancer; hiatal hernia; patient positioning; and provider fac-
tors. Assessing preoperative risk factors may assist in planning preventative
measures and minimize the risk of intraoperative pulmonary aspiration. The
first step in successful management of an intraoperative aspiration is immedi-
ate recognition of gastric content in the oropharynx or airways [10]. Signs of
aspiration include persistent hypoxia, high airway pressures, bronchospasm,
and abnormal breath sounds following intubation. It is important to suction
the airway prior to positive pressure ventilation and to position the patient
with the head down and rotated laterally if possible. If the patient is not
intubated, it is recommended that the airway be secured as rapidly as possible
to prevent further aspiration and facilitate airway clearance.

Airway Management Techniques

Mask Ventilation
Mask ventilation is fundamental to the practice of anesthesia. This most basic
skill is one of the most important tools in airway management. It is performed
prior to ET intubation and used as a rescue maneuver if intubation is difficult
or fails. Obtaining a tight seal with the face mask is an important aspect of
successful mask ventilation. The face mask should fit over the bridge of the
nose and enclose the mouth, with the bottom positioned between the lower lip
and the chin. Leaks may develop if the mask is not of the correct size, the
cushion is improperly inflated, or the patient has a beard or an abnormal
anatomy. Risk factors for difficult mask ventilation include presence of
a beard, increased body mass index (BMI), edentulousness, limited mandib-
ular protrusion, Mallampati score III or IV, history of snoring or obstructive
sleep apnea (OSA), airway masses or tumors, history of neck radiation, male
gender, and age >55. In order to maximize pharyngeal patency, the triple
maneuver (jaw thrust, head extension, and chin lift) should be used. Once the
triple maneuver is performed, the left hand holds this position, with the mask
sealed tightly to the face, while the right hand squeezes the reservoir bag. If
maintaining the triple maneuver position or an adequate seal with one hand
proves difficult, the two-handed mask ventilation technique should be utilized
and a second provider assists ventilation with the bag. An oral or nasal airway
may be required to overcome obstruction resulting from the tongue falling
back to the posterior pharyngeal wall. It is important to note that using an oral
airway may elicit a gag reflex or cause laryngospasm if the depth of anesthesia
is inadequate. A nasal airway is better tolerated in these situations. Ventilating

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 Airway Management 31

pressure should not exceed 20 cmH2O to avoid gastric distension, regurgita-

tion, and aspiration. If mask ventilation proves difficult or impossible, alter-
native strategies to ventilate the patient must be attempted, such as intubation
or placement of a supraglottic airway [11, 12].

Supraglottic Airways
Supraglottic airway (SGA) devices are an alternative method to mask ventila-
tion and ET intubation, and have made their way into the difficult airway
algorithm with their ease of use and rescue ventilation ability. Quick place-
ment, less sympathetic stimulation, avoidance of neuromuscular blockers, and
maintenance of spontaneous ventilation are a few advantages of using SGAs
over ET tubes. SGAs may be used as primary airway devices for selected
patients and surgeries, in emergency situations in and out of the hospital, to
facilitate ET intubation, and most importantly for airway rescue in the unable-
to-ventilate-or-intubate situation. Nonfasting status, morbid obesity, and
pregnancy are contraindications for laryngeal mask airway (LMA) use as the
primary airway. OSA, gastro-esophageal reflux disease (GERD), gastroparesis,
and position other than supine are factors that increase the risk of complica-
tions when using SGAs [13].
The LMA Classic, one of the first SGAs, is a reusable device made of
silicone. A disposable, single-use version of the LMA Classic is the LMA
Unique. Designed for intraoral procedures, the LMA Flexible has a wire-
reinforced shaft to allow flexible positioning away from the surgical site. The
LMA Fastrach, an intubating LMA, has a rigid, curved shaft and handle that
facilitates placement of an ET tube through its ventilating tube, with or with-
out the assistance of a fiberoptic scope. The reusable LMA ProSeal was the first
LMA designed with a drainage tube to reduce the risk of aspiration. This
drainage tube also facilitates placement of an orogastric tube. The LMA
ProSeal’s design creates an improved airway seal without adding pressure to
the oropharyngeal tissue. A disposable alternative to the LMA ProSeal is the
LMA Supreme. In addition to the gastric drainage tube, such as the LMA
ProSeal, the LMA Supreme has a curved shaft similar to the LMA Fastrach.
The LMA Classic Excel is an intubating version of the LMA Classic. The AirQ
(disposable) and Intubating Laryngeal Airway (reusable) were designed with
unique features to assist ET intubation but may also be used as a primary
airway. The Cobra Perilaryngeal Airway (PLA) differs from the previously
discussed SGAs with its high-volume, low-pressure pharyngeal cuff that sits
just proximal to the cuffless mask. It also allows passage of an ETT. The Gnana
Laryngeal Airway, a novel SGA device, is similar to the LMA Classic in basic
design, but with an additional suction port on the convex portion of the
laryngeal mask to remove saliva. The Esophageal-Tracheal Combitube and
the King Laryngeal Tube have been designed to be able to achieve ventilation

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 32 C. N. Okeagu, M. K. Craig, B. Girma, et al.

after blind insertion, making them useful for prehospital use or by unskilled
operators. Their double cuff design allows ventilation via the larynx by inflat-
ing the distal cuff in the esophagus and the proximal cuff in the hypopharynx.
The uniquely designed I-GEL device uses a cuffless mask made of a gel
material that conforms to the larynx. It also has a gastric drainage tube that
allows passage of an orogastric tube [14].

Endotracheal Intubation
ET intubation is achieved with an ET tube via an orotracheal or nasotracheal
approach. There are several types of ET tubes used to achieve ET intubation.
The standard cuffed ET tube is single lumen and comes in a variety of sizes,
based on the internal diameter of the tube. Specialty single-lumen tubes
include oral and nasal Ring–Adair–Elwyn (RAE) tubes, wire-reinforced
tubes, laser-resistant tubes, and electromyogram (EMG) tubes. Oral and
nasal RAE tubes have a preformed bend to allow positioning of the tube and
circuit away from the surgical field for facial, oral, or dental surgeries or
neurosurgeries. Wire-reinforced tubes contain a metal wire that is spiraled
along its length to minimize kinking or allow positioning away from the
surgical field. Laser-resistant tubes are used during laser surgery of the
upper airway to decrease the risk of airway fire. EMG monitoring tubes,
such as the neural integrity monitor (NIM) tube, allow monitoring of the
recurrent laryngeal nerve during thyroid and other neck surgeries [15, 16].
Several techniques are available for ET intubation. Orotracheal intubation
is most commonly performed via direct laryngoscopy using a Macintosh
(curved) or Miller (straight) blade to directly visualize the glottic opening
and insert the ET tube. Indirect visualization using a video laryngoscope may
be chosen for patients with suspected difficult airway or immobilization of the
cervical spine. Video laryngoscopes are categorized as either channeled or
nonchanneled. Nonchanneled videoscopes include the more commonly used
Glidescope, C-MAC, and McGrath. While these devices provide improved
glottic visualization, there can still be difficulty in directing the ET tube into
the glottis. Channeled videoscopes have a guide channel into which the ET
tube is preloaded and which directs the tube towards the glottic opening.
Airtraq and King Vision Video Laryngoscope are types of channeled devices.
A disadvantage of these devices is that the thicker blades require a greater
interincisor distance. Fiberoptic intubation is another option for the manage-
ment of a known or suspected difficult airway. It allows intubation in an awake
patient; however, this technique requires airway anesthesia. Nasotracheal
intubation is typically chosen for intraoral and mandibular surgeries. It can
be performed blindly, with the assistance of direct or video laryngoscopy or
a fiberoptic scope [17, 18]. Table 2.2 summarizes intubation techniques and
their indications and contraindications.

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 Table 2.2 Intubation techniques

Technique Indications Contraindications Equipment

Oral route Airway protection Penetrating trauma of upper Laryngoscope/fiberoptic

Prolonged mechanical airway Stylet
ventilation Bougie/Eschmann
General anesthesia for Airway exchange catheter
surgery
Intubation introducer/catheter

Nasal route Intraoral surgery Basilar skull fracture Laryngoscope/fiberoptic

Mandibular surgery Nasal fractures McGills
Poor mouth opening Epistaxis Red rubber
Nasal polyps
Coagulopathy

Direct laryngoscopy Airway protection Poor mouth opening Light handle

Prolonged mechanical Documented difficult Blade
ventilation airway
General anesthesia for Airway mass/tumor
surgery

Video laryngoscopy History of difficult Severe bleeding of upper Videoscope handle and screen
intubation airway
Suspected difficult

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intubation
Inability to extend the neck
Cervical instability
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