Contents Section I: General Considerations 1. General Principles for Emergency Anesthesia .................................................................................................... 3 Manju N Gandhi, Kanchan R Rupwate, Kamlesh G Gotiwale, Manish B Kotwani • • • • • • Definition of Emergency Surgery Definition of Urgent Surgery Environment Consideration and Preparedness Preoperative Assessment Emergency Investigations Preanesthetic Preparation 4 4 4 5 5 5 2. Medical Disorders and Emergency Anesthesia ................................................................................................ 18 Manju N Gandhi, Amala G Kudalkar, Kamlesh G Gotiwale, Devendra W Thakare • • • • • • • • Patient with Thyroid Disease Patient with Diabetic Mellitus Patient with Renal Disease Patient with Hypertension Patient with Ischemic Heart Disease Patient with Valvular Heart Disease Patient with Chronic Obstructive Pulmonary Disease (COPD) Patient with Liver Disease 20 25 29 33 36 41 45 48 3. Choice of Anesthetic Agents for Emergency Surgery ..................................................................................... 54 Aparna A Nerurkar, Deepti M Kotwani, Manju N Gandhi • • • • • • • • Intravenous Induction Agents Inhalational Anesthetic Agents Neuromuscular Blocking Agents Nondepolarizing Neuromuscular Blocking Agents Antagonism of Residual Neuromuscular Blockade Opioids Individual Opioids Benzodiazepines 55 60 64 66 68 70 73 76 4. Blood and Blood Component Therapy in Emergency Anesthesia ............................................................... 80 Aparna A Nerurkar, Manish B Kotwani • • • • • • Technical Aspects of Blood Component Administration Massive Blood Transfusion Practical Approach to Massive Blood Transfusion Treatment of Other Factor Deficiencies Checklist for Giving Blood and Blood Components Future Goals 82 86 86 95 96 97 xiv A Practical Approach to Anesthesia for Emergency Surgery Section II: Cardiovascular Emergency Procedures 5. Anesthesia for Emergency Myocardial Revascularization ........................................................................... 103 Section 1: Anaesthesia for Neurosurgical Procedures Manju N Gandhi, Aparna A Nerurkar • • • • • • • • • • • • • • • • • • • • Indications for Emergency Revascularization Patient Profile Investigations Treatment Options Stabilization Monitoring Percutaneous Coronary Intervention Premedication Induction Other Cardiovascular Drugs to be Kept Ready Maintenance Coagulation Considerations Protamine Administration Temperature Maintenance Systemic Inflammatory Response Syndrome Myocardial Protection Choice of Ionotropes/Vasopressors/Vasodilators Postoperative Management Role of Regional Anesthesia Management of Post MI Complications 104 104 106 107 107 109 110 112 112 114 114 114 115 115 115 115 115 116 116 116 6. Anesthesia for Emergency Valvular Heart Procedure ................................................................................... 120 Kanchan R Rupawate, Shalaka A Gandhi, Manju N Gandhi • • • • • • • Mitral Stenosis (MS) Goals of Perioperative Management Monitoring Anesthetic Management Acute Mitral Regurgitation Aortic Stenosis (AS) Acute Aortic Incompetence (AAI) 121 123 123 124 124 126 128 7. Anesthesia for Emergency Blalock-Taussig Shunt ........................................................................................ 136 Manju N Gandhi, Aparna A Nerurkar, Deepti M Kotwani • • • • • • Types Of Shunts Clinical Presentation Laboratory Studies Hypercyanotic (TET) Spells Management of Anesthesia Operative Details of a modified Blalock-Taussig Shunt 137 138 140 141 141 144 Contents xv 8. Anesthesia for Emergency Vascular Surgery .................................................................................................. 147 Kanchan R Rupwate, Kamlesh G Gotiwale, Manju N Gandhi • • • • • • • • • • • Pathophysiology of Aortic Occlusion and Reperfusion Aortic Cross-clamping Aortic Unclamping Preoperative Evaluation Emergency Abdominal Aorta Repair Anesthesia for Emergency Thoracoabdominal Aorta (TAA) Repair Anesthetic Management Anesthesia for Emergency Endovascular Aortic Repair Anesthesia for Emergency Lower Extremity Revascularization Cardiac Trauma and Great Vessel Injury Anesthesia for Emergency Pulmonary Embolectomy 148 148 148 148 149 151 151 153 154 155 156 9. Anesthesia for Cardioversion ............................................................................................................................. 160 Aparna A Nerurkar, Manish B Kotwani • • • • • Basic Principles Indications and Contraindications Contraindications Overview of the Procedure Anesthesia for Cardioversion 161 161 162 162 163 Section III: General Surgery 10. Anesthesia for Intestinal Obstruction ............................................................................................................... 171 Amala G Kudalkar, Trupti S Pethkar • • • • Etiology Pathophysiology Fluid Shifts Plan of Anesthesia 172 173 178 184 11. Anesthesia for Abdominal Sepsis ..................................................................................................................... 190 Amala G Kudalkar • • • • • • • • • • • What is Sepsis? Postoperative Peritonitis Pathophysiology Physiological Sequelae of Sepsis Clinical Features Role of Anesthesiologist in the Management of Abdominal Sepsis Preoperative Assessment and Optimization History Examination Investigations Initial Resuscitation 191 192 192 193 195 196 196 196 196 197 198 xvi A Practical Approach to Anesthesia for Emergency Surgery • • • • • • • Volume of Resuscitation Colloids or Crystalloids Diagnosis Antibiotic Therapy Source Control Use of Vasopressors and Inotropes Premedication 199 199 200 200 200 200 201 Section 1: Anaesthesia for Neurosurgical Procedures 12. Gastrointestinal Bleeding .................................................................................................................................... 206 Amala G Kudalkar, Devendra W Thakare • • • • • • • • • • • • • • • • • Occult Bleeding Upper Gastrointestinal Bleeding Clinical Features Diagnosis Early Pharmacological Management Management of Nonvariceal Upper Gastrointestinal Bleeding Acid Suppression and Agents to Arrest Bleeding Surgical Management Child-pugh’s Grading of Chronic Liver Disease Sengstaken-Blakemore Tube Management of Bleeding Varices not Controlled by Endoscopy Lower Gastrointestinal Bleeding Anesthetic Considerations General Approach to the Patient with Acute GI Hemorrhage Anesthesia for Injection of Bleeding Esophageal Varices Preanesthetic Management Postanesthetic Management 207 207 209 209 211 211 212 213 213 214 215 215 216 216 217 217 218 Section IV IV:: Obstetric Emergencies 13. Anesthesia Management of Pregnant Patient for Emergency Surgery ...................................................... 223 Smita S Lele, Preeti Rustagi • • • • • • • • • • • • Altered Maternal Physiology and its Anesthetic Implications Cardiovascular System Fetal Effects from Anesthesia and Surgery Uteroplacental Perfusion and Fetal Oxygenation Prevention of Preterm Labor Practical Considerations Anesthetic Management for Nonobstetric Surgery Premedication Special Situations Anesthetic Management General Anesthesia Regional Anesthesia 224 225 226 228 229 229 229 230 232 236 236 237 Contents xvii 14. Pregnancy Induced Hypertension and Anesthesia ........................................................................................ 240 Shantanu B Kulkarni, Urvi H Desai, Manju N Gandhi • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Classification Preeclampsia Eclampsia HELLP Syndrome Chronic Hypertension Incidence and Predisposing Factors Etiology Classification of Preeclampsia Pathophysiology Cardiovascular System Anesthetic Implications Respiratory System Anesthetic Implications Central Nervous System Anesthetic Implications Kidney Anesthetic Implications Liver Anesthetic Implications Fetoplacental Unit Hematological Unit Anesthetic Implications Management Preoperative Assessment Monitoring Analgesia for Labor and Vaginal Delivery Epidural Analgesia Technique Combined Spinal and Epidural Analgesia (CSE) Choice of Anesthesia for Cesarean Section Regional Anesthesia Technique for Regional Anesthesia General Anesthesia Management of Pulmonary Edema Eclampsia Principles of Treatment of Eclampsia Magnesium Therapy Anesthetic Management Management of Patient with HELLP Syndrome 240 240 240 240 240 241 241 241 241 241 241 242 242 242 242 242 242 242 242 242 242 243 243 243 244 244 244 244 244 245 245 245 245 246 246 247 247 247 248 xviii A Practical Approach to Anesthesia for Emergency Surgery 15. Anesthesia for Hemorrhagic Obstetric Patient ............................................................................................... 250 Smita S Lele, Urvi H Desai, Manju N Gandhi • • • • • Suggested Plan for Anesthesia Antepartum Hemorrhage (APH) Postpartum Hemorrhage (PPH) Management of Hemorrhagic Shock in Obstetric Patients Management of Disseminated Intravascular Coagulation (DIC) 254 254 258 260 261 16. Anesthesia for Pregnant Patient with Medical Disorders ............................................................................ 265 Shantanu B Kulkarni, Preeti Rustagi, Smita S Lele, Manju N Gandhi Section 1: Anaesthesia for Neurosurgical Procedures • • • • • • • • • Cardiovascular Diseases Anemia Obesity Thyroid Disorders Diabetes Mellitus Viral Hepatitis Renal Diseases in Pregnancy Malaria Human Immunodeficiency Virus (HIV) 266 277 278 282 286 288 291 294 295 Section V ediatric Emergencies V:: Neonatal and P Pediatric 17. General Consideration in Neonatal and Pediatric Emergency Surgeries ................................................. 303 Anila D Malde, Nilam D Virkar • • • • • • • • Physiology Pharmacology Preoperative Assessment Preoperative Preparation Induction of Anesthesia Early Postinduction Period Emergence and Extubation Basic Postoperative Care 304 310 312 312 313 314 317 317 18. Anesthetic Management of Neonatal Thoracic Emergencies ...................................................................... 321 Anila D Malde • Congenital Diaphragmatic Hernia • Esophageal Atresia and Tracheoesophageal Fistula • Congenital Lobar Emphysema (CLE) 322 330 337 19. Anesthesia for Neonatal and Pediatric Abdominal Emergencies ............................................................... 345 Anila D Malde, Trupti S Pethkar, Aklesh S Tandekar • Abdominal Wall Defects • Congenital Hypertrophic Pyloric Stenosis • Necrotizing Enterocolitis 346 351 354 Contents • • • • • • Intestinal Obstruction Meconium Ileus Malrotation and Volvulus Anorectal Malformation Intussusception Roundworm Obstruction xix 358 360 362 363 364 365 Section VI: ENT and Ophthalmic Emergencies 20. Anesthesia for Post-tonsillectomy Bleeding Patient ...................................................................................... 371 Swati S Chhatrapati, Nilam D Virkar, Anila D Malde • Anesthetic Considerations in Post-tonsillectomy Bleeding 372 21. Anesthetic Considerations in Deep Neck Space Infections ......................................................................... 377 Anila D Malde, Swati S Chhatrapati • • • • • • • Deep Neck Infections: A Constant Challenge Retropharyngeal Space Lateral Pharyngeal Space Peritonsillar Space Submandibular Space Risk Factors for the Development of Deep Neck Infections Management of Airway 377 379 379 379 380 380 385 22. Anesthesia for Removal of Foreign Body from Airway and Upper Digestive Tract ............................. 388 Anila D Malde, Swati S Chhatrapati • Foreign Body Aspiration • Foreign Body in the Upper Digestive Tract 389 398 23. Anesthesia for Ophthalmic Emergencies ......................................................................................................... 402 Swati S Chhatrapati, Nishant S Bawankule • Types of Ophthalmologic Emergencies • Common Types of Eye Injury • Anesthetic Management of Penetrating Eye Injury 402 403 403 Section VII: Neurosurgical Emergencies 24. Anesthesia for Neurosurgical Decompression ................................................................................................ 411 Hemangi S Karnik, Naina P Dalvi, Dhawal R Wadaskar • Applied Neurophysiology • Anesthesia for Emergency Craniotomy • Specific Emergency Conditions 411 420 427 xx A Practical Approach to Anesthesia for Emergency Surgery 25. Anesthesia for Cerebrovascular Emergencies ................................................................................................. 432 Hemangi S Karnik • • • • Intracranial Aneurysms Arteriovenous Malformation (AVM) Spontaneous Intracerebral Hemorrhage (SICH) Acute Ischemic Stroke 432 439 441 444 Section VIII: T rauma Trauma 26. Anesthesia for Head Injuries .............................................................................................................................. 451 Hemangi S Karnik, Jyoti S Magar, Devangi A Parikh • • • • • Head Injury Immediate Assessment Diagnosis of Head Injury Immediate Management Monitoring Injured Brain 452 457 458 459 466 Section 1: Anaesthesia for Neurosurgical Procedures 27. Anesthesia for Acute Spine injury .................................................................................................................... 473 Naina P Dalvi, Devangi A Parikh, Hemangi S Karnik • • • • • • • • • • • Epidemiology Mechanism of Spinal Cord Injuries Pathophysiology Classification Role of Anesthesiologist in ASCI Clinical Clearance or Radiological Diagnosis of Spine Injury General Management Surgical Intervention Intraoperative Management Plan for Airway Management in a Patient with Cervical Spine Injury Complications in Spine Surgery 474 474 475 476 476 479 479 481 481 483 485 28. Anesthesia for Thoracic Trauma ........................................................................................................................ 488 Jyoti S Magar, Deepali P Thakur • • • • Airway Assessment and Management Circulation Maintenance of Anesthesia Invasive Monitoring 490 494 500 501 29. Anesthesia for Abdominal Trauma ................................................................................................................... 508 Hemangi S Karnik, Nazmeen I Sayed • • • • Relevant Anatomy Specific Organ Injuries Immediate Assessment and Resuscitation Diagnosis of Abdominal Trauma 508 509 510 512 Contents • • • • • • • • • Pathophysiology of Hemorrhagic Shock Resuscitation Surgical Management Anesthetic Management Intraoperative Concerns Emergence and Tracheal Extubation Damage Control Surgery (DCS) Abdominal Compartment Syndrome (ACS) Associated Conditions xxi 513 513 517 517 520 522 522 523 524 30. Anesthesia for Pelvic and Long Bone Fractures ............................................................................................. 527 Jyoti S Magar, Hema B Gupta • • • • • • Pelvic Fractures Associated Injuries Long Bone Fractures Primary Survey and Resuscitation Definitive Management Anesthetic Considerations 528 529 530 530 531 533 31. Anesthesia for Patients with Crush Injury ...................................................................................................... 538 Naina P Dalvi, Dhawal R Wadaskar • • • • • • • • • • • • • • • • Pathophysiology of Crush Injury Toxins Released in Crush Injury Clinical Presentation Prehospital Care Emergency Management Stabilization of Hemodynamic Status Surgical Management of Crush Injury Complications after Crush Injury Compartment Syndrome Measurement of Intracompartmental Pressures Rhabdomyolysis Pathophysiology Clinical Features Investigations Management Anesthesia in Crush Injury Patients 538 539 539 539 540 540 541 541 541 541 541 542 542 542 542 542 32. Anesthetic Considerations in Blast and Burn Injuries .................................................................................. 546 Jyoti S Magar, Deepali P Thakur • • • • • Etiology Mechanism of Injury in Blast Burns Pathophysiology of Burns Resuscitation 547 548 555 556 558 xxii A Practical Approach to Anesthesia for Emergency Surgery 33. Anesthesia for Maxillofacial and Upper Airway Trauma ............................................................................ 565 Geeta A Patkar, Hema B Gupta • • • • • • Related Anatomy of Upper Airway and Maxillofacial Structures Mechanisms of Injury to the Maxillofacial Structures and Upper Airway Maxillofacial Fractures Associated Injuries and their Implications Acute Management Elective Management 566 568 569 570 570 573 Section IX: Miscellaneous 34. Anesthesia for Emergency Microvascular Surgeries .................................................................................... 579 Shakuntala N Basantwani, Sohini S Shah • Practical Considerations in Management of Patients 582 Section 1: Anaesthesia for Neurosurgical Procedures 35. Anesthesia for Emergency Renal Transplant .................................................................................................. 588 Shakuntala N Basantwani, Geeta A Patkar, Nazmeen I Sayed • • • • • • • • • • • Types of Renal Transplantation Contraindications for Cadaveric Organ Donation Diagnosis of Brain Death Organ Dysfunction in Cadaver and its Management Kidney Recipient Pathophysiology of Chronic Renal Failure (CRF) Dialysis Preoperative Assessment Preoperative Investigations and Preparation Anesthetic Management Surgical Steps 589 589 590 591 593 594 597 598 599 36. Role of Anesthesiologist in Disaster Management ........................................................................................ 606 Kanchan R Rupwate, Shalaka A Gandhi, Manju N Gandhi • • • • • • • • • • • Definition of Disaster Types of Disaster Phases of Disaster Management Activities Involved in Disaster Management Prehospital Response Service Emergency Reception, Triage and Resuscitation Service Emergency Operative and Postoperative Service Psychological Rehabilitation Aftercare Service Specific Conditions of Disaster Radiation Management Special Considerations 607 607 607 608 612 612 613 614 615 617 617 Index .......................................................................................................................................................................... 619