Data Interpretation in Anesthesia 2017

Data
Interpretation
in Anesthesia
A Clinical Guide
Tilak D. Raj
Editor
123
Data Interpretation in Anesthesia
Tilak D. Raj
Editor
Data Interpretation
in Anesthesia
A Clinical Guide
Editor
Tilak D. Raj, MD, MRCP, FRCA
Chairman of Anesthesia
Alliance Health Midwest
Midwest City, OK
USA
ISBN 978-3-319-55861-5 ISBN 978-3-319-55862-2 (eBook)

DOI 10.1007/978-3-319-55862-2
Library of Congress Control Number: 2017946757
© Springer International Publishing AG 2017

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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
I would like to dedicate this book to my late parents, Arthur and Prema
and also to: Catherine, Vijay, Anushka, Kieran, and Roshan
Foreword
In their daily practice, anesthesiologists are faced with a tremendous amount of data
during the clinical management of their patients. This textbook, Data Interpretation
in Anesthesia: A Clinical Guide, focuses on the interpretation of data commonly
available to an anesthesiologist.
The book is divided into five parts, including monitoring, laboratory testing,
imaging, physiologic studies, and conceptual images. It consists of 83 chapters
starting with a presentation of a data point, followed by relevant questions and
answers with discussion. Pertinent references are provided in each chapter.
Another textbook in this format is not currently available for the discipline of
anesthesiology. There are a variety of reviews that are vignette driven, or are discus-
sions of general topics, but none that focus concisely on the individual data points
that an anesthesiologist must quickly and astutely interpret for patient care. This
format allows the consultant to efficiently reference areas of review.
The editor of this much needed book, Tilak D. Raj, MD, is a cardiothoracic and vas-
cular anesthesia fellowship-trained, board-certified anesthesiologist (both in the UK and
the USA), who has been involved in clinical practice and academic medicine for 20 years.
Contributors include an excellent selection of anesthesiologists, cardiologists,
and an interventional neurologist.
Anesthesiology as a specialty is seeing amazing advancements in patient care.
More and more advanced clinical algorithms emerge every day to help anesthesiolo-
gists understand data points, interpret results, and make decisions. This book will be
very useful for all anesthesiologists, anesthesia residents, and practitioners involved
in Maintenance of Certification in Anesthesiology (MOCA). It is not a book that
just sits on a shelf collecting dust. It is a must read. I hope you enjoy it!
Carin A. Hagberg, MD
Division Head, Division of Anesthesiology,
Critical Care & Pain Medicine,
Helen Shaffer Fly Distinguished Professor
of Anesthesiology UT MD Anderson Cancer Center
1400 Holcombe Blvd, Faculty Center, Unit 409, Houston, TX 77030, USA
vii
Preface
It is a pleasure to finally bring to fruition an idea I have had for a couple of years. As
anesthesiologists, we come across a vast amount of clinical and investigative data
during the perioperative care of our patients. This book should serve as a reference,
providing information about the data we encounter in our daily practice. The current
edition has 83 chapters and the list covers most of the data that we encounter. There
is a basic layout for the chapters which start with a data point followed by discus-
sion in a question and answer format. I chose this format to stimulate analytic
thought and facilitate learning.
The chapters in the book are grouped into five parts. The “Conceptual Images”
part has topics which are not strictly data but more topics of exam interest. They
share the same format and provide additional knowledge in those areas.
This text should help residents and anesthesiologists striving to become board-
certified anesthesiologists in practice working toward Maintenance of Certification
in Anesthesiology (MOCA).
The project could not have been completed without the expert and valuable con-
tribution by authors from different specialties both from America and England, to
whom I am extremely grateful. Editing and contributing to this book has provided a
great learning experience for me, not just in medicine and anesthesiology but also
in life and human nature.
Physicians should be passionate lifelong learners to provide good patient care,
and physicians in academic settings should do the same not just for patient care but
also to teach and act as good role models for students and residents. I shall close
with the apt and inspiring quote by John Cotton Dana.
“Who dares to teach must never cease to learn.”
Edmond, OK Tilak D. Raj
ix
Acknowledgments
I would like to thank my colleagues in helping me with compiling the list of chap-
ters and parts; Dwight Reynolds, MD, for the wonderful X-rays we used in Chap.
46 (CXR—CIED); Scott Tatum, R.N., B.S.I.T., for providing some ECGs used in
the “ECG Quiz” chapter; and the “expert” Dan Mason from Haemonetics for his
invaluable help in two chapters on TEG.
I am also greatly indebted to Carin Hagberg, MD, for kindly agreeing to provide
a foreword for this book; my precious artist Gail Gwin, who provided the drawings
for many chapters which she tirelessly worked on, outside of her busy work sched-
ule; to Vijay Raj for his help with some images and graphs; to all the residents who
provided valuable feedback; and last but not the least my wife Catherine who kept
me focused and on track and to my children Vijay, Anushka, Kieran, and Roshan—
“it can be done and you can do it!”
xi
Contents
Part I Monitoring
1 CVP �� 3
Teodora Nicolescu
2 Pulmonary Artery Catheters�� 7
Teodora Nicolescu
3 ECG�� 13
Teodora Nicolescu
4 A-Line�� 19
Teodora Nicolescu and Tilak D. Raj
5 Intracranial Pressure�� 25
Jacqueline J. Smith
6 Capnography I �� 35
Raghuvender Ganta and Tilak D. Raj
7 Capnography II�� 39
Raghuvender Ganta
8 Pulse Oximetry �� 43
Alberto J. de Armendi and Ranganathan Govindaraj
9 Cooximetry �� 47
John B. Carter
10 Cerebral Oximetry�� 51
Jacqueline J. Smith
11 EEG �� 57
Mehmet S. Ozcan
xiii
xiv Contents
12 SSEP’s and More�� 61

Mehmet S. Ozcan
13 Bispectral Index �� 67
Mehmet S. Ozcan
14 Fetal Heart Rate Monitoring�� 73
Casey Windrix
15 ECG (12 Lead)�� 77
Talla A. Rousan
16 Minimally Invasive Cardiac Output Monitor �� 83
Marcos E. Gomes
17 ECG I�� 89
Edward Kosik
18 ECG II�� 95
Edward Kosik
19 ECG III �� 101
Tanmay Shah
20 ECG IV �� 105
Ranganathan Govindaraj and Talla A. Rousan
21 ECG V �� 111
Madhumani Rupasinghe
22 ECG Exercise�� 115
Tilak D. Raj and Aneesh Venkat Pakala
23 Intra-aortic Balloon Pump (IABP)�� 125
Mohammad A. Helwani and John David Srinivasan
24 Peripheral Nerve Stimulator�� 131
Gulshan Doulatram
Part II Laboratory Testing
25 Complete Blood Count (CBC)�� 139

John David Srinivasan and Mohammed A. Helwani
26 Basic Metabolic Panel I �� 143
Tilak D. Raj
27 Basic Metabolic Panel II�� 147
Raghuvender Ganta
28 Liver Function Testing�� 151
Robert C.M. Stephens
Contents xv
29 Coagulation Profile�� 155

Abigail Whiteman
30 Thromboelastogram I�� 161
Tilak D. Raj
31 Thromboelastogram II�� 167
Tilak D. Raj
32 Urine Testing�� 175
John David Srinivasan
33 Drug Testing �� 181
Alberto J. de Armendi and Gulshan Doulatram
34 Chest Pain Profiles �� 187
35 BNP�� 191
36 Blood Gas I �� 195
Tanmay Shah
37 Blood Gas II�� 199
Daniel A. Biggs
38 Blood Gas III�� 203
Pramod Chetty
39 Blood Gas IV�� 209
Ranganathan Govindaraj
40 CBC/Chemistries I �� 213
Daniel A. Biggs
41 CBC/Chemistries II �� 217
Tanmay Shah
42 Blood Gas: Fetal �� 221
Tanmay Shah
Part III Imaging
43 Ultrasound: Abnormal Placenta�� 227

44 CXR I�� 231
Raghuvender Ganta
45 CXR II�� 235
Marcos E. Gomes
xvi Contents
46 CXR III �� 237

German Barbosa-Hernandez
47 CXR/CT IV�� 247
Marcos E. Gomes
48 CT I �� 253
Pramod Chetty
49 CT II�� 259
Ankur Garg
50 CT/MRI III �� 265
Ankur Garg
51 MRI Spine�� 273
Gulshan Doulatram
52 TEE I �� 279
Kofi B. Vandyck
53 TEE II �� 285
Kofi B. Vandyck
54 Echo: Doppler I�� 291
Kofi B. Vandyck
55 Echo: Doppler II�� 299
Talla A. Rousan
56 Echo: Doppler III�� 303
Nicole T. Tran
57 Echo IV �� 311
58 Ultrasound I�� 317
59 Ultrasound II�� 321
60 Lung Ultrasound�� 327
Marcos E. Gomes
61 Abdominal X-Ray�� 331
Abhinava S. Madamangalam
62 Angio I�� 335
Aneesh Venkat Pakala
63 Angio II �� 341
Contents xvii
64 Angio III�� 345

65 CXR: Pediatric I�� 351
Frederic J. Sage and Frederick van Damme
66 CXR: Pediatric II �� 357
Frederick van Damme and Frederic J. Sage
67 ECHO: 3D�� 367
Nicole T. Tran
Part IV Physiologic Studies
68 Pulmonary Function Testing�� 377

John B. Carter
69 Stress Test�� 383
70 Flow Volume Loops�� 389
Edward Kosik
71 Cath Report�� 395
Talla A. Rousan
72 CIED: Interrogation�� 401
73 Pressure–Volume Curves�� 407
Marcos E. Gomes
Part V Conceptual Images
74 Dissociation Curve �� 415

75 Frank-Starling Curve�� 421
Deepinder Mann
76 West’s Zones �� 427
Abhinava S. Madamangalam and Tilak D. Raj
77 Spirometry�� 431
Daniel A. Biggs
78 Autoregulation Curves�� 435
79 Anesthesia Circuits�� 439
Alberto J. de Armendi
xviii Contents
80 Flowmeters�� 443
John B. Carter
81 Cardiac Bypass Machines �� 447
82 Line Isolation Monitor�� 451
83 Machine: Schematic�� 455
Index�� 461
List of Contributors
Alberto J. de Armendi, MD, PhD, MBA Department of Anesthesiology, The

Children’s Hospital, University of Oklahoma Health Sciences Center, Oklahoma
City, OK, USA
German Barbosa-Hernandez, MD Department of Anesthesia, Oklahoma University
Health and Science Center, Oklahoma City, OK, USA
Daniel A. Biggs, MD, MSc Department of Anesthesiology, Oklahoma University
Medical Center, Oklahoma City, OK, USA
John B. Carter, MD Department of Anesthesiology, Oklahoma University Medical
Center, Oklahoma City, OK, USA
Pramod Chetty, MD Department of Anesthesiology, OU Health Sciences Center,
Oklahoma City, OK, USA
Frederick van Damme, MB, ChB (Stell), FRCA Department of Anaesthesia,
East Surrey Hospital, Redhill, UK
Gulshan Doulatram, MD Department of Anesthesiology, University of Texas
Medical Branch, Galveston, TX, USA
Raghuvender Ganta, MD, FRCA Department of Anesthesiology, VA Hospital,
OUMC, Oklahoma City, OK, USA
Ankur Garg, MD Orlando Neurosurgery, Orlando, FL, USA
Marcos E. Gomes, MD Department of Anesthesiology, University of Oklahoma
Health Sciences Center, Oklahoma City, OK, USA
Ranganathan Govindaraj, MD, FRCA Associate Professor for Anesthesia and
Pain, Department of Anesthesiology, UTMB, Galveston, TX, USA
Director for Ultrasound Guided Regional Anesthesia, Galveston, TX, USA
Mohammad A. Helwani, MD, MSPH Assistant Professor, Divisions of Critical
Care and Cardiothoracic Anesthesiology, Washington University, St. Louis, School
of Medicine, MO, USA
xix
xx List of Contributors
Edward Kosik, DO Department of Anesthesiology, University of Oklahoma Health

Sciences Center, Oklahoma City, OK, USA
Abhinava S. Madamangalam, MBBS, MD Department of Anesthesiology and
Perioperative Medicine, Augusta University Medical Center, Augusta, GA, USA
Deepinder Mann, DO Department of Anesthesiology, University of Texas Medical
Branch, Galveston, TX, USA
Teodora Nicolescu, MD Department of Anesthesiology, Oklahoma University
Mehmet S. Ozcan, MD, FCCP Department of Anesthesiology, The University of
Oklahoma Health Sciences Center, Oklahoma City, OK, USA
Aneesh Venkat Pakala, MD Section of Cardiovascular Disease, Department of
Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
Tilak D. Raj, MD, MRCP, FRCA Department of Anesthesiology, Alliance Health
Midwest, Midwest City, OK, USA
Talla A. Rousan, MD, FACC Department of Medicine, The University of
Oklahoma Health Sciences Center and the Veteran Affairs Medical Center,
Madhumani Rupasinghe, MBBS, FRCA Department of Anesthesiology,
University of Texas Health Science Center at Houston, Houston, TX, USA
Frederic J. Sage, MD, FRCA, FFICM John Hammond Department of Anaesthesia,
East Surrey Hospital, Redhill, UK
Tanmay Shah, MD, MBBS Department of Anesthesiology, University of Oklahoma
Jacqueline J. Smith, MD Department of Anesthesiology, University of Oklahoma
John David Srinivasan, MD Assistant Professor, Department of Anesthesiology
and Critical Care, Saint Louis University, School of Medicine, MO, USA
Robert C.M. Stephens, BA, MBBS, FRCA, MD, FFICM Department of
Anaesthesia, University College London Hospitals, London, UK
Nicole T. Tran, MD Department of Cardiology, University of Oklahom Health
Sciences Center, Oklahoma City, OK, USA
Kofi B. Vandyck, MD Department of Anesthesiology, University of Oklahoma
Abigail Whiteman, MA (Cantab), MB BChir., FRCA, PGCert. Med. Ed.
Department of Anaesthesia and Perioperative Medicine, University College London
Hospitals, London, UK
Casey Windrix, MD Department of Anesthesiology, OUHSC, Edmond, Oklahoma,
USA
Part I
Monitoring
Chapter 1
CVP
Teodora Nicolescu
The below pressure waveform is obtained from an IV in the neck of a patient being
monitored.
1. Identify the components labeled 1–5. Explain what they signify.
2. What information can be deduced from the central venous pressure measurements?
3. What determines the central venous pressure?
4. What factors influence the reading of central venous pressure?
5. What are the indications and contraindications of central venous catheter insertion?
6. Give some examples of CVP waveforms in pathological states.
T. Nicolescu, MD
Department of Anesthesiology, Oklahoma University Health Sciences Center,
750 NE 13th Street, Suite 200, Oklahoma City, OK, USA
e-mail: [email protected]
© Springer International Publishing AG 2017 3

T.D. Raj (ed.), Data Interpretation in Anesthesia,
DOI 10.1007/978-3-319-55862-2_1
4 T. Nicolescu
Fig. 1.1 Central venous 1

pressure waveform 2
4 5
Fig. 1.2 Normal CVP a

c
x y
Answers
1. 1, a wave; 2, c wave; 3, v wave; 4, x descent; and 5, y descent.
The a wave of the central venous pressure represents the atrial contraction.
The right atrial pressure is at the highest value. It is mirrored by the PR interval
on the ECG tracing. Notably, the a waves are absent in atrial fibrillation and are
exaggerated in junctional rhythms and heart blocks (cannon waves). It is also
enlarged in tricuspid and pulmonary stenosis as well as pulmonary
hypertension.
The c wave is due to the bulging of the tricuspid valve into the right atrium
during early ventricular contraction (ventricular systole), while the v wave is
due to the rise in the atrial pressure that occurs before the opening of the tricus-
pid valve. The v waves are prominent in tricuspid regurgitation.
There are also two descents noted in the central venous pressure waveform.
The x descent is due to the atrial relaxation or possibly by the tricuspid
annular downward displacement during systole [1].
The y descent represents the tricuspid valve displacement during diastole, as
atria start emptying [2].
2. Central venous pressure measures right atrial pressure, which is a major determi-
nant of right ventricular end-diastolic volume. It is used to assess (right) ventricu-
lar volume, filling, and therefore fluid status. It does however have limitations,
mostly related to ventricular compliance which can be affected by a variety of
1 CVP 5
factors (e.g., impaired relaxation, ischemia, and pharmacologic manipula-

tion). Of note, even in healthy patients, there is a wide variability in cardiac
compliance. Although a very low CVP measurement may indicate volume deple-
tion, a high value may be due to volume overload or poor ventricular compliance.
Isolated central venous pressure measurements are not useful; instead, the trend
of measurements over a given time and the response to a fluid challenge may
provide useful information on the intravascular fluid status of a patient.
It is also important to keep in mind that filling pressure estimation is unreli-
able in predicting fluid responsiveness, particularly in septic patients. CVP mea-
surement should be considered in the context of other parameters of a patient’s
volume status like heart rate, blood pressure, and urine output. In healthy hearts,
right and left ventricular performances are parallel, t herefore left ventricular fill-
ing can be approximated by the central venous pressure.
3. Determinants of the central venous pressure are as follows:
(a) Right ventricular function
(b) Venous return that in turn is determined by total blood volume, venous tone,
cardiac output, right ventricular contractility, and intrathoracic pressure [3].
It has to be understood that the central venous pressure can be overesti-
mated, mainly due to fluctuations with respiration of the mean central venous
pressure. Proper placement of the catheter just outside of the right atrium may
insure more accurate readings. The pressure at the base of the c wave repre-
sents the right atrial pressure at the start of the right ventricular systole, mak-
ing it the best estimate of right ventricular preload. Central venous
measurements should be taken at end exhalation (lowest negative intrathoracic
pressure) [5].
4. Several factors will influence the accuracy of the central venous pressure

reading:
(a) Changes in intrathoracic pressure (PEEP, ascites).
(b) Cardiac rhythms disturbances.
(c) Tricuspid valve disease.
(d) Myocardial compliance changes (pericardial disease, tamponade). In tam-
ponade there is equalization of diastolic pressures (in the absence of left
ventricular dysfunction).
RAP = RVEDP = LAP = LVEDP
Of note, the limited ventricular filling abolishes the y descent. In return the x
descent (atrial relaxation) is accentuated or normal [4].
5. Indications:
(a) Fluid management (particularly hypovolemia and shock)
(b) Infusion of vasoactive drugs
(c) Hyperalimentation
(d) Insertion of pacemaker wires
(e) In surgeries with air embolism potential
(f) Difficult IV access
6 T. Nicolescu
Fig. 1.3 Abnormal
CVP—steep x and y
descent (constrictive
pericarditis)
x y
Raised CVP with abrupt x and y descent
Fig. 1.4 Abnormal c
CVP—steep x descent a
(pericardial tamponade)
Steep x descent & Absent y descent
Contraindications:
(a) Right atrial tumor extension (renal cell carcinoma)
(b) Endocarditis (fungating valve vegetations)
(c) Relative presence of ipsilateral carotid endarterectomy
6. Waveform analysis
Large a waves Pulmonary hypertension, tricuspid, and pulmonic stenosis
Cannon a waves Irregular—complete heart block
Regular—AV dissociation
Large v waves Tricuspid regurgitation
Exaggerated x descent Pericardial tamponade, constrictive pericarditis
Sharp y descent Severe tricuspid regurgitation, constrictive pericarditis
References
1. Johnson B. Decrease in central venous pressure by lower body negative pressor or blood loss
elicits similar responses. J Appl Physiol (1985). 2014;117(2):131–41.
2. Butterworth JF. Atlas of procedures in anesthesia and critical care D. Berlin-Starling curves
and central venous pressure. Crit Care. 2015;19(1):55.
3. Avcil M. Comparison of estimating central venous pressure. Int J Clin Exp Med. 2015;8(7):
10586–94.
4. Carmona P, Mateo E, et al. Management of cardiac tamponade after cardiac surgery.
J Cardiothorac Vasc Anesth. 2012;26(2):302–11.
5. Pittman JAL, Ping JS, et al. Arterial and central venous pressure monitoring. Int Anesthesiol
Clin. 2004;42(1):13–30.
Chapter 2
Pulmonary Artery Catheters
Teodora Nicolescu
30 30
0 0
Fig. 2.1 Pulmonary artery catheter normal waveform
Questions
1. The above sequence of waveforms was encountered during a line placement in a
patient. Describe what you see.
2. What information does the PA catheter provide?
3. How does ventilation management affect the accuracy of data from a PA

catheter?
4. When is the pulmonary artery occlusion pressure (PAOP), also referred to as
pulmonary capillary wedge pressure (PCWP), different from the left ventricular
end-diastolic pressure (LVEDP)?
5. What do large v waves on the PA catheter tracing mean?
6. How can you accurately interpret mixed venous oxygen saturation?
7. What are the indications, complications, and evidence for PAC use?
T. Nicolescu, MD

DOI 10.1007/978-3-319-55862-2_2
8 T. Nicolescu
R R
30 30
a
c v
0 0
Right atrium Right ventricle
R R
30 30
a c v
0 0
Pulmonary artery Wedge
Fig. 2.2 Waveforms encountered during PAC advancement
Answers
1. When inserted, the PA catheter is first advanced through the sheath and at
approximately 15–20 cm, the balloon is inflated. Along this path the catheter will
pass through the (1) right atrium, (2) the right ventricle, and (3) the pulmo-
nary artery, at which point, with slight advancement into a small arterial branch,
it can obtain (4) the pulmonary artery occlusion pressure.
The right atrial pressures (values 0–5 mmHg) will be similar to a central
venous tracing that varies with respiration.
A sudden systolic pressure increase (values 15–30 mmHg) confirms
entrance into the right ventricle.
Advancement into the pulmonary artery will result in a sudden increase in
diastolic pressures (values 8–15 mmHg) confirming entrance into the pulmo-
nary artery.
The pulmonary capillary wedge pressure (values 8–12 mmHg) will rapidly
fall once the balloon is inflated and reveal a left atrial pressure waveform with a,
c, and v waves, just like a central venous tracing except the waves appear later.
2. The PA catheter provides a more precise left ventricular diastolic pressure
estimation.
2 Pulmonary Artery Catheters 9
The right ventricular pressures do not correlate with pulmonary artery pressures
distal to the occlusion point. However, this is not true for the relationship PAOP,
LAP, and LVEDP which correlate.
Theoretically at least, at end diastole no pressure gradient should occur, making end
diastole the best time for pressures correlation.
The values obtained from the PA catheter are as follows [2]:
(a) Cardiac output (CO)—the only value measured (all the rest are calculated
values).
The cardiac output measurements are obtained by the thermodilution method, the
basic principle being that the difference in temperature between the cold injec-
tate and body temperature is inversely proportional to the pulmonary blood flow
(cardiac output).
Accuracy of measurements is directly dependent on the speed of injection and pre-
cise quantification of injectate volume and temperature.
Once the average value of three measurements is obtained, calculations can provide
the rest of the data derived from the PA catheter.
(b) Cardiac index(CO/BSA) where CO represents cardiac output and BSA is body
surface area
(c) Systemic and pulmonary vascular resistance:
( MAP - CVP ) ´80
SVR ( systemic vascular resistance ) =
CO
Normal: 900–1600 dynes.sec.cm−5
where MAP represents mean arterial pressure, CVP central venous pressure, and
CO cardiac output.
PVR ( pulmonary vascular resistance ) =
( MPA – LAP {PAOP}) ´ 80
Pulmonary flow ( CO )
where MPA represents mean pulmonary artery pressures, LAP left atrial pressure
(PAOP—pulmonary artery occlusion pressure), and CO cardiac output.
Normal: 20–130 dynes.sec.cm−5
(d) Stroke volume and index:
CO ´ 1000
Stroke volume =
HR
Stroke volume
Stroke index =
BSA
3. PA catheter data may be unreliable due to intrathoracic pressure variations.

Balloon inflation will not occlude capillaries unless it is placed in West lung zone
III (arterial pressure exceeds venous, which exceeds alveolar pressure), where
10 T. Nicolescu
the capillaries can remain open. Placement in zone I or II can obstruct blood flow
rendering the readings inaccurate, reflecting alveolar rather the pulmonary occlu-
sion pressures.
Thus, it is important to remember that intravascular volume depletion or
PEEP, for example, may convert a lung zone III to a zone II (alveolar pressure
exceeds arterial pressure), thereby affecting the readings. This may also occur
during any ventilation management in which there is insufficient expiratory time
(air trapping or inverse ratio ventilation).
Pressures are evaluated at end expiration to minimize the effect of pleural
pressures on intracardiac pressures.
4. There are conditions when PAOP overestimates or underestimates the LVEDP.
Overestimation:
(a) Tachycardia (shortened diastolic filling time). At rates greater than 115/min,
the pulmonary artery end-diastolic pressure (PAEDP) is greater than the
PAOP.
(b) Increase in pulmonary vascular resistance (sepsis, pulmonary disease,

obstruction to venous drainage).
(c) Mitral stenosis, atrial myxoma.
(d) Increased intrathoracic pressures (mediastinal tumors).
(e) Conditions associated with large PA v waves (large v waves may obscure
catheter wedging with pulmonary artery rupture being a real danger). The
normal PA waveform has an arterial waveform with an upward slope, a
downward slope, and a dicrotic notch associated with the pulmonic valve
closure. While the peak systolic wave on the PA tracing corresponds to the
electrographic T wave, by contrast, the large v waves occur after the electro-
cardiographic T wave. Large v waves on the PAC are seen in mitral regurgi-
tation, VSD, and CHF.
Underestimation:
(a) Aortic regurgitation.
(b) Non-compliant left ventricle—transmyocardial filling pressure and LVEDP
have a curvilinear relationship, therefore changes in left ventricular end-
diastolic volume (LVEDV) will result in changes in the LVEDP based on the
location on the curve. Of note, ventricular compliance is affected by vasoac-
tive drugs, and beta-blockers.
(c) Pulmonary embolism.
(d) Right bundle branch block (delay in right ventricular systole).
(e) Pulmonary edema.
5. Large v waves are seen in (1) myocardial ischemia, (2) mitral regurgitation, (3)
decreased atrial compliance, (4) or increased SVR. The diastolic PAOP offers the
best approximation for the LVEDP when large v waves are present.
2 Pulmonary Artery Catheters 11
6. Fiber-optic PACs can be used to measure mixed venous oxygen saturation

(SvO2). Mixed venous oxygen saturation is the percentage of oxygen bound to
the hemoglobin returning to the right side of the heart. It reflects the “leftover”
oxygen after tissues have removed their needed oxygen (oxygen extraction).
Normal SvO2 values are 60–80% with a 10% change considered significant [3].
Low mixed venous oxygen saturation (SvO2) is caused by the following:
• Decreased oxygen delivery
–– Low cardiac output
–– Decrease in arterial oxygenation (SaO2)
–– Decrease in hemoglobin concentration
• Increased oxygen consumption
–– Hyperthermia
–– Neuromuscular blocker re-dosing needed during anesthesia
High SvO2 is caused by the following:
• Increased O2 delivery (high FiO2, hyperoxia)
• Decreased O2 demand (hypothermia, neuromuscular blockade)
• High flow states (sepsis, liver disease)
Changes in SvO2 come early before changes in hemodynamics manifest. A sur-
rogate of SvO2 measurement the SvcO2 (normally being over 70%) is obtained from
the internal jugular vein or subclavian vein and used to identify changes in a patient’s
oxygen extraction. An increase in extraction is the way tissue oxygen needs are met
when the amount of oxygen reaching tissues is decreased [4].
It is important to note, however, that a normal SvO2 value does not always reflect
adequate oxygenation. In situations such as carbon monoxide poisoning and sepsis,
SvO2 levels may be normal or high despite end-organ hypoxia.
The accuracy of the SvO2 values is affected by the optical intensity of the
reflected light at the end of the catheter. This may be affected by physical factors
such as migration of the catheter, its kinking, occlusion, or clot at the end. Signal
quality indicator is displayed continuously on the monitor which should be used to
evaluate the accuracy of the measurement [5].
7. Indications for PAC use include the following:
Cardiac conditions—valvular disease, myocardial ischemia management, evi-
dence of heart failure
Fluid management for shock, sepsis, acute burns
Pulmonary artery hypertension management
Obstetric conditions—placental abruption
Contraindications include left bundle branch block (insertion when this is pres-
ent will trigger complete heart block) and certain arrhythmias such as WPW or
Epstein’s anomaly due to the possibility of inducing tachyarrhythmias.
12 T. Nicolescu
Evidence, Outcome: UK National Health Service PAC-Man (PAC in patient

management in ICU)—no difference in hospital mortality in groups managed with
and without a PAC.
ESCAPE (Evaluation Study of Congestive Heart Failure and PAC Effectiveness)
trial—no difference in hospital mortality and length of hospital stay in groups using
clinical judgment and PAC compared with clinical judgment alone.
Complications: Incidence of complications was 10% in the PAC-Man and 5%
in the ESCAPE studies. Any prolonged use, over 48 h, has been associated with
complications that range from arrhythmias (particularly on insertion), clot develop-
ment, or infections to serious ones rarely, such as pulmonary artery rupture [6].
Concluding comments:
Judicious data interpretation should be used when evaluating the PA catheter
information. Aside from the potential errors mentioned above, there are a few pit-
falls associated with hemodynamic indices’ interpretation worth mentioning:
1. Adjusting SVR to body weight or using RAP in certain calculation (e.g., septic
shock where large beds of capillaries are removed increase arteriolar resistance
but not tone).
2. Careful evaluation of contractility indices (left and right ventricular stroke work
indices) needs to be performed to avoid underestimation of contractility (when
PAOP is different from LVEDP).
References
1. Jean Louis Vincent A. Clinical review: update on hemodynamic monitoring – a consensus of

16. Crit Care. 2011;15(4):229.
2. Marik PE. Obituary: pulmonary artery catheters from 1970 to 2013. Ann Intensive Care.
2013;3:38.
3. Journois D, Safran D. Continuous monitoring of mixed oxygen saturation. Ann Fr Anesth
Reanim. 1993;12(4):393–408.
4. Raper R, Sibbald WJ. Misled by the wedge? The Swan Ganz catheter and left ventricular pre-
load. Chest. 1986;89:427.
5. Tuman KJ, Caroll GC. Pitfalls in interpretation of pulmonary artery catheter data. J Cardiothorac
Anesth. 1989;3(5):625–41.
6. Hadian M, Pinsky MR. Evidence based review of the use of pulmonary artery catheter: impact
data and complications. Crit Care. 2006;10(Suppl 3):S8.
Chapter 3
ECG
Teodora Nicolescu
Questions
1. In the image above, mark the following—P, Q, R, S, T, and U and PR, QRS, and
QT intervals.
2. Questions: Which cardiac electric activity are P-waves indicative of and why do
we see biphasic P-waves in lead V1?
3. What cardiac electric cycle occurs during the PR interval? What can affect it?
4. What is the QT interval and what can prolong it?
5. How do we determine the heart axis from the EKG and what can it represent?
6. What is the Osborn wave and what does it represent?
7. What is right bundle branch block and the criteria for its diagnosis? What is its
significance when present on EKG?
8. What is left bundle branch block? What are the diagnostic criteria and its
significance?
T. Nicolescu, MD

DOI 10.1007/978-3-319-55862-2_3
14 T. Nicolescu
Fig. 3.1 Normal EKG
ST
segment T
P
U
PR Q
interval
S
QRS
interval
QT interval
Fig. 3.2 Normal EKG (components labeled)
Answers
1. P-waves represent atrial depolarizations. The right atrial depolarization will
precede the left one, due to the fact that the sinoatrial node is located in the right
atrium. It is the minute difference between those depolarizations that is responsi-
ble for the biphasic P-wave in lead V1. P-waves are best visible in leads II and V1.
2. The PR interval encompasses atrial depolarization and conduction through the
atrioventricular node and the Purkinje system. The normal duration is 0.12–0.2 s.
Short PR interval less than 0.12 s occurs in preexcitation.
A long PR interval (over 200 ms) is associated with first-degree blocks,
electrolyte disturbances (hypokalemia), or Lyme disease myocarditis. PR seg-
ment depression on EKG represents a sign of atrial injury. A long PR interval has
been considered a normal finding in older patients; however a study by McCabe
3 ECG 15
and Newton Cheh that analyzed data of over 7500 patients at Massachusetts
General Hospital suggested that when the PR interval is above 200 ms, patients
had twice the overall risk of developing atrial fibrillation, three times the risk of
needing a pacemaker, and one and a half times the risk of earlier death, when
compared with patients of the same age with normal PR interval [1].
3. QT interval is composed of the QRS complex, ST segment, and T wave. In
contrast to the ST segment, the QT segment is inversely proportional to the
heart rate. QT interval shortens at faster heart rates and prolongs at slower heart
rates. For this reason, QT corrected to heart rate (QTc) is calculated which allows
comparisons at different heart rates. There are multiple ways to calculate QTc.
Bazzett’s formula, for example, is accurate at heart rates of 60–100 (QTc = QT
measured/ RR ); however at heart rates above 100 or below 60, the Fredericia
formula (QTC = QT/RR1/3) is the most accurate.
Causes of prolonged QT:
(a) Genetic: Romano Ward and Jervell Lange-Nielsen syndromes
(b) Acquired: Antibiotics(macrolides), antidepressants/antipsychotics (phenothi-
azines), antihistamines, certain diuretics and diabetic medications,
cholesterol-lowering medications, and antiarrhythmic medications will all
cause QT prolongation. The same prolongation can be caused by electrolyte
abnormalities such as hypokalemia, hypocalcemia, and hypomagnesemia [2].
An abnormally prolonged QT interval increases the risk of ventricular
arrhythmias especially torsades de pointes (treated with magnesium which short-
ens QT) and sudden cardiac death.
There are two possible mechanisms that are responsible for the occurrence
of the torsades:
(a) Reentry due to the presence of different action potentials in adjacent myo-
cardial cell units that have different durations—a phenomenon that is called
“transmural dispersion of repolarization” [3].
(b) Triggered activity initiated by early or delayed after depolarization [4].
4. Determining the heart axis will have to take into account leads I and II and AVF.
If the QRS complex in leads I/II is positive—the heart axis is normal and
between 30 and 90°.
If the QRS complex is positive in lead I but negative in lead II, it is left axis
(0–90°).
If the QRS complex is negative in lead I but positive in lead II, it is right axis
(+90 to 180°).
J wave
Fig. 3.3 J wave

16 T. Nicolescu
If the QRS complex is negative in both leads I and II, there is an extreme axis
shift (−90 to +180°)—northwest axis.
Causes that produce right-axis shift include but are not limited to physiologic
inspiration, right bundle branch block, left posterior fascicular block, ASD
secundum, or WPW syndrome.
Similarly, left-axis shift is produced by physiologic expiration, ascites, left
ventricular hypertrophy, left bundle branch block, or left anterior fascicular
block [5].
5. The Osborn wave or J wave is characterized by positive deflection at the J point
(the point where the QRS complex finishes and the ST segment begins) [6].
Causes Hypothermia (temp <30°C)

Hypercalcemia
Normal variant
Neurological insults—head injury, subarachnoid hemorrhage
Vasospastic angina
Ventricular fibrillation
6. Right bundle branch block (RBBB) represents injury to the right branch of the
His fascicle.
EKG features include an RSR’ QRS complex (M shaped) with a duration of
over 120 ms (leads V1, V3) and the presence of a wide S wave in leads I, aVL,
and V5, V6. ST depression and T wave inversions are visible in the right precor-
dial leads (V1–V3).
Causes of RBBB: pulmonary embolism, right ventricular hypertrophy, isch-
emic or rheumatic heart disease, cardiomyopathies, and the presence of a septal
defect—ASD or VSD. Brugada syndrome (genetic sodium ion channel abnor-
mality associated with sudden death) must be considered in the differential
diagnosis.
7. Left bundle branch block (LBBB) is a conduction abnormality occurring in the
left branch (the two divisions—left anterior and left posterior—may be individu-
ally affected) of the His fascicle. The electrocardiography of LBBB includes a
QRS complex duration of over 120 ms, tall, monophasic, notched R waves (V6),
and deep S waves (V1). Left axis deviation may be present. It is associated with
organic cardiac disease [7].
Causes of LBBB: aortic stenosis, hypertension, ischemic cardiac disease,
and cardiomyopathies as well as certain drug toxicity, such as digoxin.
Pacemakers have induced LBBB since the right ventricle is stimulated first.
LBBB is an indication of diffuse myocardial disease and possibly of abnormal
septal activity. There is evidence that LBBB is associated with worse outcomes
than RBBB. The risk of heart failure is threefold higher in patients that have
ECG evidence of LBBB vs RBBB. It is hypothesized that the relative conduction
3 ECG 17
RBBB
V1 V6
LBBB
V6
V1
Fig. 3.4 Bundle branch block
delay is followed by mechanical asynchrony, regional workload differences,

asymmetric hypertrophy, and early onset of heart failure as a result [8].
A newly diagnosed LBBB has been associated with a higher all-cause mortal-
ity and a higher risk of heart failure. At an ejection fraction of under 35%, the pres-
ence of LBBB induces a large drop in the cardiac output and cardiac efficiency.
The simultaneous presence of right and left bundle branch blocks leads to
complete atrioventricular block and may require pacing.
BBB can be reproduced consistently at either high or very low heart rates.
This is called rate dependent BBB and is due to damaged or inactivated sodium
channels and lack of response during repolarization.
References
1. McCabe E, Newton CC. Long term outcomes in individuals with prolonged PR interval or first
degree AVB. JAMA. 2009;24301(24):2571–7.
2. Estefanous FG, Barash PG, et al. Cardiac anesthesia, principles and clinical practice. 3rd ed.
Lippincott Williams and Wilkin; 2001.
3. Wood M, Wood AJJ. Drugs and anesthesia-pharmacology for the anesthesiologist. 2nd ed.
Lippincott Williams and Wilkins; 1999.
4. Napolitano C, Priori SG. Drugs. 1994;47(1):51–65.
5. Rodrigues JC, Erdei T, et al. Electrocardiographic detection of hypertensive left atrial enlarge-
ment in the presence of obesity: re-calibration against cardiac magnetic resonance. J Hum
Hypertens. 2016; doi:10.1038/jhh.2016.63.
6. Omar HR, Mirsaeidi M. Cardiovascular complications and mortality determinants in near
drowning victims a 5 year retrospective analysis. J Crit Care. 2016;37:237–9.
7. Eriksson P, Hansson PO. Bundle branch block in a general male population. Circulation.
1998;98:2494–500.
8. Van Dijk J, Mannaerts HFJ. Left bundle branch revised with novel imaging. Neth Heart
J. 2006;14:372–80.
9. Cramer MMJ, De Boeck BW. 3-dimensional echocardiography: prime time in cardiology. Neth
Heart J. 2007;15(3):87–8.
Chapter 4
A-Line
Fig. 4.1 Arterial
waveform
2
120
Pressure (mmHg)
80 4
5
120–200 Time
msec
Questions
1 . In the Fig. 4.1, what are the components marked 1–5?
2. Describe the components of the arterial line waveform?
3. What are the indications and contraindications of arterial line placement?
4. What is damping and how does it affect an arterial line?
5. Does the site of monitoring affect the arterial waveform?
6. What other information can be derived from arterial line waveforms?
T. Nicolescu, MD (*)
T.D. Raj, MD, MRCP, FRCA
Department of Anesthesiology, Alliance Health Midwest, Midwest City, OK, USA

DOI 10.1007/978-3-319-55862-2_4
20 T. Nicolescu and T.D. Raj
Answers
1. 1, Systolic upstroke; 2, peak systolic pressure; 3, dicrotic notch; 4, end-diastolic
pressure; 5, area under the curve—mean arterial pressure (MAP).
2. A correctly placed arterial line will have a sharp upstroke representing ventricu-
lar ejection, the systolic phase, whose peak denotes the peak systolic pressure.
The systolic phase follows the R in the ECG after a 120–200 ms delay. This
delay is due to the spread of depolarization, isovolumetric left ventricular con-
traction, aortic valve opening, ventricular ejection, transmission of the pressure
wave to the monitored artery, and the pressure signal from the catheter to the
transducer. In the hardened and atheromatous vascular tree, it’s poor compliance
increases the reflected wave causing a high systolic peak pressure. The steepness
of the ascending limb is also related to heart rate increase, high peripheral resis-
tance, or use of vasoconstrictors; conversely the use of vasodilators or impaired
myocardial contractility will decrease the rate of upstroke. Aortic stenosis causes
slurring and slowing of the upstroke.
The peak systolic pressure is followed by the systolic decline as the ventricu-
lar contraction comes to an end.
Systole ends with the closure of the aortic valves, and this is marked by the
dicrotic notch when the tracing is obtained in the aorta. The appearance of the
notch with its subsequent brief upstroke in pressure is due the elastic recoil of the
aorta following the transient reversal of flow that precipitates closure of the aortic
valve. A flat or nonexistent notch implies a dehydrated patient, or valve insuffi-
ciency. A low notch may be due to low systemic vascular resistance (SVR). In the
setting of severe aortic insufficiency, a dual notch can appear (pulse bisferiens).
Peripherally, the dicrotic notch and wave are due to a reflected pressure wave.
Diastole starts at the dicrotic notch with a gradual downstroke slope corre-
sponding to the diastolic decline. Its shape will be affected by changes in
SVR. In patients with decreased arteriolar resistance, the dicrotic limb has a
steep fall off due to reduced afterload. In contrast, patients with a high peripheral
vascular resistance will have a prolonged fall off curve.
The end of the downstroke marks the end-diastolic pressure. This is higher
in hardened noncompliant vessels and lower in the presence of low SVR and
aortic regurgitation.
Mean arterial pressure (MAP) is the area under the pressure curve divided
by its duration and averaged over several beats [1]. This determines perfusion to
organs.
3. Indications:
(a) Situations where beat-to-beat monitoring of blood pressure is required and
where rapid hemodynamic changes is expected (surgeries with rapid blood
loss potential, cardiovascular procedures)
4 A-Line 21
( b) Use of intraoperative deliberate hypotension

(c) Surgeries or patient conditions requiring frequent arterial blood gases sam-
pling or use of vasoactive drugs
(d) In patients where a noninvasive blood pressure monitoring could be difficult
(burn patients, multiple limb injuries, morbidly obese patients)
Contraindications:
(a) Vascular concerns (Raynaud’s syndrome, thromboangiitis obliterans, full
thickness burns, and inadequate collateral circulation)
(b) Local infection
(c) Trauma distal to the site
Routine evaluation of collateral circulation is controversial as the incidence of
ischemic injury is rare, and common testing such as the Allen test has both poor
sensitivity and specificity [2].
4. The arterial waveform is the summation of numerous harmonic waves to form a

single complex waveform by Fourier analysis. The monitoring system for the arte-
rial pressure must have a frequency response that exceeds the natural frequency of
the arterial pulse (1–3 Hz). Most commercially available systems have a frequency
response in the several hundred Hertz. Factors that alter the energy in the oscillat-
ing monitoring system will alter the amplitude of oscillations. This is termed
damping. Damping of the arterial line can be tested by its dynamic response which
is a function of natural resonant frequency (how quickly the system vibrates to
pressure change) and damping coefficient (how quickly those vibrations stop).
This is done by the square wave test. When the flush valve is squeezed and
released, it should produce a square wave with a sharp rise, plateau, and a sharp
fall. A good arterial line trace would have a dicrotic notch and two oscillations after
the flush test.
An overdamped waveform would not demonstrate a dicrotic notch, and the
square wave test would show only one oscillation. Factors such as debris, air
bubbles, vasospasm, using a soft cannula or tubing, additional lengths of tubing,
and three-way stopcocks decrease the resonant frequency of the monitoring sys-
tem and cause overdamping.
Overdamping (damping factor greater than 1.0) leads to under-reading of
systolic blood pressure (SBP) and over-reading of diastolic blood pressure
(DBP).
An underdamped system would show many oscillations with the flush test.
Underdamping (damping coefficient less than 0.7) occurs due to resonance
and leads to overestimation of the SBP and underestimation of DBP. It is usually
due to increased vascular resistance and stiff noncompliant tubing.
In both scenarios, MAP is not affected [3].
Fig. 4.2 Arterial
waveforms at different
locations
Aorta
Radial artery
Femoral artery
Dorsalis pedis
5. The arterial line waveform is different at different sites of measurement due to

the physical characteristics (impedance and harmonics) of the vascular tree. As
the pressure wave travels from the aorta to the periphery, one sees:
• Delay in the waveform (60 ms later in the radial)
• Steeped systolic upstroke
• Higher peak systolic pressure
• Dicrotic notch appearing later
• Diastolic wave becoming more prominent
• End-diastolic pressure lowering
In summary, when compared to central aortic pressures, peripheral arterial
waveforms have higher SBP, lower DBP, and a wider pulse pressure. MAP is
only slightly higher in the aorta compared to the radial artery (Fig. 4.2).
4 A-Line 23
6. Other than blood pressure, arterial line can provide the following information:
• Pulse rate and rhythm.
• Slope of the upstroke reflects myocardial contractility (dp/dt).
• Pulse contour analysis allows calculation of certain derived parameters:
–– Stroke volume (SV)
–– Cardiac output (CO)
–– Vascular resistance
–– During positive pressure ventilation stroke volume variation (SVV) and
pulse pressure variation (PPV) as a means of intravascular volume
estimation
• Specific waveform pattern might be diagnostic like pulsus alternans in tam-
ponade and slow-rising upstroke with a delayed peak in aortic stenosis [4].
References
1. Magee P, Tooley M. The physics, clinical measurement and equipment of anaesthetic practice.
Oxford University Press 2005.
2. MA J, Jarvis CL, Jones PR, Spyt TJ. Reliability of Allen’s test in selection of patients for radial
artery harvest. Ann Thorac Surg. 2000;70(4):1362–5.
3. Romagnoli S, Ricci Z. Accuracy of invasive arterial blood pressure monitoring in cardiovascu-
lar patients. Crit Care. 2014;18(6):644.
4. Esper SA, Pinsky MR. Arterial waveform analysis. Best Pract Res Clin Anaesthesiol.
2014;28:363–80.
Chapter 5
Intracranial Pressure
Jacqueline J. Smith
A 27-year-old male involved in a motorcycle accident. He presented to emergency

room unresponsive and intubated. Vital signs: blood pressure 180/100, pulse 50,
SaO2 = 96%. Physical exam: unresponsive, intubated male. HEENT: facial abra-
sions, pupils were unequal, and sluggishly reactive; c-collar in place, and aside from
a femur fracture, the remaining PE was unremarkable. He was sent for CT and
found to have a large subdural hematoma requiring emergent evacuation in the oper-
ating room. Once taken to the operating room and the bone flap is removed, the
surgeon notes the brain is “bulging and tense.” Postoperatively, an intraventricular
catheter was left in place to monitor ICP. In the ICU the ICP monitor showed the
following (Fig. 5.1):
50
10
0
Fig. 5.1 ICP waveform 0 25 50
J.J. Smith, MD
Department of Anesthesiology, University of Oklahoma Health Sciences Center,
750 NE 13th Street, OAC 200, Oklahoma City, OK, USA

DOI 10.1007/978-3-319-55862-2_5
26 J.J. Smith
1 . What are normal values for intracranial pressure?

2. How does a patient with intracranial hypertension present?
3. What is cerebral perfusion pressure?
4. What are the causes for intracranial hypertension?
5. What is the significance of increased intracranial pressure?
6. Describe the Monro-Kellie hypothesis and Cushing’s Triad.
7. Name some indications and contraindications for invasive ICP monitoring.
8. Name some types of ICP monitors, and what kind of information can an invasive
monitor display?
9. Name some therapeutic maneuvers that could be used to reduce intracranial
hypertension?
5 Intracranial Pressure 27
Answers
1. Normal values for intracranial pressure (ICP) are 7–15 mmHg in supine adults.
ICP is positional resulting in lower values with head elevation. ICP > 15 mmHg
is considered abnormal, and >20 mmHg is considered pathological. ICPs over
20 mmHg, particularly if sustained can lead to worse outcomes.
2. Intracranial hypertension may present with headache, hypertension, bradycardia,
and irregular respirations or apnea (Cushing’s Triad). Rarely do these symptoms
occur concurrently. A focused neurological exam may reveal papilledema, neu-
rological deficits, and altered consciousness as assessed by the Glasgow Coma
Scale.
Uncontrolled intracranial hypertension may lead to brain herniation.
Herniation can occur in the supratentorial or infratentorial region of the brain.
Common sites for herniation include cingulum (subfalcine), medial temporal
lobe (uncal), and inferior cerebellum (tonsillar) [1]. Signs of herniation include
dilated and nonreactive pupils, asymmetric pupils, motor exam that demonstrates
extensor posturing or no response, and progressive decline in neurologic condi-
tion (decrease in GCS > 2 points) that is not associated with non-TBI causes.
Signs of uncal herniation specifically include acute loss of consciousness, ipsi-
lateral pupillary dilation (CN III), and contralateral hemiparesis. Transtentorial
herniation may cause ipsilateral cerebral infarction because of posterior cerebral
artery occlusion.
3. Cerebral perfusion pressure (CPP) is the driving force of blood across the intra-
cranial arterioles and a major determinant of cerebral blood flow (CBF). The
relationship between CPP and CBF can be described by the expression
CBF = CPP/CVR (cerebral vascular resistance). CPP can be estimated using the
formula CPP = MAP–ICP since ICP is generally higher than CVP. Management
of patients with intracranial hypertension focuses on optimizing cerebral perfu-
sion by minimizing ICP and maximizing MAP and minimizing increases in
CVR. CPP < 60–70 mmHg adversely affect brain tissue oxygenation and metab-
olism. Attempts to exceed a CPP of 70 mmHg are counterproductive (Level II),
and a CPP of <50 mmHg should be avoided. [2]
4. Causes can be grouped into three processes: extra-axial, focal, and diffuse.
Extra-axial process would include epidural hemorrhage, subdural hemorrhage,
subdural empyema, extra-axial brain tumor, and pneumocephalus. Focal brain
process would include brain tumor (primary, metastatic), ischemic stroke, pri-
mary intracerebral hemorrhage, brain abscess, traumatic brain injury, and
hydrocephalus. Diffuse brain process would include traumatic brain injury,
aneurysmal subarachnoid hemorrhage, infectious meningitides and encephaliti-
des, noninfectious neuroinflammatory disorders, hepatic encephalopathy, and
28 J.J. Smith
toxic-metabolic encephalopathies. Additionally, an increase in venous pressure

due to cerebral venous sinus thrombosis, heart failure, superior vena cava, or
jugular vein thrombosis/obstruction can cause increased ICP. Metabolic disor-
ders like hypo-osmolality, hyponatremia, or uremic encephalopathy may mani-
fest with increased ICP. Pseudotumor cerebri, idiopathic intracranial
hypertension, and choroid plexus tumors (increased CSF production) must also
be considered in the differential [1].
5. The significance of increased ICP depends on its effect on cerebral perfusion
pressure. A retrospective look at 427 patients in the NMDA antagonist Selfotel
trial found that the most powerful predictor of neurological worsening was
ICP > 20 mmHg either initially or during neurologic deterioration. There was
no correlation with cerebral perfusion pressure (CPP) as long as it was greater
than 60 mmHg. CBF is kept constant by autoregulation (Fig. 5.2).
Autoregulation is a process of adjustment by the brain’s arterioles to keep
cerebral blood flow constant over a wide range of MAP or CPP. When MAP is
high, those arterioles constrict increasing cerebral vascular resistance (CVR)
and reducing the pressure. When MAP is low, CVR decreases and maintains
CPP/CBF. When MAP is less than 65 mmHg or greater than 150 mmHg, the
arterioles are unable to autoregulate, and CBF becomes dependent on the
MAP, described as “pressure-passive flow” which also occurs in abnormal
brain. MAP < 65 mmHg place the brain at risk for ischemia and
MAP > 150 mmHg may cause excess CBF and may result in increased ICP
and edema.
Optimally the goal is to maintain CPP greater than 60 mmHg by either
decreasing ICP or increasing MAP using vasopressors (only vasopressors that do
not increase ICP). As long as CPP > 60 mmHg, ICP control is more important
than further increases in CPP in terms of neurologic outcome [2].
PaCO2
PaO2
100
CBF (mL/100g/min)
75
50
25
0 50 100 150 200

Fig. 5.2 Cerebral
autoregulation MAP (mmHg)
Fig. 5.3 Compliance curve
80
60
ICP (mmHg)
40
20
Intracranial volume
6. Normal or abnormal ICP is a function of the volume and compliance of each

component of the intracranial compartment. Known as the Monro-Kellie hypoth-
esis, this doctrine states that the cranial compartment is enclosed in a nonexpand-
able case of bone, and thus the volume inside the cranium is fixed. In an
incompressible cranium, the blood, CSF, and brain exist in a state of volume
equilibrium. A volume increase in one component is compensated by a recipro-
cal decrease in each of the other components. Once the compensation limits are
exceeded, intracranial pressure rises, and CBF can fall (Fig. 5.3).
In 1903, Cushing described as a clinical tool what is now widely known as the
“Cushing’s reflex.” It consists of a widening pulse pressure (rising systolic, declin-
ing diastolic) and bradycardia [2]. When the arterial pressure is less than the intra-
cranial pressure, a reflex called the “CNS ischemic response” or “Cushing’s reflex”
is initiated by the hypothalamus in the brain. The hypothalamus activates the sym-
pathetic nervous system, causing peripheral vasoconstriction and an increase in car-
diac output. These two effects serve to increase arterial blood pressure. When
arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is
restored. The increased arterial blood pressure caused by the CNS ischemic response
stimulates the baroreceptors in the carotid bodies, thus slowing the heart rate drasti-
cally often to the point of a bradycardia. The Cushing reflex helps save brain tissues
during periods of poor perfusion. It’s a late sign of increasing intracranial pressure
and indicates that brainstem herniation is imminent. A related term is “Cushing’s
triad,” which is the presence of hypertension, bradycardia, and irregular respirations
in a patient with increased intracranial pressure. These findings are another manifes-
tation of the Cushing reflex. The irregular respirations are due to reduced perfusion
of the brainstem from swelling or possible brainstem herniation.
7. Indications: [6]
• An ICP monitor should be placed in patients with a Glasgow Coma Score less
than 8 T after resuscitation and after reversal of paralytics or sedatives that
may have been used during intubation.
30 J.J. Smith
• GCS 3–8 and abnormal CT scan.

• GCS 3–8 with normal CT scan and 2 or more of the following:
Age > 40 years
Motor posturing
SBP < 90 mmHg
• GCS 9–15 and CT scan:
Mass lesion (extra-axial >1 cm thick, temporal contusion, ICH > 3 cm)
Effaced cisterns
Shift >5 mm
• Following craniotomy.
• A patient at risk for increased ICP undergoing a necessary non-neurosurgical
procedure under general anesthesia rendering clinical observation
impossible.
• Patients who have nonsurgical intracranial hemorrhage but are intubated for
non-neurosurgical reasons preventing clinical examination.
• Patients with moderate head injury due to brain parenchymal contusions that
are at risk of developing cerebral edema or continued hemorrhage. Extreme
vigilance and clinical judgment must be used for lesions in the temporal
fossa, since their proximity to the brainstem can lead to herniation and brain-
stem compression with little change in global ICP.
• Patients who have undergone tumor or arteriovenous malformation resection
and are at risk for cerebral edema who cannot be assessed clinically.
Placement of an ICP monitor has no absolute contraindications because of its
relatively low risk. The following conditions increase the risk for hemorrhage and
merit careful clinical judgment.
( a) Patients with a known bleeding disorder
(b) Patients with thrombocytopenia (platelets count < 10,000/μL)
(c) Known platelets dysfunction (aspirin/clopidogrel or uremic encephalopathy)
(d) Prothrombin time > 13 s
(e) International normalized ratio greater than 1.3
Potential complications include intraparenchymal, interventricular, or subdural
hemorrhage. Catheter-related hemorrhages occur in 1–33% of patients. Infection
occurs in 1–12% of patients. Higher rates of ventriculitis/meningitis occur with
longer duration of EVD placement [3]. Infection rates increase exponentially after
5 days [4].
8. Types of intracranial pressure monitors: invasive vs noninvasive
• Epidural
• Subarachnoid
• Intraparenchymal fiber-optic
• Intraventricular
• Transcranial Doppler
• Optic nerve sheath diameter
ICP monitoring allows measurement of ICP at a given point but also provides
information about intracranial dynamics and brain compliance from waveform
Fig. 5.4 Normal ICP

waveform
P1
P2
P3
analysis. Prognosis of survival following head injury and optimization of CPP-

guided therapy can be based on parameter analysis.
A normal ICP trace is pulsatile and reflects cardiac and respiratory cycles.
Amplitude reflects changes in intrathoracic pressure and varies between 2 and
10 mmHg (Fig. 5.4). Respiratory variation diminishes with rising ICP and eventu-
ally disappears entirely.
The pulse component of a normal ICP waveform consists of 3 peaks generally
1–4 mmHg in amplitude and correlate with the arterial waveform that occurs with
each cardiac cycle.
The P1 wave or percussion wave reflects the arterial pulse transmitted through
the choroid plexus into the CSF. The P2 or the tidal wave reflects cerebral compli-
ance as the arterial pulse wave bounces off the springy brain parenchyma. The
dicrotic wave or P3 correlates with aortic valve closure making the trough prior to
P3 equivalent to the dicrotic notch.
Based on the morphology of the CSF pulsations, the state of brain compliance
can be estimated. As ICP increases above resting level, the cardiac pulse component
amplitude increases while the variability of the respiratory component decreases
(Fig. 5.5). The waveform can provide information about altered intracranial dynam-
ics and compliance such as increased waveform amplitude, elevated P2, waveform
rounding, and plateau wave presence, all suggesting significant increase in ICP that
would warrant intervention.
As intracranial compliance decreases, the greater the effect a 1 cc withdrawal of
CSF has on ICP (>5 mmHg). Additionally, pathological waves or Lundberg A, B,
and C waves appear (Fig. 5.6). Lundberg A waves or plateau waves are characteris-
tic of conditions that lead to reduced intracranial compliance. With amplitude of
50–100 mmHg occurring for 5–10 min duration, they indicate a situation of low
CPP and ischemia. If ICP is left untreated, they are an ominous sign for the develop-
ment of brain herniation.
32 J.J. Smith
Fig. 5.5 ICP waveform

reflecting decreased brain
compliance
P2
P1
Fig. 5.6 ICP waveform 50

with illustrated Lundberg
waves
40
30
20
10
0
0 5 10 15 20 25 30 35 40 45 50
Lundberg Lundberg Lundberg
A B B
waves waves waves
Lundberg B waves are rhythmic oscillations, sharply peaked occurring every

1–2 min. In a crescendo manner, ICP increases to 20–30 mmHg from a variable
baseline and are not sustained.
Lundberg C waves have no clinical significance being documented in healthy
patients. These waves correspond to fluctuations in arterial pressure brought about
by oscillations in baroreceptor and chemoreceptor reflex control systems [5].
9. Management of increased intracranial pressure can fall along three tiers of
therapy.
(a) Tier 0: Standard measures which include assessment of adequate circulation,
airway patency, and ventilation. The head of the bed should be elevated to
30° or higher to facilitate cerebral venous drainage. Any stimuli like tracheal
suctioning should be minimized as it can raise ICP. Lower body and brain
temperature if hyperthermia is present. Only iso or hyperosmotic fluids
should be administered as intravenous solutions. Correct hyponatremia
slowly. Vasogenic edema from brain tumors, abscesses, or noninfectious

neuroinflammatory conditions should be treated with high-dose corticoste-
roid therapy. A non-contrast head CT should be obtained when patient can
be safely transported.
(b) Tier 1: If acute obstructive hydrocephalus is present on CT, an external ven-
tricular drainage (EVD) system should be placed emergently. If an EVD is
in place, 5–10 mL of CSF should be drained. Mannitol should be adminis-
tered as a 0.5–0.1 g/kg bolus and repeated every 4–6 h if monitoring serum
osmolality. Stop osmotic therapy if serum osmolality is >320 mOsm/kg. A
brief course of hyperventilation (<2 h) to a PaCO2 of 30–35 mmHg may be
considered. Hyperventilation is known to lower ICP but also decreases CBF
3–4% for every mmHg decrease in PaCO2. This can lead to dangerous drops
in CBF in TBI scenarios. Decompressive surgical options may be considered
if Tier 1 interventions do not resolve clinical signs of herniation or increased
ICP. If surgery is not appropriate, move to Tier 2 therapies.
(c) Tier 2: Hypertonic saline in concentrations ranging from 2–23.4% can effec-
tively treat brain edema and ICP. Concentrations > 3% are preferably admin-
istered via a central venous catheter. However, with careful monitoring of
the peripheral IV site, 3% and 7.5% saline solutions should not be withheld
when treatment indicated. Bolus 23.4% saline has been associated with ICP
reduction and transtentorial herniation reversal. A target serum sodium level
should be identified and checked every 4–6 h when using hypertonic saline
therapies.
Propofol reduces cerebral metabolic oxygen consumption (CMRO2) and
cerebral blood volume (CBV) consequently reducing ICP. Administer as a
bolus of 1–3 mg/kg and continue as an infusion at 25–200 μg/kg/min titrated
as vital signs allow. CPP may be supported with intravenous fluids and/or
vasopressors/inotropes. If these fail reconsider decompressive surgery.
(d) Decompressive surgical interventions include:
• Placement of a ventricular drain
• Evacuation of extra-axial lesion (epidural hematoma)
• Resection of intracerebral lesion (lobar hemorrhage)
• Removal of brain parenchyma (cerebellar mass)
• Uni- or bilateral craniectomies
(e) Tier 3: This is the most aggressive level of management. These guidelines
are consensus driven.
• Barbiturate coma induction can be administered while following EEG con-
tinuous monitoring. Using pentobarbital, induction is started with a 10 mg/
kg bolus over 30 min, and then 5 mg/kg/h × 3 h, followed by a maintenance
infusion of 1–4 mg/kg/h titrated to ICP goal. The infusion rate is adjusted
according to either burst suppression of 5–20 s or ICP. This infusion can be
continued for 24–96 h while the underlying processes causing the ICP
issues are managed. This therapy is not without complications. Pentobarbital
is associated with respiratory depression, circulatory instability, immune
34 J.J. Smith
suppression, and paralytic ileus. Pupillary reactivity is the only neurologic

assessment finding, and drug clearance may take days after infusion has
stopped.
• Moderate hypothermia to a target core temperature of 32–34°C can be
induced with external cooling or cold intravenous fluids to decrease
CMO2 and theoretically achieve some brain protection. Treatment may be
associated with shivering, cardiac dysrhythmias, sepsis, coagulopathy,
and electrolyte disturbances.
• Moderate hypocapnia to a PaCO2 of 25–35 mmHg thru hyperventilation
can be used if patients have not responded to other therapeutic maneuvers
to decrease ICP. Cerebral ischemia can be avoided if some cerebral oxy-
genation monitor like jugular venous oximetry or a brain tissue oxygen
probe is used along with hyperventilation. Prolonged hyperventilation for
>6 h is not beneficial and may cause ischemic brain injury [1].
References
1. Stevens RD, Huff JS, Duckworth J, Papangelou A, Weingart SD, Smith WS. Emergency neu-
rological life support: intracranial hypertension and herniation. Neurocrit Care. 2012;
doi:10.1007/s12028-012-9754-5.
2. Gupta G. Intracranial pressure monitoring: background, indications, and contraindications.
Emedicine. Medscape.com/article/1829950-overview.
3. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of
Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury.
VI. Indications for intracranial pressure monitoring. J Neurosurg. 2001;95:560–8.
4. Kirmani AR, Sarmast AH, Bhat AR. Role of external ventricular drainage in the management
of intraventricular hemorrhage; its complications and management. Surg Neurol Int.
2015;6:188.
5. Abraham M, Singhal V. Intracranial pressure monitoring. J Neuroanaesthesiol Crit Care.
2015;2:193–203.
6. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of
Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury.
VIII. Intracranial pressure thresholds. J Neurotrauma. 2007;24(Suppl 1):s55–8.
Chapter 6
Capnography I
Fig. 6.1 Inhalation begins
40 D
C
CO2
(mmHg)
A B E
0
Time (seconds) 1
Exhalation begins
Questions
1. What does the picture (Fig. 6.1) above depict?
2 . In the picture above, what do points A and D denote?
3. Differentiate between capnometry, capnogram, and capnography.
4. Explain the phases of capnography.
5. How do capnographs work?
6. What are the types of capnometers?
7. Name some uses of capnography?
8. What are the factors that affect ETCO2?
9. What is the principle of calorimetric CO2 detector?
R. Ganta, MD, FRCA (*)

Department of Anesthesiology, VA Hospital, OUMC, 921 NE 13th Street, Oklahoma City,
OK 73104, USA
Department of Anesthesiology, Alliance Health Midwest, MIdwest City, OK, USA
DOI 10.1007/978-3-319-55862-2_6
36 R. Ganta and T.D. Raj
Answers
1. The picture above shows a normal capnography.
2. Point A denotes the beginning of exhalation and D denotes the end-tidal CO2
level and the start of inhalation of CO2 free gas.
3. Capnometry is the measurement and numeric representation of the CO2 concen-
tration during inspiration and expiration. A capnogram is a continuous
concentration-time display as a waveform, of the CO2 sampled at a patient’s
airway during ventilation (Fig. 6.2). Capnography is the continuous monitoring
of the patient’s capnogram. Capnograph is the machine that generates a wave-
form and the capnogram is the actual waveform.
4. The capnogram is divided into four distinct phases (Fig. 6.3).
Phase I: Exhalation of CO2 free gas from dead space A–B
Phase II: Combination of dead space and alveolar gas B–C
Phase III: Exhalation of mostly alveolar gas C–D
Phase IV: Inhalation of CO2 free gas D–E
5. Capnographs usually work on the principle that CO2 absorbs infrared radiation.
A beam of infrared light is passed across the gas sample to fall on a sensor. The
presence of CO2 in the gas leads to reduction in the amount of light falling on the
sensor changing the voltage in a circuit.
6. Types of capnometers:
(a) Mainstream: A cuvette containing the CO2 sensor which is heated to 40 °C is
placed between the ET tube and the breathing circuit. Response time is fast.
(b) Sidestream: The CO2 sensor is in the main unit away from the patient and
expiratory gas is sampled by means of a long capillary tube which is con-
nected to a T-piece placed between the ET tube and the breathing circuit.
The rate of gas sampling is usually between 50 and 500 mL/min. If the sam-
pling rate is more than the expired gas flow, then contamination from fresh
gas occurs. Due to the sampling, there is a certain delay in detection.
Advantages include ability to monitor in non-intubated, spontaneously
breathing patients and also in prone positions.
ETCO2
ETCO2
40 RR
RR 40 10
10
Capnography Capnometry
• Continues concentration-time display • Measurement and numeric display of the

as waveform (capnogram) of the CO2 CO2 concentration without waveform
sampled at patient’s airway • Measured by a Capnometer
• Measured by a capnograph
Fig. 6.2 Capnography and capnometry

6 Capnography I 37
Normal capnograph
End expiration
plateau
Expiratory EtCO2
Phase 3
Phase 2
Phase 4
Expiratory Expiratory
upstroke downstroke
Phase 1 Phase 1
Inspiratory baseline Expiration
Fig. 6.3 Four phases of capnogram
7. Capnography is used in the following areas:

It is essential in determining the appropriate placement of endotracheal tubes
and is part of ASA standard in monitoring.
As a clue to valve/ CO2 absorber dysfunction/exhaustion.
To monitor adequacy of ventilation and cardiac compression during resuscitation.
Detection of adverse respiratory events such as hypoventilation, esophageal
intubation, endotracheal dislodgement, and circuit disconnection [1, 2].
During procedures done under sedation, capnography provides useful infor-
mation, e.g., on the frequency and regularity of ventilation, than pulse oximetry.
Monitoring during postoperative patient-controlled analgesia can improve patient
safety and reduce adverse events by early detection of respiratory depression [3, 4].
8. The factors that affect ETCO2 are:
(a) The factors that increase ET CO2 are:
• Hyperthermia including malignant hyperthermia
• Hyperthyroidism including “thyroid storm”
• Rebreathing (baseline elevation)
• Hypoventilation
• Release of cross-clamp/tourniquet
(b) The factors that decrease ETCO2 are:
• Hypothyroidism
• Pulmonary/air Embolism
• Hyperventilation
• Low cardiac output
Fig. 6.4 Calorimetric CO2

detector
9. Calorimetric CO2 detector (Fig. 6.4) acts as a “detector” and not a monitor. The
detector uses chemically treated paper that changes color when exposed to CO2.
A typical device has three color ranges based on the amount of CO2 detected, and
it requires six breaths for detection.
Purple—EtCO2 is less than 0.5%
Tan—EtCO2 is 0.5–2%
Yellow—EtCO2 is greater than 2%
Normal ETCO2 is greater than 4% hence the device has to turn yellow in people
with intact circulation. It may change color due to acidic contaminants like stom-
ach acid, lidocaine, or epinephrine.
References
1. Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring
detect respiratory events prior to current sedation monitoring practices? Acid Emerg Med.
2006;13(5):500–4.
2. Langhan ML, Ching K, Northrup V, Alletag M, et al. A randomized controlled trial of
Capnography in the correction of simulated endotracheal tube dislodgement. Acad Emerg
Med. 2011;18(6):590–6.
3. Gravenstein JS, Paulus DA, Hayes TJ. Capnography in clinical practice. Boston: Butterworths;
1989.
4. McCarter T, Shaik Z, Scarfo K, Thompson LJ. Capnography monitoring enhances safety of
postoperative patient-controlled analgesia. Am Health Drug Benefits. 2008;1(5):28–35.
Suggested Readings
5. Jaffe MB. Infrared measurement of carbon dioxide in the human breath: “breathe-through”
devices from Tyndall to the present day. Anesth Analg. 2008;107(3):890–904.
6. Raemer DB, Calalang I. Accuracy of end-tidal carbon dioxide tension analyzers. J Clin Monit.
1991;7(2):195–208.
Chapter 7
Capnography II
Raghuvender Ganta
Fig. 7.1
A
CO2 (mmHg)
50 Real-time
37 C D
A B E
0
B
CO2 (mmHg)
50 Real-Time
37
C
CO2 (mmHg)
Real-Time
50
37
D
CO2 (mmHg)
50 Real-Time
37
R. Ganta, MD, FRCA

Department of Anesthesiology, VA Hospital, OUMC,
921 NE 13th Street, Oklahoma City, OK 73104, USA
DOI 10.1007/978-3-319-55862-2_7
40 R. Ganta
E
CO2 (mmHg)
50 Real-Time
37
F
CO2 (mmHg)
50
Real-Time
37
G
50
25
H
a b
I
CO2 (mmHg)
Real-Time
Question
What do the above waveforms A to J depict?
7 Capnography II 41
Answers
A. Normal capnograph (Fig. 7.1A)
A–B: baseline
B–C: expiratory upstroke
C–D: expiratory plateau
D: ETCO2 value
D–E: inspiration begins
B. The baseline of the capnogram does not return to zero, e.g., rebreathing
(Fig. 7.1B)
• An exhausted co2 absorber [1]
• Channeling of the gas within the co2 absorber
• An incompetent unidirectional inspiratory or expiratory valve [1]
• Accidental administration of co2
• Inadequate fresh gas flow
C. Obstruction in airway or breathing circuit (Fig. 7.1C)
• Partially kinked or occluded artificial airway
• Obstruction in expiratory limb of breathing circuit [2]
• Bronchospasm
• Presence of foreign body in the airway.
D. Increased end-tidal CO2 (Fig. 7.1D)
• Hypoventilation [2]
• Increased metabolic rate
• Hyperthermia
E. Curare cleft (Fig. 7.1E)
• Inspiratory efforts of patient
• Hiccups
• Inadequate muscle relaxation [3]
F. Endotracheal cuff leak (Fig. 7.1F)
• Leak around the endotracheal tube
• Leakage of the sampling line [3, 4]
G. Cardiac oscillations (Fig. 7.1G)
• Movement of the heart produces small tidal volumes
• Capnograph can be affected by perfusion and cardiac function [4]
H. ROSC (return of spontaneous circulation) during cardiac arrest (Fig. 7.1H)
• HA: hypoperfusion, marked hypotension.
• HB: Correction of ET tube obstruction.
42 R. Ganta
Increase in pulmonary circulation brings more CO2 into the lungs for
elimination.
I. Esophageal intubation (Fig. 7.1I)
• Endotracheal tube in the esophagus
• Little or no CO2 present
J. Flat ETCO2 trace (Fig. 7.1J)
• Ventilator disconnection
• Airway misplaced extubation, oesophageal intubation
• Cardiac arrest
References
1. Kodali BS. Capnography outside the operating rooms. Anesthesiology. 2013;118:192–201.

2. Gravenstein JS, Jaffe MB, Gravenstein N, Paulus DA. Capnography. 2nd ed. New York:
Cambridge University Press; 2011.
3. Kodali BS. 2014. http://www.capnography.com
4. Kodali BS. Capnography during cardiopulmonary resuscitation: current evidence and future
directions. J Emerg Trauma Shock. 2014;7(4):332–40.
Chapter 8
Pulse Oximetry
Alberto J. de Armendi and Ranganathan Govindaraj
Fig. 8.1 Absorption 10
spectra for oxyhemoglobin (Red) (Infrared)
660 nm 940 nm
and reduced hemoglobin
Hbo2
Isosbestic
point
Hb
0.1
600 700 800 900 1000
Wavelength (nm)
A.J. de Armendi, MD, PhD, MBA (*)

Department of Anesthesiology, The Children’s Hospital, University of Oklahoma Health
Sciences Center, 750 NE 13th Street, Suite 200, PO Box 5318, Oklahoma City,
OK 73104, USA
R. Govindaraj, MD, FRCA
Associate Professor for Anesthesia and Pain, Department of Anesthesiology,
UTMB, Galveston, TX, USA
Director for Ultrasound Guided Regional Anesthesia, Galveston, TX 77555,USA

DOI 10.1007/978-3-319-55862-2_8
44 A.J. de Armendi and R. Govindaraj
Questions
1 . How is the pulse oximeter value obtained?
2. What principle does it utilize?
3. What is isosbestic point?
4. What are the normal pulse oximeter values and how accurate is it?
5. What are the common sources of error?
6. What are the signs and symptoms of hypoxemia?
7. What other information can you obtain from a pulse oximeter?
8. What is perfusion index?
8 Pulse Oximetry 45
Answers/Discussion
1. A sensor in the form of a probe is generally placed on the finger, toe, or earlobe
of the patient. The probe has diodes which emit light of two different wave
lengths—660 nm in the visible red light range and 940 nm in the infrared range in
a rapid on—off mechanism. The oxygenated hemoglobin allows red light through
and absorbs infrared light, while the deoxygenated hemoglobin allows infrared
light through and absorbs more red light. The ratio of oxygenated to deoxygen-
ated hemoglobin determines the amount of red and infrared light absorbed which
is read by a sensor attached to a photodetector. Comparison of their absorption at
these wavelengths enables the oximeter to calculate the oxygen saturation which
is read during the pulsatile component of the blood. The microprocessor displays
SpO2, heart rate, and a plethysmograph on the screen [1].
2. Pulse oximeters work on the principle of absorption spectrophotometry explained
by Beer’s and Lambert’s laws. Beer’s law states that the absorption of radiation
by a given thickness of a solution of a given concentration is the same as that of
twice the thickness of a solution of half the concentration [5]. Lambert’s law
states that each layer of equal thickness absorbs an equal fraction of radiation
which passes through [3].
3. Isosbestic points are wavelengths at which both oxyhemoglobin and deoxyhe-
moglobin absorption is similar which is 808 nm, and the absorbance at this point
depends only on the hemoglobin concentration. Earlier pulse oximeter models
used a wavelength at an isosbestic point to compensate for hemoglobin concen-
tration but newer models use various wavelengths.
4. Pulse oximeter data are accurate on average to ±2% of a simultaneously obtained
arterial blood gas value. The SpO2 values correlate with PO2 values in the range
from 70 to 100% given the variability between individuals, where the pulse
oximeter probe is placed (finger versus earlobe, distal versus closer to the heart)
and the manufacturer’s variability range for healthy volunteers at sea level.
Values greater than 95% are considered to be within the normal range. In healthy
subjects, hypoxemia is defined as a pulse oximeter value less than 92% at sea
level when breathing room air [2].
5. Common sources of error [4]:
• Strength of Arterial Pulse: Any factor that reduces arterial pulsations will
reduce the ability of the instrument to obtain and analyze the signal—hypo-
thermia, hypotension, and vasopressor use.
• Body Movement: Extraneous movements can cause interference—shivering
and Parkinsonian tremors [6].
• Carboxyhemoglobin (CoHb): CO binds to heme competitively with 250 times
the affinity of oxygen, and COHb has the same absorption pattern of 660 nm
light as O2Hg causing artificial high SpO2 readings.
• Methemoglobin: Methemoglobin absorbs as much 660 nm red light as it does
the 940 nm infrared. Saturation approaches 85% and is falsely low at high
SpO2 and falsely high at low SpO2.
46 A.J. de Armendi and R. Govindaraj
• Methylene blue, indigo carmine, and indocyanine green cause a drop in SpO2.
• Color Interference: Pulse oximetry is not affected by skin color but is affected
by artificial or opaque nail finishes that may interfere with transmission of light.
• Physical factors like electrocautery and restriction of blood flow during BP
cuff inflation.
• Venous pulsations secondary to AV fistulas.
• Saturations below 80% are inferred and the saturation is overestimated.
6. Some of the common signs and symptoms of hypoxemia are:
• Restlessness
• Altered or deteriorating mental status
• Increased or decreased pulse rate
• Increased or decreased respiratory rate
• Decreased oxygen oximetry readings
• Cyanosis (late sign)
7. Additional information received from pulse oximeter include heart rate and perfu-
sion index if the oximeter is designed with this special feature. Pleth variability index
(PVI) is an automatic and continuous monitor of the respiratory variation of the
pulse oximeter’s plethysmographic waveform amplitude [7]. This has been shown to
predict fluid responsiveness noninvasively in mechanically ventilated patients.
8. Ratio between the pulsatile and the nonpulsatile blood is used to measure the (3)
perfusion index (PI) in the peripheral tissues. Optimum monitoring sites may be
chosen based on relatively high PI. Another use would be a spike in PI indicating
that epidural anesthesia has initiated peripheral vasodilatation which occurs
before the onset of anesthesia.
References
1. Pulse Oximeter. American Thoracic Society. Patient Information Series. Am J Respir Crit Care
Med. 2011;184:1. Online Version: www.thoracic.org. ATS Patient Education Series © 2011
American Thoracic Society. 2013;1–2.
2. Pulse Oximetry Training Manual. Lifebox. WHO surgical safety checklist. Safe surgery saves
lives. World Health Organization. Patient safety. A World Alliance for Safer Health Care. ISBN
979 92 4 150113 2. NLM Classification: WO 178. 1–24. http://www.who.int/patientsafety/
safesurgery/en/index.html. http://www.who.int/patientsafety/safesurgery/pulse_oximetry/en/
index.html
3. Fearnley SJ. Pulse oximetry. Update in anaesthesia. http://www.nda.ox.ac.uk/wfsa/html/u05/
u05_003.htm
4. Hill E, Stoneham MD. Practical applications of pulse oximetry. http://www.nda.ox.ac.uk/wfsa/
html/u11/u1104_01.htm
5. Principles of pulse oximetry. http://www.oximeter.org/pulseox/principles.htm
6. Goldman JM, Petterson MT, Kopotic RJ, Barker SJ. Masimo signal extraction pulse oximetry.
J Clin Monit Comput. 2000;16:475–83.
7. Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory
variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid
responsiveness in the operating theatre. Br J Anaesth. 2008;101(2):200–6.
Chapter 9
Cooximetry
John B. Carter
A patient is in pre-op holding with these vital signs.

HR 102 BP 135/88 RR 22 SaO2 89%.
Supplemental O2 6 L/min is administered by face mask with no improvement.
ABG: pH 7.42 PaO2 206 PaCO2 35 SaO2 100%.
The patient is asymptomatic with cyanosis, but an otherwise normal physical
exam.
1. Why is the O2 saturation different between the pulse oximeter and the blood gas?
2 . How would cooximetry be helpful?
3. What variants of hemoglobin are detected by the cooximeter?
4. Describe the pathology and treatment of methemoglobinemia (MetHb).
5. Describe the pathology and treatment of carboxyhemoglobinemia (COHb).
J.B. Carter, MD
Department of Anesthesiology, Oklahoma University Medical Center,
750 NE 13th Street, OAC 200, Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_9
48 J.B. Carter
Answers
1. There are three distinct methods of determining the oxygen saturation of blood.
The results may be interchangeable in healthy people, but different in
dyshemoglobinemias.
(a) Pulse oximetry utilizes the Beer-Lambert law, which states that light absor-
bance is proportionate to the concentration (c) of the light attenuating sub-
stance. Oxyhemoglobin (O2Hb) and deoxyhemoglobin (HHb) have differing
absorption of light. Oxyhemoglobin (O2Hb) absorbs more at 940 nm and
deoxyhemoglobin (HHb) more at 660 nm, and it is the ratio of absorption of
light at 660 nm to 940 nm that determines the saturation, using an algorithm
derived from healthy controls. The SaO2 assumes the presence of only O2Hb
and HHb, thus
cO2 Hb
SaO2 =
cO2 Hb + cHHb
cO2HB is content of oxy Hb and cHHb is deoxy Hb. It will be inaccurate
if abnormal hemoglobin’s such as methemoglobin (MetHb) and carboxyhe-
moglobin (COHb) are present. MetHb is absorbed at both 660 and 940 nm.
COHb is absorbed at 940 nm, similar to O2Hb.
(b) In the arterial blood gas (ABG) analysis, the pH and partial pressure of oxy-
gen in the blood are measured, and the saturation is calculated from the
standard oxygen dissociation curve.
(c) Cooximetry also utilizes the Beer-Lambert law. Using multiple wavelengths
of light, the concentrations of O2Hb and other Hb species are determined by
their different absorption at various wavelengths (Fig. 9.1). This allows the
calculation of a fractional SaO2 or percentage of oxyhemoglobin as a percent
of total Hb including abnormal species.
O2 Hb ´ 100
Fractional SaO2 =
O2 Hb + HHb + COHb + MetHb
Cooximetry results for this patient measured 70% O2Hb, 29% MetHb,
and 1% COHb; thus, the fractional SaO2 would only be 70%. Only 70% of
the Hb is available for O2 transport [1].
2. Cooximetry may be indicated if cyanosis or hypoxia measured by pulse oximetry
fails to improve with O2 administration or if there are discrepancies between O2
sat and PaO2 by ABG. It is also indicated for suspected carbon monoxide expo-
sure. The cooximeter measures absorption at multiple wavelengths and can mea-
sure the concentration of many different Hb species. Pulse cooximetry applies
multiple wave lengths of light to measure dyshemoglobins such as COHb and
total hemoglobin concentration. They are not yet as accurate as a lab cooximeter
and should be confirmed by the lab.
3. Cooximeters measure absorbance at more than two wavelengths from a mini-
mum of six to as many as 128. Fractions of HHb, O2Hb, COHb, and MetHb are
9 Cooximetry 49
10 Red Infrared
(660 nm) (940 nm)
Methemoglobin
Extinction coefficient
Oxyhemoglobin
Reduced
.1 hemoglobin
Carboxyhemoglobin
.01
600 700 800 900 1000
Wavelength, nm
Fig. 9.1 Absorbance spectra of oxyhemoglobin, reduced hemoglobin, carboxyhemoglobin, and

methemoglobin. Jubran. Critical Care.2015.19:272 (Open Access under terms of the Creative
Commons Attribution License)
routinely measured. Arterial or venous blood may be used. It is important to note

the difference of O2 saturation versus fractional oxyhemoglobin in the presence
of increased COHb or MetHb.
4. In methemoglobinemia the normal ferrous (Fe++) in the hemoglobin (Hb) is oxi-
dized to the ferric (Fe+++) state which cannot bind oxygen and also shifts the
oxygen dissociation curve to the left. Autoxidation of Hb to MetHb occurs spon-
taneously with a normal level of <2%. This is balanced by its reduction back to
the ferrous state by cytochrome b5 reductase; an alternative is the NADPH gen-
erated by G6PD in the RBC, requiring an exogenous electron donor such as
methylene blue. Methemoglobinemia may be hereditary, but it is more com-
monly acquired.
Substances which may cause methemoglobinemia include:
With high levels of MetHb, the pulse oximeter reading trends toward 85%; the
O2 dissociation curve shifts to the left. The fractional oxyhemoglobin will be
lower than the SaO2. When acutely acquired, MetHb levels <20% maybe asymp-
tomatic. Symptoms include headache, fatigue, dyspnea, and lethargy. At levels
>40%, altered consciousness, seizures, and death may occur. The diagnosis
should be considered if the pulse oximetry is lower than the O2 sat from an
ABG. This can be confirmed with cooximetry.
50 J.B. Carter
Dapsone Aniline dyes

Benzocaine Primaquine
Lidocaine Chloroquine
Prilocaine Sulfonamides
Inhaled nitric Chlorates
oxide
Nitrites Benzene derivatives
Nitroglycerin Methylene blue
The treatment is to identify and stop the causative agent and administer methy-
lene blue (MB) 1 to 2 mg/kg IV over 5 min. The response is usually rapid, and the
MB may be repeated after 1 h if MetHb persists. MB will be ineffective and
should be avoided in individuals with G6PD deficiency, more common in those of
African or Mediterranean or Southeast Asian descent. If MB is contraindicated,
ascorbic acid may be given 300–1000 mg/day orally. Supportive care as indicated
may include ventilation, high inspired oxygen, and exchange transfusion [2].
5. Carbon monoxide poisoning is common and causes include faulty home heaters,
inadequate home ventilation, auto exhaust, and house fires. Exposure may be
chronic or acute. Iatrogenic carbon monoxide poisoning may result from the
reaction of halogenated volatile agents, particularly desflurane and isoflurane
with desiccated soda lime or baralyme. This has typically occurred on a Monday
morning after O2 was left flowing through the circuit drying out the absorbent
canister [3]. Carbon monoxide has 200 times the affinity for Hb as O2; thus low
concentrations can produce significant COHb. COHb is normally 0–2% in non-
smokers and up to 9% in smokers. High levels of COHb reduce oxygen carrying
capacity of the blood and will give a falsely high pulse oximetry reading. CO
causes inflammatory response and binds to cytochrome c oxidase at the mito-
chondrial level, impairing cellular respiration. There are high rates of early and
late neurocognitive and cognitive deficits, as well as cardiovascular dysfunction
and acidosis. Symptoms are nonspecific and range from mild such as headache
to severe such as confusion, loss of consciousness, or death.
Treatment is administration of 100% O2 at high flow rates. This hastens the
release of CO from the Hb. Hyperbaric oxygen has been demonstrated to
decrease late neurologic sequelae and may be indicated if COHb > 25% [4].
References
1. Haymond SC, Cariappa R, Eby C. Laboratory assessment of oxygenation in Methemoglobinemia.

Clin Chem. 2005;51(2):434–44.
2. Prchal J. Clinical features, diagnosis, and treatment of Methemoglobinemia. UpToDate 2015.
3. Weaver L. Carbon monoxide Poisoning. NEJM. 2009;360(12):1217–25.
4. Berry P. Severe carbon monoxide poisoning during Desflurane anesthesia. Anesth.
1999;90(2):613–6.
Chapter 10
Cerebral Oximetry
Jacqueline J. Smith
Fig. 10.1 An example of a

cerebral oximeter monitor
with normal values
Questions
1 . What is cerebral oximetry?
2. How does it work? Is it similar to pulse oximetry?
3. In what clinical scenarios might the cerebral oximetry be used?
4. What are normal values? What are abnormal values?
5. What interventions can be performed to improve rSO2 values?
6. What are some interference sources for NIRS?
7. What are the current FDA-approved cerebral oximetry devices in the United
States?
J.J. Smith, MD
750 NE 13th Street, OAC 200, Oklahoma City, OK, USA

DOI 10.1007/978-3-319-55862-2_10
52 J.J. Smith
Answers
1. Cerebral oximetry (CO) has been available to clinicians for more than two
decades [1, 2]. Currently this monitor can be used as a “first alert” of impending
organ dysfunction [3]. The cerebral cortex is an area of the brain that is particu-
larly susceptible to changes in the demand and supply of oxygen and has a lim-
ited oxygen reserve. CO estimates the oxygenation of regional tissue by
transcutaneous measurement thru the cerebral cortex.
2. Cerebral oximeters consist of adhesive sensors applied over the frontal lobes which
both emit and capture reflected light based on near-infrared spectroscopy (NIRS).
CO depends on the ability of light to penetrate the skull to determine hemoglobin
oxygenation from the underlying brain tissue according to the amount of light
absorbed by hemoglobin [4]. NIRS uses two photodetectors with each light source.
Selective sampling of tissue beyond a specified depth beneath the skin is measured
by the technology. Near-field photodetection can be subtracted from far-field pho-
todetection to provide selective measurements of tissue oxygenation. Tissue sam-
pling is mainly from venous (70–75%) rather than arterial (25%) blood (Fig. 10.1).
It is independent of pulsatile blood flow. As opposed to pulse oximetry, which mon-
itors arterial blood hemoglobin saturation (SpO2), cerebral oximetry monitors
hemoglobin saturation in mixed arterial, venous, and capillary blood in cerebral
tissue (SctO2). As a result SctO2 is determined by two physiologic considerations.
The first is the proportional volumes of arterial, venous, and capillary blood in the
brain region illuminated by cerebral oximetry. SctO2 is higher if the sample has an
increased ratio of saturated arterial blood to desaturated venous blood and con-
versely lower if the ratio is decreased. The volume percentage of each blood com-
partment is not fixed. It varies interindividually and possibly between different brain
regions of the same individual. It may also change with hypoxia, hyper-/hypocap-
nia, neural excitation, and vasoconstrictor administration [5].
The second consideration is the balance between cerebral oxygen supply and
demand. Cerebral oxygen supply is determined by cerebral blood flow and arte-
rial blood oxygen content. If arterial blood content is stable, an increase in CBF
will expand arterial blood volume and shift the volume ratio toward more arterial
blood. Cerebral oxygen demand is determined by cerebral metabolic rate of oxy-
gen. If cerebral oxygen supply is stable, an increase in cerebral metabolic rate of
oxygen will expand venous blood volume ratio toward more venous blood.
These physiologic processes alter SctO2 readings. When CMRO2, arterial blood
content, and the volume percentage of different blood compartments are all rela-
tively stable, SctO2 can be regarded as a surrogate of cerebral perfusion [5].
3. Clinical Scenarios:
Cardiac Surgery
Multiple clinical outcome studies [3, 6, 7] support the concept that CO may
allow clinicians to use the brain as an index organ that points to the adequacy of
tissue perfusion and oxygenation of other vital organs. Data from the Society of
Thoracic Surgeons (STS) National Database strongly suggest that the intraop-
erative use of CO in cardiac surgery patients frequently (23%) served as a “first
10 Cerebral Oximetry 53
alert” indicator of an intraoperative dynamic that could lead to potential adverse

clinical outcomes in both adult and pediatric patients. The cerebral frontal cortex
is a vulnerable watershed tissue that is sensitive to small decreases in oxygen
saturation and therefore can provide an “early warning” about compromised
oxygen delivery to the rest of the brain and other major organs [8].
Patients whose saturations fell below 75% of preoperative levels and who
were treated spent less time in the ICU and had less morbidity/mortality than the
untreated group [6, 9, 10].
Cerebral oximetry has been shown to predict the lower limits of autoregula-
tion during cardiopulmonary bypass [11]. Real-time monitoring of rSO2 pro-
vided more accurate information than routine blood pressure monitoring in
identifying the lower limit of autoregulation.
Cerebral Vascular Surgery, Geriatric Surgery, and Thoracic Surgery
Cerebral oximetry preinduction value and/or an intraoperative decrease in
rSO2 value can guide in advance decisions regarding blood pressure manipulation
or elective shunting for carotid endarterectomy. For cerebral vascular disease, a
cutoff value of 25% or 20% below baseline for prolonged hypoperfusion is used
to opt for shunting [12].
Aggressively treating values that fall below 75% of baseline rSO2 in general
surgery and geriatric patients improved or maintained scores on the Mini-Mental
State Examination at postoperative day 7 and reduced the length of stay in the
postanesthesia care unit [7].
Early cognitive dysfunction after thoracic surgery with single lung ventilation
was found to be directly related to intraoperative decline of rSO2 [13, 14].
Trauma
NIRS cerebral oximetry has been found to correlate with cerebral blood flow
in trauma patients with brain injuries [14]. This monitor has found a use in
trauma patients on the scene and en route to the hospital providing valuable
information [15]. Cerebral oximetry may be a useful technique for predicting
mortality and/or adequacy of CPR from cardiac arrest.
Heart Failure and ECMO
In heart failure patients, rSO2 may be a potential important biomarker and
useful monitor of target organ perfusion. When ECMO must be used for a pro-
longed period of time, brain perfusion in the setting of normal vital signs is
undetermined. Sensors measuring rSO2 can be placed on the forehead and lower
extremities to monitor perfusion. When rSO2 values drop to below 40 or greater
than 25% of baseline, interventions such as fluid administration, increase in
ECMO flow, vasopressors, or replacement of a functioning distal perfusion cath-
eter can be initiated to reduce the incidence of stroke or limb ischemia [16].
Beach Chair Position
This is an emerging area of cerebral oxygen saturation monitoring. Cerebral
malperfusion may be unappreciated in this setting. Blood pressure monitoring may
not be optimal, head position may impede cerebral venous drainage thereby
decreasing CBF, and positive pressure ventilation impedes an already compromised
decreased venous return to the heart because of beach chair positioning [8, 17].
54 J.J. Smith
Fig. 10.2 An example of a

cerebral oximeter monitor
with abnormal values
4. In this technology, near-field photodetection is subtracted from far-field photo-

detection to provide selective tissue oxygenation measurement beyond a pre-
defined depth [3]. Normal Sr02 baseline values would be 60–80%. Generally
speaking, greater than 25% decrease or 20% decrease from baseline or a SrO2
value less than 40% is considered a trigger for intervention.
5. The guiding principle in the treatment of cerebral desaturation (Fig. 10.2) is to
increase oxygen delivery to the brain and/or decrease cerebral metabolic rate of
oxygen utilization. Ways to augment CBF include:
(a) Increasing cerebral perfusion pressure if it is below the lower limit of cere-
bral autoregulation and autoregulation is intact
(b) Increasing cerebral perfusion pressure irrespective of the lower limit if auto-
regulation is impaired
(c) Augmenting cardiac output
(d) Avoiding hyperventilation and hypocapnia, maintaining PaCO2 greater than
or equal to 40 mmHg
(e) Administering a cerebral vasodilator
(f) Using inhalational anesthetic agents based on their intrinsic cerebral vasodi-
lating properties at less than 1 MAC
(g) Checking head position to assure optimal cerebral venous outflow
(h) Augmenting cerebral venous drainage with 30 degree reverse Trendelenburg
position.
Additionally, interventions capable of improving arterial blood oxygen con-
tent such as increased inspired oxygen fraction and red blood cell transfusion
should be considered to boost oxygen delivery to the brain.
On the consumption side, deepening anesthesia causes a progressive decline
in cerebral metabolic rate of oxygen until EEG becomes isoelectric. Too deep of
an anesthetic though causes hypotension and abolishes autoregulation which
would be counterproductive [5].
10 Cerebral Oximetry 55
Interventions depending on the clinical scenario but would include:

Cardiac Surgery: correction of patient or cannula positioning, increasing
blood pressure, increasing cardiac output or CPB flow to greater than 2.5 L/m2/
min, increasing FI02, increasing PaC02 to >40 mmHg by decreasing minute ven-
tilation or decreasing oxygenator fresh gas sweep flows during CPB, administer-
ing anesthesia and/or muscle relaxants as indicated, and administering a red
blood cell transfusion if the hematocrit is <20%.
Carotid Endarterectomy: all of the above maneuvers aside from those related
to CPB would be appropriate. Additionally, if rSO2 values are particularly low
on the one side or the other, elective shunting would be indicated for the proce-
dure rather than just clamping the vessel.
6. Essentially any pharmacologic or anatomic abnormality which might involve
blood flow, hemoglobin abnormalities affecting light absorption in the same
spectra as NIRS, or distance between the near and far-field photodetection.
Variations in oximeter design, use of systemic vasoconstrictors, and underlying
skin pigmentation may affect the accuracy of cerebral oximetry readings [18].
Deeper anatomical structures such as the skull and frontal sinus may also play a
role. Hyperostosis frontalis interna with the resultant shallow frontal sinus may
cause unreliable rSO2 readings. With skull thickness causing low readings, mov-
ing the oximeter probes to a more lateral or more cephalad positions where the
skull is not as thick or the sinus as superficial might improve readings [19].
Bilirubin dampens the spectrophotometry determined cerebral saturation at
733 and 809 nm. Normal absorption spectra for this technology are 700 to
1000 nm. A bilirubin level of 370 mmol/L, tissue pigment deposits, or both may
render cerebral oxygen saturation impossible [18].
7. Current devices approved by the FDA for CO monitoring include:
INVOS (Somanetics Corporation, Troy, MI, recently COVIDIEN, Boulder, CO)
FORE-SIGHT (CAS Medical Systems, Inc., Branford, CT)
EQUANOX (NONIN Medical, Inc., Minneapolis, Minn.)
References
1. Jobsis FF. Non-invasive monitor of cerebral and myocardial oxygen sufficiency and circula-
tory parameters. Science. 1977;198(4323):1264–7.
2. McCormick PW, Stewart M, Goetting MG, Balakrishnan G. Regional cerebral vascular oxy-
gen saturation measured by optical spectroscopy in humans. Stroke. 1991;22(5):596–602.
3. Frost E. Cerebral oximetry emerging applications for an established technology. Anesthesiology
News Special Edition, October 2012:27–34.
4. Ferari M, Mottola L, Quarisima V. Principles, techniques, and limitations of near infrared
spectroscopy. Can J Appl Physiol. 2004;29(4):463–87.
5. Meng L, Gelb A. Cerebral oximetry: Three questions to ask. Rev Col Anesth. 2015;43(Suppl
1):52–6.
56 J.J. Smith
6. Murkin JM, Adam SJ, Novick RJ, et al. Monitoring brain oxygen saturation during coronary
artery bypass surgery: a randomized prospective study. Anesth Analg. 2007;104(1):51–8.
7. Casati A, Fanelli G, Pietropaoli P, et al. Continuous monitoring of cerebral oxygen saturation
in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential
hypoxia. Anesth Analg. 2005;101(3):740–77.
8. Trojanos CA. Cerebral oximetry may provide helpful information. ASPF Newsletter.
2009:Spring.
9. Goldman S, Sutter F, Ferdinand F, Trace C. Optimizing intraoperative cerebral oxygen deliv-
ery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical
patients. Heart Surg Forum. 2004;7(5):E376–81.
10. Slater JP, Guarino T, Stack J, et al. Cerebral oxygen desaturation predicts cognitive decline and
longer hospital stay after cardiac surgery. Ann Thorac Surg. 2009;87:36–45.
11. Joshi B, Ono M, Brown C, et al. Predicting the limits of cerebral autoregulation during cardio-
pulmonary bypass. Anesth Analg. 2012;114(3):503–10.
12. Pedrini L, Magnoni F, Sensi L, et al. Is near infrared spectroscopy a reliable method to evaluate
clamping ischemia during carotid surgery? Stroke Res Treat. 2012;156975:2012.
13. Tang L, Kazan R, Taddei R, Zacuter C, Cyr S, Hemmerling TM. Reduced cerebral oxygen
saturation during thoracic surgery predicts early post-operative cognitive dysfunction. Br
J Anaesth. 2012;108(4):623–9.
14. Taussky P, Oneal B, Daugherty WP, et al. Validation of frontal near-infrared spectroscopy as
noninvasive bedside monitoring for regional cerebral blood flow in brain injured patients.
Neurosurg Focus. 2012;32(2):E2.
15. Weatherall A, Skowno J, Lansdown A, Lupton T, Garner A. Feasibility of cerebral near-
infrared spectroscopy monitoring in the pre-hospital environment. Acta Anaesthesiol Scand.
2012;56(2):172–7.
16. Wong JK, Smith TN, Picher HT, Hirose H, Cavarocci NC. Cerebral and lower limb near infra-
red spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs.
2012;36(8):659–67.
17. Cullin DJ, Kirby RR. Beach chair position may decrease cerebral perfusion: catastrophic out-
comes have occurred. APSF Newsletter. 2007;22:25–7.
18. Madsen PL, Skak C, Rasmussen A, Secher N. Interference of cerebral near-infrared oximetry
in patients with icterus. Anesth Analg. 2000;90:489–93.
19. Doshi TL, Kangrga I, Vannucci A. Hyperostosis frontalis interna as a potential source of cere-
bral oximetry signal interference. Eur J Anaesthesiol. 2015;32:439–50.
Chapter 11
EEG
Mehmet S. Ozcan
Fig. 11.1
M.S. Ozcan, MD, FCCP

Department of Anesthesiology, The University of Oklahoma Health Sciences Center,
700 NE 13th Street, Suite 200, Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_11
58 M.S. Ozcan
Fig. 11.2
Questions
1. What does Fig. 11.1 represent? Describe the characteristics of various EEG
waveforms.
2. Describe the channels and their labels.
3. Identify some of the dominant waveforms seen in Fig. 11.1.
4. What does Fig. 11.2 represent? What is the significance of this EEG pattern for
the anesthesia provider?
11 EEG 59
Answers
1. This is a bilateral, multichannel EEG recording, showing normal (i.e., non-
pathologic) waveforms. EEG signals originate from the pyramidal cells of the
cerebral cortex. Each EEG electrode can capture the electrical activity of the
underlying 1 in square cerebral cortex. For this reason, multiple electrodes
simultaneously recording several channels are required to get an overall repre-
sentation of the electrical activity of the brain. EEG signals are classified in four
frequency bands. These are alpha (8–13 Hz), beta (>13 Hz), theta (4–7 Hz), and
delta (<4 Hz) [1]. In a nonanesthetized individual, normal EEG can display
waveforms that can fall in any one of these categories. However, location of the
recording (e.g., posterior vs frontal), age of the individual, and conscious state
are all important factors to determine whether a particular frequency band can be
regarded as normal or not.
2. EEG electrodes are placed on the scalp at precise locations based on their dis-
tance from standard landmarks. Most common method is the International 10–20
system, employing 21 electrodes. Majority of the electrodes are labeled with a
letter followed by a number. Letters indicate the region of the scalp: frontal (F),
parietal (P), frontal polar (Fp), temporal (T), occipital (O), and central (C).
Auricular (A) electrodes are commonly used as reference point. Odd and even
numbers that follow the letters indicate left and right sided placement, respec-
tively. The smaller the number, the closer the location of the electrode to the
midline. Midline electrodes are labeled with a letter “z” instead of a number
(e.g., Fz for the “frontal midline” electrode location). Labels of the individual
channels indicate the active (recording) electrode followed by the reference elec-
trode. If both of these are active electrodes, then it is a “bipolar” montage (e.g.,
Fp1-F7). Alternatively, the reference electrode can be a non-cephalic electrode,
which makes the montage “referential” (e.g., Fp1-A1). In the top figure, there are
20 bipolar channels that are arranged in the following fashion: 5 left-hemispheric
(starting with Fp1-F7), 5 right-hemispheric (starts with Fp2-F8), 4 right-
hemispheric (starts with Fp1-F3), 4 right-hemispheric (starts with Fp2-F4), and
2 midline (Fz-Cz and Cz-Pz) channels. There is also one EKG lead (to assist
with artifact rejection) and two ocular electrodes to document eye opening/clo-
sure which is an important factor for analysis.
3. There are predominantly beta and alpha frequencies in Fig. 11.1. The solid verti-
cal lines indicate 1 s intervals, which is crucial to determine frequency. In the
frontal channels (e.g., Fp1-F7), waveforms have low voltage with a frequency of
greater than 13 Hz (i.e., more than 13 small waves between 2 vertical solid lines).
These are beta waves. On the other hand, posterior channels (e.g., T5-O1) pre-
dominantly display waveforms that have a higher voltage with a frequency in the
8–13 Hz range. The ocular electrodes (last two channels) indicate closed eyes.
This is a normal pattern (i.e., alpha dominance in posterior channels) in healthy
adults, who are awake with eyes closed. There is symmetry between correspond-
ing channels on the left and right hemispheres. Therefore, this is a normal EEG.
60 M.S. Ozcan
4. Figure 11.2 shows bursts of EEG activity interrupting an isoelectric waveform,

commonly known as burst suppression pattern. It can be observed secondary to
high doses of certain anesthetic drugs (i.e., iatrogenic) or as a result of a disease
process (i.e., pathologic). Certain inhalation anesthetics (e.g., isoflurane, sevo-
flurane) can cause burst suppression of the EEG in the higher end of their dose
range, typically around 1.3 MAC [2]. However, in elderly individuals or patients
with severe coexisting severe systemic illness, burst suppression can be observed
even around 1 MAC (age adjusted) [3]. Among intravenous anesthetics, barbitu-
rates, propofol, and etomidate can result in burst suppression of the EEG at high
plasma concentrations. Short periods of burst suppression can be unintentionally
observed during the course of an anesthetic. However, it can be specifically
aimed to provide brain protection during procedures in which ischemic brain
injury is possible. An example to this is temporary clip application during cere-
bral aneurysm clipping. This is usually achieved by a continuous infusion of an
intravenous agent such as pentobarbital. Burst suppression secondary to underly-
ing pathology is usually an ominous sign and can be seen in critically ill patients
with hypoxemia and hypotension [4].
References
1. Purdon PL, Sampson A, Pavone KJ, Brown EN. Clinical electroencephalography for anesthe-
siologists: part I: background and basic signatures. Anesthesiology. 2015;123(4):937–60.
doi:10.1097/ALN.0000000000000841.
2. Pilge S, Jordan D, Kreuzer M, Kochs EF, Schneider G. Burst suppression-MAC and burst
suppression-CP50 as measures of cerebral effects of anaesthetics. Br J Anaesth.
2014;112(6):1067–74. doi:10.1093/bja/aeu016.
3. Purdon PL, Pavone KJ, Akeju O, et al. The ageing brain: age-dependent changes in the electro-
encephalogram during propofol and sevoflurane general anaesthesia. Hemmings HC, ed. Br
J Anaesth. 2015;115(Suppl 1):i46–57. doi:10.1093/bja/aev213.
4. Myles PS, Daly D, Silvers A, Cairo S. Prediction of neurological outcome using bispectral
index monitoring in patients with severe ischemic-hypoxic brain injury undergoing emergency
surgery. Anesthesiology. 2009;110(5):1106–15. doi:10.1097/ALN.0b013e31819daef6.
Chapter 12
SSEP’s and More
Mehmet S. Ozcan
1. What is the monitoring modality depicted in Figs. 12.1 and 12.2? What do the
green and white waveforms correspond to?
2. What are those letters and numbers marked on the waveforms?
3. What types of surgery are suitable for using the above SSEP method?
4. What constitutes a “significant change” from baseline?
5. What are the effects of commonly used anesthetic agents on SSEPs?
6. What are some other physiologic variables known to affect SSEP monitoring?
7. What does Fig. 12.3 represent? What is the advantage of this modality? What are
some specific anesthetic concerns with this technique?
Fig. 12.1


DOI 10.1007/978-3-319-55862-2_12
62 M.S. Ozcan
Fig. 12.2
Fig. 12.3
12 SSEP’s and More 63
Answers
1. This is an SSEP recording. SSEP is a neuromonitoring technique that involves the
repetitive stimulation of peripheral nerves and recording responses at different
points along the course of signal propagation [1]. Typically, recordings are
obtained at three different points: on the peripheral nerve at a more proximal level,
brainstem, and cerebral cortex. In this regard, one can assess the integrity of the
peripheral nerve, sensory tracks of the spinal cord, and the sensory cortex by SSEP
monitoring. In the Figs. 12.1 and 12.2, median and posterior tibial nerves are stim-
ulated to obtain the tracings, respectively. In the perioperative setting, monitoring
is usually performed by comparing the SSEP signals obtained during surgery with
the baseline signal obtained immediately before surgery. Therefore, the most cur-
rent tracings (green and yellow lines) are displayed usually along with the baseline
(i.e., control) tracing (red and white) to make the comparison easier.
2. Signals (i.e., peaks and troughs) are typically marked on the tracing with a letter
and a number. The letter indicates the direction of the signal: N for negative and
P for positive. The height of the signal (in microvolts) is the amplitude. The
number shows the duration (in milliseconds) from the delivery of the stimulus
until the signal is obtained (i.e., the latency). For example, the median nerve
signals labeled on the top panels are N13 (brainstem) and N20 (cerebral cortex).
In other words, the signal is detected 13 and 20 ms after its generation at these
anatomic locations. For the tibial nerve (the lower panel), the signals are N9
(popliteal fossa), N28 (brainstem), and N45 (cerebral cortex). Compared to the
median nerve, there is significantly more delay (i.e., greater latency) in the detec-
tion of the signal from the tibial nerve (e.g., 20 ms vs. 45 ms for cortical signals)
simply because there is a greater distance for the signal to propagate.
3. Using SSEPs, any structure in the nervous system from the point of stimulus to
the sensory cerebral cortex can be monitored. Therefore, SSEP is commonly
used for cerebrovascular surgery (to monitor cerebral cortex), spinal surgery (to
monitor the posterior one-third of the spinal cord, i.e., the ascending sensory
neurons), as well as surgery on the thoracic aorta where perfusion of the spinal
cord could be at stake. Although less commonly employed, peripheral nerves and
the plexi they originate from (e.g., median nerve/brachial plexus) can be moni-
tored using SSEPs. For monitoring the cerebral cortex, both the upper and lower
extremity nerves can be chosen, and the cortical signals (e.g., N20 in Fig. 12.1)
on the ipsilateral side of the surgery are monitored for a significant change with
potential insult. For spinal cord monitoring, upper extremity (e.g., median nerve)
stimulation can only detect a problem above C6 level (i.e., the level of entry of
the sensory pathways of the median nerve). As a result, lower extremity stimula-
tion is usually the norm for spinal surgery since it monitors the whole length of
the sensory pathways. For spinal surgery, both the brainstem (e.g., N28 in
Fig. 12.2, middle tracing) and the cortical (e.g., N45 in Fig. 12.2, lower tracing)
64 M.S. Ozcan
signals are expected to change with insult. In the setting of both cortical and
spinal cord monitoring, continued presence of brachial plexus and popliteal fossa
signals serves as reassurance that the signal is indeed delivered and detected
before the area of concern is reached, ruling out technical problems.
4. A significant change in an SSEP signal is defined as a >50% decrease in ampli-
tude or a >10% increase in latency. As an example, the N45 (cortical) signal in
the left tibial nerve SSEPs has an amplitude of 1 μV at baseline and a latency of
45 ms (left lower panel). If the amplitude decreases to less than 0.5 μV or
detected later than 49.5 ms following stimulus, it constitutes a significant change
from baseline. If a significant change occurs, the surgeon and the anesthesiologist
should be immediately notified so that they can review potential causes and
agree on an action plan before irreversible damage occurs.
5. Many anesthetic agents have profound effects on SSEP. All halogenated agents
decrease the amplitude and increase the latency of the cortical signals in a dose-
dependent manner [2]. Nitrous oxide has the same effect, even more profound
than halogenated agents at equipotent doses [3]. Opioids as well as many
commonly used IV hypnotics (including barbiturates, propofol, and midazolam)
may cause a small decrease in amplitude with no effect on latency [4, 5].
Neuromuscular blocking agents (NMBs) do not directly affect SSEPs but indi-
rectly improve signal quality by eliminating artifacts related to EMG activity.
Ketamine and etomidate both increase the amplitude of the cortical SSEP signals.
In fact, their use could be an asset in improving monitoring when baseline signals
have low amplitude to begin with [6]. In summary, a total intravenous anesthesia
is the most acceptable technique for facilitating SSEP monitoring. Nitrous oxide
should be avoided, and halogenated agents should be used in the smallest possi-
ble doses if preferred. Whatever technique is used, concentrations of anesthetic
agents should not be changed during critical parts of surgery since their effect on
SSEPs may mask (or mimic) changes consistent with surgical insult.
6. Amplitude of SSEP (especially cortical) signals decreases with age, so obtaining
good baseline signals may become more challenging in the elderly. Hypothermia
and hypotension are two modifiable factors that can be controlled by the anesthe-
siologist. Every 1 °C decrease in body temperature increases cortical signal latency
by 0.75–1 ms. Hypotension decreases amplitudes and increases latency, although
the blood pressure threshold below which these changes occur is more variable. In
general, systolic blood pressures above 80 mmHg should not be expected to pro-
duce changes, but due to variability in limits for cerebral autoregulation, certain
individuals may need a higher blood pressure to preserve signals. Similar to the
concentrations of anesthetic medications, temperature and blood pressure should
be maintained as stable as possible during critical parts of SSEP monitoring.
12 SSEP’s and More 65
7. Figure 12.3 represents a motor evoked potential (MEP) tracing. As discussed

above, SSEPs only monitor the posterior one-third of the spinal cord. Therefore,
in complex spinal surgeries, it is a common practice to monitor MEP along with
SSEP for a more complete picture [7]. Besides spinal surgery, MEP is a valuable
adjuvant to SSEP in monitoring the cerebral cortex. In one large case series, add-
ing MEP monitoring to SSEP decreased false negatives in CEA surgery in
detecting cortical ischemia [8]. MEP monitoring is achieved by transcranial
stimulation of the motor cortex and eliciting muscle contraction as the response.
Therefore, neuromuscular blocking agents clearly present a challenge. Most pro-
viders would avoid NMB altogether when MEP is monitored, although a careful
maintenance of a stable, partial neuromuscular block (e.g., three-fourths in a
train-of-four stimulation) can be feasible. Other anesthetic agents that affect
MEPs are similar to that for SSEPs: volatile agents and nitrous oxide are the
worst offenders, whereas TIVA with propofol and opioid remains the least con-
founding technique [9].
References
1. Toleikis JR. American Society of Neurophysiological Monitoring. Intraoperative monitoring

using somatosensory evoked potentials. A position statement by the American Society of
Neurophysiological Monitoring. J Clin Monit Comput. 2005;19(3):241–58. doi:10.1007/
s10877-005-4397-0.
2. Fletcher JE, Hinn AR, Heard CM, et al. The effects of isoflurane and desflurane titrated to a
bispectral index of 60 on the cortical somatosensory evoked potential during pediatric scoliosis
surgery. Anesth Analg. 2005;100(6):1797–803. doi:10.1213/01.ANE.0000152193.90756.4E.
3. Lam AM, Sharar SR, Mayberg TS, Eng CC. Isoflurane compared with nitrous oxide anaesthe-
sia for intraoperative monitoring of somatosensory-evoked potentials. Can J Anaesth.
1994;41(4):295–300. doi:10.1007/BF03009907.
4. Kimovec MA, Koht A, Sloan TB. Effects of sufentanil on median nerve somatosensory evoked
potentials. Br J Anaesth. 1990;65(2):169–72.
5. Sloan TB, Fugina ML, Toleikis JR. Effects of midazolam on median nerve somatosensory
evoked potentials. Br J Anaesth. 1990;64(5):590–3.
6. Stoicea N, Versteeg G, Florescu D, et al. Ketamine-based anesthetic protocols and evoked
potential monitoring: a risk/benefit overview. Front Neurosci. 2016;10(89):263. doi:10.3389/
fnins.2016.00037.
7. Pajewski TN, Arlet V, Phillips LH. Current approach on spinal cord monitoring: the point of
view of the neurologist, the anesthesiologist and the spine surgeon. Eur Spine J. 2007;16(2):115–
29. doi:10.1007/s00586-007-0419-6.
8. Malcharek MJ, Ulkatan S, Marinò V, et al. Intraoperative monitoring of carotid endarterectomy
by transcranial motor evoked potential: a multicenter study of 600 patients. 2013;124(5):1025–
1030. doi:10.1016/j.clinph.2012.10.014.
9. Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgi-
cal anaesthesia. 2006;19(5):498–503. doi:10.1097/01.aco.0000245274.69292.ad.
Chapter 13
Bispectral Index
Mehmet S. Ozcan
Fig. 13.1


DOI 10.1007/978-3-319-55862-2_13
68 M.S. Ozcan
1. What is the monitoring modality seen in Fig. 13.1? Describe the numeric data
fields and waveforms displayed on the screen.
2. What are the clinical states that correspond to different BIS ranges?
3. What is an acceptable BIS range for general anesthesia?
4. Which anesthetic drugs are suitable for BIS to be used?
5. List common indications for this monitoring modality in anesthesia practice.
6. Besides anesthetic agents, what are some other conditions that can affect BIS?
13 Bispectral Index 69
Fig. 13.2
Answers
1. This is a bispectral index (BIS) monitor. BIS is a form of processed EEG that aims to
monitor the effect of certain anesthetic medications in an objective fashion. Typically,
a single channel of EEG obtained through a strip of skin electrodes over the forehead
is acquired by the monitor and analyzed. The process that is used to compute the BIS
involves several steps including artifact detection, power spectrum analysis, suppres-
sion detection, and fast Fourier transformation [1]. The end result is the “BIS,” a
unitless number between 0 and 99 (Fig. 13.2). Other information available on the
monitor are signal quality index (SQI), a semiquantitative EMG display, and the real-
time EEG graph. Suppression ratio (the percentage of isoelectric EEG over a unit
time) can also be displayed by turning that variable “on” in the menu. In the lower
part of the screen in the picture, a moving trend of BIS is displayed for an overview.
Although the algorithm aims to filter the EMG signal from analysis, the presence of
EMG can introduce artifact and lead to falsely elevated BIS values.
70 M.S. Ozcan
2. The range of BIS (0–99) can be divided into several zones in terms of clinical
state of alertness and sedation [2]. The highest end of the BIS range (i.e., 92–99)
corresponds to the EEG waveform of an awake individual. BIS in the high 80s to
low 90s is consistent with light sedation. An individual with BIS in mid-80s is
likely to fit in a state of “conscious sedation” (i.e., responds after name is called
loudly). BIS in the high 70s to low 80s is a state of deep sedation (i.e., responds
to shaking) with a potential for airway obstruction. Values lower than mid-70s
are usually consistent with an anesthetized state. It is important to note that there
is interindividual overlap between BIS ranges and degrees of sedation.
3. BIS range of 45–60 corresponds to a state of general anesthesia. To be more
precise, BIS is specifically an index of the hypnotic component of the general
anesthetic state, measured through cerebral cortical electrical activity. Since
movement to surgical stimulus is mediated largely by the spinal cord, immobility
will not be ensured even in the lower end of this range. Equally important is the
combination of anesthetics that is producing a certain BIS value: an individual
with a BIS value of 50 with propofol alone is more likely to move with noxious
stimulus, compared to the same individual with the same BIS value with a com-
bination of propofol and remifentanil. However, explicit recall is highly unlikely
with BIS values less than 60 [3], regardless of the anesthetic regimen employed.
BIS values below 45 refer to a deep hypnotic state where side effects of anesthet-
ics (e.g., hypotension, prolonged recovery) could be evident without a clear ben-
efit. There have also been reports of increased long-term mortality associated
with prolonged periods of BIS values below 45 [4]. Finally, burst suppression
pattern starts around BIS of 30, with burst-suppression ratio gradually increasing
to 100% as the BIS decreases to 0. In cases where cerebral protection is aimed
by inducing burst suppression, BIS can be a useful tool [5].
4. BIS is useful to monitor the hypnotic effect of volatile anesthetics (isoflurane,
sevoflurane, desflurane), propofol, and etomidate. The addition of dexmedetomi-
dine to a general anesthetic is also reflected on the BIS [6]. The effects of nitrous
oxide or opioids on the hypnotic effect of an anesthetic agent are not reliably
reflected on BIS monitoring [7, 8]. Finally, ketamine may lead to a paradoxical
increase in BIS, while lower doses of it may not have any effect [9].
5. BIS is not routinely indicated for all patients undergoing general anesthesia [10].
However, it is a useful tool in monitoring the hypnotic component of general anesthe-
sia with volatile anesthetics as well as total intravenous anesthesia (TIVA) with propo-
fol [11]. Compared to standard anesthesia practice, using BIS may decrease the risk of
awareness, decrease anesthetic consumption, and modestly improve certain recovery
profiles such as time to eye opening, time to extubation, and time to orientation [12].
6. The spectrum of electromyographic (EMG) activity (30–200 Hz) is faster than
that of EEG (0.5–30 Hz). The presence of EMG activity of the facial muscles
often creates an artifact that results in an erroneously higher BIS value.
Therefore, if the BIS readings are higher than what the clinical assessment sug-
gests, reviewing the EMG display is helpful to rule this out. If NMBs are indi-
13 Bispectral Index 71
cated, their administration will easily get rid of this artifact and enable an
accurate BIS measurement. Electrocautery unit (ECU) is another common
source of artifact. ECU, especially when a unipolar device is used for periods
longer than 5 s, usually renders any meaningful measurement impossible. This
would be evident in a decreased SQI value, and any interpretation of BIS should
be postponed until SQI improves. Drugs that are beta-receptor agonists (e.g.,
isoproterenol) or antagonists (e.g., esmolol) have also been shown to increase or
decrease BIS values, respectively [13, 14]. Clinical implications of these effects
have not been established. Hypotension and hypothermia both result in decreases
in BIS, probably related to decreased cerebral metabolic rate. Finally, baseline
BIS values are often significantly lower (i.e., ranging from 75 to 90) in children
with cerebral palsy as well as elderly with dementia. Although administration of
anesthetics results in further decreases in BIS values from those baselines, inter-
pretation of absolute values becomes more difficult in these populations since
the algorithms have only been validated in individuals without underlying brain
pathology.
References
1. Rampil IJ. A primer for EEG signal processing in anesthesia. Anesthesiology. 1998;
89(4):980–1002.
2. Liu J, Singh H, White PF. Electroencephalographic bispectral index correlates with intraopera-
tive recall and depth of propofol-induced sedation. Anesth Analg. 1997;84(1):185.
3. Myles PS, Leslie K, McNeil J, Forbes A, Chan MTV. Bispectral index monitoring to prevent
awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet.
2004;363(9423):1757–63. doi:10.1016/S0140-6736(04)16300-9.
4. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after
noncardiacsurgery.AnesthAnalg.2005;100(1):4–10.doi:10.1213/01.ANE.0000147519.82841.5E.
5. Bruhn J, Bouillon TW, Shafer SL. Bispectral index (BIS) and burst suppression: revealing a
part of the BIS algorithm. J Clin Monit Comput. 2000;16(8):593–6.
6. Le Guen M, Liu N, Tounou F, et al. Dexmedetomidine reduces propofol and remifentanil
requirements during bispectral index-guided closed-loop anesthesia a double-blind, placebo-
controlled trial. Anesth Analg. 2014;118(5):946–55. doi:10.1213/ANE.0000000000000185.
7. Ozcan MS, Ozcan MD, Khan QS, Thompson DM, Chetty PK. Does nitrous oxide affect
bispectral index and state entropy when added to a propofol versus sevoflurane anesthetic?
J Neurosurg Anesthesiol. 2010;22(4):309–15. doi:10.1097/ANA.0b013e3181e4b7c8.
8. Lysakowski C, Dumont L, Pellégrini M, Clergue F, Tassonyi E. Effects of fentanyl, alfentanil,
remifentanil and sufentanil on loss of consciousness and bispectral index during propofol
induction of anaesthesia. Br J Anaesth. 2001;86(4):523–7. doi:10.1093/bja/86.4.523.
9. Sengupta S, Ghosh S, Rudra A, Kumar P, Maitra G, Das T. Effect of ketamine on bispectral
index during propofol – fentanyl anesthesia: a randomized controlled study. Middle East
J Anesthesiol. 2011;21(3):391–5.
10. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advi-
sory for intraoperative awareness and brain function monitoring: a report by the American
society of anesthesiologists task force on intraoperative awareness. Anesthesiology.
2006;104(4):847–64.
11. Johansen JW. Update on bispectral index monitoring. Best Pract Res Clin Anaesthesiol.
2006;20(1):81–99.
72 M.S. Ozcan
12. Punjasawadwong Y, Boonjeungmonkol N, Phongchiewboon A. Bispectral index for improving

anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev.
2007;(4):CD003843. doi:10.1002/14651858.CD003843.pub2.
13. Gautam NK, Rafique MB, Numan MT. Impact of isoproterenol infusion on BIS and metabolic
values in pediatric patients undergoing electrophysiology studies. J Clin Anesth.
2014;26(8):611–5. doi:10.1016/j.jclinane.2014.05.007.
14. Johansen JW. Esmolol promotes electroencephalographic burst suppression during propofol/
alfentanil anesthesia. Anesth Analg. 2001;93(6):1526–31–table of contents.
Chapter 14
Fetal Heart Rate Monitoring
Casey Windrix
Fig. 14.1 Fetal heart tracing
1 . What pattern is this heart rate tracing in Fig. 14.1?

2. What does this tracing tell you about the condition of the fetus?
3. What is the significance of “V”-shaped decelerations in this tracing?
4. How would acidemia present on the fetal heart tracing?
5. What action if any should be taken?
6. What are the characteristics of a normal fetal heart tracing (FHR)?
7. What are the categories of FHR tracings?
8. What are limitations of electronic fetal monitoring (EFM)?
C. Windrix, MD
Department of Anesthesiology, OUHSC, Edmond, Oklahoma, USA

DOI 10.1007/978-3-319-55862-2_14
74 C. Windrix
Answers
1. This tracing contains multiple decelerations. Decelerations are characterized by
a decrease from baseline of at least 15 beats per minute (BPM), lasting at least
15 s and no longer than 2 min. A deceleration is considered prolonged when it
lasts beyond 2 min. Specifically, the tracing above depicts variable decelerations.
Variable decelerations have inconsistent shape and timing in relationship to uter-
ine contractions. Variable decelerations are caused by cord compression.
By contrast early decelerations occur in sync with contractions such that the
nadir of the deceleration occurs at the peak of the contraction. Early decelera-
tions relate to fetal head compression during contraction. Late decelerations are
also closely associated with contractions with the decrease in heart rate begin-
ning immediately after the peak of the contraction, mirroring the contraction in
shape. Late decelerations represent uteroplacental insufficiency and may be due
to hypotension or other factors [1].
2. Fetal heart rate is a surrogate measurement for fetal oxygenation and acid/base
status. Anytime there is a deceleration, there is presumed to be a decrease in
delivery of oxygen to the fetus. This may be mild and of little concern, as in the
case of early decelerations, or clinically significant as in the case of late, vari-
able, or prolonged decelerations. With repeated decelerations, hypoxia may lead
to acidosis, which could eventually lead to neurologic injury. In particular injury
may occur when umbilical artery pH decreases below 7.0 or there is a base defi-
cit of greater than 12 [2].
3. There is no evidence in the literature to support older terms for describing decel-
erations, such as the presence of “shoulders,” variable with late component, or
shape of the deceleration. Similarly it is a distraction to categorize the decelera-
tion pattern by severity.
4. The absence of variability is a marker for acidemia. Moderate variability or the
presence of accelerations is a very sensitive measure for a normal acid/base sta-
tus. This strip still has the presence of moderate variability, defined by changes
in the baseline heart rate that are nonuniform, which essentially rules out meta-
bolic acidosis.
5. This strip would be defined as a category 2 tracing, which would require careful
observation at the least. Further action or intervention would depend on the clini-
cal situation. Recurrent decelerations, in the presence of good variability, usually
would be treated by oxygen, repositioning, augmentation of maternal blood
pressure, and/or reduction or discontinuation of oxytocin if infusing.
6. A normal fetal heart varies between 110 and 160 beats per minute. It fluctuates
irregularly in amplitude and frequency with variability from baseline of at least
6 BPMs. It may include accelerations, which are sudden increases in heart rate with
a change from onset to peak in less than 30 s, lasting no longer than 2 min. There
may be the presence of early decelerations, which mirror uterine contractions.
14 Fetal Heart Rate Monitoring 75
7. The American Congress of Obstetricians and Gynecologists has a three-tier

interpretation and intervention system that represents a common language and
framework to discuss FHTs [3]:
(a) Category 1 FHR tracings have a normal baseline rate, the presence of at least
moderate variability, may lack accelerations, and do not have clinically sig-
nificant decelerations (anything other than early). These strips are consid-
ered normal and do not require any specific action.
(b) Category 2 tracings lack clear signs of acidemia and are indeterminate.
These strips require careful surveillance and may suggest the need for fur-
ther testing to ensure the health of the fetus.
(c) Category 3 tracings have absent variability, recurrent late or variable decel-
erations, or bradycardia, or a sinusoidal pattern. These strips indicate fetal
acidemia, are abnormal, and require immediate action.
8. Fetal heart monitoring is prone to many errors and shortfalls. Fetal heart rate
may be difficult to consistently observe due to changes in positioning of the
mother or fetus. There is significant variability in interobserver interpretation
and responses. While the presence of variability may ensure a normal acid/base
status, its absence does not assure acidemia, leading to potentially unnecessary
action. Finally, continuous fetal heart monitoring alone has not been definitively
proven to reduce perinatal mortality; despite its increased use, it has not impacted
the rate of cerebral palsy, which has remained constant over decades [4].
References
1. ACOG. Practice Bulletin #106, Intrapartum fetal heart rate monitoring: nomenclature, interpre-
tation, and general management principles. Obstet Gynecol. 2009;114(1):192–202.
2. MacLennan A. A template for defining a causal relation between acute intrapartum events and
cerebral palsy: international consensus statement. BMJ. 1999;319:1054–9.
3. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child
Health and Human Development workshop report on electronic fetal monitoring: update on
definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112:661–6.
4. Graham EM, Petersen SM, Christo DK, Fox HE. Intrapartum electronic fetal heart rate moni-
toring and the prevention of perinatal brain injury. Obstet Gynecol. 2006;108(3 Pt 1):656–66.
Chapter 15
ECG (12 Lead)
Talla A. Rousan
Fig. 15.1 An electrocardiogram illustrating changes suggestive of myocardial ischemia

(ST-segment depression in the anterolateral leads I, aVL, and V2–V6)
T.A. Rousan, MD, FACC

Department of Medicine, The University of Oklahoma Health Sciences Center
and the Veteran Affairs Medical Center, 800 Stanton L. Young Blvd, COM 5400,
Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_15
78 T.A. Rousan
Fig. 15.2 An electrocardiogram illustrating changes suggestive of myocardial injury (ST-segment

elevation in the lateral leads I and aVL)
Questions
1. Interpret Figs. 15.1 and 15.2.
2. What are the electrocardiographic findings in myocardial ischemia and

infarction?
3. How are myocardial ischemia and infarction different?
4. What is the management of perioperative myocardial ischemia and infarction?
5. What is the prognosis of patients with myocardial ischemia or infarction follow-
ing noncardiac surgery?
6. Describe the role of preoperative cardiac evaluation in patient undergoing non-
cardiac surgery.
15 ECG (12 Lead) 79
Answers
1. The figures represent electrocardiograms (ECGs) for patients presenting with
chest pain. Figure 15.1 illustrates changes suggestive of myocardial ischemia
(ST-segment depression in the anterolateral leads I, aVL, and V2–V6). The ECG
shown in Fig. 15.2 depicts changes suggestive of myocardial injury (ST-segment
elevation in the lateral leads I and aVL).
2. ECG is considered to be an essential tool in the evaluation for myocardial isch-
emia or infarction. Changes to indicate myocardial ischemia or infarction
include peaked or inverted T waves, ST-segment elevation or depression, and
changes in the QRS complex [1]. ST-segment elevations present on the ECG
accompanied by symptoms or signs concerning of myocardial infarction (includ-
ing chest pain, dyspnea, or hemodynamic instability) are an emergency that
require immediate attention. The threshold values for significant ST-segment
elevation vary based on the gender and age of the individual [1]. For men
40 years of age or older, 2 mm elevation in leads V2 and V3 and 1 mm elevation
in all other leads is considered to be significant. For men younger than 40 years
old, a significant ST-segment elevation is 2.5 mm in leads V2 and V3. For women
of all ages, ST-segment elevation of 1.5 mm in V2 or V3 and 1 mm in all other
leads is considered to be significant.
3. Myocardial ischemia results from an imbalance between myocardial oxygen

demand and supply [2]. Myocardial oxygen demand is determined by the heart rate,
myocardial contractility, preload (end-diastolic pressure or volume), afterload (arte-
rial impedance), and muscle mass. Determinants of myocardial oxygen supply
include coronary blood flow and arterial oxygen content [3]. Myocardial infarction
(myocardial cell death) occurs if myocardial ischemia is prolonged (as little as
20 min or less). Myocardial infarction is characterized by myocyte necrosis as
detected by elevated cardiac biomarkers (troponin-T, troponin-I (preferably), or
CKMB) along with ischemia symptoms and ECG changes (as described above) [2].
4. Perioperative management of patients with myocardial ischemia and infarction
starts from early detection. Myocardial ischemia or infarction can be detected
intraoperatively by ECG changes, ventricular arrhythmias, and hemodynamic
instability [4, 5]. If myocardial ischemia or infarction is suspected, a 12-lead unfil-
tered ECG should be obtained promptly, and cardiac biomarkers should be sent.
In addition, a transesophageal echocardiogram can be done (if readily available)
to detect the ejection fraction and any new myocardial wall motion abnormalities.
The surgeon should be informed to make a decision on completing versus abort-
ing the surgery. If tachycardia along with normo- or hypertension is present, a
beta-blocker (intravenous esmolol or metoprolol) or a non-dihydropyridine cal-
cium channel blocker—if left ventricular ejection is normal—(intravenous diltia-
zem) should be administered [6]. Tachycardia along with hypotension is
challenging. Evaluate and treat potential causes (e.g., hypovolemia or anemia).
80 T.A. Rousan
Vasopressors should be added to maintain mean adequate perfusion pressure

(mean arterial blood pressure 65 mmHg or more). In cases of tachyarrhythmias
(atrial flutter or fibrillation), direct current cardioversion may be necessary. If
ST-segment elevations are present, an emergent cardiology consultation should be
obtained to consider coronary angiography and revascularization. The manage-
ment of patient with suspected myocardial infarction or ischemia in the postop-
erative period is as challenging given the limitations for the use of anticoagulants
and antiplatelet agents. If based on symptoms, acute coronary syndrome is sus-
pected, an ECG should be promptly obtained to assess for changes suggestive of
ischemia or infarction. Oxygen should be administered if oxygen saturation is
below 90%. Short-acting nitroglycerin (sublingual tablets or oral spray) should be
administered to alleviate angina (avoid in hypotension). If there are no contraindi-
cations for antiplatelet agents, administer aspirin 162–324 mg oral [7]. Cardiology
consult should be sought to direct further management. If changes suggestive of
acute ST-segment myocardial infarction are present, cardiology should be con-
tacted emergently. The decision to proceed with invasive coronary angiography
should be decided based on the risk-benefit ratio analysis in any given patient
weighing the risk of bleeding and the risk of ongoing myocardial ischemia.
5. Patients experiencing a myocardial infarction following noncardiac surgery

(whether symptomatic or asymptomatic) are at increased risk for in-hospital and
short-term mortality [8, 9]. Nonfatal myocardial infarction is associated with
increased in-hospital mortality reaching 25% in some cohorts. A 30-day mortal-
ity in this subset of patients was estimated to be approaching 12% [10]. Patients
who experience cardiac arrest perioperatively are at the highest risk for cardiac
mortality occurring in up to 65% of the cases. Although silent myocardial infarc-
tion is associated with increased adverse outcomes, routine postoperative screen-
ing with serum troponin levels is not recommended [11]. The usefulness of
screening with troponin levels in patients at high risk for myocardial infarction
is uncertain especially in the absence of a well-defined management strategy.
6. Studies have shown that patients undergoing noncardiac surgery are at risk of
periprocedural myocardial infarction and increased mortality (up to 2% in some
cohorts) [8, 9, 11, 12]. The risk of major cardiovascular and cerebral events
increases in patients with prior history of diabetes mellitus, hypertension, coro-
nary artery disease, congestive heart failure, stroke, peripheral artery disease,
chronic kidney disease, and advanced age [8, 12]. The risk of adverse outcomes
decreases as the length of time following an MI increases. Given those reasons,
the need for preoperative evaluation rises especially in patients older than
55 years, with history of coronary artery disease or stroke, or patients with symp-
toms to suggest myocardial ischemia (angina). One of the best tools to risk-
stratify patients is using the algorithm and risk calculators available in the 2014
ACC/AHA Perioperative Clinical Practice Guidelines [11]. Based on those
15 ECG (12 Lead) 81
guidelines, patients undergoing emergent surgery need to proceed with surgery

without delay. Patients with acute coronary syndrome require to be treated prior
to the planned surgery based on the practice guidelines. In patients with low
calculated risk (<1%) and also in those with high risk but with good functional
capacity (four metabolic equivalents (METs) or greater), one may proceed with
surgery without further testing. The subset of patients with high risk and poor
functional capacity may require noninvasive functional study (stress test) if it
would alter perioperative management. Routine coronary angiography and
revascularization are not recommended prior to noncardiac surgery.
References
1. Wagner GS, et al. AHA/ACCF/HRS recommendations for the standardization and interpreta-
tion of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from
the American Heart Association Electrocardiography and Arrhythmias Committee, Council on
Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm
Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll
Cardiol. 2009;53(11):1003–11.
2. Thygesen K, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol.
2012;60(16):1581–98.
3. Burkhoff D, Naidu SS. The science behind percutaneous hemodynamic support: a review and
comparison of support strategies. Catheter Cardiovasc Interv. 2012;80(5):816–29.
4. Ludbrook GL, et al. Crisis management during anaesthesia: myocardial ischaemia and infarc-
tion. Qual Saf Health Care. 2005;14(3):e13.
5. Satinder Gombar AKK, Gombar KK. Perioperative myocardial ischaemia and infarction–a
review. Indian J Anaesth. 2007;51(4):287–302.
6. Landesberg G, et al. Perioperative myocardial infarction. Circulation. 2009;119(22):2936–44.
7. Amsterdam EA, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-
ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2014;64(24):e139–228.
8. Botto F, et al. Myocardial injury after noncardiac surgery: a large, international, prospective
cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
Anesthesiology. 2014;120(3):564–78.
9. Devereaux PJ, et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a
review of the magnitude of the problem, the pathophysiology of the events and methods to
estimate and communicate risk. CMAJ. 2005;173(6):627–34.
10. Devereaux PJ, et al. Characteristics and short-term prognosis of perioperative myocardial
infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med.
2011;154(8):523–8.
11. Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and
management of patients undergoing noncardiac surgery: executive summary: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2014;130(24):2215–45.
12. Lee TH, et al. Derivation and prospective validation of a simple index for prediction of cardiac
risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.
Chapter 16
Minimally Invasive Cardiac Output Monitor
Marcos E. Gomes
During major abdominal surgery, urine output in a 90 kg patient decreases to 20 mL
per hour over the prior 2 h. Noninvasive cardiac output is being monitored in this
patient with a FloTrac system, and the parameters are depicted in Fig. 16.1. which
changes to what is depicted in Fig. 16.2 after a single maneuver by the
anesthesiologist.
1 . What do the figures show?
2. What is the importance of monitoring cardiac output?
3. What are the advantages of the FloTrac/EV1000 system?
4. How does the FloTrac estimate stroke volume?
5. What are the limitations of the FloTrac?
6. What other minimally invasive monitors are available?
7. What is stroke volume variation?
8. Why is the stroke volume higher during the inspiratory phase of the respiratory
cycle?
9. What is the relationship of stroke volume variation and the Frank-Starling curve?
M.E. Gomes, MD

DOI 10.1007/978-3-319-55862-2_16
84 M.E. Gomes
Answers
1. The figures above represent the moment before and after a fluid challenge on a
patient with low urine output. Notice that the cardiac output/cardiac index
increased, while the SVV decreased from 19% to 6%. The patient’s urine output
responded accordingly, representing improved kidney perfusion with the fluid
challenge.
2. Monitoring cardiac output is a common practice in anesthesia and critical care as
it provides important information about cardiac function, tissue perfusion, and
oxygen delivery. It is utilized as a marker of oxygen delivery to tissues based on
the equation below:
DO2 = CO × (1.39 × [Hb] × SaO2 + (0.003 × PaO2))
DO2: Rate of oxygen delivery
CO: Cardiac output
Hb: Hemoglobin concentration
SaO2: Hemoglobin oxygen saturation expressed as a fraction
PaO2: Partial pressure of oxygen in the blood
Its measurement can identify patients at risk for morbidity and/or mortality.
In addition, monitoring cardiac output can be used to guide treatment with both
fluid resuscitation and/or vasoactive/inotropic drugs.
3. Among different minimally invasive cardiac output monitors, the FloTrac/
EV1000 system has the following advantages: no central line required, any
arterial line location can be used, easy to set up, no external calibration
required, changes in vascular tone and site of arterial cannulation are corrected
by built-in software, correction occurs every 60 s, waveform analysis occurs
every 20 s, extrasystoles and small artifacts are eliminated by built-in algo-
rithm, option for attaching central venous pressure with which SVR/SVRI
(Fig. 16.1) can be calculated, and option to attach PreSep catheter with which
ScvO2 can be continuously monitored. In addition, this monitor is able to cal-
culate stroke volume variation (SVV) which is an extra tool to assess volume
status.
4. The FloTrac system uses pulse contour analysis with patient demographics and
physical characteristics for arterial impedance estimation and ultimately stroke
volume (SV) calculation. The basic principle is the linear relation between the
pulse pressure and the SV. The SV is estimated using the following equation:
SV = SDap × X. The waveform analysis that occurs every 20 s results in 2000
data points. SDap is the standard deviation of these data points and reflects the
pulse pressure. The factor X stands for the conversion factor that depends on
arterial compliance, mean arterial pressure, and waveform characteristics. These
variables are adjusted by the built-in software, and this process is repeated every
60 s. Once SV is calculated, it is multiplied by the heart rate to result in the car-
diac output [1].
16 Minimally Invasive Cardiac Output Monitor 85
Fig. 16.1 FloTrac monitor showing four different parameters: cardiac output (CO), cardiac index
(CI), stroke volume (SV), and stroke volume variation (SVV)
Fig. 16.2 FloTrac monitor showing four different parameters: cardiac output (CO), cardiac index
(CI), stroke volume (SV), and stroke volume variation (SVV)
86 M.E. Gomes
5. The use and accuracy of FloTrac/EV1000, specially for monitoring of SVV, may
be compromised in the following scenarios: poor signal, intra-aortic balloon
pump, ventricular assist devices, open chest, spontaneous breathing, small tidal
volumes, arrhythmia, poor lung compliance, high PEEP, severe obesity (effect of
abdominal pressure in lung compliance), and medications (norepinephrine,
vasodilators, beta-blockers).
6. Minimally invasive CO monitors using pulse contour analysis can be divided
into uncalibrated (or autocalibrated) and calibrated. FloTrac, PulsioFlex,
LiDCOrapid, PRAM, Nexfin, and esCCO monitors are examples of uncalibrated
monitors, while PiCCO plus and LiDCOplus are examples of calibrated ones.
Three other principles support other types of monitors: pulse Doppler technol-
ogy, applied Fick principle, and bioimpedance/bioreactance [2, 3, 4].
Calibrated:
The PiCCO plus monitor uses the pulse contour analysis to estimate CO and
utilizes the transpulmonary thermodilution method for intermittent calibration. It
involves the administration of a cold injectate in the superior vena cava (central
venous catheter required) and its detection by a thermistor in the aorta or a major
arterial branch (femoral, axillary, or brachial). Other variables measured by this
device are global end-diastolic volume (preload estimate), intrathoracic blood
volume, extravascular lung water, and pulmonary vascular permeability index.
The LiDCOplus monitor uses lithium dilution technique to intermittently cali-
brate the system, generate a curve, and use a built-in equation to calculate CO
based on pulse power rather than pulse contour analysis. This system uses a
pulse pressure algorithm called PulseCO to obtain such analysis.
Uncalibrated:
PulsioFlex is a monitor that uses a ProAQT sensor that connects to the peripheral
arterial catheter and analyzes the arterial waveform 250 times per second. Patient’s
characteristics (biometrics) are also inserted into the system. The LiDCOrapid
system has the same technology as the LiDCOplus but instead of thermodilution
uses nomograms for the calculation of the CO. PRAM (pressure recording analyti-
cal method) is based on a mathematical assessment of the pressure signal obtained
from an arterial line (pulse contour analysis), without calibration, resulting in esti-
mates of SV and therefore CO. The Nexfin monitor does not require an arterial
line catheter. It uses an inflatable cuff around the middle phalanx of the finger that
is able to generate a pressure waveform. Through a built-in software, the system
is able to construct a brachial artery waveform based on the finger version, which
is then used as the basis for calculation of continuous CO. The esCCO monitor
uses a technology that derives the CO using the pulse wave transit time (PWTT),
which is obtained by the pulse oximetry and the electrocardiogram signals in each
cardiac cycle. It is also completely noninvasive, like the Nexfin system.
Others:
Pulse Doppler technology uses esophageal or transthoracic Doppler probes to
estimate CO by multiplying the cross-sectional area of the aorta by blood flow
16 Minimally Invasive Cardiac Output Monitor 87
velocity. Applied Fick principle is used in the NICO system, which uses the cal-
culation of carbon dioxide production and elimination every 3 min to estimate
CO. Electrical bioimpedance uses electric current stimulation to identify tho-
racic or body impedance variations induced by blood flow changes resulted from
each heartbeat. The signal variation is analyzed by built-in algorithms,
continuously providing the estimation of the cardiac output. Electrodes can be
placed on the skin or endotracheal tubes. Devices that use bioreactance tech-
nique need further validation studies.
7. Stroke volume variation is a functional hemodynamic variable that estimates
fluid responsiveness in ventilated patients with low preload and thus also aids in
the guidance of fluid resuscitation therapies. The concept is that cyclic changes
in the intrathoracic pressure during positive pressure ventilation induce changes
in SV and pulse pressure variation (PPV) secondary to multiple mechanisms.
SVV represents the variability of SV during a respiratory cycle, in which it
increases during inspiration and decreases during expiration (the opposite occurs
during spontaneous ventilation). It is calculated by the following equation: SV
max – SV min/SV mean. A result of more than 13% (10–15%) suggests potential
preload responsiveness [5].
8. In a given respiratory cycle, during mechanical ventilation, the initial effects of
increased intrathoracic pressure cause a preload increase as blood is expelled
from the lungs, an afterload decrease, a direct pressure of the expanded lungs on
the heart assisting the pump effect, and an improved left ventricular compliance
due to the volume decrease in the right chambers of the heart. As the cycle pro-
gresses in what is called pulmonary transit time, those effects become overtaken
by the gradual decrease on venous return, resulting in a decrease in SV. Such
variability is found to be more pronounced in under-resuscitated patients.
9. In the zone of the ascending limb of the Frank-Starling curve, SVV is pro-
nounced indicating low preload (fluid responsiveness). In the shallow part of the
curve, SVV is small, indicating no fluid responsiveness.
References
1. Argueta E. Flotrac monitoring system: what are its uses in critically ill medical patients? Am
J Med Sci. 2015;349(4):352–6.
2. Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc
Anesth. 2012;27:1–13.
3. Alhashemi JA, Cecconi M, Hofer CK. Cardiac output monitoring: an integrative perspective.
Crit Care. 2011;15:214.
4. Chamos C, et al. Less invasive methods of advanced hemodynamic monitoring: principles,
devices, and their role in the perioperative hemodynamic optimization. Perioper Med.
2013;2:19.
5. Cannesson M, et al. Pulse pressure variation; where are we today? J Clin Monit Comput.
2010;25(1):45–56.
Chapter 17
ECG I
Edward Kosik
A 76-year-old female patient is in the postanesthesia care unit after an ORIF of an

acetabular fracture. She underwent general anesthesia with an uneventful surgical
procedure. You have been called to evaluate the rhythm above (Fig. 17.1).
Pulse 136, BP 110/50, and SpO2 97% on 2 L O2 via nasal cannula
NKDA
Medical history: hypertension (takes amlodipine for it).
Preoperative vital signs
SpO2 98%, blood pressure 140/90, HR 96, temp 36.4, EKG normal sinus rhythm,
normal transthoracic echocardiogram.
Fig. 17.1 EKG obtained in the postoperative period
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90 E. Kosik
1 . How would you describe this rhythm?

2. Name and define different types (based on occurrence and duration) of the
arrhythmia shown above.
3. What is the incidence in the general population? What is the incidence after car-
diothoracic surgery and after non-cardiac surgery?
4. How would you treat this patient?
5. What concerns are there whenever a patient with persistent AF is cardioverted?
6. What are precipitants of postoperative atrial fibrillation?
7. What are the CHADS2 and CHA2DS2-VASc scores?
8. Is there any relation between neuraxial anesthesia and atrial fibrillation?
9. How does the treatment for Wolff-Parkinson-White syndrome with preexcitation
AF differ from atrial fibrillation alone?
17 ECG I 91
Answers
1. This rhythm is atrial fibrillation (AF) with a rapid ventricular response. The pat-
tern is irregularly irregular. The rhythm strip has no distinct p wave but instead
many f waves (also known as fibrillary waves) followed intermittently by narrow
QRS complexes.
2. Lone atrial fibrillation—An outdated term also known as idiopathic atrial
fibrillation. It originally meant atrial fibrillation that occurs in a person 40 years
or younger without intrinsic cardiac disease [1].
Paroxysmal atrial fibrillation—AF that occurs spontaneously, lasts less than a
week, and occurs at variable frequency [2].
Persistent atrial fibrillation—Atrial fibrillation that lasts longer than 7 days. It
may go away on its own or resolve with treatment [2].
Long-standing persistent atrial fibrillation—AF lasting longer than
12 months [2].
Permanent atrial fibrillation—more of a therapeutic decision between the
patient and clinician to stop attempting to treat AF for conversion to sinus
rhythm [2].
3. Atrial fibrillation is the most common heart arrhythmia. It affects an estimated
2.7–6.1 million people in the United States. About 2% of people over the age of
45 have atrial fibrillation, while 9% of people greater than age 65 have it. It is
more likely after cardiac surgery and can affect from 10% to 65% of patients
after cardiac surgery. AF is rare after non-cardiac surgery and can affect about
1–3% of the patients. Patients who develop postoperative atrial fibrillation have
higher morbidity and mortality rates and have higher costs of care.
4. Complete discussion of the treatment of atrial fibrillation is extensive, but some
basic tenets can be kept for this patient’s new-onset AF.
(a) Correct manageable causes
(b) Rate and/or rhythm control
(c) Anticoagulation if CHADS2 and CHA2DS2-VASc (see description below)
scores indicate a benefit
Acute treatment of atrial fibrillation focuses on keeping the patient hemody-
namically stable. Rate and rhythm control are of paramount importance.
Symptomatic and unstable patients with mental status changes, chest pain, con-
gestive heart failure, or hypotension should be treated with electrical cardiover-
sion if rate control cannot be accomplished with intravenous medications.
A history and physical exam should be conducted. Special attention should
be paid to cardiac and pulmonary comorbidities. Electrolytes, complete blood
count, cardiac enzymes (troponin), thyroid studies (TSH and free T4), renal
function, and chest radiograph should be obtained. A transthoracic echocardio-
gram should be performed to assess for causes of AF and to rule out a thrombus
in the left atrial appendage. Consultation of a cardiologist may be necessary.
92 E. Kosik
Rate control could be achieved using intravenous medications such as beta-

blockers (BBs) like esmolol, metoprolol, or propranolol and nondihydropyridine
calcium channel antagonists (CCAs) such as diltiazem and verapamil. The effect
of these medications is slowing of AV node conduction. Digoxin is not typically
used for acute rate control and is more often reserved for chronic AF caused by
heart failure (do not use beta-blockers in decompensated heart failure) or in patients
who do not respond to BBs or CCAs. Amiodarone may be used for patients whose
atrial fibrillation is unresponsive to beta-blockers or the calcium antagonists.
Rhythm control strategies use electrical and chemical cardioversion.
Medications include amiodarone, flecainide, dofetilide, propafenone, ibutilide,
and others.
Additionally, anticoagulation may be warranted in several different situa-
tions. Some of these include (1) when the patient remains in AF even after phar-
macologic or electrical cardioversion attempts, (2) if there are plans of
cardioversion and the AF had an onset of >48 h, and (3) to decrease the risk of
stroke by providing antithrombotics 4 weeks after cardioversion.
5. There is a concern that a thrombus could be located in the left atrial appendage
which could embolize to the brain and cause a stroke. A transthoracic echocar-
diogram or transesophageal echocardiogram is usually performed to rule out the
existence of a thrombus.
6. Congestive heart failure
Dilated chambers on the left side of the heart
Ischemic heart disease
Age >65
Hypomagnesemia
Hyperkalemia
Hypokalemia
Anemia
Hypovolemia
Hypervolemia
Hypertension
Obesity
European ancestry
Diabetes
Hyperthyroidism
Chronic kidney disease
ETOH use [3, 4]
7. The CHADS2 and CHA2DS2-VASc scores are (Fig. 17.2) clinical tools used to
assess the risk of stroke in patients with or without atrial fibrillation. Ultimately,
the scores help determine the need for anticoagulation to prevent stroke.
The CHADS2 score is an acronym tool that assigns one or two points for each
stroke risk factor (congestive heart failure, hypertension, age >75 years, diabetes,
stroke/transient ischemic attack/thromboembolism).
17 ECG I 93
Fig. 17.2 Annual adjusted CHA2DS2 - VASc score

stroke risk. The sum of the
risk factors equals the Acronym Risk factor Point
CHA2DS2 score. Scores are C Congestive Heart failure or left ventricular systolic dysfunction 1
matched to associated H HTN 1
annual adjusted rate of A2 Age ≥ 75 years 2
stroke. 0 = 0%, 1 = 1.3%, D Diabetes mellitus 1
2 = 2.2%, 3 = 3.2%, S2 Prior stroke/TIA/thromboembolism 2

V Vascular disease (PVD, Mi, aortic plaque) 1
4 = 4.0%, 5 = 6.7%, A2 Age between 65 and 74 1
6 = 9.8%, 7 = 9.6%, Sc Sex/female gender 1
8 = 6.7%, 9 = 15.2% Annual adjusted stroke risk
CHA2DS2 Score = Associated stroke risk
[2, 5] 0 = 0%, 1 = 1.3%, 2 = 2.2%, 3 = 3.2%, 4 = 4.0%, 5 = 6.7%, 6 = 9.8%, 7 = 9.6%, 8 = 6.7%, 9 = 15.20%
The CHA2DS2-VASc is an updated version of the CHADS2 score. It gives two

points for a patient >75 years of age and adds other risk factors such as vascular
disease (such as previous myocardial infarction, age 65–75, or female sex).
CHA2DS2-VASc also includes heart failure with or without preserved ejection
fraction under the C listing [2, 5].
8. There are case reports that have documented the onset of atrial fibrillation with
the placement of an epidural. This is a rare occurrence and does not necessarily
mean that the patient has underlying heart pathology. However, it would be pru-
dent to perform a cardiac workup if atrial fibrillation is encountered in these
patients.
A meta-analysis showed no clear benefit of reducing supraventricular tachyar-
rhythmias after placement of thoracic epidurals for cardiac surgery [6, 7].
9. Treatment with amiodarone, adenosine, digoxin, or nondihydropyridine calcium
channel antagonists (diltiazem, verapamil) in patients with Wolff-Parkinson-
White syndrome who have preexcitement AF can cause an accelerated ventricu-
lar rate that leads to ventricular fibrillation.
Because of this danger, treatment with electrical cardioversion is usually a better
choice for rate and rhythm control [8].
References
1. Wyse DG, Van Gelder IC, Ellinor PT, Go AS, Kalman JM, et al. Lone atrial fibrillation. Does
it exist? J Am Coll Cardiol. 2014;63(17):1715–23. doi:10.1016/j.jacc.2014.01.023.
2. January CT, Wann LS, Alpert JS, MD CH, Cigarroa JE, et al. 2014 AHA/ACC/HRS guideline
for the management of patients with atrial fibrillation: executive summary. A report of the
Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246–80.
doi:10.1016/j.jacc.2014.03.021.
3. Sohn GH, Shin DH, Byunetal KM, Han HJ, Cho SJ, et al. The incidence and predictors of post-
operative atrial fibrillation after noncardiothoracic surgery. Korean Circ J. 2009;39(3):100–4.
94 E. Kosik
4. Vaporciyan AA, Correa AM, Rice DC, Roth JA, Smythe WR, et al. Risk factors associated with
atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac
Cardiovasc Surg. 2004;127(3):779–86. http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/
fs_atrial_fibrillation.htm. Accessed 30 Mar 2016.
5. Lip GH, Lane DA. Stroke prevention in atrial fibrillation: a systematic review. JAMA.
2015;313(19):1950–62. doi:10.1001/jama.2015.4369.
6. Rogers WK, Schroeder KM. Perioperative atrial fibrillation and epidural anesthesia. J Clin
Anesth. 2012;24:329–33. Accessed 30 Mar 2016.
7. Stedman RB, Prejean MA, Russo M. Onset of lone atrial fibrillation during labor under epi-
dural analgesia. Ochsner J. 2013;13(4):544–6. PMCID: PMC3865834. Accessed 04 Apr 2016.
8. Weigner MJ, Caulfield TA, Danias PG, Silverman DI, Manning WJ. Risk for clinical thrombo-
embolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting
less than 48 hours. Ann Intern Med. 1997;126(8):615.
Chapter 18
ECG II
Edward Kosik
You are on the obstetrics ward. You are answering an “Anesthesia Stat” call to the
operating room. As you walk into the operating theater, this is the rhythm that is
present on the vitals monitor:
A parturient, gravida 7 para 6 at 38 weeks gestation, was placed under general
anesthesia for an emergent C-section secondary to fetal bradycardia (Category III
fetal heart rate tracings).
Fig. 18.1 Observed EKG in obstetrics operating theater
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96 E. Kosik
The anesthesiologist who performed the induction briefs you that a rapid
sequence induction included cricoid pressure, 100 μg of fentanyl, 120 mg of propo-
fol, and 100 mg of succinylcholine administered intravenously. A grade I view of
the airway was obtained with laryngoscopy and a #7 oral endotracheal tube placed
without difficulty. Initially, ETCO2 was positive and auscultation of the lungs
revealed bilateral breath sounds.
Preinduction vital signs were SpO2 100%, pulse 88, BP 110/56, temp 36.6, and
weight 55 kg.
1 . How would you describe this arrhythmia?
2. In general, what are the potential causes of this arrhythmia in parturients?
3. What are the common causes and prevalence of maternal cardiac arrest?
4. What are your next steps in managing this case?
5. What laboratory tests would you order to help in your management?
6. When should perimortem C-section start?
An OR team member identifies an empty 250 mL bag of 0.25% ropivacaine and
2 μg of fentanyl per mL. With more investigation, the team realizes that this bag was
accidentally brought into the OR and administered as “antibiotics.”
7 . Knowing this information how would you manage the case?
8. Which medications would you avoid in treating this disorder?
9. Is there an upper limit to the amount of medicine/treatment that you would give
in this situation?
18 ECG II 97
Answers
1. If the EKG leads are attached and accurate, this is cardiac arrest presenting as
pulseless fine ventricular fibrillation.
2. In 2015, the American Heart Association released its first statement regarding
maternal cardiac arrest. In that statement they listed common etiologies of mater-
nal arrest and mortality. This list is a mnemonic of the letters A through H, most
of which are listed below.
Anesthetic complications - (neura xial, hypoxia, hypotension) and accidents/
trauma (trauma and suicide)
Bleeding—coagulopathy, placental causes, uterine atony and/or rupture, sur-
gical causes
Cardiovascular causes—myocardial infarction, cardiomyopathy, pulmonary
hypertension, valvular disease, aortic dissection
Drugs—oxytocin, magnesium, drug error (local anesthetic), illicit drugs, opi-
oids, insulin, and anaphylaxis
*Note that many anesthetic drugs may cause prolonging of the QT interval (vola-
tile anesthetic agents, ondansetron, antibiotics such as ciprofloxacin, erythromycin,
etc.) which may result in ventricular fibrillation.
Embolic causes—pulmonary embolism, amniotic fluid embolism, cerebro-
vascular event
Fever—sepsis and infections
General—Hs and Ts (hypoxemia, hypovolemia, hypo-/hyperkalemia, hydro-
gen ion (acidosis), hypothermia, tension PTX, tamponade—cardiac, toxins,
thrombosis—coronary, thrombosis, pulmonary)
Hypertension—preeclampsia, eclampsia, HELLP syndrome, intracranial
bleed
3. According to Suresh and colleagues, the major causes of maternal cardiac arrest
are:
Pulmonary embolism 29%
Hemorrhage 17%
Sepsis 13%
Peripartum cardiomyopathy 8%
Stroke 5%
Preeclampsia-eclampsia 2.8%
Anesthesia complications (failed intubation, LAST, aspiration) 2% [1]
Mhyre et al. reported different findings for the Nationwide Inpatient Sample
(NIS) from 1998 to 2011:
Postpartum hemorrhage 27.9%.
Antepartum hemorrhage 16.8%.
Heart failure 13.3%.
Amniotic fluid embolism 13.3%.
Sepsis 11.2%.
Anesthesia complications 7.8%.
Maternal cardiac arrest occurs in 1 in 12,000 hospitalizations for delivery [2].
98 E. Kosik
4. Help should be summoned by announcing maternal code blue. In this cardiac

arrest scenario, it is vital to start immediate cardiopulmonary resuscitation (chest
compressions of 100–120 per minute, 2 inches in depth with full recoil, and the
person doing compressions should switch every 2 min). For a parturient with a
uterus located at or above the umbilicus, a left uterine tilt of 15° should be insti-
tuted, or if enough help is available, a manual lateral tilt might provide better
resuscitation results [1, 3]. Maintaining the airway and avoiding hyperventilation
is paramount. ACLS guidelines should be followed.
An AED or defibrillator should be obtained as quickly as possible, pads
placed, and the patient defibrillated with the manufacturer recommended joules,
360 J if it is monophasic or the maximum amount of energy if the recommended
energy is unknown. Internal fetal monitors should be removed before defibrilla-
tion to reduce chances of team member electrocution [1]. Anesthetic gases
should be discontinued and 100% oxygen administered. For the anesthesiologist,
it is imperative to verify that the endotracheal tube is secured despite an easily
placed airway. Effective chest compressions should show EtCO2 of >10 mmHg.
A backboard may not be necessary on a minimally cushioned OR table but
should be considered.
A person should be assigned to document the event. Epinephrine 1 mg IV
should be given after the second defibrillation and repeated every 3–5 min.
Amiodarone 300 mg IV may be administered for ventricular fibrillation resistant
to defibrillation (after three shocks) [4, 5].
Intravenous access should be present above the diaphragm. A crisis checklist
should be used if available and team members are trained in using one.
5. If time permits an arterial blood gas or venous blood gas will permit quick
assessment of electrolyte abnormalities, blood status, oxygenation, and ventila-
tion status. A transthoracic echocardiogram or transesophageal echocardiogram
will allow quick assessment of the cardiac function. A chest X-ray may help with
assessment of the thorax.
6. Perimortem C-section should start at 4 min and the baby delivered by 5 min.
However, the obstetric team should prepare for Cesarean section before this time [6].
7. Local anesthetic toxicity treatment requires Intralipid 20% administered in an
initial dose of 1.5 mL/kg infused intravenously with simultaneous high-quality
CPR maintained. A continuous infusion of 0.25–0.5 mL/kg/min is recom-
mended. Dosages of epinephrine should be decreased to 1 μg/kg. Notify appro-
priate personnel for cardiac bypass [7].
8. Medications to avoid in local anesthetic toxicity would be lidocaine (once a
treatment for ventricular tachycardia or PVCs), calcium channel blockers, vaso-
pressin, and beta-blockers. Propofol should not be substituted for Intralipid [7].
9. ASRA recommends an upper level of 10 mL/kg of lipid emulsion infused over
30 min. Infusion longer than this may indicate other causes of cardiac collapse [7].
Acknowledgment Special acknowledgment to Scott Tatum, R.N., and CAE for EKG image.
18 ECG II 99
References
1. Suresh MS, Mason LC, Munnur U. Cardiopulmonary resuscitation and the parturient. Best
Pract Res Clin Obstet Gynaecol. 2010;24(3):383.
2. Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leffert LR, Bateman BT. Cardiac Arrest during
Hospitalization for Delivery in the United States, 1998–2011. Anesthesiology. 2014;120:810–
8. doi:10.1097/ALN.0000000000000159.
3. Kundra P, Khanna S, Habeebullah S, Ravishankar M. Manual displacement of the uterus during
Caesarean section. Anaesthesia. 2007;62(5):460.
4. Jeejeebhoy FM, et al. Cardiac arrest in pregnancy a scientific statement from the American
Heart Association. Circulation. 2015;132:1747–73. doi:10.1161/CIR.0000000000000300.
5. Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias during pregnancy.
Heart. 2007;93(12):1630–6. doi:10.1136/hrt.2006.098822.
6. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol.
1986;68(4):571.
7. Neal JM, Bernards CM, Butterworth JF, et al. https://www.asra.com/advisory-guidelines/arti-
cle/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity. Accessed 30 Mar 2016.
Chapter 19
ECG III
Tanmay Shah
A 71-year-old male with no known past medical history was admitted to the hospital
with a chief complaint of dyspnea on exertion, swollen legs, and frequent falls since
the last 3 weeks. On admission the patient had leukocytosis, bradycardia, and
hyponatremia, and an EKG showed second-degree AV block with 2:1 AV conduc-
tion. An EKG taken a few hours later is shown below.
Fig 19.1 EKG showing dissociated pattern for P waves and QRS pattern
T. Shah, MD, MBBS


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102 T. Shah
1 . How will you interpret this EKG? (Fig. 19.1)

2. Can you determine the site of block in the AV conduction system by looking at
the EKG?
3. Does this patient require any urgent intervention?
4. What are the causes of this condition?
5. How will you decide whether this patient needs permanent pacemaker before
proceeding to surgery or not?
6. If this patient has to go for urgent/emergent surgery, is there any preoperative
preparation required?
7. What monitors will you use intraoperatively for this patient?
19 ECG III 103
Answers
1. This EKG shows atrial (P waves) and ventricular (QRS complexes) activity
which are independent of each other, and there is no association between P waves
and QRS complexes. That confirms that our patient has sinus rhythm with com-
plete heart block (CHB).
2. Ventricular rate can help determine the site of block in conduction system.
Junctional rhythm tends to have a ventricular rate between 40 and 60 beats per
minutes (bpm), while ventricular escape rhythm will have rates of 40 beats per
minute or less, and they are often unstable, requiring immediate cardiology
intervention [1]. In most cases, the atrial rate will be faster than the ventricular
escape rate, and as a general rule, the more distal the level of block in AV con-
duction and His-Purkinje system, the slower the ventricular rate will be.
If EKG shows:
(a) Narrow QRS complex with junctional or AV nodal rhythm, then the AV
block has occurred within the AV node or at the level of the bundle of His.
(b) Wide QRS complex with subjunctional escape rhythm, then the AV
block is distal to the His conduction system.
3. Our patient has ventricular rate of 46 beats per minute with narrow QRS com-
plexes which indicate that blockade is around AV node or at the His bundle. Even
though our patient has frequent falls, currently he is hemodynamically stable.
This patient needs to be admitted to a telemetry bed for continuous EKG moni-
toring along with serial 12-lead EKG. Cardiology consultation should take place
as early as possible to determine the need for pacemaker placement, although an
immediate intervention may be needed if ventricular rate stays less than 40 bpm
along with any of the following signs/symptoms:
(a) Hypotension
(b) Altered mental status
(c) Signs of shock
(d) Ischemic chest discomfort
(e) Acute heart failure
4. Major causes of CHB can be divided into two categories:
(a) Pathologic causes:
• Myocardial ischemia involving the conduction system
• Cardiomyopathy
• Fibrosis and sclerosis of conduction system (e.g., amyloidosis, sarcoidosis)
• Myocarditis (e.g., Lyme disease)
• Congenital heart disease
• Endocarditis with abscess formation
• Hyperkalemia
• Increased vagal tone
104 T. Shah
(b) Iatrogenic causes:

• AV nodal blocking medications (e.g., digitalis, calcium channel blockers,
amiodarone, adenosine)
• Post-cardiac surgery
• Post-catheter ablation
• Transcatheter aortic valve implantation
• Transcatheter ablation of ventricular septal defect (VSD)
• Alcohol septal ablation of hypertrophic obstructive cardiomyopathy
(HOCM)
5. After excluding all reversible causes of CHB, if surgery is not urgent, then an
intracardiac His bundle study can be done in order to determine the need for
permanent pacemaker placement (PPP) [2, 3]. If HV interval (the interval from
the His bundle to the right ventricle) is greater than 100 ms, then PPP is required
prior to surgery, but if HV interval is normal or 60–100 ms, then PPP may not be
needed; however, central venous access (internal jugular) is recommended
before proceeding to surgery for transvenous pacing if needed.
6. A temporary transvenous pacemaker or transcutaneous pacemaker should be
placed and checked before proceeding with urgent surgery [4]. All drugs and
equipment, necessary for cardiopulmonary resuscitation, should be readily avail-
able in the operating room. It is also recommended that defibrillator pads are
applied to the patient.
7. In addition to standard ASA monitors, an arterial line will be helpful in a patient
with poor ventricular function. The EKG monitor should be set to diagnostic
mode. In order to minimize interference from electrocautery, if patient has per-
manent pacemaker in situ, then the grounding plate should be placed as far from
the pacemaker generator as possible. Bipolar cautery should be used, limiting its
power output in those cases.
References
1. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: Lange
Medical Books/McGraw-Hill; 2006.
2. Guimond C, Puech P. Intra-His bundle blocks (102 cases). Eur J Cardiol. 1976;4:481.
3. Narula OS, Scherlag BJ, Javier RP, et al. Analysis of the A–V conduction defect in complete
heart block utilizing His bundle electrograms. Circulation. 1970;41:437.
4. Yao FSF. Yao & Artusio’s anesthesiology problem-oriented patient management. 7th ed.
Philadelphia: Wolters Kluwer; 2012.
Chapter 20
ECG IV
Ranganathan Govindaraj and Talla A. Rousan
A 65-year-old female presents for emergency laparotomy in the middle of the night.
Her ECG is presented below.
Fig. 20.1
R. Govindaraj, MD, FRCA (*)

UTMB, Galveston, Texas, USA
Director for Ultrasound Guided Regional Anesthesia, Galveston, TX 77555, USA
Department of Medicine, The University of Oklahoma Health Sciences Center and the
Veteran Affairs Medical Center,
800 Stanton L. Young Blvd, COM 5400, Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_20
106 R. Govindaraj and T.A. Rousan
1 . What is shown in the above image?

2. How do we know if the patient is pacemaker dependent or not?
3. What do the letters before a pacemaker signify?
4. What is a rate modulating pacemaker?
5. What is pacemaker syndrome?
6. What is biventricular pacing? What are its indications and advantages?
7. Why do we place a magnet over a pacemaker?
8. How does the type of cautery affect the pacemaker?
9. How should this device be managed perioperatively?
20 ECG IV 107
Answers
1. The image shows a 12-lead ECG with pacing spikes before P waves (a spike)
and QRS complexes (v spike), at a rate of 60/min indicating a dual chamber
pacemaker.
2. The definition of pacemaker dependency varies in the literature. It can be defined
as the absence of an intrinsic (or escape) rhythm for 30 s during temporary pac-
ing at 30 beats per minute with the pacemaker switched off [1]. To determine if
the patient is pacemaker dependent, it is essential to identify the indication for
the pacemaker implantation (complete heart block and syncope, for instance,
would infer dependency) [1]. In addition, pacemaker interrogation in pacemaker-
dependent patients would reveal pacing 100% of the time.
3. This is nomenclature describing the pacemaker therapy modes. Permanent pace-
maker nomenclature is based on recommendations by the North American
Society of Pacing and Electrophysiology (NASPE) and by the British Pacing and
Electrophysiology Group (BPEG).
AAI pacemaker is useful for sinus bradycardia if the AV node function is
normal.
VVI pacemaker is useful in atrial fibrillation with slow ventricular response.
DDD is useful if there is complete AV block with a normal sinus node.
Pacing modes with AV synchrony are AAI, DVI, DDI, and DDD.
Pacing modes that sense atrial activity and trigger ventricular activity are
VAT, VDD, and DDD. They are used during slow ventricular rates or AV nodal
block. These modes are synchronous modes.
Asynchronous modes AOO, VOO, and DOO are not inhibited by the electri-
cal activity of the heart or other exogenous electrical activities (cautery) in con-
trast to synchronous modes like DDD or VVI which are inhibited. Asynchronous
mode is used in emergency situations like in the operating rooms by converting
AAI to AOO, VVI to VOO, or DDD to DOO.
Table 20.1 NASPE/BPEG pacemaker code

III IV
I II Response to Rate VI
Chamber paced Chamber sensed sensing responsiveness Multisite pacing
0 = none 0 = none 0 = none 0 = none 0 = none
A = atrium A = atrium T = triggered R = rate A = atrium
modulation
V = ventricle V = ventricle I = inhibited V = ventricle
D = dual (A+V) D = dual (A+V) D = dual (T+I) D = dual (A+V)
S = single (A or S = single (A or
V) V)
Management of Pacemaker (PM)

Perioperatively
Is the patient PM dependent?
yes No
Is Electrocautery above the Proceed with magnet available

Umbilicus or within 6 inches of No in the OR
the generator?
yes
Reprogram to asynchronous
mode/Magnet secured over
Pacemaker Generator
Electrocautery short bursts
Consider invasive monitoring,

Availability of External Pacing
Fig. 20.2 Perioperative management algorithm for pacemaker
4. Rate modulation comes into play when metabolic demands are to be met during
conditions such as exercise where physical activity increases. With conventional
pacemakers, heart rate functions at a set rate, but pacemakers with rate modulat-
ing function adjust the paced rate based on the patient’s activity. This is achieved
by using sensors like accelerometer to sense motion or by using sensors to cal-
culate thoracic impedance or minute ventilation.
5. The pacemaker syndrome is an iatrogenic condition that occurs as a sequel of
ventricular pacing (e.g., VVI) [2, 3]. One postulated mechanism is loss of atrio-
ventricular synchrony [3]. Symptoms of this syndrome include lethargy, palpita-
tions, hypotension, and syncope [2]. The symptoms of this syndrome overlap
with those encountered with pacemaker malfunction; thus excluding pacemaker
malfunction is the first step when this syndrome is suspected [2]. Restoration of
atrioventricular synchrony results in remission of the symptoms [3].
20 ECG IV 109
6. Biventricular pacemaker is used when the right ventricular and the left ventricu-
lar activities are asynchronous. It is achieved by three leads (right atrium, right
ventricle, and coronary sinus (to pace the left ventricle)). The indication for
Bi-V pacing (cardiac resynchronization therapy) with the highest level of evi-
dence is EF ≤ 35% and sinus rhythm with LBBB and QRS duration 150 ms or
more and NYHA II–III or ambulatory IV (class I indication) [4]. Other indica-
tions with lower level of evidence also exist, but a full discussion of the guide-
lines is beyond the scope of this chapter. It is not indicated (no benefit) for
patients with NYHA I–II symptoms, non-LBBB pattern with QRS duration less
than 150 ms [4].
7. Cautery current or other external electrical signals are inappropriately recog-
nized as native cardiac activity, and pacing is inhibited (oversensing). Magnets
are placed over pacemaker generator to turn off sensing and hence convert them
from synchronous to asynchronous or fixed-rate (usually 70–90/min depending
on programming and battery life) mode [5–7].
8. In unipolar cautery the current flows from the generator to the coagulation or
cutting end of the cautery tip to the tissues and then through the body to the cau-
tery plate and back to the generator.
In bipolar cautery the current flows from the generator to the tip of the bipolar
cautery holding the tissues and back to the generator via the opposite tip. As the
distribution of current is limited to the cautery tips and tissue held within, electrical
interference is restricted minimizing potential pacemaker malfunction [5–7].
9. Emergency surgery in the middle of the night does not provide much time or
access to the CIED team to interrogate and ascertain pacemaker function or
dependency. For the purpose of this emergency laparotomy where the top of the
incision will probably extend to within 6 inches of the pacemaker generator, it
would be safe to assume pacemaker dependency and proceed with the following
plan—an arterial line, a magnet over the generator, communication with the sur-
geon regarding the need for short bursts with the electrocautery, and having
external pacing equipment available nearby [6, 7].
References
1. Lelakowski J, et al. Pacemaker dependency after pacemaker implantation. Cardiol J. 2007;14(1):

83–6.
2. Travill CM, Sutton R. Pacemaker syndrome: an iatrogenic condition. Br Heart J. 1992;68(2):
163–6.
3. Ausubel K, Boal BH, Furman S. Pacemaker syndrome: definition and evaluation. Cardiol Clin.
1985;3(4):587–94.
4. Epstein AE, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/
HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the
American College of Cardiology Foundation/American Heart Association Task Force on

Practice Guidelines and the Heart Rhythm Society. Circulation. 2013;127(3):e283–352.
5. Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable
electronic devices. Br J Anaesth. 2011;107(Suppl 1):i16–26.
6. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society
of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of
patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and
patient management this document was developed as a joint project with the American Society
of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA),
and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8:1114–54.
7. American Society of Anesthesiologists. Practice advisory for the perioperative management of
patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-
defibrillators: an updated report by the American society of anesthesiologists task force on peri-
operative management of patients with cardiac implantable electronic devices. Anesthesiology.
2011;114:247–61.
Chapter 21
ECG V
A 68-year-old man with hypertension and diabetes on an ACE inhibitor and insulin
presents for an AV fistula placement. He appears lethargic and complaints of nau-
sea. His ECG shows the following rhythm.
Fig. 21.1 12-lead ECG
M. Rupasinghe, MBBS, FRCA

Department of Anesthesiology, University of Texas Health Science Center at Houston,
6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA

DOI 10.1007/978-3-319-55862-2_21
112 M. Rupasinghe
1 . What is concerning about this ECG?

2. What factors contribute toward this presentation?
3. How do you emergently correct this abnormality?
4. What are the risks of anesthetizing a patient with this ECG?
21 ECG V 113
Answers
1. The clinical scenario and presentation along with the ECG suggests hyperkale-
mia.Hyperkalemia is defined as a potassium level >5.5 mEq/L. Moderate hyper-
kalemia is a serum potassium >6.0 mEq/L, and severe hyperkaliemia is a serum
potassium >7.0 mE/L. Easily distinguished ECG signs of hyperkalemia are:
Serum potassium >5.5 mEq/L [1]
Peaked T waves
Serum potassium >6.0 mEq/L
P wave widening and disappearance
Prolongation of the PR interval
QT interval shortening
Serum potassium >7.0 mEq/L
ST changes (which may mimic myocardial infarction)
Conduction block
Wide QRS, which may progress to a sine wave pattern and asystole
2. The common reasons that bring about hyperkalemia are:Excessive intake: oral or
intravenous supplementation, salt substitute, and blood transfusionsDecreased
excretion: diabetic nephropathy, renal failure, congestive heart failure, hypoaldo-
steronism, systemic lupus erythematosis, and medications, e.g., ACE inhibitors,
NSAIDs, and diureticsShift from intra- to extracellular space: hyper osmolality,
rhabdomyolysis, malignant hyperthermia (MH), tumor lysis, succinylcholine
administration, insulin deficiency, or acute acidosisPseudohyperkalemia:
improper blood collection and lab error [2]
3. Stabilize myocardial membrane with the administration of calcium.Drive extra-
cellular potassium into the cells with insulin and glucose, beta-adrenergic ago-
nists (albuterol), or sodium.Eliminate potassium from the body with loop
diuretics or dialysis.Sodium polystyrene sulfonate (kayexalate) may be used for
non-emergent management [3].
4. Hyperkalemia alters cardiac conduction, increasing automaticity and enhancing
repolarization. The use of succinylcholine can dangerously aggravate hyperkale-
mia. As the effects of hyperkalemia are aggravated by hypoventilation and aci-
dosis, potassium must be lowered preoperatively; otherwise, the patients are at
risk of developing ventricular premature contractions, ventricular tachycardia,
fibrillation, and cardiac arrest.
References
1. Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes
in hyperkalemia. Clin J Am Soc Nephrol. 2008;3(2):324–30. doi:10.2215/CJN.04611007.
2. Evans KJ, Greenberg A. Hyperkalemia: a review. J Intensive Care Med. 2005;20(5):272–90.
PMID:16145218.
3. Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Physician. 2006;73(2):283–
90. PMID: 16445274
Chapter 22
ECG Exercise
Tilak D. Raj and Aneesh Venkat Pakala
For each of the ECGs below, what is the diagnosis/abnormality?

1. A 68-year-old male with type II diabetes mellitus being evaluated for inguinal
hernia surgery.
Fig. 22.1
T.D. Raj, MD, MRCP, FRCA (*)

A.V. Pakala, MD
Section of Cardiovascular Disease, Department of Medicine, University of Oklahoma
College of Medicine, Oklahoma City, OK, USA
e-mail: [email protected]; [email protected]

DOI 10.1007/978-3-319-55862-2_22
116 T.D. Raj and A.V. Pakala
2. A 65-year-old asymptomatic male with hypertension and COPD awaiting total

knee replacement.
Fig. 22.2
3. A 45-year-old asymptomatic female awaiting cholecystectomy.
Fig. 22.3
22 ECG Exercise 117
4. A 68-year-old male with ischemic heart disease and diabetes mellitus type II
and presents with syncope.
Fig. 22.4
5. A 55-year-old asymptomatic male with chronic obstructive pulmonary disease.
Fig. 22.5
6. A 40-year-old asymptomatic male with hypertension being treated with

beta-blockers.
Fig. 22.6
7. A 24-year-old female with palpitations.
Fig. 22.7
22 ECG Exercise 119
8. A 78-year-old male with type II diabetes mellitus and hypertension admitted

with facial trauma and complains of extreme fatigue and dizziness.
Fig. 22.8
9. A 60-year-old male with heart failure and reduced systolic function (EF 30%)
and history of syncope.
Fig. 22.9
10. A 45-year-old asymptomatic male on diltiazem for hypertension.
Fig. 22.10
11. A 60-year-old male awaiting routine screening colonoscopy.
Fig. 22.11
22 ECG Exercise 121
12. A 45-year-old male awaiting ventral hernia repair. He was recently prescribed
azithromycin for acute bronchitis.
Fig. 22.12
13. A 60-year-old female with end-stage renal disease on dialysis awaiting AV fis-
tula repair.
Fig. 22.13
Answers
1. Left bundle branch block (LBBB) [1].
2. Atrial fibrillation.
3. Normal sinus rhythm. Normal ECG.
4. Mobitz type II second-degree AV block. PR intervals constant. P waves blocked
intermittently, PR intervals normal.
5. Right bundle branch block (RBBB).
6. Mobitz type I second-degree AV block. PR intervals progressively prolonged
until P wave is blocked.
7. Narrow complex tachycardia (SVT) at a rate of about 150 per minute.
Management: If the patient is stable, then vagal maneuvers followed (if
unsuccessful) by adenosine 6 and 12 mg IV push (repeated twice if needed)
followed by beta-blocker and an expert consult. Unstable (chest pain, hypoten-
sion, altered mental status) patients require synchronized cardioversion [2, 3].
8. Complete heart block. P-P intervals constant, R-R intervals constant but no
relationship.
9. Wide complex tachycardia. Rate 188 per minute. Is it VT or SVT with aberrancy?
Chapters have been written and there are algorithms for differentiating the two.
Generally, VT occurs in people over 35 years of age with heart disease or a family
history of sudden cardiac death. VT is generally regular (maybe polymorphic—
Torsades) and demonstrates AV dissociation with occasional P waves showing
capture (SA node “captures” the ventricles producing a normal QRS) or fusion
beats (sinus and a ventricular complex fuse to produce a hybrid complex) [4].
Brugada’s sign: Onset of QRS to the nadir of the S wave >100 ms.
Ultrasimple Brugada criterion: Onset of QRS to S nadir or peak R if
greater than 50 ms in lead II favors VT.
Management: If the patient is stable, then expert help can be sought or
amiodarone 150 mg over 10 min.
An unstable patient requires synchronized cardioversion.
10. First-degree AV Block. PR interval >0.2 s.
11. Dextrocardia. Occurs in 1:12,000 people. QRS negative in leads I and II (is it
northwest axis?). aVR and aVL are reversed meaning the complexes are posi-
tive in aVR and negative in aVL. In the chest leads the R waves regress from V1
to V6. The differential diagnosis is reversed arm leads which would show simi-
lar features, but the chest leads show normal R wave progression.
22 ECG Exercise 123
12. Normal sinus rhythm, prolonged QT. Normal QT interval is 350–430 ms; pro-

longed QT is usually >440 ms. QT interval varies with heart rate and several
formulae exist for determining corrected QT (QTc). Bazett’s formula is the
most widely used QTc=QT/ RRinterval [5, 3].
QT prolongation can be inherited as in Romano-Ward or Jervell and Lange-
Nielsen syndromes or acquired in a variety of clinical settings including
electrolyte abnormalities, medications, acute intracranial event, or hypother-
mia. Prolonged QT is a risk factor for developing polymorphic ventricular
tachycardia (Torsades de pointes).
13. ST and T wave changes secondary to hyperkalemia.
Acknowledgment Scott Tatum RN, BSIT, for the ECGs.
References
1. Eriksson P, Hansson PO. Bundle branch block in a general male population. Circulation.
1998;98:2494–500.
2. Walraven G. Basic arrhythmias. 7th ed. Boston: Pearson Education; 2011.
3. Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart
Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascu-
lar care. Circulation. 2015;132(suppl 2):S315–67.
4. Pava LF, Perafán P, Badiel M, Arango JJ, Mont L, Morillo CA, Brugada J. R-wave peak time
at DII: a new criterion for differentiating between wide complex QRS tachycardias. Heart
Rhythm. 2010 Jul;7(7):922–6.
5. Goldberger AL, Goldberger ZD, SHvilkin A. Goldberger’s clinical electrocardiography: a sim-
plified approach. 8th ed. Philadelphia, PA: Elsevier; 2013.
Chapter 23
Intra-aortic Balloon Pump (IABP)
Mohammad A. Helwani and John David Srinivasan
A 65-year-old male presented with progressing chest pain and dyspnea over the last
3 days. He was diagnosed with acute anteroseptal myocardial infarction.
Transthoracic echocardiography revealed akinetic anterior and lateral wall and
moderate mitral regurgitation. Coronary angiogram revealed three-vessel disease
including severe left main stenosis. An intra-aortic balloon counterpulsation pump
(IABP) catheter was inserted, and the patient was taken to the operating room for
coronary artery bypass graft surgery.
1. Describe the parts of the IABP device.
2. What are the hemodynamic effects of IABP augmentation?
3. What are the triggers used for balloon counterpulsation?
4. What is the advantage of IABP in this patient?
5. What gas is used for the inflation and why?
6. What is the ideal position of balloon and how can we verify that?
7. Complications of IABP?
8. Contraindication of IABP?
9. What is the IABP-SHOCK II study and the final results?
10. Give some examples of abnormal timing of the balloon and consequences.
M.A. Helwani, MD, MSPH

Assistant Professor, Divisions of Critical Care and Cardiothoracic Anesthesiology,
Washington University in St. Louis, School of Medicine, 660 South Euclid Ave.,
Campus Box 8054, St. Louis, MO 63110, USA
J.D. Srinivasan, MD (*)
Assistant Professor, Department of Anesthesiology and Critical Care,
Saint Louis University, School of Medicine, 3635 Vista Ave.,
PO Box 15250, St. Louis, MO 63110-0250, USA

DOI 10.1007/978-3-319-55862-2_23
126 M.A. Helwani and J.D. Srinivasan
Answers
1. The IABP device is composed of two main parts:
(a) A flexible catheter with two lumens, one that allows pressure monitoring and
the second that permits the periodic delivery and removal of gas to a closed
balloon (2.5–50 mL in volume to fit any age and size of patients).
(b) A console that contains the system for gas transfer as well as computer con-
trol of the inflation and deflation cycle.
2. Intra-aortic balloon pump (IABP) is the most common form of mechanical sup-
port for the failing heart, and it is useful as a bridge to definitive therapy. Inflation
and deflation of the balloon has two major consequences:
(a) Inflation occurs immediately after aortic valve closure displacing blood
from the thoracic aorta and increasing diastolic pressure and therefore
increasing coronary perfusion pressure and coronary perfusion (↑ O2 sup-
ply). Systemic perfusion is also improved. This is brought about by aug-
mentation of the intrinsic Windkessel effect whereby potential energy
stored in the aortic root during systole is converted to kinetic energy with
its elastic recoil (Fig. 23.1) [1].
(b) Rapid deflation just before aortic valve opening reduces left ventricular
diastolic pressure (afterload) and therefore wall tension and ↓ MVO2
demand) [2].
The cardiac output is augmented by about 40%, and the left ventricular
stroke work is decreased and therefore the myocardial oxygen demand.
These effects may be quite variable, and they depend upon the volume of
the balloon, its position in the aorta, heart rate and rhythm, the compliance
of the aorta, and synchronization with the cardiac cycle [2, 3].
3. The most commonly used triggers are the ECG and arterial waveform.
Normal 1:2 IABP assist
Diastolic augmentation
Unassisted systolic
Unassisted diastolic
Decreased end diastolic pressure
Fig. 23.1 Normal IABP 1:2 assist: diastolic augmentation and decreased end-diastolic pressure
23 Intra-aortic Balloon Pump (IABP) 127
Balloon inflation (onset of diastole after aortic valve closure): middle of T

wave on the ECG and the dicrotic notch on the arterial waveform.
Balloon deflation (onset of systole just before aortic valve opening): peak of R
wave or just before the systolic upstroke on the arterial waveform [1].
4. Augmentation of diastolic pressure during balloon inflation improves coronary
circulation, and the presystolic deflation of the balloon reduces the resistance
to systolic output and decreases myocardial work. The overall effects of the
IABP therapy in this patient are an increase in the myocardial oxygen supply/
demand ratio and improved forward flow and decreased mitral regurgitation.
5. Both helium and carbon dioxide have been used as driving gases; however the use of
helium has theoretical advantages because it is less dense facilitating rapid transfer
to and from the console. Both helium and carbon dioxide are easily absorbed into the
bloodstream (compared to nitrogen and oxygen) in case of rupture of the balloon [1].
6. The closer the balloon is to the aortic valve, the greater the diastolic pressure
elevation. It is obvious that local anatomical factors limit the position of the
balloon within the aortic arch; therefore the optimal balloon position is situ-
ated distal to the left subclavian artery take off. Incorrect balloon position
results in reduced diastolic augmentation and increases vascular morbidity.
With optimal IABP position, on CXR, the tip is seen just below the aortic
knob or at 2 cm above the carina. The position can also be confirmed by trans-
esophageal echocardiography [4].
7. Complication of IABP:
(a) Vascular complications: including limb (and visceral) ischemia, vascular
laceration, major hemorrhage, and arterial dissection
(b) Position complications including obstruction of arterial flow causing vis-
ceral ischemia
(c) Air or plaque embolism
(d) Thrombosis
(e) Sepsis and groin infection
(f) Hemolysis and thrombocytopenia [5]
8. Contraindications to IABP placement [5]
(a) Moderate or severe aortic regurgitation since the degree of aortic regurgita-
tion will be increased by counterpulsation
(b) Aortic dissection or clinically significant aortic aneurysm
(c) Uncontrolled sepsis
(d) Uncontrolled bleeding disorder
(e) Severe peripheral artery disease
9. The IABP-SHOCK II trial was a randomized, open-label, multicenter trial.
Patients with cardiogenic shock complicating acute myocardial infarction who
were undergoing early revascularization and optimum medical therapy were
randomly assigned (1:1) to IABP versus control. IABP did not reduce 30-day
or 12-month mortality [6].
10. Suboptimal timing of counterpulsation has hemodynamic consequences.

(a) Early inflation: Balloon inflation before aortic valve closure (before
dicrotic notch) (Fig. 23.2).
Effects include reduced stroke volume/CO, potential increase in LVEDV
and LVEDP, increased LV wall stress and afterload, and increased MVO2
demand.
(b) Late inflation: Inflation occurs markedly after aortic valve closure (after
the dicrotic notch) (Fig. 23.3).
Effects include suboptimal coronary perfusion.
Early inflation – before dicrotic notch
Unassisted systolic
Fig. 23.2 Early inflation: before dicrotic notch—increased afterload
Late inflation – after the dicrotic notch
Unassisted systolic
Fig. 23.3 Late inflation: after dicrotic notch—suboptimal diastolic pressure augmentation
23 Intra-aortic Balloon Pump (IABP) 129
(c) Early deflation: sharp decrease in waveform after diastolic augmentation.

Assisted aortic end-diastolic BP may be equal to or lower than the unas-
sisted aortic end-diastolic pressure (Fig. 23.4).
Assisted systolic pressure may increase. Effect may be suboptimal coro-
nary perfusion, suboptimal afterload reduction and increased MVO2 demand.
(d) Late deflation: IABP may impede LV ejection, afterload reduction is
essentially absent, and as the LV ejects against greater resistance, the work-
load of the LV is increased and the MVO2 consumption is increased. CO is
decreased (Fig. 23.5).
Early deflation – suboptimal diastolic augmentation
Unassisted systolic
Sharp drop following

augmentation
Fig. 23.4 Early deflation: suboptimal diastolic augmentation
Late deflation – diastolic augmentation widened
Unassisted systolic
No decrease in end diastolic pressure

Fig. 23.5 Late deflation: widened diastolic augmentation

References
1. Parissis H, Graham V, Lampridis S, Lau M, Hooks G, Mhandu PC. IABP: history-evolution-

pathophysiology-indications: what we need to know. J Cardiothorac Surg. 2016;11:122.
2. Krishna M, Zacharowski K. Principles of intra-aortic balloon pump counterpulsation.
Continuing education in anaesthesia. Crit Care Pain. 2009;9(1):24–8.
3. Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97(9):1391–8.
4. Kim JT, Lee JR, Kim JK, Yoon SZ, Jeon Y, et al. The carina as a useful radiographic landmark
for positioning the intraaortic balloon pump. Anesth Analg. 2007;105(3):735–8.
5. Gilotra NA, Stevens GR. Temporary mechanical circulatory support: a review of the options,
indications, and outcomes. Clin Med Insights Cardiol. 2014;8:75–85.
6. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, et al. Intra-aortic balloon counter-
pulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II):
final 12 month results of a randomised, open-label trial. Lancet. 2013;382:1638–45.
Chapter 24
Peripheral Nerve Stimulator
Gulshan Doulatram
a Time c Time
Tetanus 50 Hz
Single twitch
0.2 ms 20 ms
0.2 ms duration
b d
Train of four Tetanus 100 Hz
0.2 ms 10 ms
0.2 ms duration 500 ms
Time
e
Double burst
stimulation (DBS)
3.2
0.2 ms 750 ms
Fig. 24.1 Different patterns of nerve stimulation
Questions
1 . What does the above figure depict?
2. Are there different types of peripheral nerve stimulation?
3. What is the principle behind a peripheral nerve stimulator? Describe its use.
4. Describe the commonly used patterns of stimulation.
5. What sites are used to monitor peripheral nerve stimulation?
6. How do different muscles vary in their response to neuromuscular blockade?
7. What are the quantitative measures of neuromuscular monitoring?
G. Doulatram, MD
Department of Anesthesiology, University of Texas Medical Branch,
301 University Blvd, Galveston, TX, USA

DOI 10.1007/978-3-319-55862-2_24
132 G. Doulatram
Answers
1. Figure 24.1 illustrates the different patterns of stimulation obtained when moni-
toring peripheral neuromuscular function. The responses recorded serve as a
guide during critical periods including intubation and recovery from a general
anesthetic. Neuromuscular monitoring should be always used as an adjunct to
other clinical signs of muscle recovery, including grip strength, sustained head
lift maneuver, and respiratory mechanics.
2. Neuromuscular function is monitored intraoperatively by evaluating the muscu-
lar response to supramaximal stimulation of a peripheral motor nerve [1]. There
are two kinds of stimulation: electrical and magnetic. Electrical nerve stimula-
tion is used most commonly clinically. Magnetic stimulation has a theoretical
advantage of not being painful and not requiring body contact. However, the bulk
of the equipment and difficulty monitoring the train-of-four responses to stimu-
lation preclude its practical use in the operating room.
3. The reaction of a single muscle fiber to an electrical stimulus is an all-or-none occur-
rence. The response of the muscle will decrease depending on the number of muscle
fibers blocked in response to a neuromuscular blocking agent. The electrical stimulus
applied should be 20% to 25% above that necessary for a maximal response to obtain
a consistent response. This supramaximal stimulation, although painful, is possible
during anesthesia [2]. A current of uniform amplitude (20–60 mA) at a short duration
(0.1–0.2 ms) is applied to a peripheral nerve and the motor response is observed.
Common sites include facial nerve (facial twitch) and ulnar nerve (thumb abduction).
A current of greater than 0.5 ms will cause direct muscle stimulation which is not
optimal. Assessment is most commonly by tactile or visual method of elicited muscle
twitches. While this is the most practical method, it is subjective and not accurate.
Objective methods including electromyography, acceleromyography, and mechano-
myography will give a more accurate assessment compared to tactile responses [3].
The peripheral nerve stimulator should be able to generate 60 to 70 mA, be battery
operated, and alarm if the current is not being delivered. The stimulator should be
able to deliver single-twitch stimulation, TOF, and double-burst, tetanic stimulation
and have a time constant to facilitate a posttetanic count [2].
4. There are five patterns of stimulation:
(a) Single-twitch stimulation: A single supramaximal electric current is applied
at a frequency ranging from 1.0 Hz (one every second) to 0.1 Hz (one every
10 s) (Fig. 24.1A).
Time
A. Single twitch
Fig. 24.1A Single-twitch
stimulation 0.2 ms duration
24 Peripheral Nerve Stimulator 133
(b) Train-of-four stimulation: Four stimuli at 2 Hz are applied (four stimuli in
2 s) that are repeated every 10 to 12 s if needed. The ratio of the fourth
response to the first response (T4/T1 ratio) is used to assess the presence of
neuromuscular blockade and its degree. In the absence of neuromuscular
block, the ratio is 1. During a nondepolarizing block, the ratio decreases in
proportion to the degree of the block. A depolarizing block, on the other
hand, decreases all the four responses equally with TOF ratio of 1. A decrease
in the TOF ratio after the administration of succinylcholine is indicative of
phase II block. TOF value of 0.70 is associated with impaired respiratory
muscle function, hypoxia, and aspiration in the immediate postoperative
phase. Neostigmine is given only when the TOF count has returned sponta-
neously to three and preferably four responses. The availability of sugam-
madex as a reversal agent does not obviate the need for monitoring. The
appropriate dose of sugammadex is adjusted according to the TOF and
posttetanic stimulation responses (Fig. 24.1B).
(c) Tetanic stimulation: A stimulus of 30, 50, 100, or 200 Hz is applied for 5 s
and the response of the muscle is recorded. The response of the muscle to
this stimulus is sustained both in normal neuromuscular transmission and in
a depolarizing block. The response however is not sustained in a nondepolar-
izing block and a phase II depolarizing block. The decrease in the response
is called fade and is caused by depletion of acetylcholine stores over time
and is directly proportional to the degree of neuromuscular blockade.
Posttetanic facilitation is caused by an increase in the muscle response when
stimulated right after tetanic stimulation. This is caused by mobilization and
synthesis of acetylcholine to give a stronger response. The degree of postte-
tanic potentiation is also dependent on the degree of neuromuscular block.
The major disadvantage of tetanic stimulation is that is it painful and only
applicable in an anesthetized patient (Fig. 24.1C and D).
(d) Posttetanic count stimulation: When response to TOF and single-twitch
stimulation is absent due to high degree of neuromuscular block, posttetanic
count stimulation can be used to determine the degree of blockade. A tetanic
stimulation (50 Hz for 5 s) is applied, and the posttetanic response to single-
twitch stimulation given at 1 Hz starting 3 s after the end of tetanic stimula-
tion is observed. During very intense blockade, there is no response to either
tetanic or posttetanic stimulation. The first response to posttetanic twitch
stimulation occurs as the block begins to dissipate. The time until the return
B. Train of four
Fig. 24.1B Train-of-four
stimulation 0.2 ms duration 500 ms
134 G. Doulatram
Fig. 24.1C and D Tetanic Time

stimulation
C. Tetanus 50 Hz
0.2 ms 20 ms
D. Tetanus 100 Hz
0.2 ms 10 ms
Fig. 24.1E Double-burst
stimulation E. Double burst
stimulation (DBS)
3,2
0.2 ms 750 ms
of the first response to TOF stimulation is related to the number of postte-

tanic twitch responses present at a given time (the posttetanic count).
(e) Double-burst stimulation: DBS consists of two short bursts of 50-Hz tetanic
stimulation separated by 750 ms. The duration of each square wave impulse in
the burst is 0.2 ms. The most commonly used is DBS with three impulses in
each of the two tetanic bursts. In the absence of neuromuscular blockade, the
response to DBS is two short muscle contractions of equal strength. In nonde-
polarizing block, the second response is weaker than the first. DBS allows for
detection of small amounts of residual blockade during emergence and in the
postoperative period. The DBS response is more easily felt than TOF making
it a superior option. As with all modalities of testing, the frequency and dura-
tion should be kept constant for the entire operative time (Fig. 24.1E).
5. The ulnar and fascial nerves are the most common sites used for peripheral nerve
stimulation. Other sites include common peroneal and posterior tibial nerves. In
the case of ulnar nerve, the electrodes are placed on the volar surface of the wrist
with the negative electrode 1 cm proximal to the wrist on the ulnar nerve and the
positive electrode 2–5 cm proximal to it, and the response to adductor pollicis is
recorded [4]. In the case of fascial nerve, the negative electrode is placed directly
over the fascial nerve and the positive electrode is placed over the forehead and
response of orbicularis oris and corrugator supercilii muscles is recorded.
6. The diaphragm is the most resistant muscle to neuromuscular blockade; how-
ever, it recovers the fastest compared to the hand muscles. The most sensitive
muscles include the abdominals, the muscles of the extremities, and upper air-
way. The response to facial nerve stimulation mimics the response of laryngeal
24 Peripheral Nerve Stimulator 135
muscles; however, an adequate response might not be an indicator for extubation

as the peripheral muscles might still be blocked. Reliance on facial muscles is
associated with an increased incidence of postoperative residual neuromuscular
block in the PACU. A normal response from the ulnar nerve would ensure that
the muscles of the diaphragm and larynx have completely recovered. On the
other hand, an absent response during intubation may not ensure appropriate
intubating conditions.
7. The tactile and visual responses are subject to human error especially when the
TOF ratio is greater than 0.4 [5]. Quantitative monitoring techniques give a more
precise assessment of neuromuscular blockade especially during emergence,
before, and after neostigmine administration. There is good emerging evidence
that objective monitoring performed perioperatively ensures both a TOF greater
than 0.9 and a subsequent decrease in the incidence of postoperative residual
paralysis [2]. The techniques include mechanomyography (MMG), electromy-
ography (EMG), acceleromyography (AMG), and phonomyography (PMG).
AMG measures the isotonic acceleration of the stimulated muscle. It uses a
small piezoelectric transducer, which is attached to the stimulated muscle. The
movement of muscle generates voltage in the piezoelectric crystal, which is pro-
portionate to the acceleration of that muscle. The signals are analyzed and
recorded. The monitors are small, portable, and easy to use [6]. PMG measures
low-frequency sounds that are generated by the contraction of skeletal muscles,
and MMG measures force of the contraction to indicate the degree of neuromus-
cular blockade. While all these techniques give you quantitative measures, they
cannot be reliably compared to each other.
References
1. Viby-Mogensen J. Neuromuscular monitoring. Curr Opin Anaesthesiol. 2001;14(6):655–9.

2. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular
blockade. Curr Opin Anaesthesiol. 2014;27:616–22.
3. Viby-Mogensen J, Casper C. Evidence-based management of neuromuscular block. Anesth
Analg. 2010;111(1):1–2.
4. Ghai B, Makkar JK, Wig J. Neuromuscular monitoring: a review. J Anaesth Clin Pharmacol.
2006;22(4):347–56.
5. Jensen E, Viby-Mogensen J, Bang U. The accelograph: a new neuromuscular transmission
monitor. Acta Anaesthesiol Scand. 1988;32:49.
6. Miller RD, Pardo MC. Basics of anesthesia. 6th ed. Philadelphia, PA: Elsevier Saunders; 2011.
Part II
Laboratory Testing
Chapter 25
Complete Blood Count (CBC)
John David Srinivasan and Mohammed A. Helwani
A 25-year-old man is brought to the emergency department after a motor vehicle

accident in which he was an unrestrained passenger. He is otherwise healthy.
Clinically he was alert but confused and in pain. BP on arrival was 88/60 mmHg, HR
124/min, and RR 24/min. He weighed 70 kg. His skin was cool and clammy to touch.
X-rays showed right thigh and pelvic fracture. CT scans of the head, chest, and abdo-
men were normal. CT scan of the pelvis showed a complex fracture of pelvis.
Labs on admission were hemoglobin 9.1 gm/dL, platelets 118,000/mL, pro-
thrombin time (PT) and partial thromboplastin time (PTT) mildly elevated, and lac-
tate 4.2 mmol/L. The patient had received 1500 cc of normal saline from the time of
injury to admission.
Questions
1 . Is the patient in hemorrhagic shock?
2. What is the estimated blood volume in this patient?
3. Does this patient need blood transfusion with hemoglobin of 9.1 gm/dL?
4. Was this patient coagulopathic on admission?
5. How is ATC initiated?
6. What other factors exacerbate ATC?
7. What are the current guidelines regarding transfusion of blood and blood prod-
ucts in massive trauma?
J.D. Srinivasan, MD (*)

Assistant Professor, Department of Anesthesiology and Critical Care, Saint Louis University,
School of Medicine, 3635 Vista Ave., PO Box 15250, St. Louis, MO 63110-0250, USA
M.A. Helwani, MD, MSPH
Assistant Professor, Divisions of Critical Care and Cardiothoracic Anesthesiology,
Washington University in St. Louis, School of Medicine, 660 South Euclid Ave.,
Campus Box 8054, St. Louis, MO 63110, USA

DOI 10.1007/978-3-319-55862-2_25
140 J.D. Srinivasan and M.A. Helwani
Table 25.1 Classification of stages of hemorrhagic shock

Hemorrhagic shock
class I II III IV
Blood loss (mL) (% <750 (15%) 750–1500 1500–2000 >2000 (>40%)
blood volume) (15–30%) (30–40%)
HR <100 >100 >120 >140
BP Normal Normal Decreased Decreased
PP Normal Decreased Decreased Decreased
RR 14–20 20–30 30–40 >35
UOP >30 20–30 5–15 Negligible
CNS Slightly Mildly anxious Anxious, Confused,
anxious confused lethargic
HR heart rate, BP blood pressure, PP pulse pressure, UOP urine output, CNS central nervous sys-
tem
Answers
1. The patient is in hemorrhagic shock—a condition produced by rapid and significant
loss of intravascular volume, which may lead sequentially to hemodynamic instabil-
ity and decreased tissue perfusion. The injuries this patient suffered are associated
with significant amount of bleeding. Fractures of the pelvis and femurs can hide
massive amounts of bleeding with little external evidence and potentially put the
patient at risk for hemorrhagic shock. Signs of shock in this patient are decrease in
BP, tachycardia, tachypnea, confusion, cool and clammy skin, and elevated lactate.
Other signs that could be present in shock state include oliguria and metabolic aci-
dosis. This patient most likely has class III hemorrhagic shock (Table 25.1) [1].
2. The average adult blood volume represents 7% of body weight (or 70 mL/kg of
body weight) [2]. Estimated blood volume for a 70 kg person is approximately 5 L.
3. Yes, maintaining a higher hemoglobin level of 10 g/dL is a reasonable goal in
actively bleeding patients and with signs of shock. Hemoglobin concentration in
an actively bleeding individual has dubious diagnostic value because it takes
time for the various intravascular compartments to equilibrate. Hemoglobin con-
centration should not be the only therapeutic guide for blood transfusion in
actively bleeding patients. Rather, therapy should be guided by the rate of bleed-
ing and changes in hemodynamic parameters.
4. Yes, as evident by the prolongation of the PT and PTT. Many patients with severe
injuries seen in the emergency department have an established coagulopathy
called trauma-induced coagulopathy or acute traumatic coagulopathy (ATC). ATC
is an impairment of hemostasis and activation of fibrinolysis that occurs early after
injury and is biochemically evident prior to, and independent of, the development
of significant acidosis, hypothermia, or hemodilution. This has driven a change in
the early resuscitation of these patients with blood and blood components [3].
25 Complete Blood Count (CBC) 141
5. Acute traumatic coagulopathy (ATC) or trauma-induced coagulopathy (TIC), as

stated earlier, is an impairment of hemostasis and activation of fibrinolysis that
occurs in response to severe injury and hypoperfusion. TIC can contribute sig-
nificantly to the bleeding from the injury. It is mediated primarily by activation
of the thrombomodulin-protein C system. Activated protein C inhibits coagulation
cofactors V and VIII, reducing further thrombin generation. Platelet dysfunction
has an important role in the pathophysiology of TIC. When present in excess,
activated protein C depletes plasminogen activator inhibitor-1 (PAI-1) thus
reducing tissue plasminogen activator (tPA) inhibition and accelerating the con-
version of plasminogen to plasmin [3].
6. Acidosis and hypothermia alongside consumption and blood loss and the dilu-
tional effects of resuscitation may worsen ATC/TIC.
7. The recommendations suggest early plasma-based resuscitation, targeting ratios
of packed red blood cells, FFP, and platelets approaching 1:1:1 [4]. The PROPPR
(Pragmatic Randomized Optimal Platelet and Plasma Ratios) trial randomly
assigned 680 severely injured patients identified at risk of requiring massive
transfusion from 12 North American level I trauma centers to transfusions of
plasma, platelets, and red blood cells in ratios of either 1:1:1 or 1:1:2. There were
no significant differences in primary outcomes of 24-h or 30-day mortality
between the groups. But, death from hemorrhage was significantly less common
in the 1:1:1 cohort at 3 h after injury [5–7].
References
1. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: hemorrhagic shock. Crit Care.
2004;8(5):373. doi:10.1186/cc2851.
2. Kasuya H, Onda H, Yoneyama T, Sasaki T, Hori T. Bedside monitoring of circulating blood
volume after subarachnoid hemorrhage. Stroke. 2003;34(4):956–60. doi:10.1161/01.
str.0000064321.10700.6.
3. Cap A, Hunt BJ. The pathogenesis of traumatic coagulopathy. Anaesthesia. 2014;70:96–e34.
doi:10.1111/anae.12914.
4. Helwani MA, Gillihan JR. Mortality and ratio of blood products used in patients with severe
trauma. JAMA. 2015;313(20):2078. doi:10.1001/jama.2015.4424.
5. White NJ. Mechanisms of trauma-induced coagulopathy. Hematology Am Soc Hematol Educ
Program. 2013;2013(1):660–63. ASH Education Book.
6. Brohi K. Trauma induced coagulopathy—LTC2008 Karim Brohi, London, UK, October 18,
2009. http://www.trauma.org/index.php/main/article/927/
7. Holcomb JB, Tilley BC, Baraniuk S. Transfusion of plasma, platelets, and red blood cells in a
1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized
clinical trial. JAMA. 2015;313(5):471–82.
Chapter 26
Basic Metabolic Panel I
Tilak D. Raj
HR 105, BP 155/89, Sats 94%.

Hb 9.9 g/dL, Hct 29.7%, Na 120 mEq/L, K 3.2 mEq/L, Ca 9.1 mg/dL, BUN
7 mg/dL, glucose 100 mg/dL.
Above values are obtained in a patient in PACU 30 min post-TURBT. The patient
is extremely drowsy and not arousable. No medications were given in PACU.
Questions
1. What are the causes of postoperative drowsiness and the likely cause in this
patient?
2. What is the next step?
3. How do you calculate plasma osmolality?
4. What is the difference between osmolality and osmolarity?
5. How would you manage this condition?
6. What is SIADH?

Department of Anesthesiology, Alliance Health Midwest, MIdwest City, OK, USA

DOI 10.1007/978-3-319-55862-2_26
144 T.D. Raj
Answers
1. (a) Medications including long-acting anesthetics, benzodiazepines, barbitu-
rates, long-acting opiates, or large doses of fentanyl
(b) Timing of the medications—if the medications were given toward the end of
the procedure
(c) Profound hypoxemia
(d) hypercarbia—PCO2 greater than 75 mmHg
(e) Hypothermia and hypotension
(f) Hypoglycemia and hyperglycemia
(g) Cerebral—ischemia, hemorrhage, preexisting causes like tumor, trauma, sei-
zures, and intracranial spread of local anesthetics (associated with apnea)
(h) TURP syndrome—circulatory overload, hyponatremia, glycine, and ammo-
nia toxicity
(i) Hypothyroidism, hepatic or renal failure
Likely cause in this patient is hyponatremia (defined as serum sodium less than
135 mEq/L).
2. At this stage a few things need to be done—clinical assessment of the patient for
acuteness (hyponatremia 120 mmol/L and below is severe), volume status, cal-
culation, and measurement of plasma osmolality and measurement of urine
sodium to assess the cause of hyponatremia Fig. 26.1.
Hyponatremia
Evaluation of Fluid Status
Hypovolemia Normovolemia Hypervolemia

(Edema)
Renal Loss External Loss Plasma Osmolality Congestive cardiac failure

Cirrhosis
Nephrotic syndrome
Diuretic abuse Normal Low
Hypoadrenalism Diarrhea
(280–300 mosm) (<280 mosm)
Salt-losing conditions– Vomiting
Renal and cerebral Third-space losses Pseudo hyponatremia SIADH
Hyperlipidemia Drugs (SSRI MAIO, ACE
Renal tubular acidosis
Hyperproteinemia inhibitor, chemotherapy and
Glucose, Glycerol Sulphonylureas)
Glycine Hypothyroid
Spurious Hyponatremia Renal Failure
Blood sampling proximal to Adrenal Insufficiency
dextrose infusion
Urine sodium >20 mmol L–1 Urine sodium >15 mmol L–1
Urine sodium > 20 mmol L–1 Urine sodium < 20 mmol L–1
Depletional states
Saline required Dilutional states
Fluid restriction required
Fig. 26.1 Causes of hyponatremia [1, 2]

26 Basic Metabolic Panel I 145
Plasma osmolality is calculated with the formula:

(2 × Na + K) + (glucose/18) + (urea/2.8)
Lab values for glucose and urea are reported in conventional units (mg/dL) and
need conversion to SI units (mmol/L). An alternate method of conversion is glu-
cose × 0.0555 and urea × 0.357.
Normal = 280–300 mosm/kg.
The difference between the measured and calculated osmolality is the osmolal
gap normally less than 10 mosm/kg. Elevated levels are seen in the presence of
ethanol, methanol, isopropyl alcohol, and ethylene glycol.
3. Osmolarity is a measure of the osmoles of solute per liter of solution. A capital
letter M is used to designate units of mmol/L. Volume of solution changes with
the amount of solute added and also with temperature and pressure changes.
Osmolality is a measure of the osmoles of solute per kilogram of solvent and
is reported commercially using mOsm/kg. As the amount of solvent remains
constant regardless of temperature and pressure changes, osmolality is preferred
and is commonly used.
4. Management [1, 3, 4]:
(a) Correct underlying cause.
(b) If severe, expert help should be obtained.
(c) The magnitude and rapidity of correction is controversial due to observa-
tions that rapid correction may lead to central pontine myelinosis with paral-
ysis, coma, and death.
(d) Severe cases may need 3% (hypertonic) saline which contains 514 mmol/L
of sodium in aliquots of 3–5 mL/kg over 15 min–1 h to raise the plasma
sodium by 2–4 mmol/L and only to return the plasma concentration to
125 mmol/L.
(e) In less severe cases, management depends on fluid status. Hypovolemia
requires 0.9% saline. In normovolemic and hypervolemic states, correction
is done by fluid restriction with or without diuretics.
5. The syndrome of inappropriate ADH secretion (SIADH) is characterized by
hyponatremia, low plasma osmolality with normovolemia, and an inappropri-
ately high urine osmolality [5]. It may be seen in the presence of malignant
tumors which produce ADH-like substances, in neurological disorders (head
injury, tumors), and in pneumonia. Some drugs (barbiturates, opioids, chlorprop-
amide, anticonvulsants, and indomethacin) may also potentiate or increase ADH
effect. Treatment is with fluid restriction, and in severe or resistant cases, deme-
clocycline or lithium may be tried.
146 T.D. Raj
References
1. Fourlanos S, Greenberg P. Managing drug-induced hyponatraemia in adults. Aust Prescr.

2003;26:114–7.
2. Aitkenhead AR, Moppett IK, Thompson JP. Smith and Aitkenhead’s textbook of anesthesia.
6th ed. London, UK: Churchill Livingstone Elsevier; 2013.
3. Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol.
2009;29(3):282–99.
4. Craig S. Hyponatremia in emergency medicine, Medscape, Apr 2010.
5. Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl
J Med. 2007;356(20):2064–72.
Chapter 27
Basic Metabolic Panel II
Raghuvender Ganta
A 63-year-old man with hypertension, diabetes, and generalized weakness presents

for resection of small bowel. The patient’s medications include furosemide, meto-
prolol, and acetazolamide.
Lab values: HR 90, BP 105/65, Sats 96%, Hb 11 g/dL, Hct 31%, Na 130 mEq/L,
K 2.3 mEq/L, and Cr 2.0
His EKG shows the following rhythm.
Fig. 27.1 Reproduced with permissions from The Permanente Journal [1]
R. Ganta, MD, FRCA


DOI 10.1007/978-3-319-55862-2_27
148 R. Ganta
Questions
1 . What are your concerns regarding his EKG?
2. What are the causes for this abnormality?
3. How do you emergently correct low potassium preoperatively in this patient?
4. How do you monitor and manage perioperatively?
5. What are the anticipated problems and concerns anesthetizing this patient?
27 Basic Metabolic Panel II 149
Answers
1. The clinical presentation along with EKG (Fig. 27.1) features (prominent U
waves and apparent QT/U prolongation) suggests significant hypokalemia.
Hypokalemia is defined as plasma potassium of less than 3.5 mEq/L. For
every 0.3 mEq/L decrease in plasma potassium, the total body potassium
stores decrease by 100 mEq/L.
Mild hypokalemia is serum potassium >2.0 mEq/L; Severe hypokalemia is
serum potassium <2.0 mEq/L.
The electrocardiographic changes include:
Early—decrease in T wave.
Later—ST depression and T inversion. PR interval prolongation. U waves
appear in mid precordial leads.
Severe—U and T fuse-producing giant U waves and apparent prolongation
of QT interval which is actually QU interval.
2. Causes:
(a) Inadequate intake: diet and alcoholism.
(b) Excessive renal loss: mineralocorticoid excess, Cushing’s syndrome, diuret-
ics, hydrochlorothiazide and furosemide therapy, carbonic anhydrase inhibi-
tors, chronic metabolic alkalosis, renal tubular acidosis, and
ureterosigmoidostomy.
(c) Gastrointestinal losses: vomiting and diarrhea, which are commonly impli-
cated as nutritional deficiency causes; nasogastric suctioning; and villous
adenoma [2, 3].
(d) β-Adrenergic agonists, insulin, and alkalosis (respiratory and metabolic)
shift potassium to the intracellular space.
(e) The most common renal cause of hypokalemia is diuretic therapy when loop
diuretics and thiazides are co-prescribed. Loop diuretics block the sodium-
potassium-chloride cotransporter in the thick ascending limb of the loop of
Henle, while thiazides block the sodium-chloride cotransporter in the distal
convoluted tubule [4].
3. Hypokalemia treatment consists of oral or intravenous replacement of

potassium.
Mild hypokalemia (>2.0 mEq/L): infuse potassium chloride up to 10 mEq/h iv
Severe hypokalemia (<2.0 mEq/L, ECG changes, intense skeletal muscle weak-
ness): infuse potassium chloride up to 40 mEq/h iv, with continuous ECG monitor.
Total KCL required is determined by calculating the K deficit.
K deficit (mEq/L) = (Goal K – Measured K)/serum Creatinine × 100
K deficit (mEq/L) = (4.0−2.3)/2 × 100
= 1.7/2 × 100 = 85 mEq/L
= 85 mEq/L
150 R. Ganta
4. (a) Monitoring
• EKG
• Plasma potassium levels
• ABG
• Peripheral nerve stimulator
(b) Maintenance
• Avoid hyperventilation.
• Avoid hyperglycemia.
• Avoid epinephrine and other beta-2 agonist.
• Avoid diuretics unless supplemented with potassium chloride.
5. (a) Severe hypokalemia may lead to arrhythmias, ventricular tachycardia, and
ventricular fibrillation [5].
(b) Hypokalemic patients may be sensitive to vasodilators or cardiac-depressant
effects of volatile anesthetics.
(c) Potential for prolonged response to non-depolarizing muscle relaxants.
(d) Digoxin toxicity can occur with low potassium levels.
(e) Insulin therapy can lower potassium levels.
(f) While treating hypokalemia, concurrent hypomagnesemia should also be
corrected.
References
1. Lewis JT. ECG diagnosis: hypokalemia. Perm J. 2012;16(2):57.

2. Alasdair R, Gareth J, Chris I. Hypokalaemia: common things occur commonly—a retrospec-
tive survey. JRSM Short Rep. 2012;3:80.
3. Faust RJ. Anesthesiology review. 4th ed. New York: Churchill Livingstone; 2014. p. 109–10.
4. Morgan GE, Jr. Clinical anesthesiology. 3rd ed. New York: Lange Medical Books/McGraw-
Hill Medical Publishing Division; 2014.
5. Rastergar A, Soleimani M. Hypokalemia and hyperkalemia. Postgrad Med J. 2001;77:759–64.
Chapter 28
Liver Function Testing
Robert C.M. Stephens
A 75-year-old man is scheduled to undergo urgent laparotomy for small bowel

obstruction. On preoperative examination he looks jaundiced, and you request a full
liver function test profile including total bilirubin, AST, ALT, Alk Phos, gamma-
glutamyl transferase (γGT), and glucose. The results show:
Total bilirubin 3.2 mg/dL (0.2–1.2 mg/dL)

Direct bilirubin 2.8 mg/dL (0.1–0.4 mg/dL)
AST 14 U/L (10–40 U/L)
ALT 35 U/L (7–56 U/L)
Alk phos 260 IU/L (44–147 IU/L)
γGT 73 IU/L (0–30 IU/L)
Glucose 81 mg/dL (79.2 to 110 mg/dL)
Albumin 3.9 (3.4 to 5.4 g/dL)
Questions
1. What are liver function tests, and what are the different ways we can monitor
liver function via blood tests?
2. Why might the bilirubin be elevated?
3. What are AST and ALT?
4. Why are alkaline phosphatase and γGT elevated?
5. Why order blood glucose?
6. Are there any other tests that might reflect liver function?
7. What might be the next steps to use or further investigate these results?
R.C.M. Stephens, BA, MBBS, FRCA, MD, FFICM

Department of Anaesthesia, University College London Hospitals, London, UK

DOI 10.1007/978-3-319-55862-2_28
152 R.C.M. Stephens
Answers
1. Liver function tests can [1]:
• Detect the presence of liver disease and dysfunction
• Distinguish between different types of liver disorders
• Monitor the extent of liver damage
• Monitor responses to treatment
Liver function tests can look at the liver’s function in the following ways:
• Hepatic cell death: transaminases
• Biliary tree: alkaline phosphatase and γGT
• Bilirubin manufacture, conjugation, and bile obstruction
• Synthetic function: albumin, coagulation, and glucose
2. Total bilirubin is made up of unconjugated and conjugated (often called direct) bili-
rubin. Unconjugated bilirubin is initially formed from heme, mostly from red cell
hemoglobin, and is hydrophobic so it is mainly albumin bound. It can also be made
from muscle myoglobin, mitochondrial cytochromes, catalase, peroxidase, and
nitric oxide synthase. The liver clears the blood of unconjugated bilirubin via hepa-
tocyte conjugation to make it conjugated water-soluble bilirubin. This is secreted
into the bile and subsequently the intestine where metabolism of conjugated biliru-
bin into urobilinogen and its reabsorption accounts for the yellow color of urine.
The metabolism of urobilinogen into stercobilin while in the bowels accounts for
the brown color of stool; hence having white or clay-colored stool may indicate a
blockage in bilirubin processing and thus potential liver dysfunction or obstruction
to bile (cholestasis). Raised bilirubin above about 3 mg/dL causes jaundice (from
the French “jaune,” yellow), the dark yellow pigmentation of the skin, sclerae, and
other mucous membranes resulting from excess bilirubin in the extracellular fluid.
Raised unconjugated bilirubin is caused by pathology prior to the conjugation
process: hemolysis, abnormal erythropoiesis, reduced delivery of bilirubin to the
liver (cardiac failure, drugs), and defective bilirubin conjugation (congenital
syndromes and hyperthyroidism).
Conjugated hyperbilirubinemia occurs in individuals with hepatocellular
damage, biliary obstruction (either intra or extra hepatic), and sepsis.
3. The enzymes aspartate transaminase (AST) (also known as serum glutamic oxa-
loacetic transaminase, or SGOT) and alanine transaminase (ALT) (formerly
called serum glutamic pyruvic transaminase or SGPT) are associated with liver
parenchymal cells, and if the liver is damaged, the increased permeability of the
hepatocyte membrane causes enzyme leakage out into the systemic circulation.
ALT is mainly hepatic, but AST can also be found in cardiac and skeletal muscle.
Any liver damage from hepatitis, physical trauma (e.g., surgery), ischemia, or
injury from some drugs or toxins may elevate AST and ALT [2].
4. Slightly different forms of the enzyme alkaline phosphatase (Alk Phos) are pres-
ent in many tissues including the liver, bile ducts, and bones. The enzyme
gamma-glutamyl transferase (γGT) is also present in many tissues including the
bile duct, pancreas, gallbladder, and kidneys.
28 Liver Function Testing 153
Both Alk Phos and γGT are often elevated together in diseases of the biliary
tract. Due to γGT’s role in drug detoxification, it can be raised by large amounts
of alcohol ingestion, although it is not specific to alcohol.
5. If there is severe liver damage, blood glucose can fall as hepatic gluconeogene-
sis—the liver’s ability to produce glucose from noncarbohydrates—goes down,
although this is a late feature.
6. Prothrombin time (PT) and its derivative the international normalized ratio (INR)
are measures of the extrinsic coagulation pathway. Factors I (fibrinogen), II (pro-
thrombin), V, VII, and X are made in the liver. When liver function is signifi-
cantly reduced, lowered hepatic production of these factors prolongs the PT and
raises the INR.
Albumin is made in the liver. It transports (hormones, fatty acids, drugs, cal-
cium), buffers plasma pH, and maintains oncotic pressure. Liver disease can
result in hypoalbuminemia, although it can also be lost via damaged kidneys, the
GI tract (enteropathy), skin (burns), and other conditions. As it is a weak acid,
hypoalbuminemia can cause a metabolic alkalosis.
7. After a history and examination, a liver ultrasound or CT abdomen can image the
liver, biliary tree, and surrounding structures and identify any hepatic space-
occupying lesions. Other tests, for example, for viruses, autoantibodies, or a
“fibroscan” (a noninvasive test to quantify liver fibrosis) may be requested as
needed.
Several liver function tests are used as part of risk scoring systems. The Child-
Pugh score considers five factors, three of which assess the synthetic function of
the liver (total bilirubin level, serum albumin, and INR) along with two more
subjective clinical factors (degree of ascites and hepatic encephalopathy). The
Model for End-Stage Liver Disease (“MELD”) score uses bilirubin, creatinine,
and the INR. These scores have been used to predict mortality in patients with
hepatic cirrhosis, in patients with cirrhosis undergoing abdominal surgery or
hepatic procedures and as part of the assessment for liver transplantation [3, 4].
The King’s College Criteria for transfer to a liver center includes some liver
function tests, which differ depending on the cause of the liver disease.
References
1. Limdi JK, Hyde GM. Evaluation of abnormal liver function tests. Postgrad Med
J. 2003;79(932):307–12.
2. Giannini ED, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. CMAJ.
2005;172(3):367–79.
3. Vaja R, McNicol L, Sisley I. Anaesthesia for patients with liver disease. Contin Educ Anaesth
Crit Care Pain. 2010;10(1):15–9.
4. Angermayr B, Cejna M, Karnet F, et al. Child-Pugh versus MELD score in predicting survival
in patients undergoing transjugular intrahepatic portosystemic shunt. Gut. 2003;52(6):79–885.
Chapter 29
Coagulation Profile
Abigail Whiteman
A 36-year-old gentleman is admitted to the intensive care unit following major

trauma secondary to a road traffic accident. In the course of resuscitation and emer-
gency surgery, he required a 20-unit blood transfusion. Six hours following admis-
sion, it is noted that he is bleeding from wound and line puncture sites. The following
lab blood tests results are received:
Hemoglobin 73 g/L (115–145)

Platelets 46 × 109/L (150–400)
Prothrombin time 33 s (10–12)
INR 3.3 (0.7–1.3)
Activated partial thromboplastin time 102 s (25–37)
Fibrinogen 0.6 g/dL (1.5–4)
D dimer units 1026 ng/mL (<250)
Questions
1 . What is the differential diagnosis of a low platelet count?
2. What is the likely cause of the low platelets in this patient, and how is this condi-
tion diagnosed?
3. Which other clinical states are associated with it?
4. Can you describe the pathophysiology behind this condition?
5. What are the principles of management of this condition?
6. Most patients suffering this complication require extensive transfusion of blood
products. What are the short- and long-term complications of transfusions of
blood products?
7. What is the prothrombin time, and how is it related to the INR?
A. Whiteman, MA(Cantab),MB BChir,FRCA,PGCert

Department of Anaesthesia and Perioperative Medicine,
University College London Hospitals, London, UK

DOI 10.1007/978-3-319-55862-2_29
156 A. Whiteman
Answers
1 Thrombocytopenia is defined as a platelet count of less than 150 × 109/L7. It may
be due to:
• A decreased production of platelets:
–– Selective impairment of platelet production: drugs (alcohol, thiazide
diuretics, cytotoxic drugs) and viral infections
–– Generalized disease of the bone marrow: aplastic anemia or marrow infil-
tration in leukemia or dissemination cancer
• Decreased platelet survival
–– With an immune basis: idiopathic thrombocytopenia purpura, systemic
lupus erythematosus, drugs (heparin), and infections (infectious mononu-
cleosis, HIV, CMV)
–– Without an immune basis: disseminated intravascular coagulation, throm-
botic thrombocytopenic purpura, and cardiopulmonary bypass
• Sequestration
–– Hypersplenism
• Dilutional
–– Following massive transfusion of stored blood
2 The likely diagnosis in this patient is disseminated intravascular coagulation

(DIC). The diagnosis of DIC is not made by the examination of a single labora-
tory marker but based on the combination of clinical history and a number of test
results [1, 2].
Features suggestive of DIC in the clinical history include the presence of
clinical conditions known to trigger DIC (see below) and also the clinical presen-
tation due to the resultant consumptive coagulopathy: widespread petechiae and
ecchymosis and blood oozing from wound sites, intravenous lines, catheters, and
surgical drains. When injury to the pulmonary vasculature occurs, hemoptysis
and acute respiratory distress syndrome may result. Other serious complications
of DIC include acute renal failure, thrombosis, gangrene, and loss of digits,
intracerebral hematoma, and cardiac tamponade.
Laboratory features suggestive of DIC include:
• Rapidly declining platelet count
• Prolonged prothrombin (PT) time
• Prolonged activated partial thromboplastin (aPTT) time
• Low fibrinogen levels, although only a clinical feature of approximately 30%
of the more severe cases
• Raised fibrin degradation products (FDPs) and elevated D dimer level
3 Disseminated intravascular coagulation is an acquired complication of an under-

lying illness where systematic activation of the coagulation system occurs when
blood is exposed to procoagulants [1, 2]. The process can be classified as either:
• Acute or decompensated DIC, which occurs over a short-time period
29 Coagulation Profile 157
• Chronic or compensated DIC, where small amounts of procoagulant are

released over longer-time period
Conditions commonly associated with DIC include:
• Sepsis and severe infection
• Trauma: severe tissue injury, head injury, fat embolism
• Cancer: myeloproliferative diseases and solid tumors, e.g. pancreatic or pros-
tate carcinomas
• Obstetric complications: amniotic fluid embolism and placental abruption
• Vascular disorders: aortic aneurysm and giant hemangiomas
• Reaction to toxins: snake venom and drugs
• Immunologic disorders: severe allergic reaction, hemolytic transfusion reac-
tion, and transplant rejection
4 Disseminated intravascular coagulation is characterized by systemic activation

of coagulation through the release of tissue thromboplastin or thromboplastic
substances into the circulation. This leads to the widespread intravascular depo-
sition of fibrin throughout the microcirculation [1, 2, 3]. As a result of this wide-
spread thrombosis, there is a depletion of coagulation factors and platelets. There
is also a secondary pathological activation of fibrinolysis.
Thus DIC may result in microinfarcts and tissue hypoxia caused by microem-
boli as well as a coagulopathy due to the deletion of factors required for hemo-
stasis (consumption coagulopathy).
5 Management of DIC should involve:
1. Treatment of the underlying cause
2. Supportive therapy and replacement of blood components [4]
The major focus of management of DIC is specific and vigorous treatment of
the underlying disorder. This may be an aggressive management of sepsis or an
infective source, evacuation of the uterus in the case of intrauterine death or
debridement of tissues in the case of severe burns or trauma. Without manage-
ment of the cause, treatment of DIC is likely to fail.
The decision to transfuse blood products should not be based on the results of
coagulation tests alone but on the need to treat an actively bleeding patient.
Blood products may also be used as prophylaxis to prevent bleeding but the lit-
erature to support this use is limited.
Commonly transfused products to correct coagulopathy:
• Fresh frozen plasma: a standard dose of 10–15 mL/kg should be used during
active hemorrhage, aiming for an INR of less than 1.5 and an aPTT ratio of less
than 1.5.
• Platelets: the current British Society of Haematology guidelines suggest that
platelet counts should be maintained at over 75 × 10−9/L in patients who are
bleeding. The platelet count is expected to rise by 30–50 × 10−9/L after the
transfusion of a single pooled unit.
158 A. Whiteman
• Cryoprecipitate: cryoprecipitate should be used in a bleeding patient when the

fibrinogen level is less than 1.5 g/L. A standard transfusion of two bags of cryo-
precipitate is expected to increase the fibrinogen concentration by 0.5 to 1 g/L.
The use of anticoagulants, such as heparin, has been proposed to interrupt the
systemic activation of coagulation seen in DIC. However, clinical trials have so
far failed to show benefit.
6 The transfusion of blood products to support the hemoglobin level and correct coag-
ulation abnormalities can be a life-saving intervention in DIC [7]. However, prior to
any transfusion, full consideration should be given to its necessity; transfusion of
blood products has been proven to have multiple long- and short-term complica-
tions [5, 4].
Early complications of blood product transfusion
• Hemolytic reactions
–– Immediate
–– Delayed
• Acute nonhemolytic transfusion reactions
–– Febrile
–– Allergic
–– Hypotensive
• Transfusion-related acute lung injury (TRALI)
• Transfusion-associated circulatory overload (TACO)
• Reactions secondary to bacterial contamination
Complications specific to massive transfusion (complete replacement of the
circulating blood volume in 24 h)
• Hypothermia
• Dilutional coagulopathy if inadequate coagulation factors replaced relative to
packed red cells
• Hyperkalemia
• Citrate toxicity resulting in hypocalcemia and hypomagnesemia
Late complications of blood product transfusion
• Transmission of infection
–– Viral (hepatitis A, B, and C, HIV and CMV)
–– Bacterial (Treponema pallidum, Salmonella)
–– Parasites (malaria, toxoplasma)
• Transfusion-associated graft-versus-host disease
• Immune modulation possibly resulting in worse outcomes in cancer recur-
rence and metastases
• Immune sensitization (Rhesus D antigen)
7 The prothrombin time is an assay to evaluate factors within the extrinsic pathway
of the coagulation cascade: II, V, VII, and X [6]. Tissue thromboplastin (a brain
29 Coagulation Profile 159
extract) and calcium are added to citrated plasma. Clotting normally takes place
in 10 to 12 s.
The prothrombin time has significant interlaboratory variability influenced by
the thromboplastin used. In an effort to offset variation in thromboplastin reagent
and enhance standardization of PT in patients receiving oral anticoagulants, the
World Health Organization (WHO) introduced the international normalized ratio
(INR) in 1983.
The INR is a mathematical conversion of a patient’s PT that accounts for the
sensitivity of the reagent used in a given laboratory, by factoring in the interna-
tional sensitivity index (ISI). Each manufacturer assigns an ISI value for any
tissue factor they manufacture. The ISI value indicates how a particular batch of
tissue factor compares to an international reference tissue factor. The ISI is usu-
ally between 0.94 and 1.4.
The INR is then calculated using the following formula:
INR = [Patient PT/Mean PT]ISI
In this formula, patient PT is measured prothrombin time, mean PT is geo-
metric mean PT of at least 20 healthy subjects of both sexes tested at a particular
laboratory, and ISI is international sensitivity index that is specific to each
reagent-instrument combination.
References
1. Levi M, Ten-Cate H. Disseminated intravascular coagulation. N Engl J Med. 1999;341(8):586–92.

2. Levi M. Disseminated intravascular coagulation. Crit Care Med. 2007;35(9):2191–5.
3. Kumar V, Cotran RS, Robbins SL. Basic pathology. 6th ed. Philadelphia: Saunders; 1997.
4. Maxwell MJ, Wilson MJA. Complications of blood transfusion. Contin Educ Anaesth Crit Care
Pain. 2006;6(6):225–9.
5. Clevenger B, Kelleher A. Hazards of blood transfusion in adults and children. Contin Educ
Anaesth Crit Care Pain. 2014;14(3):112–8.
6. Levy JH, Szlam F, Wolberg AS, Winkler A. Clinical use of the activated partial thromboplastin
time and prothrombin time for screening: a review of the literature and current guidelines for
testing. Clin Lab Med. 2014;34(3):453–77.
7. Retter A, Barrett NA. The management of abnormal haemostasis in the ICU. Anaesthesia.
2015;70:121–7.
Chapter 30
Thromboelastogram I
Tilak D. Raj
a 30 min
A30 (LY 30)

MA
R K
Fig. 30.1
Questions
1 . What does the data in Fig. 30.1 show?
2. When can it be used?
3. How is it produced?
4. What do the parameters R, K, α, MA, and A30 (LY30) indicate?
5. How can the above parameters be used to guide therapy?
6. What is platelet mapping and how does it help?
7. How does thromboelastography (TEG®) differ from rotational thromboelastom-
etry (ROTEM®)?


DOI 10.1007/978-3-319-55862-2_30
162 T.D. Raj
Answers

1. The data shown represents a typical thromboelastography (TEG) trace.
Thromboelastography is a viscoelastic hemostatic assay that measures global
properties of whole blood clot formation. It shows the interaction of platelets
with the coagulation cascade including aggregation, clot strengthening, fibrin
cross-linking, and fibrinolysis. TEG is an effective and convenient means of
monitoring whole blood coagulation and provides a global assessment of hemo-
static function.
It can assist in determining if a patient has normal hemostasis or is bleeding
due to a coagulopathy or anticoagulant therapy.
2. Conventional coagulation tests like PT and aPTT poorly reflect in vivo hemosta-
sis. As they are performed in plasma, they assess only a portion of the coagula-
tion system and do not provide information on the full balance between
coagulation and anticoagulation. In contrast TEG is performed on whole blood
and provides information on clot formation, stabilization, and dissolution thus
assessing coagulation and fibrinolysis.
TEG is used to assess hemostasis during liver transplantation, postpartum hem-
orrhage, cardiac surgery, and in trauma resuscitation. It can also be used in coagu-
lopathy due to other reasons such as sepsis and guide management. TEG can also
provide information on the presence and adequacy of platelet inhibition.
In cardiac surgery during cardiopulmonary bypass, abnormal coagulation can
be identified before heparin reversal with the addition of heparinase to the testing.
This will be useful in long pump runs, in deep hypothermia, in the presence of
ventricular assist devices, and in major vascular procedures. In pinpointing the
specific problem, TEG has been shown to reduce blood transfusion in cardiac
surgery [1, 2].
3. The test sample is placed in an oscillating cup (4–45° every 5 s) heated to
37 °C. A pin is suspended into the sample by a torsion wire which is attached to
a mechanical/electrical transducer. The elasticity and strength of the developing
clot changes the motion of the pin which is converted into a graphical and
numerical output which is displayed.
4. The above tracing can be looked at in the following phases.
(a) Initial clot formation
Split point (SP) time = from the start of the test to the split of the trace
(first detectable fibrin)
Reaction (R) time = from the start till the trace reaching 2 mm amplitude
(1 mm either side of baseline) and represents continued production of throm-
bin and conversion of fibrinogen to fibrin (normal 4–9 min kaolin activated).
Prolonged R in factor deficiency and anticoagulants.
R-SP = delta (Δ). Thrombin burst. Low delta indicates hypercoagulability
and vice versa (normal 0.7–1.1 min). The test can be performed with hepari-
nase (TEG-H), and a difference of more than 2 min between R value of TEG
and TEG-H indicates heparin effect.
30 Thromboelastogram I 163
Fig. 30.2 TEG technology—how

it works
Torsion
wire
Pin
Cup
.36 mL whole
blood
4˚45
Thrombosis Fibrinolysis
a 30 min
20 mm
A30 (LY30)
alpha
MA
SP
K
R
Time to maximum amplitude Clot lysis time
Fig. 30.3 Components of normal TEG tracing
(b) Conversion of fibrinogen to fibrin

Kinetics (K) time = time interval between 2 mm and 20 mm on the
trace and represents fibrin cross-linkage and rate of bonding between
fibrin and platelets and is a measure of fibrinogen function (normal
1–3 min kaolin activated). Prolonged by anticoagulants, hypofibrinogen-
164 T.D. Raj
emia and thrombocytopenia and shortened by increased fibrinogen level

and platelet function.
Angle (α) = the angle at which the curve rises from SP to K and is related
directly to K time as a measure of fibrin platelet interaction and therefore
functional fibrinogen (normal 59–74°)
(c) Clot strength
Maximum amplitude in mm (MA) = represents clot strength and platelet
function (normal 55–74 mm).
G = this is calculated from platelet performance (MA) and expressed as
resistance unit (normal 5.3–13.2 dynes/cm2).
(d) Clot lysis
A30, LY30, EPL30 = percentage amplitude at 30 min post-MA (A30). Clot
lysis begins a short period after MA is reached and continues for about
15 min. The software estimates the percent lysis during this period (EPL30).
After 30 min the EPL30 becomes the percent lysis LY30 (normal 0–7.5%).
The interpretation of the parameters can be summarized as:
Hypocoagulable ↑ R (min) ↑ K (min) ↓ MA LY30 > 7.5%

↓ α (deg) EPL > 15%
Hypercoagulable ↓ R (min) ↓ K (min) ↑ MA NA
↑ α (deg
5. Increased R time—FFP (one unit of FFP will decrease R time by 2.5 min)

Decreased angle—cryoprecipitate
Decreased MA—DDAVP for slight decrease and platelets for more signifi-
cant decrease (one unit of platelets increase MA by 7–9 m)
Fibrinolysis—tranexamic acid, aminocaproic acid, or aprotinin
TEG interpretation and

treatment protocol—guidelines
TEG parameter Cause Treatment
R and K decreased, MA increased Hypercoagulability Anticoagulant
Normal parameters, patient Surgical Reexplore
bleeding
Difference in R between TEG Heparin Protamine
plain and TEG-H > 2 min
Delta <1.2, R > 9 min, normal MA Hemodilution If bleeding reexploration
and G or DDAVP
Prolonged R and delta, normal MA Factor deficiency FFP (one unit for every
2.5 min R prolongation)
Angle less than 45° Low fibrinogen Cryo 0.06 U/kg
MA 46–54 mm Low platelet function DDAVP 0.3 mcg/kg
MA less than 45 mm Very low platelet function Platelets one unit for
every 8 mm
LY30 7.5% or more, CI < 1 Primary fibrinolysis, e.g., TPA Antifibrinolytic
LY30 7.5% or more, CI > 3 Secondary fibrinolysis (DIC) Anticoagulant
30 Thromboelastogram I 165
6. Platelet mapping provides the degree of inhibition of platelets via the ADP
(Plavix) and AA (Aspirin) pathways and thereby the effectiveness of the
antiplatelet drugs which cannot be done with routinely available coagulation
tests. This involves four separate (channels) analyses.
(a) Baseline—kaolin activates platelets maximally as in regular TEG.
(b) Activator—heparin (via heparinized tube to draw the sample) to inhibit
thrombin and activator to convert fibrinogen to fibrin. Activator is reptilase
and Factor XIIIa (contribution of fibrin to clot).
(c) ADP—like previous (for fibrin clot) plus ADP added to activate platelets via
the GP IIb/IIIa receptor.
(d) AA—activator for fibrin clot and arachidonic acid to activate thromboxane
A2 pathway producing platelet aggregation.
It is possible to determine the (percent) platelet inhibition by comparing the rela-

tive strengths of the clots in the activator, ADP or AA cups with the baseline. The
residual function (percent aggregation) is multiplied by the baseline G to get the
net G or net clot strength. The goal is to maintain it between 5 and 9 to prevent
bleeding or thrombosis [3].
7. While TEG and ROTEM both measure the viscoelastic hemostasis of whole
blood ROTEM is a modern modification of TEG. There are differences in the
operations of the testing and the nomenclature. In ROTEM, the heated cup with
the sample is fixed, but the pin suspended on a ball bearing mechanism rotates
through an arc of 4–75° every 6 s, and the clot characteristics are measured by an
optical sensor.
ROTEM can measure four samples, while TEG can measure two samples
simultaneously.
ROTEM utilizes automated pipetting, while TEG requires manual pipetting.
TEG is sensitive to vibrations, whereas ROTEM is resistant to mechanical shocks.
Nomenclature (not interchangeable) for ROTEM as compared to TEG:
Clotting time (CT) = R (reaction) time (time for trace to reach 2 mm in both)
Alpha
MCF
LI30
CT
CFT
Fig. 30.4 Components of normal ROTEM tracing

166 T.D. Raj
Clot formation time (CFT) = K (kinetics) time (time for trace to reach 20 mm in
both)
α angle = α angle
Maximum clot firmness (MCF) = maximum amplitude (MA)
Lysis = lysis index 30 (LI30) is the percent reduction in MCF 30 min after CT in
ROTEM, whereas in TEG LY30 and LY60 (lysis 30 and lysis 60) are the percent
reductions of the curve 30 and 60 min after MA is reached.
Additional ROTEM assays:
INTEM = contact activation, information similar to APTT
EXTEM = tissue factor activation, information similar to PT
HEPTEM = assesses heparin effect
APTEM = in conjunction with EXTEM assesses fibrinolysis
FIBTEM = in conjunction EXTEM allows qualitative analysis of the contribu-
tion of fibrinogen to clot strength independent of platelets [4].
References
1. Müller MC, et al. Utility of thromboelastography and/or thromboelastometry in adults with
sepsis: a systematic review. Crit Care. 2014;18:R30.
2. Thakur M, Ahmed AB. A review of thromboelastography. Int J Periop Ultrasound Appl
Technol. 2012;1(1):25–9.
3. TEG: THEORY AND APPLICATION. http://www.visaliapath.com/tegtheory/. Accessed 2
June 2016.
4. Whiting W, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am
J Hematol. 2014;89:228–32.
Chapter 31
Thromboelastogram II
Tilak D. Raj
For each of the TEG tracings below, provide the abnormality and intervention if
appropriate.
1.
R K Angle MA PMA G EPL A CI LY30

min min deg mm d/sc % mm –1.8 %
4.8 2.7 57.6 47.0 0.0 4.4K 0.0 49.0 –3—3 0—8
2—8 1—3 55—78 51—69 4.6K—10.9K 0—15
Fig. 31.1


DOI 10.1007/978-3-319-55862-2_31
168 T.D. Raj
2.
R K Angle MA PMA G EPL A CI LY30

min mm
2 8 0.2
Fig. 31.2
3.
3 Rapid TEG
Post-protamine
10 mm
TEG ACT R Sp K Angle MA G EPL LY30 A

sec min min min deg mm d/sc % % mm
113.0 0.7 0.5 3.5 67.3 46.8 4.4K 0.0 0.0 47 .8
76—110 0—1 1—1 66—82 54—72 5.4K—12.3K 0—15 0—8
Fig. 31.3
31 Thromboelastogram II 169
4.
3 Citrated kaolin
96 inhibition: --
10 mm
TEG ACT SP R K Angle MA G EPL LY30 A

min min min deg mm d/sc % % mm
4.3 4.9 N\A 53.3 17.5 1.1K 93.0 93.0 0 .2
5—10 1—3 53—72 50—70 4.5K—11.0K 0—15 0—8
Fig. 31.4
5.
3 Rapid TEG
Post-protamine
10 mm
TEG ACT R Sp K Angle MA G EPL LY30 A

sec min min min deg mm d/sc % % mm
245.0 2.1 0.5 1.6 66.2 64.6 9.1K 0.0 0.0 66.4
76—110 0—1 1—2 66—82 54—72 5.4K—12.3K 0—15 0—8
Fig. 31.5
170 T.D. Raj
6.
1 Citrated Kaolin
10 mm

2.6 2.9 0.8 77.3 69.9 11.6K 8.2 8.2 58.6
5—10 1—3 53—72 50—70 4.5K—11.0K 0—15 0—8
Fig. 31.6
7.
Baseline 1 Citrated Kaolin
10 mm

3.4 3.7 0.8 78.8 72.3 13.0K 2.5 2.5 68.0
5—10 1—3 53—72 50—70 4.5K—11.0K
0—15 0—8
Fig. 31.7
8.
1 Citrated Kaolin
10 mm

5.8 6.2 1.2 72.8 71.8 13.0K 1.9 1.9 69.3
5—10 1—3 53—72 50—70 4.5K—11.0K 0—15 0—8
Fig. 31.8
9.
10 millimeters

min min min deg mm d/sc mm
32.5 39.7 13.3 16.0 *37.6* *3.0K* 37.6
5—10 1—3 53—72 50—70 4.5K—11.0K
Citrated kaolin with heparinase

13.1 3.2 51.0 52.1 5.4K 0.0 0.0 53.9
12.2 5—10 1—3 53—72 50—70 4.5K—11.0K 0—15 0—8
Fig. 31.9
172 T.D. Raj
10.
% Inhib 42.1 % Agg 57.9

mm Kd/sc
MA (CK) 67.5 G (CK) 10.4
MA (A) 16.9 G (A) 1.0
MA (ADP) 46.2 G (ADP) 4.3
SP R K Angle MA G EPL LY30 A

min min min deg mm dyne/sc % % mm
7.1 8.3 1.5 67.4 67.3 10.6K 0.0 0.0 65.8
2–8 1–3 55–78 51–69 4.6K–10.9K 0–15 0–8
Fig. 31.10
Answers
1. The low MA and G demonstrate hypocoagulable platelet function. If the patient
is bleeding, platelets and/or DDAVP may be indicated.
2. This flatline tracing demonstrates a complete inability to form a clot and can be
a result of several things. Clinically, it can be an extreme deficiency/suppres-
sion of factor function due to hemorrhage or over-anticoagulation. It could also
be a technical error in the running of the test (not adding calcium to a citrated
sample, or not loading the cup/pin properly). If it is due to any of the clinical
reasons mentioned, FFP or reversal of anticoagulation would be indicated.
3. This tracing shows a minor decrease in factor function (TEGACT) and a significant
reduction in platelet function with the low MA and G values. Fibrinogen function
is also affected slightly (angle and K). If the patient is bleeding, a dose of platelets
should not only improves platelet function but contains a unit of thawed plasma and
about 400 mg of fibrinogen, which should normalize the TEGACT and K values.
DDAAVP may be useful to get the maximum impact from the platelets.
4. This tracing demonstrates primary fibrinolysis. The key criteria are a decreased
MA and G and elevated fibrinolysis (LY30). Treatment is an antifibrinolytic
like Amicar or tranexamic Acid. Factors demonstrate slightly hypercoagulabil-
ity with the shortened R value, but no assessment of fibrinogen or platelet func-
tion can be made, until the fibrinolysis is corrected. The antifibrinolytic will
typically correct the lysis quickly.
5. This tracing shows prolonged TEGACT indicating either factor deficiency or
anticoagulant effect. Since this is a post-protamine sample, it may be due to
residual heparin still circulating. If the heparinase tracing shows a lower
TEGACT value, then additional protamine would be indicated. If the TEGACT
does not shorten in the heparinase cup, then FFP would be indicated.
6. This tracing shows hypercoagulability of factors (shortened R); fibrinogen (K
and angle), and platelets indicate slight hypercoagulability. Fibrinolysis (LY30)
is also elevated. This could be indicating stage 1 DIC, or a patient with some
form of thrombus that is initiating the lytic system. The assessment of the
patient should focus on identifying the underlying cause of the hypercoagula-
bility and treating the cause, and possibly treating the hypercoagulability with
some form of anticoagulant.
7. This tracing shows hypercoagulability of factors (R), fibrinogen (K and angle),
and platelets (MA and G). First priority is to identify the cause of the hyperco-
agulability. If it is thrombin driven (due to trauma, cancer, or some other inflam-
matory process), then anticoagulation may be the treatment of choice. If it is
likely platelet driven (stents or artificial surfaces exposed to the blood), then
antiplatelet agents may be the treatment of choice.
8. Platelet function is hypercoagulable (MA and G), and fibrinogen function
(angle) is borderline hypercoagulable. As the angle is indicative of platelet-
fibrin interaction, platelets would be the primary target of inhibition.
9. The citrated kaolin tracing (white) shows decreased function of all parameters.
This dysfunction significantly improves in the heparinase cup, leaving only
milder factor deficiency (R), and slightly hypocoagulable fibrinogen function
(K and angle). Treatment would be protamine to treat the heparin effect, and
possibly some FFP (depending upon presence or degree of bleeding). The
approximately 300 mg of fibrinogen contained within a bag of FFP will likely
correct the fibrinogen values.
10. This set of tracings is an ADP study of the PlateletMapping® assay. There is a
slight prolongation of the R value (8.3; range: 2–8), but with 42.1% inhibition
on the ADP assay, the platelet function is not at the high end of normal, as the
basic TEG would suggest. Looking at the MA value of the ADP tracing (46.2 in
the popup box), this is a little below the normal range for MA of 51–69 mm.
This would indicate decreased platelet function and, if the patient was going for
a procedure, an increased risk of bleeding with the procedure. Options would
be to delay procedure, if elective, until the inhibition decreases (if due to meds)
or, if urgent, to proceed with platelets and/or DDAVP being available.
Further Reading
1. Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thromboelastography can replace
conventional coagulation tests in the emergency department. Ann Surg. 2012;256(3):476–86.
2. Kashuk JL, Moore EE, Wohlauer H, et al. Initial experiences with point-of-care rapid throm-
boelastography for management of life threatening postinjury coagulopathy. Transfusion.
2012;52:23–33.
3. McGrath DJ, et al. [Thromboelastography analysis] maximum amplitude predicts postoperative
thrombotic complications including myocardial infarction. Anesth Analg. 2005;100:1576–83.
4. Cryer GH, et al. Massive transfusion in trauma guidelines. In American College of Surgeons.
Trauma Quality Improvement Program. Best Practice Guidelines. https://www.facs.org/~/
media/files/quality%20programs/trauma/tqip/massive%20transfusion%20in%20trauma%20
guildelines.ashx. Accessed 9 October 2016.
Chapter 32
Urine Testing
A 55-year-old, 110 kg male with a history of alcoholic cirrhosis was admitted with
mental status changes and a decrease in urine output over the last 2 days.
Labs from this admission showed: creatinine 3.4 mg/dL (was 1.1 mg/dL, a month
ago), blood urea nitrogen (BUN) 70 mg/dL (18 mg/dL, a month ago), serum biliru-
bin 3 mg/dL, potassium 5.7 mg/dL, and sodium 125 mEq/L. The patient was diag-
nosed with acute renal failure.
Questions
1 . What is the initial step in the evaluation of this patient?
2. What are the basic diagnostic tests that are used to distinguish prerenal disease
from acute tubular necrosis (ATN)?
3. How is FENa estimated? How does it help in diagnosis?
4. What is contrast-induced nephropathy, its risk factors and measures to decrease
risk?
5. What is FEUrea? When is it used?
6. What are the causes of ARF in this patient?
7. Is hepatorenal syndrome (HRS) a type of ATN?
8. What is RIFLE criteria and AKIN classification?
J.D. Srinivasan, MD, FRCA

Saint Louis Univeristy, School of Medicine, 3635 Vista Ave., PO Box 15250, St. Louis,
MO 63110-0250, USA

DOI 10.1007/978-3-319-55862-2_32
176 J.D. Srinivasan
Answers
1. A careful history and physical examination frequently identify events and/or dis-
ease processes that result in decreased tissue perfusion that can lead to prerenal
disease (e.g., vomiting, diarrhea, bleeding, or sepsis) or post-ischemic acute
tubular necrosis (ATN). Clinical setting may help identify the underlying cause
of AKI (e.g., hypotension, sepsis, aminoglycoside therapy, NSAIDS, or the
administration of radiocontrast media).
Physical examination may suggest hypovolemia, such as unexplained tachy-
cardia, dry mucous membranes, decreased skin turgor, cool extremities, and
orthostatic hypotension. Other physical exam findings may reveal signs of heart
failure or cirrhosis presenting with edema, ascites, and other signs of specific
organ dysfunction or may reveal abdominal compartment syndrome.
Examination should also include ultrasonography of the bladder to rule out
obstructive etiology.
2. There are three basic diagnostic tests:
(a) Urinalysis with sediment examination:
• Normal or near normal (hyaline and/or fine granular casts) in prerenal
disease.
• Muddy brown granular, epithelial cell casts, and free renal tubular epithe-
lial cells in ATN.
• RBC/WBC casts could suggest glomerulonephritis.
• WBC casts with eosinophils could suggest interstitial nephritis.
(b) Fractional excretion of sodium (FENa), and to a lesser degree, the urine
sodium concentration. The fractional excretion of urea may be helpful in
patients being treated with diuretics as FENa is increased by diuretics due to
the natriuresis.
(c) Response to fluid repletion: This is the gold standard for the distinction
between prerenal disease secondary to volume depletion and post-ischemic
or nephrotoxic ATN. Return of the serum creatinine to the previous baseline
within 24 to 72 h after volume repletion represents prerenal disease, whereas
persistent AKI represents ATN.
3.
urinary Na ´ serum Cr ´ 100
FENa =
serum Na ´ urinary Cr
By definition, FENa is the ratio between the quantity of Na excreted in the urine
relative to the amount filtered at the glomerulus. Measuring urine sodium con-
centration alone is not sufficient, as the sodium concentration in urine varies with
water reabsorption. It is necessary to plug in the serum and urinary creatinine
into the calculation, in order to calculate the amount of fluid and sodium that is
filtered through to glomerulus [1, 2].
Prerenal AKI can be due to intrarenal vasoconstriction, systemic vasodilation,
and volume depletion. These patients will try to compensate and retain sodium
and usually have a FENa of less than 1%. If any of the above insults continue and
become intense, the blood supply to the renal tubules is severely reduced leading
32 Urine Testing 177
to acute tubular necrosis. Once the tubules are damaged, they lose their ability to
reabsorb sodium, and the FENa will usually be greater than 2–3%.
FENa is often used in the setting of acute renal failure to help distinguish
between prerenal (decreased renal perfusion) and intrinsic renal (ATN due to
renal hypoperfusion) causes. In general, a FENa of <1% suggests prerenal
disease, between 1 and 2% is indeterminate, and >2% suggests ATN. There are
some exceptions to this, but overall, the specificity of this test is >80%.
There are limitations to FENa. The threshold used to distinguish prerenal and
intrinsic renal disease may vary; there are other causes of low FENa and salt-
wasting conditions (like diuresis) affect urinary sodium levels.
4. Contrast-induced nephropathy (CIN) is either a relative increase in serum cre-
atinine from baseline value by 25% or an absolute increase of 0.5 mg/dL within
48 to 72 h after contrast exposure not attributable to other causes and must per-
sist for 2 to 5 days. FENa may vary widely and in the minority of patients with
oliguric CIN, the FENa may be low despite lack of clinical evidence of volume
depletion [3].
Risk factors include pre-existing renal dysfunction, diabetes with renal dys-
function, age >70 years, cardiorespiratory disease, hypotension or dehydration,
and nephrotoxic medications (NSAIDs or aminoglycosides). Contrast agent vol-
ume, route of administration (intra-arterial), hyperosmolarity, and multiple doses
in 72 h also add to the risk.
Measures to decrease risk of CIN include prehydration with saline, using
the lowest dose of low osmolar contrast, IV bicarbonate infusion, N-acetylcysteine
(controversial), discontinuation of nephrotoxic drugs for 48 h prior to contrast,
and the use of hemofiltration (expensive) pre- and post-contrast use.
5. Fractional excretion of other substances such as urea and uric acid can also be
measured to determine their renal clearance to help distinguish prerenal from
intrinsic renal causes. The FEUrea may be more accurate in distinguishing ATN
from prerenal disease in patients being treated with diuretics since diuretics as
mentioned earlier cause natriuresis.
Urinary urea ´ Serum Creatinine
FEUrea ( percent ) = ´100
Serum urea ´ Urinary Creatinine
FEUrea is 50 to 65% (>0.5) in acute tubular necrosis (ATN) and usually below
35% in prerenal disease [1, 2].
6. The differential diagnosis of acute kidney injury (AKI) or acute renal failure
(ARF) in this patient with cirrhosis includes prerenal azotemia, acute tubular
necrosis, and hepatorenal syndrome (HRS). Prerenal azotemia is caused by
hypovolemia (e.g., aggressive diuresis, diarrhea, and/or gastrointestinal bleed-
ing) or by other causes of decreased effective blood volume induced by infec-
tions or vasodilators. Prerenal azotemia responds to volume expansion, and
vasoconstrictors and dialysis are not required.
Acute tubular necrosis mostly occurs in patients presenting with shock or a
history of exposure to nephrotoxins/contrast agents. Acute tubular necrosis is
treated with renal replacement therapy if indicated.
178 J.D. Srinivasan
HRS occurs in patients with cirrhosis or liver failure when there is a sudden
rapid deterioration of liver function due to an insult like gastrointestinal bleed,
infection, or excessive diuresis. It is caused by extreme vasodilatation with
consequent renal vasoconstriction and is treated with vasoconstrictors and v olume
expansion with albumin. HRS remains a diagnosis of exclusion. Therefore, the
first step in its diagnosis is to exclude the presence of structural kidney injury
(acute tubular necrosis, glomerulonephritis, and acute interstitial nephritis) or
obstructive kidney injury (obstructive uropathy) and to then distinguish between
prerenal azotemia and HRS (the two functional types of AKI in cirrhosis).
7. Renal dysfunction in HRS is functional. The pathophysiology of cirrhosis

involves portal hypertension leading to splanchnic arterial vasodilatation. The
resultant primary systemic arterial vasodilatation leads to systemic hypotension
which in turn causes activation of the neurohumoral axis with stimulation of the
renin–angiotensin–aldosterone system (RAAS), sympathetic nervous system
(SNS), and arginine vasopressin (AVP). Stimulation of the RAAS, SNS, and
AVP contributes to maintenance of blood pressure by increasing systemic vascu-
lar resistance along with the secondary increase in cardiac output. While this
compensatory neurohumoral activation attenuates any hypotension secondary to
arterial vasodilatation, renal vasoconstriction with sodium and water retention
also occurs. This resultant diminished renal function is, however, of a functional
nature and thus should not be considered ATN in the initial phases. Prolonged
and severe HRS can then lead to ATN [4, 5].
8. The RIFLE criteria were created by the Acute Dialysis Quality Initiative
(ADQI) in 2002 to define AKI.
Stage GFR Urine output

Risk 1.5–2 × Serum Cr increase or >25% GFR <0.5 mL/kg/h <6 h
decrease
Injury SCr 2–3 times or GFR >50% decrease <0.5 mL/kg/h >12 h
Failure SCr >3 times or >4 mg/dL or GFR 75% <0.3 mL/kg/h 24 h or anuria for
decrease 12 h
Loss of Persistent acute renal failure: complete
function loss of kidney function >4 weeks
(requiring dialysis)
End-stage Complete loss of kidney function
renal disease >3 months (requiring dialysis)
The limitations include a need for a baseline creatinine level, smaller increases
in creatinine (0.3 mg/dL) which can worsen outcome is not included in RIFLE; it is
a retrospective tool and does not discriminate between the nature or the site of AKI.
In 2007 the Acute Kidney Injury Network changed the RIFLE criteria to stages
in AKI [6, 7, 8].
Stage one—Increase in serum creatinine of more than or equal to 0.3 mg/dL or
increase to more than or equal to 150% to 200% (1.5- to 2-fold) from baseline.
Urine output <0.5 mL per kg per hour for more than 6 h.
32 Urine Testing 179
Stage two—Increase in serum creatinine to more than 200% to 300% (>2- to

3-fold) from baseline. Urine output <0.5 mL per kg per hour for more than 12 h.
Stage three—Increase in serum creatinine to more than 300% (>3-fold) from
baseline (or serum creatinine of more than or equal to 4.0 mg/dL or commencement
of acute renal replacement therapy (irrespective of the preceding increase in serum
creatinine level or urine output).
More recently, the Kidney Disease: Improving Global Outcomes (KDIGO)
Acute Kidney Injury Work Group proposed changes to the staging for AKI. KDIGO
covers both the AKIN and RIFLE criteria, taking into account changes in creatinine
within 48 h or a decline in the glomerular filtration rate (GFR) over 7 days [9, 10].
RIFLE, AKIN, and KDIGO scores were all good predictors of mortality in criti-
cally ill patients, and there were no differences among them in terms of predicting
death [11, 12].
References
1. Schönermarck U, Kehl K, Samtleben W. Diagnostic performance of fractional excretion of

urea and sodium in acute kidney injury. Am J Kidney Dis. 2008;51:870.
2. Vanmassenhove J, Glorieux G, Hoste E, et al. Urinary output and fractional excretion of
sodium and urea as indicators of transient versus intrinsic acute kidney injury during early
sepsis. Crit Care. 2013;17:R234.
3. Gupta RK, Bang TJ. Prevention of contrast-induced nephropathy (CIN) in interventional radi-
ology practice. Semin Intervent Radiol. 2010;27(4):348–59.
4. Munoz SJ. The hepatorenal syndrome. Med Clin North Am. 2008;92(4):813–37.
5. Low G, Alexander GJM, Lomas DJ. Hepatorenal syndrome: aetiology, diagnosis, and treat-
ment. Gastroenterol Res Pract. 2015;2015:1–11. Web
6. Goren O, Matot I. Perioperative acute kidney injury. Br J Anaesth. 2015;115(Suppl):3–14.
7. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute kidney
injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care.
2007;11(2):R31. doi:10.1186/cc5713.
8. Schrier RW. ARF, AKI, or ATN? Nat Rev Nephrol. 2010;6(3):125. doi:10.1038/nrneph.2010.1.
9. Hoste EA, Kellum JA. Acute kidney injury: epidemiology and diagnostic criteria. Curr Opin
Crit Care. 2006;12(6):531–7.
10. Roy AK, Mc Gorrian C, Treacy C, Kavanaugh E, Brennan A, Mahon NG, et al. A compari-
son of traditional and novel definitions (RIFLE, AKIN, and KDIGO) of acute kidney injury
for the prediction of outcomes in acute decompensated heart failure. Cardiorenal Med.
2013;3(1):26–37.
11. Shah SR, Tunio SA, Arshad MH, Moazzam Z, Noorani K, et al. Acute kidney injury recog-
nition and management: a review of the literature and current evidence. Glob J Health Sci.
2015;8(5):120–4.
12. Levi TM, de Souza SP, de Magalhaes JG, et al. Comparison of the RIFLE, AKIN and KDIGO
criteria to predict mortality in critically ill patients. Rev Bras Ter Intensiva. 2013;25(4):290–6.
Chapter 33
Drug Testing
Alberto J. de Armendi and Gulshan Doulatram
Fig. 33.1 Which drugs?
A.J. de Armendi, MD, PhD, MBA (*)

Sciences Center, 750 NE 13th Street, Suite 200, PO Box 5318,
G. Doulatram, MD

DOI 10.1007/978-3-319-55862-2_33
182 A.J. de Armendi and G. Doulatram
Drug Testing Questions

1 . How does substance abuse affect anesthesiology as a specialty?
2. What test would you order for suspected fentanyl substance abuse in your
patients?
3. What test would you order for suspected cocaine substance abuse in your
patients?
4. How do you test for marijuana drug use in your patients?
5. According to the American College of Surgeons certified Level I Trauma Centers,
what percentage of patients screened are positive for both alcohol and illicit drug
misuse?
6. How do you group illicit drugs and what are their anesthetic implications?
33 Drug Testing 183
Answers
1. Eighty percent of anesthesia residency programs have at least one resident with
substance abuse. One to two percent of anesthesia residents have a problem with
substance abuse. The Massachusetts General Hospital has instituted a preplace-
ment (preemployment) and post-employment random urine testing in an attempt
to lower the incidence of substance abuse among anesthesia residents [1].
Twenty-nine percent of anesthesia residents relapse after being allowed to return/
continue in an anesthesia residency program. For residents that are allowed to
return to their residency program, the initial presentation is death (10%). Forty-
three percent of program directors feel that residents in recovery should be
allowed to attempt reentry, while 30% feel that they should not [2].
2. Fentanyl can be detected by radioimmunoassay or more selective gas chromato-
graphic techniques. Urine and blood screening involving a novel enzyme-linked
immunosorbent assay (ELISA) coupled with nanoparticles for fentanyl detection
has the advantage of being simple, sensitive, inexpensive, and capable of detect-
ing metabolites [3]. Fentanyl concentrations as low as 5 pg/well can be detected
in urine and serum samples.
3. Urine radioimmunoassay test is the initial screening test for cocaine abuse and is
positive for up to 72 h after exposure. Benzoylecgonine is the main cocaine urine
metabolite tested in cocaine drug screening [4]. Gas chromatography coupled
with mass spectrometry (GC-MS) or liquid chromatography coupled with a
mass spectrometry (LC/MS) is more sensitive and sophisticated than immunoas-
say and can be done for confirmation of various drugs and their metabolites
including cocaine. The window of testing is 1–3 days for urine testing. Although
hair testing is the most sensitive for cocaine and has the widest detection window
indicating chronic use, it is not done routinely compared to urine.
4. Urine is the preferred medium to test for marijuana use because of higher con-
centrations, longer detection time of metabolites, ease of sampling, and higher
sensitivity compared to blood [5]. The major metabolite tested in marijuana use
is tetrahydrocannabinol (THC) and carboxy tetrahydrocannabinol (THCCOOH).
The detection window for urine testing is 10 h for THC and 25 days for
THCCOOH. While immunoassay is adequate for preliminary testing, advanced
chromatographic techniques are used for quantitation of levels.
5. Eleven percent of the patients screened at Level I Trauma Centers are found to be
positive for both legally intoxicated levels of alcohol and illicit drugs [6]. The use
of alcohol and illicit drugs is especially concerning due to higher incidence of
fatal and nonfatal motor vehicle accidents and higher perioperative morbidity.
6. Illicit drugs may be grouped into opioids, barbiturates, cocaine, benzodiazepines,
ephedrine groups, cannabinoids, and hallucinogenic drugs [7].
184 A.J. de Armendi and G. Doulatram
Opioid drugs (codeine, oxycodone, pentazocine, fentanyl, propoxyphene,

methadone, heroin, morphine, meperidine) are used for analgesia. They can
cause euphoria, respiratory depression, seizures, stupor, coma, and death.
Treatment for opioid withdrawal includes clonidine, diphenhydramine, doxepin,
and/or opioids (methadone or buprenorphine).
Barbiturates (secobarbital, pentobarbital, phenobarbital) are central nervous
system depressants and can cause sedation, hypotension (central vasomotor
depression and cardiac depression), and altered drug metabolism (fluoride, war-
farin, digitalis, phenytoin).
Cocaine is a central nervous system stimulant (arterial vasoconstriction)
with anesthetic concerns for increased MAC, sympathetic hyperactivity causing
hypertension/hypotension, tachycardia, increased myocardial oxygen demand,
myocardial infarction, cardiac depression, angina, coronary spasms, thrombus,
arrhythmias, and death. Other anesthetic implications include psychosis, nasal
septum perforation, restlessness, anxiety, irritability, confusion, pupillary dilata-
tion, seizures, asthma, and pulmonary hemorrhage.
Benzodiazepines (diazepam, midazolam, flunitrazepam) are antianxiety
agents and may result in respiratory depression especially with concurrent opioid
use.
Ephedrine drugs (pseudoephedrine, methamphetamines) can cause hyper-
tension, cardiac arrhythmias, dilated pupils, hyperthermia, and cardiac arrest in
the perioperative setting. The response to treatment of hypotension with vaso-
pressors is unpredictable in amphetamine-abusing patients. Acute intake of
amphetamines increases the minimum alveolar concentration (MAC) of potent
inhaled anesthetics. In contrast, chronic intake decreases the dose requirement
for general anesthetic.
Cannabinoids have some antiemetic and analgesic properties and are the
most commonly abused drugs. They can cause hallucinations and severe periop-
erative complications including cardiac arrhythmias, cardiac depression, hypo-
tension, bradycardia, respiratory depression, bronchospasm, and pulmonary
edema.
Hallucinogens [lysergic acid diethylamide (LSD), phencyclidine (PCP, ket-
amine), psilocybin, mescaline, 3,4-methylenedioxymethamphetamine (MDMA,
ectasy), γ-hydroxybutyrate (GHB)] are psychedelic drugs used for recreational
purposes. They can cause anxiety, paranoia, delusions, panic attacks, and psy-
chosis. The effects of acute drug intake usually develop over 1 to 2 h and last for
approximately 12 h. Ingestion of these drugs activates the sympathetic nervous
system causing increased body temperature, tachycardia, hypertension, and
dilated pupils. This is treated with fluids, pressors, vasodilators, and sympatho-
lytics. Exaggerated response to sympathomimetic drugs should be expected.
These drugs also prolong the analgesic and respiratory depressants effects of
opioids. Inhibition of plasma cholinesterase activity can cause prolongation of
succinylcholine action in some patients.
33 Drug Testing 185
References
1. Fitzsimons MG, Baker KH, Lowenstein E, Zapol WM. Random drug testing to reduce the
incidence of addiction in anesthesia residents: preliminary results from one program. Anesth
Analg. 2008;107(2):630–5. doi:10.1213/ane.0b013e318176fefa.
2. Bryson EO. Should anesthesia residents with a history of substance abuse be allowed to con-
tinue training in clinical anesthesia? The results of a survey of anesthesia residency program
directors. J Clin Anesth. 2009;21(7):508–13.
3. Mao CL, Zientek KD, Colahan PT, Kuo MY, Liu CH, Lee KM, Chou CC. Development of an
enzyme-linked immunosorbent assay for fentanyl and applications of fentanyl antibody-coated
nanoparticles for sample preparation. J Pharm Biomed Anal. 2006;41(4):1332–41.
4. Bruns AD, Zieske LA, Jacobs AJ. Analysis of the cocaine metabolite in the urine of patients
and physicians during clinical use. Otolaryngol Head Neck Surg. 1994;111(6):722–6.
5. Sharma P, Murthy P, Bharath MM. Chemistry, metabolism, and toxicology of cannabis: clinical
implications. Iran J Psychiatry. 2012;7(4):149–56.
6. Langdorf MI, Rudkin SE, Dellota K, Fox JC, Munden S. Decision rule and utility of routine
urine toxicology screening of trauma patients. Eur J Emerg Med. 2002;9(2):115–21.
7. Kuczkowski KM. Anesthetic implications of drug abuse in pregnancy. J Clin Anesth.
2003;15(5):382–94.
Chapter 34
Chest Pain Profiles
A 78-year-old male underwent an open AAA repair for an 8 cm infrarenal aneurysm.
His preoperative echo showed normal EF and no wall motion abnormality. During
the surgery he had an episode of surgical bleeding and hypotension with transient
ST depression which resolved with hypotension treatment and PRBC transfusion.
On postoperative day 1, the patient developed chest pain with ST depression and
elevated cardiac troponin I (cTnI) which was 15 ng/mL. An echocardiography
showed severe anteroseptal hypokinesia.
Questions
1 . Has this patient suffered an acute myocardial infarction (MI)?
2. What are troponins?
3. What is the 2012 universal classification of myocardial infarction?
4. What conditions can raise troponin levels other than MI?
5. How would you classify this patient’s perioperative MI?
6. What should be done next?
J.D. Srinivasan, MD, FRCA

Saint Louis University, School of Medicine, 3635 Vista Ave., PO Box 15250, St. Louis,
MO 63110-0250, USA

DOI 10.1007/978-3-319-55862-2_34
188 J.D. Srinivasan
Answers
1. Yes, this patient has elevated cardiac biomarkers along with symptoms of cardiac
ischemia (chest pain) with imaging evidence of regional wall motion abnormality in
the anterioseptal wall. The term acute MI is used when there is evidence of myocar-
dial necrosis in a clinical setting consistent with acute myocardial ischemia, detec-
tion of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin)
above the 99th percentile upper reference limit with at least one of the following:
(a) Symptoms of cardiac ischemia
(b) EKG changes: new significant ST-segment–T wave changes, new left bundle
branch block, or development of pathological Q waves
(c) Imaging evidence of new regional wall motion abnormality
(d) Identification of an intracoronary thrombus by angiography or autopsy
2. Troponins are protein molecules that are part of cardiac and skeletal muscle.
Smooth muscle cells do not contain troponins. Three types of troponins exist—
troponin I, troponin T, and troponin C. Each subunit has a unique function:
Troponin T binds the troponin components to tropomyosin, troponin I inhibits the
interaction of myosin with actin, and troponin C contains the binding sites for
Ca2+ that help initiate contraction. Raised troponin levels indicate cardiac muscle
cell injury and/or death as the molecule is released into the blood upon injury to
the heart. Troponins will begin to increase within 3 h following an MI. The rec-
ommended cutoff value for an elevated cardiac troponin is the 99th percentile of
a control reference group. As the troponin test kits are made by many manufactur-
ers, the cutoff values suggested by the laboratory should be used as reference [1].
3. Universal Classification of Myocardial Infarction [2]
Type 1 (spontaneous myocardial infarction): Spontaneous myocardial infarc-
tion related to atherosclerotic plaque rupture, ulceration, erosion, or dissection
with resulting intraluminal thrombus in one or more of the coronary arteries
leading to decreased myocardial blood flow or distal platelet emboli with ensu-
ing myocyte necrosis. The patient may have underlying severe CAD but on occa-
sion non-obstructive or no CAD.
Type 2 (myocardial infarction secondary to an ischemic imbalance): In
instances of myocardial injury with necrosis where a condition other than CAD
contributes to an imbalance between myocardial oxygen supply and/or demand,
e.g., coronary endothelial dysfunction, coronary artery spasm, coronary embo-
lism, tachy-/brady-arrhythmias, anemia, respiratory failure, hypotension, and
hypertension with or without LVH.
Type 3: Myocardial infarction results in death when biomarker values are
unavailable.
Type 4a: Myocardial infarction related to percutaneous coronary intervention
(PCI).
Type 4b: Myocardial infarction related to stent thrombosis.
Type 5: Myocardial infarction related to coronary artery bypass grafting
(CABG)
34 Chest Pain Profiles 189
4. Causes of troponin elevation other than MI include the following:

(a) Myocarditis
(b) Pericarditis
(c) Cardiac contusion/trauma
(d) Aortic dissection
(e) Endocarditis
(f) Cardiac surgery
(g) Pulmonary embolism
(h) Stroke (ischemic or hemorrhagic)
(i) Cardiopulmonary resuscitation (CPR)
(j) Defibrillation
(k) Chronic severe heart failure
(l) Cardiac arrhythmias (tachyarrhythmias, brady-arrhythmias, heart blocks)
(m) Sepsis
(n) Renal failure
(o) Hypertrophic obstructive cardiomyopathy (HOCM)
(p) Takotsubo cardiomyopathy
(q) Burns
(r) Extreme exertion
(s) Infiltrative diseases such as amyloidosis
(t) Medications and toxins such as doxorubicin, trastuzumab, and snake venom
(u) Transplant vasculopathy
(v) Critical illness
5. This patient has suffered a perioperative MI, either Type 1 or type 2.
Acute Coronary Syndrome (Type 1 PMI)
Acute coronary syndrome occurs when an unstable or vulnerable plaque
undergoes spontaneous rupture, fissuring, or erosion, leading to acute coronary
thrombosis, ischemia, and infarction. Although it is currently widely accepted
that intraplaque inflammation plays a pivotal role in plaque instability and spon-
taneous acute coronary syndrome, external stressors such as those occurring
postoperatively are believed to contribute.
(a) Physiological and emotional stresses are known to predispose to
MI, likely because of the sympathetic induced hemodynamic, coro-
nary vasoconstrictive, and prothrombotic forces thought to promote
plaque disruption. These conditions are common perioperatively.
Catecholamines and cortisol increase after surgery and may remain
elevated for days. Stress hormones increase with pain, surgical trauma,
anemia, and hypothermia.
(b) Tachycardia and hypertension, common in the perioperative period,
may exert shear stress, leading to rupture of plaques with outward
(positive) remodeling, thin fibrous caps, and high circumferential ten-
sile stress or to endothelial stripping/erosion caused by high blood
velocities around plaques with inward (negative) remodeling and
severe coronary stenosis.
190 J.D. Srinivasan
Myocardial Oxygen Supply-Demand Imbalance (Type 2 PMI) [3]

Numerous studies using perioperative Holter monitoring in high-cardiac-risk
patients undergoing major surgery showed that silent, heart rate-related ST-
segment depression is common postoperatively and is associated with in-hospi-
tal and long-term morbidity and mortality. Postoperative cardiac complications,
including sudden death, occurred after prolonged silent ST-segment depression.
These findings were further corroborated by studies that correlated continuous,
online 12-lead ST-segment analysis with serial cardiac troponin measurements
after major vascular surgery. Cardiac troponin elevations occurred after prolonged
transient, postoperative ST-segment depression, and peak troponin elevations
correlated with the duration of ST depression. ST elevation occurred in <2% of
postoperative ischemic events and was a rare cause of PMI. Hence, prolonged,
ST-depression-type ischemia is the most common cause of PMI.
6. There are no clear algorithms or guidelines to navigate treatment in perioperative
MIs. This is also addressed in Chap. 15. The cardiology team is consulted and
involved early. Steps should be taken to ensure adequate oxygen supply to the
myocardium by addressing issues with oxygen saturation and anemia. Myocardial
oxygen demand should be reduced by controlling tachycardia and hypertension.
There are no randomized controlled trials to clarify if PCI or systemic anticoagu-
lation is beneficial in the perioperative setting. Retrospective analysis of over
1000 cases of perioperative MI showed that the 30-day mortality of patients who
received diagnostic catheterization was 5.2%. Those who received PCI had a
30-day mortality of 11.3%. Part of this mortality is attributed to the large postop-
erative hemorrhage risk of anticoagulation. Clinical decision making should be
made on a case by case risk benefit analysis [4, 5].
References
1. Priebe HJ. Perioperative myocardial infarction—aetiology and prevention. Br J Anaesth.

2005;95(1):3–19.
2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Writing Group on
behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of
Myocardial Infarction. Third universal definition of myocardial infarction. J Am Coll Cardiol.
2012;60(16):1581–98.
3. Landesberg G, Mosseri M, Zahger D, Wolf Y, Perouansky M, Anner H, Drenger B, Hasin Y,
Berlatzky Y, Weissman C. Myocardial infarction after vascular surgery: the role of prolonged
stress-induced, ST depression-type ischemia. J Am Coll Cardiol. 2001;37(7):1839–45.
4. Adesanya AO, Lemos JA, Greilich NB, Whitten CW. Management of perioperative myocardial
infarction in noncardiac surgical patients. Chest. 2006;130(2):584–96.
5. Dauerman HL. The expanding universe of perioperative myocardial infarction. J Am Coll
Cardiol. 2016;68(4):339–42. doi:10.1016/j.jacc.2016.03.601.
Chapter 35
BNP
A 67-year-old man presented to the ER with increasing shortness of breath, tired-

ness, and weight gain. Immunoassay for BNP showed a value of 800 pg/mL.
Questions
1 . What is BNP and NT-proBNP?
2. What are the normal levels and conditions that cause elevated levels?
3. How do these markers aid in the diagnosis of heart failure?
4. What are the other uses outside diagnosing heart failure?
5. Are there limitations?
6. What is heart failure and why is it important to diagnose it?
T. Nicolescu, MD (*)

DOI 10.1007/978-3-319-55862-2_35
Answers
1. B-type natriuretic peptide is also called brain-type natriuretic peptide (BNP) as
it was first described in 1988 after isolation from porcine brain. However, it was
soon found to originate mainly from the heart. B-type natriuretic peptide (BNP)
and N-terminal proBNP (NT-proBNP) are released by the ventricular myocar-
dium in response to myocardial wall stress initially as a 108 amino acid prohor-
mone. It is cleaved by enzymes corin/furin to BNP the 32 amino-acid, biologically
active part of the prohormone and NT-proBNP which is the 76 amino acid, bio-
logically inactive compound. BNP produces a variety of biological effects by
interaction with the natriuretic peptide receptor type A (NPR-A) causing intra-
cellular cGMP production. These include natriuresis/diuresis, peripheral
vasodilatation, and inhibition of the renin–angiotensin–aldosterone system

(RAAS) and the sympathetic nervous system (SNS).
All effects ultimately lead to decreased afterload.
BNP has a half-life of 20 min and is cleared by binding to the natriuretic pep-
tide receptor type C (NPR-C) and through proteolysis by endopeptidases. NT-
proBNP has a half-life of 120 min and is cleared by renal excretion [1, 2].
2. BNP levels are normally less than 100 pg/mL and the NT-proBNP is less than
300 pg/mL [2]. The levels are higher in:
(a) females due to differences in metabolism
(b) advancing age
(c) worsening renal function (NT-proBNP affected more due to renal clearance)
(d) LV hypertrophy
(e) Systolic and diastolic dysfunction
(f) Fluid overload
3. BNP and NT pro BNP serve as good markers of heart failure. The levels for both
markers are different to exclude or confirm the diagnosis of heart failure [3].
BNP—level < 100 pg/mL heart failure (HF) unlikely; level > 500 pg/mL HF
very likely.
Levels 100–500 use clinical judgment.
NT-proBNP—level < 300 pg/mL HF unlikely
Age < 50 years, level > 450 pg/mL—HF likely
Age 50–75 years, level > 900 pg/mL—HF likely
Age > 75 years, level > 1800 pg/mL—HF likely
A good correlation has been made between increasing levels of BNP and
functional class of NYHA classification as depicted in the Fig. 35.1.
4. BNP and NT-proBNP provide strong prognostic information, and elevated lev-
els are associated with an unfavorable outcome (death, sudden cardiac death,
readmission, or cardiac events) in patients with heart failure or asymptomatic left
ventricular dysfunction [3, 4].
They are also useful for choosing optimal treatment and monitoring its effects
in heart failure.
35 BNP 193
Beta-peptide natriuretic hormone and heart failure

1200
Median BNP Concentration (pg.mL)
1000
800
600
400
200
0
Non-CHF NYHA Class I NYHA Class II NYHA Class III NYHA Class IV
Fig. 35.1 BNP and heart failure
The current American College of Cardiology/American Heart Association

(ACC/AHA) guidelines for managing heart failure have incorporated using
natriuretic peptide levels in establishing the prognosis and disease severity of
chronic heart failure.
In patients with severe heart failure BNP and NT-proBNP assays can be used
in resynchronization therapy.
Both are also used as markers and to aid in prognosis in acute and stable coro-
nary heart disease. Higher values are associated with worse outcomes [5].
In aortic stenosis, the levels indicate disease severity, progression, functional
status, and also the optimum time for valve replacement after which the levels
decline.
In atrial fibrillation, the levels are elevated and predict the success of
cardioversion.
5. Limitations include false low levels in:
(a) Obesity
(b) Early acute heart failure
(c) Heart failure due to causes upstream from the left ventricle, e.g., mitral valve
or pericardial disease
False high levels as already mentioned in:
(a) Females
(b) Advancing age
(c) Renal failure
6. Heart failure affects approximately 5.7 million Americans, and about 670,000
new cases are diagnosed annually in the United States. It is a leading cause of
hospital admissions and readmissions in people over 65 years. The estimated
total health-care cost of HF in the United States in 2010 was $39.2 billion or
1–2% of all health-care expenditures. The risk of death is about 35% in the year
after diagnosis after which it decreases to below 10% each year.
HF is either diastolic, decreased left ventricular filling, or systolic, decreased
pump function. It is a diagnosis that is made clinically by history (breathlessness
and fatigue) and physical exam (elevated jugular venous pressure and lung
crackles). These features are not sensitive or specific, and there is no gold stan-
dard investigation to make the diagnosis. The severity is classified based on
symptoms and functional limitations into four grades according to the New York
Heart Association. Patients with heart failure suffer a decreased quality of life
with significantly reduced physical and mental health. So, early diagnosis of
heart failure, identification of the cause to determine reversibility, and institution
of appropriate management strategies which include lifestyle changes, medica-
tions, and/or surgery can potentially make a big impact on the quality and dura-
tion of life.
References
1. Klabunde R. Cardiovascular physiology concepts. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2011.
2. Weber M, Hamm C. Role of B-type natriuretic peptide (BNP) and NT-proBNP in clinical rou-
tine. Heart. 2006;92:843–9.
3. Van Kimmenade R, Pinto YM, Bayes-Genis A. Usefulness of intermediate amino-terminal pro-
brain natriuretic peptide concentrations for diagnosis and prognosis of acute heart failure. Am
J Cardiol. 2006;98:386–90.
4. Oremus M, McKelvie R, Don-Wauchope A. A systematic review of BNP and NT-proBNP in
the management of heart failure: overview and methods. Heart Fail Rev. 2014;19:413–9.
5. Berry C. Predictive value of plasms brain natriuretic peptide receptors for cardiac outcome
after vascular surgery. Heart. 2005;92(3):401–23.
Chapter 36
Blood Gas I
Tanmay Shah
A 36-year-old woman presents to the emergency room with severe abdominal pain,
nausea, vomiting, anorexia, and somnolence.
ABG: pH 7.20, PCO2 35 mmHg, pO2 68 mmHg on room air
Laboratory values: Na 130 mEq/L, Cl 80 mEq/L, HCO3 10 mEq/L
1 . How do you diagnose a simple acid–base disorder?
2. What blood gas abnormality does this patient have?
3. How do you calculate anion gap and corrected anion gap?
4. How do you diagnose a mixed acid–base disorder and does this patient have
mixed acid–base disorder?
5. What is Winter’s formula?
6. Is there any compensation in this blood gas value?
7. What are the possible causes of metabolic acidosis?
8. What are the possible causes of respiratory acidosis?
T. Shah, MD, MBBS


DOI 10.1007/978-3-319-55862-2_36
196 T. Shah
Determine
oxygenation
pH <7.35 Determine pH >7.35

Acidemic pH Alkalemic
Respiratory Respiratory
or metabolic or metabolic
[HCO3] < pCO2 > pCO2 < [HCO3] >

24 mEq/L 40 mmHg 40 mmHg 24 mEq/L
Metabolic Respiratory Respiratory Respiratory

acidosis acidosis or metabolic or metabolic
AG <12
Anion gap
AG >12 Acute or chronic
Gap Nongap
∆ Gap
Adequate
respiratory
compensation
Fig. 36.1 Diagnosis of acid–base disorders (This figure was published in Miller textbook, Chap.
21 in 2011. Permission obtained from Elsevier to reproduce the image.)
Answers
1. Initially the pH is used to determine acidosis or alkalosis, and then the value of
PaCO2/HCO3 is used to determine if the derangement is metabolic or respiratory.
If it is of respiratory origin, then we will have to determine whether the process
is acute or chronic. If it is due to a metabolic component, then respiratory com-
pensation should be calculated using the appropriate formula.
2. Our patient has a pH less than 7.4, which signifies acidosis. The HCO3 is less
than 24 mEq/L; therefore the primary abnormality in this patient is metabolic
acidosis. This chart (Fig. 36.1) shows the steps to follow in order to diagnose an
acid–base disorder [1].
3. Anion gap (AG) = Na − (Cl + HCO3)
(a) AG is the difference in the ‘routinely measured’ cations (Na) and ‘routinely
measured’ anions (Cl and HCO3) in the blood and depends on serum phos-
phate and albumin concentrations [2]. Determination of AG is useful in deter-
mining the cause of acidosis [3, 4]. The normal value for serum AG is usually
8–12 mEq/L. In our patient, AG = 130 − (80 + 10) = 40 mEq/L. So, this
patient has a high AG, most likely due to starvation or diabetic ketoacidosis.
36 Blood Gas I 197
(b) In a normal healthy patient, negatively charged albumin is the single largest
contributor to the AG [5]. Hypoalbuminemia causes a decrease in AG; hence
AG is corrected to albumin level using the equation of Figge as follows: cor-
rected AG = AG + [0.25 × (44 – Albumin)] [6].
• If corrected AG >16, there is high AG acidosis.
• If corrected AG <16, non-AG acidosis.
4. Delta gap formula can be used to assess mixed acid–base disorder.
(a) Δ gap = AG − 12 + HCO3 (12 is normal serum AG value)
• If Δ gap <22 mEq/L, then concurrent non-gap metabolic acidosis exists.
• If Δ gap >26 mEq/L, then concurrent metabolic alkalosis exists.
(b) In our patient, Δ gap = 40 − 12 + 10 = 38 mEq/L. So, there is a concurrent

metabolic alkalosis probably from vomiting in addition to high AG meta-
bolic acidosis in this patient.
So, there is a concurrent metabolic alkalosis probably from vomiting in
addition to high AG metabolic acidosis in this patient.
5. Winter’s formula is used to determine whether there is an appropriate respiratory
compensation during metabolic acidosis [1].
(a) Winter’s formula: PCO2 = (1.5 × HCO3) + 8
• If measured PCO2 > calculated PCO2, then concurrent respiratory acido-
sis is present.
• If measured PCO2 < calculated PCO2, then concurrent respiratory alkalo-
sis is present.
6. In our patient, calculated PCO2 = (1.5 × 10) + 8 = 23 mmHg according to Winter’s
formula.
Our measured PCO2 of 35 mmHg is higher than the calculated PCO2 of
23 mmHg, so our patient also has concurrent respiratory acidosis. Usually,
metabolic acidosis is compensated by respiratory alkalosis, but due to somno-
lence in this patient, concurrent respiratory acidosis exists.
7. Causes of anion gap metabolic acidosis are easily remembered by pneumonic
MUDPILES [1].
M: methanol
U: uremia
D: diabetic ketoacidosis
P: paraldehyde
I: infection, INH therapy
L: lactic acidosis
E: ethanol, ethylene glycol
S: salicylates (aspirin)
198 T. Shah
Causes of non-gap metabolic acidosis:

• Excessive administration of 0.9% normal saline
• GI losses: diarrhea, ileostomy, neobladder, pancreatic fistula
• Renal losses: renal tubular acidosis
• Drugs: acetazolamide
8. Respiratory acidosis which is from increased CO2 is due either to increased pro-
duction or decreased elimination [2].
(a) Increased production of CO2:
• Malignant hyperthermia
• Hyperthyroidism
• Sepsis
• Overfeeding
(b) Decreased elimination of CO2:

• Intrinsic pulmonary disease (pneumonia, ARDS, fibrosis, edema)
• Upper airway obstruction (laryngospasm, foreign body, OSA)
• Lower airway obstruction (asthma, COPD)
• Chest wall restriction (obesity, scoliosis, burns)
• CNS depression (anesthetics, opioids, CNS lesions)
• Decreased skeletal muscle strength (myopathy, neuropathy, residual
effects of neuromuscular blocking drugs)
• Rarely, an exhausted soda–lime or incompetent one-way valve in an anes-
thesia delivery system can contribute to respiratory acidosis.
References
1. Miller RD, Pardo MC Jr. Basics of anesthesia. 6th ed. Philadelphia: Elsevier Saunders; 2011.
2. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: McGraw-
Hill; 2006.
3. Emmett M, Narins RG. Clinical use of the anion gap. Medicine (Baltimore). 1977;56(1):
38–54.
4. Barash PG, et al. Clinical anesthesia. 6th ed. Philadelphia: Lippincott Williams & Wilkins;
2009.
5. Feldman M, Soni N, Dickson B. Influence of hypoalbuminemia or hyperalbuminemia on the
serum anion gap. J Lab Clin Med. 2005;146(6):317–20.
6. Hatherill M, Waggie Z, Purves L, et al. Correction of the anion gap for albumin in order to
detect occult tissue anions in shock. Arch Dis Child. 2002;87(6):526–9.
Chapter 37
Blood Gas II
Daniel A. Biggs
A patient is unresponsive and taking shallow breaths in the recovery room. Arterial
blood gas shows:
pH—7.26, CO2—69, O2—54, HCO3−—25
Questions
1 . What does the blood gas show?
2. What is the difference between hypoxia and hypoxemia?
3. What is the most common cause of hypoxia seen in the perioperative period?
4. What are some other possible causes of hypoxia?
5. What are some of the physiologic effects, signs, and symptoms?
6. How would you treat hypoxia?
7. What is the alveolar gas equation and how might it help in identifying the cause
of hypoxia?
D.A. Biggs, MD, MSc


DOI 10.1007/978-3-319-55862-2_37
200 D.A. Biggs
Answers
1. The blood gas shows hypoxia (pO2 less than 60) along with respiratory acidosis
with little metabolic compensation [1].
2. Hypoxia is a failure of the delivery of adequate amounts of oxygen to tissue. This
can be local, regional, or global. Hypoxemia is a low blood oxygen content. SaO2
<90%, PaO2 <60 mmHg.
3. Hypoventilation is a common problem noted in the postoperative period. There
are a number of possible causes [1]. Some of the more common etiologies that
might be seen in the PACU:
(a) Poor respiratory drive—may be caused by narcotics, sedatives, and inhala-
tional anesthetic agents.
(b) Muscle weakness—most commonly related to residual neuromuscular

blockade. It could also be seen in patients with neuromuscular disease.
(c) Airway obstruction—could be secondary to residual muscle weakness, air-
way surgery, or laryngospasm. The patient could have a history of obstruc-
tive sleep apnea.
4. Hypoxia can be divided [2]:
(a) Hypoxic hypoxia—an inadequate amount of oxygen getting to the lungs [1]
• Low inspired oxygen concentration, e.g., high altitude
• Airway obstruction
• Hypoventilation [3]
• Neuromuscular disease
• Shunting and V/Q mismatch [1, 3]
• Interstitial lung disease
(b) Anemic hypoxia
• Low hemoglobin level
• Abnormal hemoglobin, e.g., methemoglobin or carbon monoxide poison-
ing [1]
(c) Stagnant or circulatory hypoxia—inadequate blood flow to the tissues
• Generalized—causes
–– Low cardiac output—heart failure, MI [3]
–– Poor cardiac venous return
–– Shock
• Localized—causes
–– Anything which limits flow to the local tissue
(d) Histotoxic hypoxia
• Cells are unable to utilize oxygen, e.g., cyanide toxicity
5. Effects will vary based on the cause and what tissues are hypoxic.
(a) Generalized hypoxia—signs and symptoms [1]
• Tachypnea
• Tachycardia
• Shortness of breath
• Sweating
37 Blood Gas II 201
• Cyanosis (cherry red skin color in cyanide toxicity)

• Headache
• Confusion
• Restlessness
• Seizure
• Coma
6. Initial treatment is oxygen administration. Further therapy may be required
depending on the cause. Examples:
(a) Acute asthma exacerbation—bronchodilators
(b) Embolus or thrombus—removal
7. Alveolar gas equation [3]
(a) PA O 2 = FO ( )
i 2 Patm - PH 2 O - Pa CO 2 / R
PAO2—partial pressure of alveolar O2

FiO2—fraction of inspired O2
Patm—atmospheric pressure
PH2 O —partial pressure of water vapor
PaCO2—partial pressure CO2 in arterial blood
R—respiratory exchange ratio, usually 0.8
Alveolar–arterial gradient [3]
(b) A–a gradient = PAO2 − PaO2
PaO2—partial pressure of arterial O2
A–a gradient may be used to help determine the cause of hypoxia. The gradient
increases with age. Normal gradient is less than 10 mmHg plus 1 mmHg per
decade of life.
Hypoxia with normal A–a gradient
• Hypoventilation
• Low partial pressure of inspired O2 such as at high altitudes
Hypoxia with high A–a gradient
• Diffusion impairment in alveolus
• V/Q mismatch
• Right to left shunt
References
1. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, editors. Clinical
Anesthesia. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.
2. Federal Aviation Administration [Internet]. Beware of Hypoxia [2015 Jul 21, cited 2016
Jul 24]; [3 screens]. Available from: https://www.faa.gov/pilots/training/airman_education/
topics_of_interest/hypoxia/
3. Miller RD. Miller’s Anesthesia. 8th ed. Philadelphia: Elsevier Saunders; 2015.
Chapter 38
Blood Gas III
Pramod Chetty
A patient with closed fracture of the lower extremity is scheduled for an ORIF. The
patient is an unaccompanied, slender, 26-year-old male who cannot give a good his-
tory due to confusion and has deep, rapid breathing with a distinctive odor. His vital
signs show mild hypotension, tachycardia, and low-grade fever. Investigations dem-
onstrate Na+ 132, K+ 4.8, Cl− 92, HCO3− 12, BUN 24 mg, creatinine 1.6 mg, Ca++
7.8 mg, and blood sugar of 318 mg/dl. Arterial blood gas shows a pH of 7.24, PCO2
28, PO2 76, HCO3 12, BE of 14, and O2 sat of 93%. His CBC is normal with mild
leukocytosis and evidence of hemoconcentration. The chest X-ray is unremarkable
and EKG shows sinus tachycardia.
1. What is the likely initial diagnosis of this patient and how can you confirm the
diagnosis?
2. What are abnormal laboratory values in the BMP and ABGs that are seen in this
condition?
3. What is the major differential diagnosis in this clinical condition?
4. What are the principles in the treatment of this condition?
5. How do the results of the BMP and ABG trend during the treatment of this
condition?
6. How will you continue management of this patient with the planned surgery?
P. Chetty, MD
Department of Anesthesiology, OU Health Sciences Center,
750 NE 13th Street, Suite 200, PO Box 53168, Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_38
204 P. Chetty
Answers
1. The presentation of this young patient with altered sensorium, “Kussmaul”
breathing, hyperglycemia, and metabolic acidosis strongly suggests diabetic
ketoacidosis (DKA). The diagnosis can be confirmed by the presence of ketone
bodies in the urine and serum [1]. Concomitant lactic acidosis must also be
investigated [2, 3]. As with any patient with a traumatic injury and altered senso-
rium, radiological testing for cervical spine and cranial pathology must be done.
2. The laboratory values in DKA will show evidence of metabolic acidosis, electro-
lyte derangements, and evidence of severe dehydration [4].
(a) BMP
• Na+—there is a total body loss of Na+; the levels can be low normal.
Correction must be made for undermeasurement of Na+ due to hypergly-
cemia (add 1.6 meq/L to the measured Na+ for every 100 mg of glucose
above 100 mg/dl level).
• K+—there can be a significant total body loss of 3–10 meq/kg of K+. The
initial serum K+ level may be paradoxically high due to both volume
contraction and decreased movement into the intracellular compartment
[1].
• Cl−—will be decreased.
• HCO3−—will be decreased.
• Anion gap—will be increased above normal 10–14 meq/L [5]. This gap is
calculated by the formula:
AG = Na+ − (Cl− + HCO3−)
• BUN—will be increased.
• Creatinine—may be mildly increased.
• Ca++—may be decreased. Additionally magnesium and phosphate deple-
tion can also occur.
• Glucose—increases to levels greater than 250–600 mg/dl [4] but rarely
may be normal, when called euglycemic DKA [6].
(b) ABG
• pH—usually less than 7.3
• PaCO2—usually lower due to respiratory compensation for metabolic
acidosis
• PaO2—usually low normal unless a pneumonic process causes it to be
low
• HCO3—will be lower due to metabolic acidosis
• BE—will be lower to indicate significant metabolic acidosis
• O2 saturation—will be in the low 90 s with O2 supplementation unless a
pneumonic process causes it to be lower
3. The major differential diagnosis in this scenario would be non-ketotic hyperosmolar
hyperglycemia (NHH) [1]. In this condition the patient is generally a type 2 diabetic
and as such would likely be an older and often overweight patient. The patient can
38 Blood Gas III 205
present with altered mentation or in a coma. The blood sugar levels are frequently
higher (>600 mg/dl) and there is no ketone body formation [4]. Therefore metabolic
acidosis if present would likely be due to the precipitant cause such as infection with
lactic acidosis. The reason for the absence of ketone bodies is due to the presence of
some circulating insulin. This insulin can prevent the alteration in fatty acid metabo-
lism leading to ketosis but due to peripheral insulin resistance still leads to very high
serum glucose levels [6]. The presence of increased insulin counter regulatory hor-
mones (esp. glucagon) exacerbates the hyperglycemia due to increased hepatic glu-
coneogenesis [7, 8]. The resultant osmotic diuresis leads to the severe dehydration
(~12 L loss), azotemia, and hyperosmolarity (>330 mOsm/L) [4].
Serum osmolarity is calculated by the formula 2(Na+ + K+) + Glucose/18 + B
UN/2.8.
The precipitating causes can be infection, stoppage of medication, newly
diagnosed diabetes, stroke, MI, subdural hematoma, and GI diseases. The treat-
ment of this condition is hydration, correction of electrolyte aberrations, and
treatment of the causative process. Insulin use will be needed to gradually bring
down the blood sugar.
4. The principles for treatment of DKA are
(a) Insulin therapy to decrease hyperglycemia and stop production of ketone
bodies.
(b) Hydration with isotonic solutions. Deficit may be up to 9 L in the average
adult.
Start with saline and convert to isotonic fluids with K+ when K+ levels
start to decrease, and urine output is maintained [9]. Change to hypotonic
solution if Na+ level >150 meq/L [6].
Bicarb therapy is only reserved for severe acidosis (pH < 7.1).
(c) Replacement of other specific electrolytes Ca++, Mg++, PO4.
(d) Treatment of precipitating cause—infections, interruption of insulin, MI,
trauma, stress.
(e) Mental status changes—may need to have airway protected and ventilator
assistance.
(f) Ileus and other GI presentations, e.g., acute cholecystitis, either due to sys-
temic ketosis or incidental, must be clinically managed.
5. The trending changes for electrolytes and the ABG with treatment will be:
(a) BMP
• Na+—should be in the upper normal range.
• K+—after initial fluid resuscitation with use of NS (first 4 h), the K+ levels
will drop associated with the intracellular migration due now to the pres-
ence of insulin. K+ can be added to IV fluids once the level goes below
4 meq/L, and a steady urine output is maintained.
• Cl−—will increase with use of normal saline (NS). Excessive use of NS
can lead to hyperchloremic acidosis.
• HCO3—use of replacement NaHCO3 is not required unless acidosis is
severe (<pH7.1).
206 P. Chetty
• Anion gap—will move toward normal gap of <11 meq/L.

• BUN—azotemia, if present, will normalize with hydration and increased
urine production.
• Creatinine—as volume status and GFR improves, it should normalize
unless kidneys are affected.
• Ca++—can be low due to loss from osmotic diuresis—careful augmenta-
tion along with associated Mg++ and phosphate supplementation for their
measured deficiencies.
• Glucose—the target is to gradually bring the blood sugar (BS) level down
~75–100 mg/h using regular insulin as an IV bolus (0.1 u/kg) followed by
continuous infusion IV (0.1 u/kg/h) [4]. Rates of insulin infusion can be
progressively ramped up with use of any standard protocol. Once BS
levels reach the lower 200 s/dl, then 5% glucose should be added to the
IV fluids to prevent hypoglycemia [10]. Target blood sugar is in the range
120–150 mg/dl.
(b) ABG
• pH—with hydration alone, the acidosis should start to correct. Insulin is
needed to prevent further ketone production and bring down glucose
levels.
• PaCO2—as metabolic acidosis is corrected, the respiratory alkalosis
should normalize.
• PaO2—with normalization of vascular volume, the oxygenation should
improve.
• HCO3—if there is severe metabolic acidosis, then correction with exog-
enous bicarb will be required. Level should normalize with decreased
ketone body formation and elimination of the same by the normal buffer
systems.
• BE—abnormality will normalize with therapy.
• O2 saturation—with fluid resuscitation the maintenance of normal O2
saturation will be easier.
6. Once the patient has had definitive treatment for DKA and has shown metabolic
stabilization, surgery can proceed. The principles for perioperative management
would include:
(a) Continuing the use of appropriate fluids and electrolyte and IV insulin
administration by infusion.
(b) Precautions for a full stomach before induction if not already intubated.
(c) Type 1 diabetics can have a difficult airway due to stiffening of tissues of the
upper airway and rigidity of the cervical spine [7].
(d) Arterial line and good venous access for this particular case would be appro-
priate. Central venous access for volume estimation in major surgery or in
patients with comorbidity would be appropriate.
38 Blood Gas III 207
(e) Glucose checks at least hourly under anesthesia with BMP and ABG at regu-
lar intervals.
(f) At the end of the procedure, extubation would depend on preinduction sta-
tus, intraoperative course, and emergence profile. The postoperative care
should continue in an ICU setting with treatment for both initiating and
coexisting clinical issues.
(g) Once stable, the diet and treatment plan must be made with type, amount,
and route of administration of insulin determined.
References
1. Magee MF, Bhatt BA. Management of decompensated diabetes. Diabetic ketoacidosis and
hyperglycemic hyperosmolar syndrome. Crit Care Clin. 2001;17(1):75–106.
2. Lu J, Zello GA, Randell E, Adeli K, Krahn J, Meng QH. Closing the anion gap: contribution
of D-lactate to diabetic ketoacidosis. Clin Chim Acta. 2011;412(3–4):286–91.
3. Cox K, Cocchi MN, Salciccioli JD, Carney E, Howell M, Donnino MW. Prevalence and sig-
nificance of lactic acidosis in diabetic ketoacidosis. J Crit Care. 2012;27(2):132–7.
4. Kasper DL, Jameson JL, Hauser S, Loscalzo J, Fauci AS, Longo D, editors. Harrison’s prin-
ciples of internal medicine. 19th ed. New York: McGraw-Hill Medical; 2015. Chap. 418.
5. Roizen MF, Fleisher LA. Anesthetic implications of concurrent disease. In: Miller RD, editor.
Miller’s anesthesia. 8th ed. Philadelphia: Churchill Livingstone/Elsevier; 2015.
6. Delaney MF, Zisman A, Kettyle WM. Diabetic ketoacidosis and hyperglycemic hyperosmolar
nonketotic syndrome. Endocrinol Metab Clin N Am. 2000;29(4):683–705.
7. McAnulty GR, Robertshaw HJ, Hall GM. Anaesthetic management of patients with diabetes
mellitus. Br J Anaesth. 2000;85(1):80–90.
8. Nattrass M. Diabetic ketoacidosis. Medicine. 2010;38(12):667–70.
9. Chua HR, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, et al. Plasma-Lyte
148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care.
2012;27(2):138–45.
10. Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in dia-
betes mellitus. Diabetes Res Clin Pract. 2011;94(3):340–51.
Chapter 39
Blood Gas IV
Below are the values obtained on arterial blood gas measurement of a patient on
cardiopulmonary bypass (CPB).
pH 7.44
pCO2 30.8 mmHg
pO2 354 mmHg
BE 3 mmol/L
HCO3 27 mmol/L
SpO2 100%
Sample type: arterial

FiO2: 35
Temp: 30°C
1 . What type of clinical test is this and what does it measure?
2. What is the importance of temperature in the reported result?
3. What is the pH-stat approach?
4. What is the α-stat approach?
5. Which is better?

Associate Professor for Anesthesia and Pain, Department of Anesthesiology, UTMB,
Galveston, TX, USA

DOI 10.1007/978-3-319-55862-2_39
210 R. Govindaraj
Answers
1. This is an arterial blood gas (ABG) analysis; it gives information about the ade-
quacy of a patient’s gas exchange and acid–base status. It is used perioperatively,
during CPB and also in severe lung disease (severe asthma in the ER), cardiac
and kidney failure, uncontrolled diabetes, severe infections, drug overdose, and
also in the ICU. An abnormal pH value as in acidosis or alkalosis can occur in
disease states. ABG helps us to determine if the acid–base derangement is respi-
ratory or metabolic in origin. The result is always reported taking into consider-
ation the temperature of the patient at the time of collection.
2. The arterial blood sample is preheated to 37°C prior to measurement. If the
actual patient temperature is keyed in, modern blood gas machines will report
the pH value for that temperature as well. This is calculated mathematically from
the pH measured at 37°C. For clinical use, the Rosenthal correction factor is
recommended and is done as follows:
Change in pH = 0.015 pH units per degree Celsius change in temperature.
According to Henry’s law, the solubility of a gas increases with decrease in tem-
perature. PO2 is 5 mmHg lower and PCO2 is 2 mmHg lower for each degree
below 37°. Hypothermia causes a decrease in the PCO2 (hypocarbia) and a con-
comitant increase in the pH (alkalemia), yet the total body CO2 content remains
the same. There are two blood gas management strategies in hypothermia—tem-
perature correction (pH stat) or not (α stat). These have different effects on cere-
bral blood flow, oxygen dissociation curve, and intracellular enzyme and protein
activity.
3. In the pH-stat strategy (in hypothermic CPB or deep hypothermic circulatory
arrest [DHCA]), blood gases are corrected to patient’s temperature by decreasing
the CPB gas sweep rate (which decreases the removal of CO2) or adding CO2 to
the oxygenator to maintain a constant pH of 7.4 and PCO2 of 40 mmHg at vary-
ing patient temperature. pH stat requires an increased total body CO2 content to
maintain neutrality during hypothermia thereby producing an acidotic state.
The increased PCO2 exerts a cerebral vasodilatory effect (loss of autoregula-
tion). Proposed benefits of pH stat include rightward shift of the oxyhemoglobin
dissociation curve increasing oxygen delivery, increased cerebral blood flow
(CBF) decreasing the risk of cerebral ischemia during CPB, more complete and
faster cooling, and greater suppression of cerebral metabolic rate [1–3].
4. In the α-stat approach, there is no temperature correction; blood gases are always
interpreted at the same normal (37°C) temperature irrespective of the actual
patient temperature. Neutrality is maintained only at 37°C permitting the hypo-
thermic alkaline drift. No CO2 is added and cerebral autoregulation is
maintained.
Alpha is the ratio of protonated to total imidazole of histidine (degree of dis-
sociation) residues among protein molecules at 37°C. At the normal intracellular
pH of 6.8, it is 0.55. The alpha value remains constant despite changes in tem-
39 Blood Gas IV 211
perature as the pK (dissociation constant) changes with temperature. This is opti-

mal for intracellular enzyme structure and function which is the reason cited by
its proponents who also argue that the increased CBF with the pH stat strategy
may put the brain at risk from microemboli or cerebral edema. They also argue
that the alkaline pH in the α-stat approach is beneficial before the ischemic insult
of circulatory arrest [4, 5].
5. The debate over the optimal blood gas management is not over. This may not be
important in moderate hypothermia but may be critical in deep hypothermia. In
adults α-stat strategy is preferred to maintain cerebral autoregulation and limit
cerebral embolic load, and in neonates and children, the pH-stat strategy demon-
strated better outcomes. The reason for the difference may be related to the dif-
ferences in the mechanism of brain injury on CPB. In children, due to the
aortopulmonary collaterals causing hypoperfusion, the pH-stat strategy with its
increased CBF seemed to provide benefit [6].
Easy way to remember: In pH stat you pour CO2 into the circulation. In Alpha stat
you don’t.
References
1. Abdul Aziz KA, Meduoye A. Is pH-stat or alpha-stat the best technique to follow in patients
undergoing deep hypothermic circulatory arrest? Interact Cardiovasc Thorac Surg.
2010;10(2):271–82. doi:10.1510/icvts. 2009.214130.
2. Sakamoto T, Kurosawa H, Shin’oka T, Aoki M, Isomatsu Y. The influence of pH strategy on
cerebral and collateral circulation during hypothermic cardiopulmonary bypass in cyanotic
patients with heart disease: results of a randomized trial and real-time monitoring. J Thorac
Cardiovasc Surg. 2004;127(1):12–9. doi:10.1016/j.jtcvs. 2003.08.033.
3. Murkin JM, Martzke JS, Buchan AM, et al. A randomized study of the influence of perfusion
technique and pH management strategy in 316 patients undergoing coronary artery bypass
surgery: neurological and cognitive outcomes. J Thorac Cardiovasc Surg. 1995;110:349–62.
4. Reeves R. An imidazole alphastat hypothesis for vertebrate acid-base regulation: tissue carbon
dioxide content and body temperature in bullfrogs. Respir Physiol. 1972;14(1–2):219–36.
5. Rahn H. Body temperature and acid-base regulation. Pneumologie. 1974;151(2):87–94.
6. Hensley FA, Martin DE, Gravlee GP. A practical approach to cardiac anesthesia. 5th ed.
Philadelphia: Lippincott Williams & Wilkins; 2013.
Chapter 40
CBC/Chemistries I
Daniel A. Biggs
You are asked to see a healthy female at 38-weeks gestation. She has the following
lab results:
Complete blood count (CBC)
• White blood count (WBC)—12,800 × 103/mm3
• Hemoglobin (Hgb)—9.5 g/dL
• Hematocrit (Hct)—28.5%
• Platelets—148 × 109/L
Chemistries
• Sodium (Na)—136 meq/L
• Potassium (K)—3.9 meq/L
• Chloride (Cl)—108 meq/L
• Bicarbonate (HCO3)—21 mmol/L
• Anion gap (AG)—7 mmol/L
• Blood urea nitrogen (BUN)—6 mg/dL
• Creatinine (Cr)—0.6 mg/dL
• Glucose—91 mg/dL
• Total protein—5.8 g/dL
• Albumin—3.2 g/dL
• Calcium (Ca)—8.7 mg/dL
• Total bilirubin—0.4 mg/dL
• Aspartate transaminase (AST/SGOT)—20 U/L
• Alanine transaminase (ALT/SGPT)—12 U/L
• Alkaline phosphatase (AP)—165 U/L
D.A. Biggs, MD, MSc


DOI 10.1007/978-3-319-55862-2_40
214 D.A. Biggs
Questions
1 . What is the upper limit of normal for a WBC count in a term patient?
2. In a term patient what is the normal hemoglobin range? What level is considered
to be anemia?
3. What is the normal lower limit of a platelet count?
4. How does pregnancy affect the serum bicarbonate level?
5. How do the renal function tests change BUN and creatinine?
6. Are the plasma proteins affected by pregnancy?
7. Which liver function test is frequently affected?
40 CBC/Chemistries I 215
Answers
1. The upper limit for WBC increases through pregnancy. In the third trimester, this
reaches 16,900/mm3. This is primarily from an increase in neutrophils [1]. There
is frequently a spike in labor.

2. The normal hemoglobin range during the third trimester is 9.5–15 gm/dL
[1]. Anemia in pregnancy is defined as a Hgb below 11 gm/dL (compared to a
threshold of below 12 gm/dL for the non-parturient) by the American College of
Obstetrics and Gynecology and the World Health Organization [2]. The most com-
mon cause of anemia in pregnancy is iron deficiency. Other causes include micro-
nutrient deficiencies, chronic inflammation, and inherited disorders such as sickle
cell and the thalassemias. The increase in blood volume in pregnancy results in a
relatively lower Hct when compared with nonpregnant females. This is because
the plasma volume increases at a higher percentage than does the red cell mass [3].
3. Platelet count normal range changes very little in pregnancy. This range is 146–
429 × 109/L near term [1]. Approximately 8% of pregnant patients at term will
have platelet counts <150,000 and in about 1% it will be <100,000 [3].
4. Bicarbonate levels are decreased throughout pregnancy [1]. Tidal volume

increases by about 1/3, and the respiratory rate increases slightly resulting in a
30–50% increase in minute ventilation. The CO2 decreases to approximately
30 mmHg. Metabolic compensation results in a bicarbonate level of about
20 meq/L [3].
5. Both levels are decreased because of an increase by 50% in the glomerular filtra-
tion rate (GFR) and the increase in creatinine clearance from 120 ml/min to
greater that 150 ml/min [3].
Nonpregnant adult normal

Test range Third trimester pregnancy normal range
Blood urea nitrogen 7–20 mg/dL 3–11 mg/dL
Creatinine 0.5–0.9 mg/dL 0.4–0.9 mg/dL (commonly 0.5–0.6 mg/
dL)
6. Total plasma proteins and albumin are both decreased.
Nonpregnant adult normal Third trimester pregnancy normal

Test range range
Total plasma proteins 6.7–8.6 g/gL 5.6–6.7 g/dL
Albumin 4.1–5.3 g/dL 2.3–4.2 g/dL
7. Alkaline phosphatase (AP) is commonly increased 2–4 times above nonpregnant

values because of production by the placenta [3].
216 D.A. Biggs
References
1. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and Laboratory Studies: a

Reference Table for Clinicians. Obstet Gynecol. 2009;114:1326–31.
2. ACOG Practice Bulletin #95, Anemia in Pregnancy. Obstet Gynecol. 2008;112:201–7.
3. Chestnut DH, et al. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th ed.
Philadelphia: Elsevier Saunders; 2014.
Chapter 41
CBC/Chemistries II
Tanmay Shah
A 27-year-old G4P3 presented to antepartum clinic with high blood pressure and
epigastric pain. On physical examination the patient had mild epigastric tenderness
and 2+ edema over both lower extremities.
Vital signs: BP 170/120 mmHg, HR 90 bpm, RR 20 bpminute, SpO2 95% on
room air
Hb 11 mg/dL
Hct 33
Platelets 90 K
Creatinine >1.2 mg/dL
Billirubin >1.2 mg/mL
Uric acid >6 mg/mL
LDH >600 IU/L
Elevated AST/ALT
Proteinuria >0.3 g in a 24 h urine specimen
1 . What laboratory work-up is needed to confirm your diagnosis?
2. How will you differentiate mild vs severe forms of the condition based on
proteinuria?
3. What is important to look for in the complete blood count (CBC)?
4. How are blood urea nitrogen (BUN), creatinine, and uric acid levels affected in
this condition?
5. Is the epigastric pain significant in this patient?
6. What is HELLP syndrome and what are some of the diagnostic criteria?
7. What will you look for in the DIC panel?
T. Shah, MD, MBBS


DOI 10.1007/978-3-319-55862-2_41
218 T. Shah
Answers
1. Complete blood cell count (CBC), serum electrolytes, blood urea nitrogen, creati-
nine, liver function test, serum uric acid, urine analysis—microscopic and 24 h
specimen for protein and creatinine clearance. According to the American
Congress of Obstetricians and Gynecologists (ACOG) practice bulletin in 2002,
preeclampsia is defined as the new onset of hypertension and proteinuria after 20
weeks’ gestation [1]. Proteinuria is a key factor in order to differentiate preeclamp-
sia vs gestational hypertension and chronic hypertension in pregnancy. However
in 2013 ACOG guidelines, proteinuria was removed from the diagnostic criteria of
preeclampsia as it is nonspecific and doesn’t always correlate with maternal and
fetal outcomes. ACOG has suggested that any parturient with new-onset hyperten-
sion at 20 weeks of pregnancy or beyond, along with either of the following condi-
tions, should be diagnosed with preeclampsia even in the absence of proteinuria.
(a) Reduced platelet counts
(b) Renal insufficiency
(c) Severe headache
(d) Cardiopulmonary compromise
(e) Impaired liver function
2. Mild preeclampsia: BP ≥140/90 mmHg after 20 weeks of gestation
(a) Proteinuria 300 mg/24 h or 1+ result on urine dipstick
Severe preeclampsia: BP ≥160/110 mmHg
(b) Proteinuria >5 g/24 h
3. Thrombocytopenia is present in 15–30% of women with preeclampsia, and
it is the most common hematologic abnormality [2]. Platelet counts of less
than 100,000/mm3 occur mostly in severe preeclampsia or HELLP syn-
drome. Platelet counts also correlate with the severity of the disease process
and the incidence of placental abruption [3]. Therefore, serial CBC (6 h
apart) should be drawn in a patient with severe preeclampsia to follow the
progression of the disease.
Women with preeclampsia are usually intravascular volume depleted which
causes hemoconcentration with false elevation of Hb and Hct [4]. It is also an
indicator of severity, although measurements are decreased if hemolysis is pres-
ent with HELLP syndrome.
4. Glomerular filtration rate (GFR) increases by 40–60% during the first trimes-
ter of pregnancy which causes a decrease in levels of BUN, creatinine, and
uric acid [5]. These are the serum markers of renal clearance. In preeclamp-
sia, GFR is 34% lower than in normal pregnancy. Decrease in GFR contrib-
utes to higher BUN and creatinine levels in women with preeclampsia.
Abnormal or rising creatinine level suggests severe preeclampsia, especially
in the presence of oliguria.
Urate clearance decreases in women with preeclampsia with resulting increase
in serum uric acid concentration which is possibly an early indicator of pre-
eclampsia. Serum urate greater than 5.5 mg/dL is diagnostic of preeclampsia.
41 CBC/Chemistries II 219
5. Epigastric or subcostal pain is an ominous symptom and is usually caused by the

distension of the liver capsule by edema or subcapsular hemorrhage [6]. Hepatic
dysfunction is frequently seen manifested as an increase in serum transaminase
levels in patients with preeclampsia which should be followed serially to assess
the disease progression to HELLP syndrome, if it occurs.
6. HELLP syndrome is a variant of severe preeclampsia characterized by hemoly-
sis, elevated liver enzymes, and low platelet counts. It is associated with rapid
clinical deterioration.
(a) Diagnostic criteria:
• Hemolysis:
–– Bilirubin >1.2 mg/dL
–– Lactic dehydrogenase >600 IU/L
–– Abnormal peripheral blood smear
(b) Elevated liver enzymes:
• Serum glutamic oxaloacetic transaminase (SGOT) ≥70 IU/L
(c) Low platelet counts:
• <100,000/mm3
Hemolysis is usually reflected as microangiopathic hemolytic anemia on
peripheral blood smear which demonstrates schistocytes, burr cells, and
echinocytes.
7. Patients with severe preeclampsia and HELLP syndrome can develop dis-
seminated intravascular coagulation, and its presence should be confirmed
by laboratory work-up. Blood work will show a decrease in fibrinogen level
and severe thrombocytopenia as these procoagulants are decreased in DIC
along with an increase in D-dimer level and fibrinogen degradation product
(FDP) [1–3].
References
1. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number
33, January 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol
Obstet. 2002 Apr;77(1):67–75.
2. Chestnut DH, et al. Chestnut’s obstetric anesthesia: principles and practice. 4th ed. Philadelphia:
Mosby; 2009.
3. Barash PG, et al. Clinical anesthesia. 6th ed. Philadelphia: Lippincott Williams & Wilkins;
2009.
4. Yao FSF. Yao & Artusio’s anesthesiology: problem-oriented patient management. 7th ed.
Philadelphia: Lippincott Williams & Wilkins; 2012.
5. Moran P, Lindheimer MD, Davison JM. The renal response to preeclampsia. Semin Nephrol.
2004;24:588–95.
6. Walters BN. Preeclamptic angina—a pathognomonic symptom of preeclampsia. Hypertens
Pregnancy. 2011;30:117–24.
Chapter 42
Blood Gas: Fetal
Tanmay Shah
A 27-year-old woman, G1P0, had an emergent cesarean section with an epidural

anesthesia for severe fetal heart rate deceleration. A nuchal cord was found at the
time of delivery by the obstetrician and an umbilical blood gas was ordered.
Umbilical artery blood gas values were as follows:
pH 7.27, PCO2 50 mmHg, pO2 20 mmHg, HCO3 23 mEq/L, Base excess
−3.6 mEq/L
1. How will you interpret this blood gas value and what are the different types of
acidosis?
2. What are the different methods to assess fetal acid–base balance?
3. In the newborn, is blood sampling for blood gas analysis performed from the
umbilical artery or vein?
4. Is fetal blood gas estimation more reliable than Apgar scores in assessing a
newborn’s condition?
5. Is umbilical blood gas analysis done for every newborn?
6. What is the implication of fetal blood gas acidosis?
7. Does fetal acidosis have long-term sequelae on neonatal outcome?
8. What should you do as an anesthesiologist during routine/urgent cesarean
section to improve fetal outcome?
T. Shah, MD, MBBS


DOI 10.1007/978-3-319-55862-2_42
222 T. Shah
Answers
1. The given values are representative of a normal blood gas for a newborn. The
table below lists normal findings for a fetal blood gas at term gestation [1].
Umbilical artery Umbilical vein

pH 7.27 7.34
PCO2 (mmHg) 50 40
pO2 (mmHg) 20 30
Bicarbonate (mEq/L) 23 21
Base excess (mEq/L) −3.6 −2.6
During oxidative metabolism, carbonic acid is produced, which is usually

cleared by the placenta as carbon dioxide [2]. If placental blood flow is not ade-
quate, then CO2 elimination can be affected leading to respiratory acidosis.
Lactic and beta-hydroxybutyric acids are produced as a result of anaerobic
metabolism [3], which requires hours of metabolic clearance and contributes to
metabolic and mixed acidosis.
2. Fetal acid–base balance can be accessed via a number of ways:
(a) Antepartum: by percutaneous umbilical cord blood sampling
(b) Intrapartum: by fetal scalp blood sampling (after membranes have

ruptured)
(c) Postpartum: by umbilical cord blood sampling
3. Usually, blood samples from both umbilical artery and vein are collected, which
represent the fetal and maternal condition, respectively. In addition to maternal
condition, umbilical vein blood samples also represent the utero-placental gas
exchange.
In order for blood samples to be accurate, the umbilical cord should be
double clamped at least 10–20 cm apart immediately after delivery, and the
blood samples should be drawn via heparinized syringe within 15 min of
delivery [3]. For accuracy, the samples should be analyzed within 30–60 min.
Air bubbles should also be removed from the syringe to get accurate pO2
measurement.
In low birth weight infant, it can be difficult to obtain blood sample from the
umbilical artery, especially if it is small. In such situations, the newborn should
be carefully evaluated for arterial academia, since isolated venous blood gas pH
can be normal.
4. Umbilical cord blood gas analysis is routinely ordered by obstetricians if there is
suspicion of neonatal depression. It reflects the fetal condition immediately
before delivery and is a more objective indication of a newborn’s condition than
Apgar score, as Apgar score is usually done after the delivery at 1 min, 5 min,
42 Blood Gas: Fetal 223
and 10 min interval. However, there is usually a time lag between blood gas
sampling and analysis. In the meantime neonatal condition should be assessed
by the Apgar score.
Another factor that can affect umbilical arterial blood pH is the mode of
delivery. A fetus that is delivered via spontaneous vaginal delivery will have
a lower pH than the one delivered by elective cesarean section as the former
has to go through the stress of labor. Duration of labor can also affect pH
measurement, as prolonged labor in nulliparous women will lower the
fetal pH.
5. In 2006, the American Congress of Obstetricians and Gynecologists (ACOG)
recommended cord blood gas for:
(a) Cesarean delivery for fetal compromise
(b) Low 5-min Apgar score
(c) Severe growth restriction
(d) Abnormal FHR tracing
(e) Maternal thyroid disease
(f) Intrapartum fever
(g) Multiple gestation
6. The type of acidosis, if present, should be ascertained, as metabolic and mixed
acidosis are associated with an increased incidence of neonatal complications
and death [4]. One study found a higher incidence of neonatal death when the pH
of umbilical arterial blood was less than 7.00. Seizures were also reported in
infants with pH of less than 7.05.
7. According to the ACOG Task Force in 2006, an umbilical artery pH of less than
7.0 and a base deficit of greater than or equal to 12 mmol/L at delivery pointed
toward an acute intrapartum hypoxic event which could eventually cause cere-
bral palsy [5, 6].
Whenever pH is less than 7.00, the base deficit and bicarbonate values are the
predictors for neonatal morbidity [7]. Moderate to severe complications occur in
10% of infants when base deficit is 12–16 mmol/L, which increases to 40%
when base deficit is more than 16 mmol/L.
8. There are certain things that can be done by an anesthesiologist to improve the
fetal outcome during routine/urgent c-section to maintain adequate placental
perfusion.
(a) Provide left uterine displacement to avoid aorto–caval compression by
gravid uterus
(b) Support the hemodynamics by intravenous administration of fluids and
vasopressors if needed to maintain utero-placental circulation (as it is MAP
dependent)
(c) If general anesthesia is chosen, then maintain proper oxygenation by provid-
ing at least 50% oxygen when mixed with 50% N2O to avoid hypoxia
224 T. Shah
References
1. Miller RD, Pardo MC Jr. Basics of anesthesia. 6th ed. Philadelphia: Elsevier Saunders; 2011.
2. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: McGraw-
Hill; 2006.
3. Chestnut DH, et al. Chestnut’s obstetric anesthesia: principles and practice. 4th ed. Philadelphia:
Mosby; 2009.
4. Victory R, Penava D, Da Silva O, et al. Umbilical cord pH and base excess values in relation to
adverse outcome events for infants delivering at term. Am J Obstet Gynecol. 2004;191:2021.
5. American College of Obstetricians and Gynecologists (ACOG) and American Academy of
Pediatrics (AAP). Neonatal encephalopathy and neurologic outcome. 2nd ed. Washington, DC:
ACOG; 2014.
6. Low JA, Lindsay BG, Derrick EJ. Threshold of metabolic acidosis associated with newborn
complications. Am J Obstet Gynecol. 1997;177:1391.
7. Wiberg N, Källén K, Olofsson P. Base deficit estimation in umbilical cord blood is influenced
by gestational age, choice of fetal fluid compartment, and algorithm for calculation. Am
J Obstet Gynecol. 2006;195:1651.
Part III
Imaging
Chapter 43
Ultrasound: Abnormal Placenta
Fig. 43.1 Abnormal
placental implantation
(Reproduced with
permissions from Elsevier
[1])
1 . What is concerning regarding the ultrasound image in Figs. 43.1 and 43.2?

2. What risk factors are implicated in this presentation?
3. What is the classification/grading and common sonographic findings?
4. What is the frequency of this presentation?
5. How does coagulation change during pregnancy?
6. What is your choice of anesthesia?
M. Rupasinghe, MBBS, FRCA

Department of Anesthesiology, University of Texas Health Science Center at Houston,
6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA

DOI 10.1007/978-3-319-55862-2_43
228 M. Rupasinghe
Fig. 43.2 Normal
pregnancy ultrasound
image
43 Ultrasound: Abnormal Placenta 229
Answers
1. The ultrasound image depicts abnormal placental attachment to the uterine wall,
which is characterized by invasion of trophoblast into the uterine myometrium.
2. The incidence of placenta accreta has been increasing and seems to parallel the
increasing cesarean section rate. A low-lying placenta (placenta previa) and any
condition or surgeries resulting in myometrial tissue damage, along with
advanced maternal age and multiparity have been implicated as risk factors.
3. Diagnosis of placenta accreta is usually established by transabdominal and trans-
vaginal ultrasonography and may be supplemented by magnetic resonance imag-
ing (MRI). Abnormal placental attachment is defined according to the depth of
myometrial invasion as:
(a) Accreta: Chorionic villi attach to the myometrium
(b) Increta: Chorionic villi invade into the myometrium
(c) Percreta: Chorionic villi invade through the myometrium
The common sonographic findings being:
(a) Loss of normal hypoechoic retro placental zone
(b) Multiple vascular lacunae within placenta, giving “Swiss cheese”
appearance
(c) Blood vessels or placental tissue bridging uterine-placental margin
(d) Retro placental myometrial thickness of <1 mm
4. Frequency of placenta accreta according to number of cesarean deliveries and
presence or absence of placenta previa [2]:
Cesarean delivery Placenta previa No placenta previa

First (primary) 3.3 0.03
Second 11 0.2
Third 40 0.1
Fourth 61 0.8
Fifth 67 0.8
≥Sixth 67 4.7
5. Pregnancy is a relatively hypercoagulable state characterized by an increased

activity of clotting factors (I, VII, VIII, IX, X, XII), increased levels of fibrino-
gen, and decreased activity of physiologic anticoagulants (significant reduction
in protein S activity and acquired activated protein C resistance).
Procoagulant changes are balanced by significant activation of fibrinolytic
system and deactivation of natural antifibrinolytics via decrease in activity of
factors XI and XIII.
Platelet count can be low or normal. There is a dramatic short-term increase
in coagulability immediately after delivery due to increase in factor V and VIII
activity.
230 M. Rupasinghe
6. There is no single optimal anesthetic plan for all patients; both general anesthe-
sia and neuraxial techniques have been used successfully. Involvement of a mul-
tidisciplinary team which consists of MFM, anesthesiology, urology, general
surgery, and interventional radiology improves outcome. One of the primary
anesthetic considerations is the potential for significant blood loss necessitating
preparation for volume resuscitation which may require multiple large bore
venous access and invasive arterial monitoring. Appropriate preparations may
include arterial occlusion techniques, arterial embolization, skilled surgical per-
sonnel, cell salvage, as well as availability of blood products. In addition, use of
point of care monitoring (TEG) and adjuncts to transfusion such as recombinant
Factor VIIa and antifibrinolytics should be considered in cases of massive
hemorrhage [3].
References
1. Jauniaux E, Jurkovic D. Placenta accreta: pathogenesis of a 20th century iatrogenic uterine
disease. Placenta. 2012;33(4):244–51. doi:10.1016/j.placenta.2011.11.010.
2. Belfort MA, et al. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430–9. doi:10.1016/j.
ajog.2010.09.013.
3. Snegovskikh D, Clebone A, Norwitz E. Anesthetic management of patients with placenta
accreta and resuscitation strategies for associated massive hemorrhage. Curr Opin Anesthesiol.
2011;24(3):274–81. doi:10.1097/ACO.0b013e328345d8b7.
Chapter 44
CXR I
Raghuvender Ganta
Fig. 44.1
1 . What does above image Fig. 44.1 show?

2. Is there a way to classify this condition?
3. What are the causes and the clinical presentation of this condition?
4. What are the indications for surgical intervention?
5. How do you treat tension pneumothorax?
R. Ganta, MD, FRCA


DOI 10.1007/978-3-319-55862-2_44
232 R. Ganta
Answers
1. The image shows a large right-sided pneumothorax with visible margins of the
collapsed lung. Pneumothorax is the presence of gas within the pleural space
owing to disruption of the parietal or visceral pleura.
2. Classification
Neonatal, spontaneous, traumatic
• Pediatric pneumothorax – neonates with respiratory distress syndrome,
especially if they are mechanically ventilated with positive and expira-
tory pressure and are prone to pneumothorax.
• Congenital diaphragmatic hernia results in underdeveloped lung ipsilat-
eral to the defect in diaphragm. The more compliant contralateral lung
is prone to barotrauma and pneumothorax.
Spontaneous pneumothorax occurs without trauma and most often in males
between 20 and 35 years of age. These patients are often tall and slender, and
most of the patients are smokers. Recurrent spontaneous pneumothorax is com-
mon during the first year after the initial event.
Primary spontaneous pneumothorax occurs in tall, thin males aged 20–40 and
who are smokers. Secondary spontaneous pneumothorax occurs in patients with
underlying pulmonary disease, and the presentation may be more serious with
symptoms and sequelae due to comorbid conditions.
Traumatic pneumothorax
Blunt or penetrating trauma to the chest wall can cause a pneumothorax; the
most common cause is iatrogenic and is caused by subclavian line placement.
Tension pneumothorax
This occurs when air enters the pleural cavity on inspiration but, because of a
ball-valve mechanism, is unable to exit. This progressively enlarges the pleu-
ral space, shifting the mediastinum and trachea to the contralateral side and
also decreasing venous return. Tension pneumothorax is a medical emergency
and without prompt intervention leads to rapid deterioration in the patient’s
condition leading to death [1].
3. Some causes of pneumothorax were mentioned under the classification. Other
causes may include laparoscopic intra-abdominal surgical procedures such as
cholecystectomy, nephrectomy, adrenalectomy, hiatal hernia repair, or positive
end expiratory pressure (PEEP) [2].
The clinical presentation of pneumothorax can vary depending on the type
and severity and can range from no symptoms to acute distress which can be life-
threatening. Symptoms may include sudden and severe pleuritic chest pain
accompanied by dyspnea and cough.
The hemithorax is hyperresonant to percussion, with tracheal shift away from
the affected side. Neck veins may become distended. Breath sounds may be
diminished or absent. There may be increased airway pressure, decreased pul-
monary compliance, cyanosis, and hypotension during the intraoperative period.
Blood gases show hypoxia and hypercarbia in severe cases. Radiographic exami-
nation is the best diagnostic tool. Other modalities for diagnosis include chest
ultrasonography and computed tomography.
44 CXR I 233
Treatment of pneumothorax is with a chest tube, when large amounts of lung

are collapsed. The spontaneous pneumothorax usually gets absorbed when the
collapsed lung is estimated to be less than 20%. Spontaneous resorption may be
accelerated by the administration of supplemental oxygen.
4. An air leak from the lung that persists for more than 10 days may be an indication for
surgical intervention. Recurrent pneumothorax can be treated by chemical pleurode-
sis without a thoracotomy by instilling tetracycline into the pleural space [3].
5. Tension pneumothorax (Fig. 44.2) is a surgical emergency, and if suspected on
clinical grounds, time should not be spent seeking radiological evidence. A
large-bore needle should be placed in the second intercostal space in the midcla-
vicular line, allowing air to drain freely (Fig. 44.3). The needle should be left in
place until a tube thoracotomy is performed.
Fig. 44.2 Tension
pneumothorax
Fig. 44.3 After treatment

with a chest tube
234 R. Ganta
References
1. Krasnik M, Christensen B, Halkier E, et al. Pleurodesis in spontaneous pneumothorax by

means of tetracycline: follow-up evaluation of a method. Scand J Thorac Cardiovasc Surg.
1987;21:181–8.
2. Marshall BE, Longnecker NE, Fairley HB. Anesthesia for thoracic procedures. Boston:
Blackwell Scientific; 1988.
3. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical manifestations of tension pneumothorax:
protocol for a systematic review and meta-analysis. Syst Rev. 2014;3:3.
Chapter 45
CXR II
Marcos E. Gomes
Below is an image of a chest x-ray of an ICU patient on a ventilator.

1 . Name some causes for the changes seen in the image?
2. What’s the most valuable x-ray finding used to help differentiate the etiology of
this finding?
3. What is the differential diagnosis of this finding when there is no tracheal devia-
tion or mediastinal shift on chest x-ray?
4. What is the differential diagnosis when there is mediastinal shift away from the
opacity?
5. What is the differential diagnosis when there is mediastinal shift toward the
opacity?
Fig. 45.1 Chest x-ray (AP

view)
M.E. Gomes, MD
DOI 10.1007/978-3-319-55862-2_45
236 M.E. Gomes
Answers
1. The most common causes of unilateral lung whiteout on chest radiograph (Fig. 45.1)
are pneumonia, pleural effusion (including hemothorax), and collapse/atelectasis. The
ability to differentiate between collapse and pleural effusion is essential because they
require distinct treatments, which, if applied erroneously, could harm the patient [1].
2. The most important finding that may help differentiate the etiology of unilateral
whiteout is tracheal deviation or mediastinal shift.
3. With a finding of central mediastinum, diagnostic considerations include con-
solidation/pneumonia, pulmonary edema/ARDS, small to moderate pleural effu-
sions (most likely would cause a partial rather than a complete whiteout), and
mesothelioma. Small and moderate pleural effusions tend to gravitate posteriorly
without producing mediastinal shift. Encasement of the lung in a mesothelioma
patient limits mediastinal shift [2, 3].
4. With tracheal displacement away from the diffuse opacity, diagnostic consider-
ations include a moderate to large pleural effusion, large pulmonary mass, and a
diaphragmatic hernia. Diaphragmatic hernias on the right side usually consist of
liver herniation, while on the left, from herniated bowel [2, 3].
5. Mediastinal shift toward the side of the opacity is seen in lung collapse (endo-
bronchial intubation, mucus plugging), post-pneumonectomy, and pulmonary
agenesis/hypoplasia. The figure above (Fig. 45.1) illustrates a case of mucus
plugging in the ICU in a young patient with high-level spinal cord injury com-
promising the strength of his cough and therefore his ability to clear secretions.
This scenario can be encountered by the anesthesiologist quite often. Endotracheal
tube repositioning with or without bronchoscopy is a simple fix to main stem
intubation, whereas endotracheal suctioning or bronchoscopy are easily per-
formed to clear secretions and/or mucus plugs [1, 2, 3].
References
1. Fazili T, Dehadrai G. Unilateral white out on chest radiograph. Hosp Physician. 2009;45(5):27.
2. Drury N, et al. A unilateral whiteout: when not to insert a chest drain. J R Soc Med.
2010;103(1):31–3.
3. Khan AN, et al. Reading chest radiographs in the critically ill (Part II): radiography of lung
pathologies common in the ICU patient. Ann Thorac Med. 2009;4(3):149–57.
Chapter 46
CXR III
Abbreviations
AV block Atrioventricular block

BiV ICD Biventricular implantable cardio-defibrillator
CHF Congestive heart failure
CXR Chest x-ray
EF Ejection fraction
EKG Electrocardiogram
EP Electrophysiology dept
ICD Implantable cardio-defibrillator
PEA Pulseless electrical activity
VT/VF Ventricular tachycardia/ventricular fibrillation
A 65-year-old female after a motor vehicle collision requires emergency surgery for an
open lower extremity fracture; the patient tells you she has a “bad heart,” she has no
history in your institution, and no signs of heart failure. An EKG shows wide QRS
with dual-chamber pacing. A CXR on admission show (See Fig. 46.1).
1 . What type of device is shown in the image?
2. What are the indications for cardiac implantable electronic device placement?
3. What is the effect of placing a magnet over the device (pacemaker and/or ICD)?
4. In the OR, you place a magnet over the device. The patient goes pulseless after
prolonged use of electrocautery. What is your diagnosis?
G. Barbosa-Hernandez, MD
Department of Anesthesia, Oklahoma University Health and Science Center,

DOI 10.1007/978-3-319-55862-2_46
238 G. Barbosa-Hernandez
Fig. 46.1 Anterior
posterior chest x-ray
showing a cardiac device
5. What are the effects of electrocautery, radiation therapy, and radiofrequency on

a pacemaker and an ICD?
6. What measures can you take to ensure proper intraoperative device

functioning?
46 CXR III 239
Answers
1. This patient has an implantable biventricular cardio-defibrillator (BiV ICD) [1].
(a) The radiographic image of a pacemaker would show (See Fig. 46.2):

• Smaller generator
• Discreet right ventricular lead (stable diameter)
• With or without right atrial lead or coronary sinus lead
(b) The radiographic image of an ICD would show (See Fig. 46.3):
• Larger generator.
• Prominent right ventricular lead, otherwise known as shock coils. They
appear as two metallic segments along the length of the ICD lead.
(c) The radiographic image of a BiV ICD would show (See Fig. 46.4):
• Larger generator
• Prominent right ventricular lead (shock coils)
• Right atrium lead
• Coronary sinus lead
Fig. 46.2 Anterior
posterior chest x-ray
showing a pacemaker
Fig. 46.3 Anterior posterior and lateral chest x-ray showing an ICD
Manufacturer ID can be seen in the CXR as well (See Fig. 46.5).

2. Indications for cardiac implantable electronic device placement [2]:
(a) Pacemaker:
• Patients with symptomatic sinus node dysfunction and bradycardia
• Patients with complete AV block (symptoms less relevant)
• Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
(b) ICD:
• Patients at risk of sudden cardiac death: Prior ventricular tachycardia or
fibrillation, low ejection fraction [3]
• Long QT syndrome
• Hypertrophic cardiomyopathy
• Arrhythmogenic right ventricular dysplasia
• Cardiac transplantation
• Primary electrical disease: idiopathic ventricular fibrillation, short QT
syndrome, Brugada syndrome, and catecholaminergic polymorphic ven-
tricular tachycardia
(c) BiV ICD:
• Treatment of left ventricular dysfunction and heart failure, with prolonged
ventricular conduction and heart failure symptoms.
• Required ventricular pacing and low EF:
–– RV pacing in patients with low EF increases CHF admissions and
mortality.
• Cardiac resynchronization therapy [4]:
–– Improved exercise tolerance and mortality.
–– Continuous pacing provides better hemodynamic stability.
46 CXR III 241
Fig. 46.4 Anterior posterior and lateral chest x-ray showing a BiV ICD
Fig. 46.5 Magnified view of a chest x-ray showing manufacturer ID of a cardiac implantable
electronic device
3. Effect of a magnet on a device [5]:

(a) Pacemaker:
• Suspend sensing of intrinsic rhythm.
• Pacing in an asynchronous mode: the rate depends on the manufacturer
and the battery life; if the battery life is low, the rate may not be adequate
for surgery.
• Turns off “rate response.”
(b) ICD:
• Varies depending on device, manufacturer, and programming of the device.
• In general it turns off detection of tachycardia and tachycardia therapy

(discharge and pacing).
• In general, it has no effect on the pacemaker (pacing will not become
asynchronous). In patients that are pacemaker dependent due to the risk
of electrical interference and pacemaker malfunction, it is best to repro-
gram the device to address both the tachycardia and bradycardia therapy.
4. Most probably this patient has a BiV ICD and low ejection fraction and is pace-
maker dependent. The device functioned appropriately with the magnet, which
suspended the tachyarrhythmia detection. Pacing was inhibited by the prolonged
use of electrocautery. Pacing returns to an unresponsive myocardium, after a
prolonged period of asystole that might have led to PEA arrest.
5. Pacemaker [1, 6]:
(a) Electrocautery:
• Faulty sensing of intrinsic activity causing inappropriate inhibition of
pacemaker activity
–– More prominent with monopolar cautery
–– More likely with above the waist surgery
• Possible device reset or damage to the generator, or the leads, but
unlikely
(b) Radiation therapy:
• Possible device reset when performed near the device
(c) Radiofrequency:
• Electrocautery-like electromagnetic interference that could cause inap-
propriate inhibition of pacemaker activity which is more likely with pro-
cedures above the waist
• Possible device reset or damage to the generator, or the leads, but unlikely
ICD:
(a) Electrocautery:
• Faulty sensing of intrinsic activity causing inappropriate sensing of
arrhythmias
–– More prominent with monopolar cautery
(b) Radiation therapy:
• Possible device reset when performed near the device
(c) Radiofrequency:
• Electrocautery-like electromagnetic interference that could cause inap-
propriate arrhythmia sensing inhibition
46 CXR III 243
6. When facing a patient with a device one must ascertain [1, 5]:
(a) Device type (see answer to question 1) and obtain as much information as
possible
• Is there a history of cardiac arrest, arrhythmias, or VT/VF?
• Evaluate medical record, registration card.
• Contact the manufacturer.
( b) Procedure type: Location and presence of electromagnetic interference
(c) Patients characteristics:
• Pacemaker dependence:
–– Usually can tell just from the monitor or EKG. If pacing spikes are not
visible, then usually they are not dependent.
–– If there are spikes in front of all or most P waves and/or QRS com-
plexes, then assume pacemaker dependency.
• Chambers being paced
• Presence of low EF?
(d) Urgency of the case
• Elective cases:
–– Contact patient’s provider, pacemakers should be seen every year, and
ICDs every 6 months.
–– Follow recommendations.
• Emergency cases:
(1) General recommendations:
a. Have magnet immediately available.
i. If magnet impossible to place, must call EP; the device might
require reprograming before the procedure.
b. Monitor patient with plethysmography or arterial line.
i. All other forms of monitoring are unreliable due to noise
with electromagnetic interference.
c. Transcutaneous pacing and defibrillation pads should be placed
(anterior/posterior).
d. Evaluate the pacemaker or ICD before leaving a cardiac-moni-
tored environment.
e. ICD patients should be on monitor at all times while ICD is
deactivated.
f. If any device is programmed specifically for surgery, patient can-
not be taken off the monitor until the device is reprogrammed.
(2) Recommendations for patients—not pacemaker dependent
a. No ICD present:
i. If the surgery is not within 6 inches (15 cm) of the device,
then no other actions are necessary.
ii. If the surgery is within 6 inches of the device, then a magnet

can be placed or the device reprogramed by a device spe-
cialist to asynchronous mode (AOO, VOO, DOO).
b. ICD or BiV ICD present:
i. Place magnet to stop tachyarrhythmia detection.
ii. If magnet is impossible to place, or surgery is within
6 inches of the device, or is a cardiac/thoracic procedure,
then you must call the device specialist to turn off the
tachyarrhythmia detection to avoid unwarranted dis-
charges during the procedure if electrical interference is
present.
(3) Recommendations for patients—pacemaker dependent
a. No ICD present:
i. Use short electrosurgical bursts.
ii. Place magnet over device for procedures not within 6
inches (15 cm) of the device.
iii. If magnet is impossible to place or surgery is within 6
inches of the device, then the device specialists must be
called to reprogram to an asynchronous mode.
b. ICD or BiV ICD present:
i. Use short electrosurgical bursts.
ii. If the surgery is not within 6 inches of the device, then
place magnet over device to suspend tachyarrhythmia
detection and contact the device specialist to reprogram the
device to an asynchronous mode.
iii. If magnet is impossible to place or surgery within 6 inches
of the device, then contact in-hospital device specialist to
reprogram the device to an asynchronous mode to avoid
electrical interference and to turn off tachyarrhythmia detec-
tion to avoid unwarranted discharges during the procedure.
References
1. Aguilera AL, Volokhina YV, Fisher KL. Radiography of cardiac conduction devices: a compre-
hensive review. Radiographics. 2011;31(6):1669–82. doi:10.1148/rg.316115529.
2. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. 2012
ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for
device-based therapy of cardiac rhythm abnormalities: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society. J Am Coll Cardiol. 2013;61(3):e6–75. doi:10.1016/j.jacc.2012.11.007.
3. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation
of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl
J Med. 2002;346(12):877–83. doi:10.1056/NEJMoa013474.
46 CXR III 245
4. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. The effect
of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med.
2005;352(15):1539–49. doi:10.1056/NEJMoa050496.
5. Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, et al. The Heart
Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus
Statement on the perioperative management of patients with implantable defibrillators, pace-
makers and arrhythmia monitors: facilities and patient management this document was devel-
oped as a joint project with the American Society of Anesthesiologists (ASA), and in
collaboration with the American Heart Association (AHA), and the Society of Thoracic
Surgeons (STS). Heart Rhythm. 2011;8(7):1114–54. doi:10.1016/j.hrthm.2010.12.023.
6. Costa A, Richman DC. Implantable devices: assessment and perioperative management.
Anesthesiol Clin. 2016;34(1):185–99. doi:10.1016/j.anclin.2015.10.014.
Chapter 47
CXR/CT IV
Marcos E. Gomes
Fig. 47.1 Chest X-ray
M.E. Gomes, MD

DOI 10.1007/978-3-319-55862-2_47
248 M.E. Gomes
Fig. 47.2 Chest computed

tomography
1. What do the images above show and what is the differential diagnosis based on
the appearance seen in the images above?
2. What is the current definition of acute respiratory distress syndrome?
3. Name some common triggers for the development of ARDS.
4. What is the approach for mechanical ventilation on patients with the above
diagnosis?
5. Is there an indication for steroids, statins, or neuromuscular blockade (NMB) in
ARDS?
6. Which nonconventional therapies can be used to enhance oxygenation in severe
ARDS?
7. What is the role of nitric oxide and prostaglandins in ARDS?
47 CXR/CT IV 249
Answers
1. The chest X-ray (Fig. 47.1) shows diffuse bilateral coalescent opacities, whereas
the CT chest (Fig. 47.2) shows ground-glass opacification, reflecting an overall
reduction in the air content of the affected lung. It is also possible to visualize
bronchial dilatation within areas of ground-glass opacification. Differential diag-
nosis include (a) ARDS, (b) congestive heart failure, (c) pulmonary hemorrhage,
(d) pneumonia, (e) transfusion-related acute lung injury, and (f) non-cardiogenic
pulmonary edema.
2. The Berlin definition, dated 2012, states that acute respiratory distress syn-
drome is an entity characterized by hypoxemia and stiff lungs that occurs
within a week of a known clinical insult or new/worsening respiratory symp-
toms. It presents with bilateral opacities on the chest X-ray involving at least
three quadrants that are not fully explained by effusions, atelectasis, or nod-
ules. Chest computed tomography (CT) findings are opacification that is
denser in the most dependent regions as compared to more normal and
hyper-expanded lung in the nondependent ones. In addition, CT chest shows
widespread ground-glass attenuation, which is a nonspecific sign that reflects
an overall reduction in the air content of the affected lung. Respiratory failure
in ARDS must not be fully explained by cardiac failure, and an objective
assessment for exclusion of such cause may be necessary by echocardiogra-
phy. Finally, ARDS is classified as mild, moderate, or severe based on PaO2/
FiO2 ratio and PEEP. If PaO2/FiO2 ratio is between 200 and 300 mmHg with
PEEP ≥5, it is classified as mild. If PaO2/FiO2 ratio between 100 and
200 mmHg with PEEP ≥5, it is moderate. PaO2/FiO2 ratio less than 100 mmHg
with PEEP ≥5 is classified as severe. Note that the term acute lung injury has
been removed, as well as the requirement of pulmonary capillary wedge pres-
sure ≤18 mmHg [1].
3. Common risk factors for ARDS are divided into two categories: direct and
indirect.
(a) Direct causes are pneumonia, aspiration of gastric contents, inhalational
injury, pulmonary contusion, pulmonary vasculitis, and drowning.
(b) Indirect causes are non-pulmonary sepsis, major trauma, pancreatitis, severe
burns, non-cardiogenic shock, drug overdose, and multiple transfusions or
transfusion-associated acute lung injury (TRALI).
4. Protective lung strategy (also known as open lung approach or lung protective
ventilation) is the standard of care for the management of patients with
ARDS. The ARDS Network was a randomized controlled trial designed based
on the concept that the limitation of end inspiratory lung stretch may reduce
mortality in this patient population. Patients that received lower tidal volume (Vt
4–6 ml/kg ideal body weight) and maintenance of plateau pressure between 25
and 30 mmHg had a survival benefit, with a decrease in mortality from 40% to
31% [2]. Drawbacks from this mode of ventilation were hypoventilation leading
to permissive hypercapnia and shear injury due to repetitive opening and closing
of alveoli with each cycle. For that reason, PEEP should be set at above lower
250 M.E. Gomes
inflection point to prevent cyclic atelectasis. It is difficult to describe an efficient

method of applying optimal PEEP in any given patient. Applying the highest
PEEP that allows for maintenance of goal plateau pressure could be a reasonable
approach. In that study, the survival benefit was also associated with a reduction
of plasma IL-6, supporting the hypothesis that a lung protective strategy limits
the spill of inflammatory mediators into the systemic circulation, which may
induce multiple system organ failure. In refractory hypoxemia, prolonging the
inspiratory time by increasing the I:E ratio may improve oxygenation; however,
close attention must be directed to avoid air trapping, auto-PEEP, barotrauma,
and hemodynamic compromise.
5. The use of glucocorticoid treatment for ARDS remains contradictory. The
ARDS Network LaSRS study showed no benefit in mortality from the routine
use of steroids in patients with ARDS. In addition, it was associated with
increased risk of neuromuscular complications, as well as risk of death if started
2 weeks after onset of ARDS. The potential adverse effects of steroids also
include immunosuppression, superadded infection, and higher blood glucose
levels. The mineralocorticoid component contributes to fluid/sodium retention;
both of which could result in positive fluid balance, a known factor associated
with poor outcomes in lung injury. At the moment, there is insufficient evidence
to justify the routine use of steroids in patients with ARDS [3]. The SAILS trial
published in 2014 compared statin with placebo in patients with ARDS in the
setting of sepsis. Statin therapy did not reduce mortality or increase ventilator-
free days; therefore there is no evidence to support its use in ARDS
[4]. Neuromuscular blockade therapy for hypoxia has a few potential benefits.
Avoidance of large tidal volumes that predispose to volutrauma decreased oxy-
gen consumption from lack of muscle activity and improved patient–ventilator
synchrony. Literature shows that the use of NMB in early (first 48 h) ARDS is
associated with improved mortality rate. Having said that, judicious use is war-
ranted since paralysis interferes with neurological exam and has been linked to
ICU-acquired weakness and posttraumatic stress disorder.
6. Airway pressure release ventilation (APRV) is a combination of pressure-

controlled ventilation and inverted ratio ventilation on a time-triggered, pressure-
targeted, and time-cycled mode (Fig. 47.3). A higher and a lower PEEP are set,
and 80–95% of the respiratory cycle is spent during inspiration at the higher
PEEP. The patient is allowed to breathe spontaneously during both high and low
PEEP. The mean airway pressure increases without much increase in the peak
pressure, favoring lung protection. This mode has been found to be associated
with shorter ICU stay and duration of ventilation in patients with ARDS, but
contradictory literature still exists, mostly in regard to the lack of evidence of
mortality benefit.
High-frequency oscillatory ventilation (HFOV) has been evaluated
recently by two randomized controlled trials (OSCAR, and OSCILLATE) as
well as by a meta-analysis. HFOV has failed to show any mortality benefit.
The HFOV group in the OSCILLATE trial had higher mortality, higher
47 CXR/CT IV 251
Paw
PEEP High
PEEP Low
T High T Low
Flow
Fig. 47.3 Airway pressure release ventilation (APRV)
requirement for sedatives, paralytics, and vasopressors, and therefore no evi-

dence to support its use.
Prone positioning takes advantage of gravity and repositioning of the heart in
the thorax to recruit lung regions and improve ventilation–perfusion matching.
The mechanisms for the proposed benefit are change in diaphragm movements,
increased functional and residual capacity, better secretion clearance, and
reduced ventilator-induced lung injury. The PROSEVA trial, published in 2013,
brought attention back to this rescue mode after showing association with major
decrease in 28-day and 90-day mortality, increase in ventilation-free days, and
reduced time to extubation. An increase in PaO2 by 10 mmHg over the first
30 min of prone ventilation usually predicts a sustained increase in PaO2 and
deems the patient as a “responder.”
Finally, extracorporeal membrane oxygenation (ECMO) remains an important
tool for managing refractory hypoxemia that is life-threatening but often consid-
ered as a last resort. Literature on its benefit is scarce and controversial. Guidelines
suggest it should be used in scenarios that have a potential reversible cause, less
than 7 days on mechanical ventilation, age <65 years, no significant comorbidi-
ties, no contraindication to anticoagulation, and no significant neurological dys-
function. In case of isolated respiratory failure, a veno-venous approach is
advised, whereas in case of hemodynamic instability, a venoarterial approach
should be used. More evidence is needed to support its use as standard of care [5].
7. Inhaled vasodilators reduce pulmonary arterial pressure and redistribute

blood flow to well-ventilated lung regions with little to no systemic side
effects, improving the ventilation–perfusion matching. Inhaled nitric oxide
has been shown to improve oxygenation as measured by PaO2/FiO2 ratio and
252 M.E. Gomes
oxygenation index. It is expensive, gets rapidly inactivated by hemoglobin,

can result in methemoglobinemia, and carries an increased risk of renal fail-
ure. No beneficial effect on mortality or ventilator-free days has been shown
with the use of nitric oxide. Inhaled prostaglandins demonstrate similar vaso-
dilator effects when compared to nitric oxide, including improved oxygen-
ation and reduction in pulmonary hypertension; however evidence with large
randomized clinical trials is lacking. Patients on these vasodilators are con-
sidered “responders” if an improvement on oxygenation is observed within
the first 1 h of administration. Based on current evidence, inhaled vasodila-
tors must be considered only as a rescue and temporary therapy for patients
with refractory hypoxemia (with or without pulmonary hypertension) when
other methods have failed.
References
1. Fanelli V, et al. Acute respiratory distress syndrome: new definition, current and future thera-
peutic options. J Thorac Dis. 2013;5(3):326–34.
2. Donahoe M. Acute respiratory distress syndrome: a clinical review. Pulm Circ.
2011;1(2):192–211.
3. Bihari S, et al. Steroids in ARDS: to be or not to be. Intensive Care Med. 2016;42(5):931–3.
4. Truwit J, et al. SAILS: statins for acutely injured lungs (ARDS) from sepsis. Am J Respir Crit
Care Med. 2014;189:A5088.
5. Mehta C, et al. Management of refractory hypoxemia. Ann Card Anesth. 2016;19(1):89–96.
Chapter 48
CT I
Pramod Chetty
Fig. 48.1 CT showing mediastinal mass causing deviation and crescentic compression of the
trachea
P. Chetty, MD
Department of Anesthesiology, OU Health Sciences Center,
750 NE 13th Street, Suite 200, PO Box 53168, Oklahoma City, OK 73104, USA

DOI 10.1007/978-3-319-55862-2_48
254 P. Chetty
Fig. 48.2 CT showing mediastinal mass posttreatment with less deviation and loss of crescentic
compression
A 58-year-old man with a diagnosis of Hodgkin’s disease presents to the anesthesia

preoperative clinic prior to placement of a port. He complains of mild difficulty in
sleeping totally supine and clinically shows fullness of the veins of the neck. CT
scan (Fig. 48.1) shows that he has a mediastinal mass with both tracheal deviation
and crescentic compression.
1 . What are the symptoms of a mediastinal mass?
2. What are the physical ramifications of a significant mediastinal mass on the
airway?
3. What are the anesthesia considerations for a significant mediastinal mass?
4. What are techniques for the safe administration of an anesthetic for a significant
mediastinal mass?
48 CT I 255
Answers
1. Symptoms of a mediastinal mass:
(a) A mediastinal mass may be asymptomatic even when it reaches a significant
size. It may be discovered during routine radiological testing for the disease
causing the mass or just incidentally [1].
(b) When the mass reaches a critical size within the restricted mediastinal space,
it can cause signs and symptoms related primarily to the cardiac or pulmo-
nary system. This can include diminished venous return via the superior
vena cava (SVC) leading to fullness of the neck veins and in extreme cases
cardiac dysfunction from direct compression. Respiratory symptoms could
range from dyspnea, progressive orthopnea, voice changes (nerve palsy),
and in late stages stridor.
2. Physical ramifications of the mediastinal mass on the intrathoracic airway:
(a) Deviation of the trachea. This could include:
• “C”-shaped bowing of the trachea
• “S”-shaped trachea
(b) Narrowing and invasion of the lumen of the trachea and/or major bronchus:
• The trachea when externally compressed becomes crescentic as the mem-
branous posterior wall is the first to collapse.
• Narrowing can be a short segment or a long segment of the trachea.
• Encroachment can be around the entire carinal trifurcation of the
trachea.
3. Anesthesia considerations for a significant mediastinal mass:
(a) Lack of symptoms should not be considered as reassuring. This is especially
true with superior or anterior mediastinal masses. With spontaneous ventila-
tion, the mechanics of thoracic cage cause a distracting force on the larger
airways by maintaining the intrapleural pressure gradient, helping to main-
tain the patency of the lumen. The loss of bronchial tone due to general
anesthesia can also decrease lumen size. Thirdly, the distension of the major
airways will be diminished with smaller ventilatory volumes [2]. The loss of
normal spontaneous ventilation during general anesthesia can thus precipi-
tate intrathoracic airway obstruction in such cases with catastrophic results
[3].
(b) Once the airway has been secured, the anesthetic plan is determined by the
surgery and patient’s other comorbidities.
(c) Placement of a regular endotracheal tube (ETT) in a trachea with “S”-shaped
deviation can lead to the distal bevel end pushing up against the wall of the
trachea leading to obstruction.
(d) A smaller ETT size must be chosen against the measured diameter of the
lumen by CT scan.
(e) Securing the “lost” airway can possibly be done only by rigid bronchoscopy
(RB).
256 P. Chetty
(f) Long-segment tracheal narrowing is a cause for concern for ETT placement
or for the performance of rescue rigid bronchoscopy.
(g) Extracorporeal oxygenation (ECO) which takes time with significant prior
organization and access placement is the only rescue for loss of the intratho-
racic airway with failed rigid bronchoscopy [4, 5].
(h) Significant and chronic tracheal compression can lead to tracheomalacia [6].
This weakness of tracheal wall and airway swelling due to the ETT in a nar-
rowed lumen must be considered before extubation.
(i) Occlusion beyond the carina in one of the major bronchi is significant but
less concerning than total tracheal obstruction.
(j) Intravenous lines should be placed in the lower extremities if the SVC is
compromised.
4. Techniques for safe administration of anesthesia in a patient with a significant
mediastinal mass:
(a) Ascertain the significance of the mass and its encroachment of the airway
preoperatively—this consultation should include the surgeon (and CVT
surgeon), radiologist, and anesthesiologist [7]. The factors in risk assess-
ment include symptoms, type of tumor, and airway compromise.
(b) Many tumor masses will show amazing resolution with chemotherapy or
radiation prior to surgery. The CT scan in the above patient was repeated
after short definitive therapy and showed near-total resolution of tracheal
deviation and compression (Fig. 48.2). This should be done if appropriate.
(c) When feasible, consider avoidance of general anesthesia. In the case pre-
sented, if venous access for treatment was critically needed, this should be
done under monitored anesthesia care (MAC). If SVC drainage is compro-
mised, venous access should be secured in the lower extremity.
(d) Even if MAC or regional anesthesia is considered, every precaution to pre-
vent loss of spontaneous ventilation must be employed. Rigid bronchoscopy
must be available in the OR.
(e) If MAC or regional anesthesia is not feasible, the choices are maintenance of
spontaneous ventilation with either an inhalational induction or perform
awake fiber-optic intubation followed by general anesthesia with appropriate
ETT placement. This should include proper selection of the appropriate ETT
for size and made with reinforced material.
(f) In cases of significant compromise or long-segment stenosis, awake fiber-
optic intubation after placement of access catheters for extracorporeal oxy-
genation in the groin is warranted [5, 8]. In extreme cases of carinal
encroachment, the patient can be placed on ECO and rigid bronchoscopy
performed under TIVA for airway securement (personal experience).
After the anesthetic, due caution must be given to the airway, as described
above (3H), before removing the ETT which must preferably be done in the fully
awake and recovered patient.
48 CT I 257
References
1. Cooper JC, et al. The use of computed tomography in the evaluation of large multinodular
goiters. Ann R Coll Surg Engl. 1991;73:32–5.
2. Miller’s anesthesia, 8th ed. – Chapter anesthesia for thoracic surgery – Mediastinal masses.
3. Keon TP. Death on induction of anesthesia for cervical node biopsy. Anesthesiology.
1981;55:471–2.
4. Bouaggad A, et al. Prediction of difficult tracheal intubation in thyroid surgery. Anesth Analg.
2004;99:603–6.
5. Shoa Y, et al. Extracorporeal membrane oxygenation-assisted resection of goiter causing severe
extrinsic airway compression. Ann Thorac Surg. 2009;88:659–61.
6. Lee C, Cooper RM, Goldstein D. Management of a patient with tracheomalacia and supraglot-
tic obstruction after thyroid surgery. Can J Anesth. 2011;58:1029–33.
7. Seong Tan PC, Esa N. Anesthesia for massive retrosternal goiter with severe intrathoracic tra-
cheal narrowing: the challenges imposed. Korean J Anesthesiol. 2012;62(5):474–8.
8. Wang G, et al. Surgical management of tracheal compression caused by mediastinal goiter: is
extra-corporeal circulation requisite? J Thorac Dis. 2009;1:48–50.
Chapter 49
CT II
Ankur Garg
Case presentation: A 44-year-old man was brought into the hospital after being hit
by a truck while riding a bicycle. Glasgow Coma Scale (GCS) was 5 on presenta-
tion. CT images of his head on arrival are shown below (Fig. 49.1A–C).
a b
Fig. 49.1 CT head images of a patient following motor vehicle collision
A. Garg, MD
Orlando Neurosurgery, 1605 W. Fairbanks Ave,
Orlando, FL, USA

DOI 10.1007/978-3-319-55862-2_49
260 A. Garg
Fig. 49.1 (continued)
Questions
1 . Define Glasgow Coma Scale.
2. How do you grade traumatic brain injury?
3. What are the common types of traumatic brain injuries?
4. What are the abnormal findings in the images shown above?
5. What are the usual aspects of medical care of a patient with acute traumatic brain
injury?
6. Describe some of the important elements of perioperative anesthetic care in a
patient with acute traumatic brain injury.
49 CT II 261
Answers
1. Teasdale and Jennett [3] first described the Glasgow Coma Scale (GCS) in 1974
as a neurological tool to assess the level of consciousness following head injury.
The scale is since widely used by medical professionals worldwide as a reliable
and objective way of recording the conscious state of a person for initial as well
as subsequent assessments. The scale ranges from a minimum score of 3 (not
zero) to a maximum score of 15. As described in Fig. 49.2, GCS has three ele-
ments: eye response, verbal response, and motor response.
Fig. 49.2 Glasgow Coma Scale

262 A. Garg
2. Traumatic brain injury (TBI) can be classified as mild, moderate, or severe, based
on patient’s Glasgow Coma Scale (GCS) on presentation. A TBI with a GCS of 13
or above is classified as mild, 9–12 as moderate, and 8 or below as severe [4]. The
patient described above, therefore, has suffered a severe traumatic brain injury.
Other classification systems exist secondary to the limited ability of GCS alone in
predicting the outcome. The model developed by the US Department of Defense
and Department of Veterans Affairs uses three criteria: GCS after resuscitation,
duration of post-traumatic amnesia (PTA), and loss of consciousness (LOC) [5].
It has also been proposed that changes visible on neuroimaging, such as swelling,
focal lesions, or diffuse injury, should also be taken into consideration.
3. Some of the common types of traumatic brain injury include epidural hematoma,
subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage,
contusion, intraventricular hemorrhage, and diffuse axonal injury. An epidural
hematoma is the bleeding from an artery leading to collection of blood between the
skull and dura. It can present with the characteristic feature of a lucid interval fol-
lowing which the patient decompensates acutely. It is often a neurosurgical emer-
gency requiring emergent craniotomy and hematoma evacuation. Subdural
hematoma is secondary to bleeding from ruptured bridging veins leading to collec-
tion of blood between the dura and arachnoid layers of meninges. In elderly, sub-
dural hematomas can occur even from minor trauma and present with symptoms
such as new onset headache, seizures, and focal neurological deficits. Subarachnoid
hemorrhage is the bleeding into the space between arachnoid membrane and pia
mater. Trauma is the leading cause of subarachnoid hemorrhage. Intraparenchymal
or intracerebral hemorrhage is the bleeding into the brain tissue itself. A contusion
is a small intracerebral hemorrhage commonly noted in orbitofrontal and anterior
temporal cortices. Intraventricular hemorrhage is the bleeding into the ventricles of
the brain. This is often accompanied by intraparenchymal hemorrhage. An external
ventricular drain is usually placed to drain the intraventricular hemorrhage. Diffuse
axonal injury (DAI) happens when there is widespread damage to the white matter
tracts of the brain secondary to shearing forces. It is one of the most devastating
types of traumatic brain injury and can result in persistent vegetative state.
4. The CT images (Fig. 49.3A–C) show some of the common CT findings that can
be present in cases of traumatic brain injury following high-velocity motor vehi-
cle collisions. Figure 49.3A shows subdural hematomas (blue arrows) in the
midline and bilaterally (right larger than left), skull fracture (red circle), and soft
tissue swelling on the right (yellow arrow). Figure 49.3B shows significant sub-
arachnoid hemorrhage in the basal cisterns (blue margins). Figure 49.3C shows
a nondepressed skull fracture running obliquely through the bifrontal and left
parietal calvarium (blue arrows) and comminuted depressed fractures of the
bilateral nasal bones and the nasal septum (green circle).
5. Guidelines for the management of severe traumatic brain injury have been pub-
lished [6, 7]. Broadly, the acute management of a patient with traumatic brain
injury revolves around ensuring hemodynamic stability; airway protection; con-
trol of elevated intracranial pressure by emergent medical and surgical measures
such as intravenous mannitol/hypertonic infusion, hyperventilation, and place-
49 CT II 263
a b
Fig. 49.3 CT findings illustrating the subdural hematomas (blue arrows in A), subarachnoid hem-
orrhage (blue margins in B), scalp swelling (yellow arrow in A), and fractures (red circle in A and
green circle in C)
ment of external ventricular drain and/or emergent craniotomy and surgical inter-
vention; rapid identification and management of other injuries; and multimodal
monitoring. The initial approach to a trauma patient involves the primary and
secondary surveys with rapid assessment of the airway, breathing, circulation,
neurologic status (GCS), and associated injuries. Signs and symptoms of severe
264 A. Garg
traumatic brain injury and elevated intracranial pressure (such as low GCS, pupil-
lary dysfunction, Cushing’s triad) usually indicate the need for emergent surgical
interventions. Airway management in such circumstances may be complicated by
the status of the cervical spine, laryngopharyngeal integrity, and full stomach.
6. Some of the key elements of perioperative anesthetic care in a patient with acute
severe traumatic brain injury include:
(a) Treat hypotension first and then intracranial pressure (ICP). The cerebral blood
flow is more affected by the decrease in blood pressure than by elevated ICP.
(b) Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) manage-
ment: treat if ICP is above 20 mmHg but avoid prophylactic hyperventila-
tion. Define target MAP based on ICP to maintain a normal CPP and cerebral
blood flow: CPP = MAP − ICP or CPP = MAP − CVP (take the higher of
ICP or CVP). Avoid CPP <50 mmHg or >70 mmHg.
(c) Avoid hypotension: avoid SBP <90 mmHg.
(d) Avoid hypoxia: avoid PaO2 <60 mmHg or O2 SaO2 <90%.
(e) Maintain normovolemia. Avoid using hypotonic solutions such as lactated
ringer, free water, or glucose containing intravenous fluids. These can
increase ICP by increasing cerebral edema. The first choice for IV fluids in
patients with brain injury is normal saline and plasmalyte.
(f) The objective is to avoid secondary injuries from hypoxemia, hypercapnia,
hypotension, elevated ICP, and metabolic derangements.
References
1. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet
Neurol. 2008;7(8):728–41.
2. Centers for Disease Control and Prevention, National Center for Health Statistics. Mortality in
the United States, 2014. NCHS Data Brief No 229; December 2015.
3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale.
Lancet. 1974;2(7872):81–4.
4. Parikh S, Koch M, Narayan RK. Traumatic brain injury. Int Anesthesiol Clin. 2007;45(3):119–35.
5. Department of Defense and Department of Veterans Affairs. Traumatic brain injury task force.
2008. www.cdc.gov/nchs/data/icd9/Sep08TBI.pdf.
6. Brain Trauma Foundation, American Association of Neurological Surgeons AANS, Congress
of Neurological Surgeons CNS, AANS, CNS Joint Section on Neurotrauma and Critical Care.
Guidelines for the management of severe traumatic brain injury. J Neurotrauma.
2007;24(1):S1–S106.
7. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, et al. Guidelines for the acute medi-
cal management of severe traumatic brain injury in infants, children, and adolescents, 2nd
edition. Pediatr Crit Care Med. 2012;13(Suppl 1):S1–82.
Chapter 50
CT/MRI III
Ankur Garg
Case presentation: A 51-year-old woman initially presented to the hospital with

1-month history of confusion. Figure 50.1A, B illustrates the initial CT and MRI
findings. She underwent awake craniotomy with maximal resection of the mass
followed by outpatient chemotherapy and radiation. She was reoperated 6 months
later for recurrence of the lesion noted on surveillance imaging (Fig. 50.1C, D).
Eight months after that, she presented with progressive weakness, confusion, apha-
sia, and gaze preference and was found to have further progression of the disease
(Fig. 50.1E, F).
A. Garg, MD
Orlando Neurosurgery, 1605 W. Fairbanks Ave, Orlando, FL, USA

DOI 10.1007/978-3-319-55862-2_50
266 A. Garg
a b
c d
Fig. 50.1 (a) and (b) are the initial CT and MRI images of the patient presenting with an intracra-
nial mass lesion manifesting as 1 month of confusion. (c) and (d) are MRI images 8 months later
showing local recurrence. (e) and (f) are MRI images from 6 months later
50 CT/MRI III 267
e f
Questions
1 . Identify and describe the abnormal findings in the images shown above.
2. How are brain tumors classified?
3. List some of the common brain tumors.
4. What is the role of steroids in the acute management of brain tumors?
5. Describe important elements of anesthesia in a patient undergoing awake crani-
otomy for an intracranial mass lesion.
268 A. Garg
Answers
1. The CT and MRI images of the brain depicted in Figs. 50.1A, B and 50.2A, B
show an irregular heterogeneously enhancing mass lesion centered in the
region of the splenium of the corpus callosum, slightly to the left of the mid-
line. This mass extends to involve the left lateral ventricle and bilateral thal-
a b
c d
Fig. 50.2 Encircled region in (a) and (b) shows the mass lesion in the region of the splenium of
the corpus callosum. Open circles in (c) and (d) illustrate local recurrence, more toward the right
side and the blue arrows illustrate vasogenic edema. Circled regions in (e) and (f) illustrate the
recurrence in the right frontal region, while the arrows illustrate radiation-induced changes
50 CT/MRI III 269
e f
ami. These findings are concerning for a high-grade glioma, likely glioblastoma
multiforme. This patient underwent awake craniotomy and resection of the
mass followed by outpatient chemotherapy and radiation. The pathology con-
firmed the diagnosis of glioblastoma. Figures 50.1C, D and 50.2C, D depict the
local recurrence of the tumor six months later. Following this, the patient
underwent repeat craniotomy and tumor resection. Figures 50.1E, F and 50.2E,
F depict the pre- and post-contrast MRI images which reveal recurrence in the
right frontal region eight months later (encircled region). Radiation-induced
changes are also noted (blue arrows). The decision was made to pursue hospice
care at this point.
2. Brain tumors can be classified in a number of ways. A primary brain tumor is a

tumor that starts in the brain, as opposed to metastatic brain disease. Primary
brain tumors can be classified as benign tumors that tend to have slower growth
and distinct borders vs. malignant tumors that grow rapidly, invade the surround-
ing tissues and structures, and have grave prognosis. Brain tumors are also com-
monly graded using the WHO grading system. Grade I tumors such as
craniopharyngiomas and pilocytic astrocytomas grow slowly and are associated
with good long-term prognosis. Grade II brain tumors are also slow growing but
can spread into adjacent tissue. Grade III and IV tumors are malignant.
Glioblastoma is the most common example of a grade IV primary brain tumor. A
very extensive WHO classification of brain tumors was recently published and
serves as the guideline for neurosurgeons and neuropathologists [1].
270 A. Garg
3. The most common brain tumors include meningiomas, gliomas, and metastatic
brain disease. Meningiomas are the most common primary brain tumors. A
meningioma is a tumor that arises from the meninges, which are the linings of
the brain. They occur most frequently in middle-aged women. They are benign,
WHO grade I tumors, and surgery is the usual first-line treatment. Small asymp-
tomatic meningiomas can also just be observed. Approximately 5% of meningio-
mas are malignant in nature. Gliomas are tumors arising from glial cells which
form the supportive tissue of the brain. They are the second most common pri-
mary brain tumors but comprise the most common malignant brain tumor. An
astrocytoma is a glioma arising from the glial cells called astrocytes. A grade IV
astrocytoma is also called Glioblastoma multiforme or GBM. GBM can present
with a variety of neurological signs and symptoms such as headache, seizures,
and focal neurologic deficits. Usual treatment is maximal surgical resection fol-
lowed by radiation and chemotherapy, but recurrence is frequent and prognosis
is usually grave. Craniopharyngioma is a benign tumor that arises from a nest of
cells located near the pituitary stalk. These tumors can present with signs of
increased intracranial pressure by causing obstruction of CSF outflow across the
foramen of Monro. Surgery is the first-line treatment. Medulloblastoma is a
high-grade cerebellar tumor usually seen in children. They can extend into the
fourth ventricle and cause hydrocephalus by obstructing CSF outflow and metas-
tasize to the spinal cord. Treatment included resection followed by radiation and
chemotherapy. Metastatic brain disease is the spread of a primary tumor else-
where in the body to the brain. The common cancers that spread to the brain are
those arising in the thyroid, lung, breast, kidney, prostate, and colon, as well as
melanomas. The prognosis is grave.
4. Steroids are often used acutely to treat the cerebral edema that can some-
times be caused by a brain tumor. There are two broad categories of cerebral
edema: cytotoxic edema and vasogenic edema. Cytotoxic edema happens
after neuronal death and involves both grey and white matter. This is usually
seen after a stroke. Vasogenic edema involves the white matter only and is
often associated with tumors, infections, and hypertensive encephalopathy.
Steroids are very effective for vasogenic edema from brain tumors and can
temporarily relieve some of the neurologic signs and symptoms. They can be
utilized before, during, or after surgery or to treat edema caused by radiation
therapy. Steroids can also be prescribed to improve quality of life in patients
with advanced primary or metastatic neoplastic brain disease. The usual dose
in acute setting is dexamethasone 10 mg IV followed by 4 mg every 6 h.
5. Awake craniotomy is utilized when the brain lesion (such as a tumor) is located
in close proximity to an eloquent cortical region such as Broca’s area or the
motor strip. It provides the neurosurgeon the opportunity to preserve neuro-
logical function and limit deficits by performing awake functional cortical
mapping during the resection. The procedure, however, poses some unique
challenges to the anesthesiologist [2]. Patient cooperation during the proce-
dure is critical, and loss of intraoperative cooperation may result in a failed
50 CT/MRI III 271
awake craniotomy. Well-motivated and mature patients are the best candidates.
Preoperative evaluation should include a discussion of the expectations and
level of cooperation required during the procedure as well as eliciting risk fac-
tors for failed awake craniotomies such as history of alcoholism, low tolerance
to pain, and anxiety or psychiatric disorders [3]. Intraoperatively, the most
critical element of anesthesia management is provision of a rapid and smooth
transition of the anesthetic depth tailored to the different surgical stages while
maintaining a stable hemodynamic and cardiopulmonary function. Comfortable
positioning is mandatory. Several different anesthetic techniques have been
described such as conscious sedation, asleep-awake-asleep technique, and
asleep-awake technique. The choice of anesthetic agent is highly dependent
upon the requirement for functional cortical mapping and intraoperative elec-
trocorticography. Propofol infusion with a supplementary opioid is a common
anesthetic choice for awake craniotomies.
References
1. Louis DN, Perry A, Reifenberger G, Deimling AV, Figarella-Branger D, et al. The 2016 world
health organization classification of tumors of the central nervous system: a summary. Acta
Neuropathol. 2016;131:803–20.
2. Chui J. Anesthesia for awake craniotomy: an update. Rev Colomb Anestesiol. 2015;43(S1):22–8.
3. Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy and func-
tional neurosurgery. Anesthesiol Clin. 2012;30:241–68.
Chapter 51
MRI Spine
Gulshan Doulatram
A 38-year-old female has undergone an ORIF of the femur with a general anesthetic
and epidural anesthesia for postoperative pain. On the second postoperative day, she
is complaining of increasing back pain, numbness, and some weakness on the left
leg. Her VSS show a blood pressure of 110/60 mmHg, HR 85, RR 14, T-38.8 C. The
surgeon would like you to remove the epidural catheter. She is on aspirin and sub-
cutaneous heparin 5000 units three times a day.
G. Doulatram, MD

DOI 10.1007/978-3-319-55862-2_51
274 G. Doulatram
a b
c d
Fig. 51.1 T1 and T2 MR image of the thoracic spine. (a) T1-weighted MR image of the thoracic
spine in the axial view. (b) T1-weighted MR image of the thoracic spine in the sagittal view. (c)
T2-weighted MR image of the thoracic spine in the sagittal view. (d) T2-weighted MR image of
the thoracic spine in the axial view
1 . What does the MRI show you in this picture?

2. What is the incidence of this condition?
3. How does this condition present clinically?
4. What is the differential diagnosis for this patient?
5. What are its risk factors?
6. How could one prevent its occurrence?
7. What treatment options are available?
51 MRI Spine 275
Answers
1. Figure 51.1A and B shows a fluid collection in the epidural space in the thoracic
spine in a T1-weighted image in sagittal and axial views, respectively.
Figure 51.1C and D shows a hyperintense mass at the same level in a T2-weighted
image. Figure 51.1D shows an intense mass pushing on the anterior aspect of the
spinal cord (white arrows). Spinal epidural hematoma can occur spontaneously
or may follow spinal or epidural anesthesia [1]. The peridural anterolateral
venous plexus usually is most often the primary source, though arterial sources
of hemorrhage can occur rarely. This is supported by the fact that hematoma usu-
ally develops over hours to days suggesting a slow accumulation of blood from
a venous bleed. The hematoma usually extends to the dorsal aspect of thoracic or
lumbar region over several vertebral levels. If the patient has any contraindica-
tion to obtaining a MRI, then a CT myelography scan may be substituted to
make an early diagnosis. MRI is however more specific in detecting the various
stages of hematoma compared to CT myelography and is considered the first
choice diagnostic step to confirm the presence of an epidural hematoma. An
acute hematoma usually presents as low signal intensity signal on T1-weighted
image and high signal intensity on T2-weighted image [2].
2. Epidural hematoma after neuraxial anesthesia is fortunately a rare event. The
true incidence is unknown but is estimated to occur at an incidence of 1:220,000
after a spinal block and 1:150,000 after an epidural block [3]. The risk is much
higher at 1 in 3000 in certain patients with risk factors. The risk is much lower in
the obstetric population compared to vascular patients. About 1 in 430 patients
with epidural catheters will be suspected to have an epidural hematoma and
undergo a workup for it [4].
3. Patients with epidural hematoma present with severe unrelenting, nonpositional,
acute onset back pain and varying degrees of lower-limb weakness and sensory
deficits. Some patients may have motor weakness as a primary symptom in the
absence of back pain [5]. If the compression is extensive, then it could cause
bowel and bladder incontinence. Symptoms could be absent or attenuated in the
presence of a well-functioning epidural catheter infusing high concentrations of
local anesthetics. Symptoms rarely develop in the immediate postoperative
period and typically take 2–3 days. Once symptoms begin, they can progress
from back pain to a complete or partial paraplegia or even quadriplegia in a
few hours [6].
4. The differential diagnosis for this presentation can include epidural abscess,
intradural hemorrhage, prolonged and exaggerated neuraxial block, anterior spi-
nal artery syndrome, spinal cord compression due to presence of tumors, disc
herniation, worsening of previous spinal stenosis, lumbar radiculopathy, com-
pression fracture of the spine, and spinal cord infarction. There should be a high
index of suspicion for an epidural hematoma in an anticoagulated patient who
has an epidural catheter and in the presence of back pain with neurological
deficits.
276 G. Doulatram
Table 51.1 Timeline of use of anticoagulant drugs before and after neuraxial anesthesia
Time before needle/ Time to restart
catheter placement Epidural catheter anticoagulant
Drug and manipulation maintenance therapy
Antiplatelet drugs
ASA No change Yes No change
NSAIDs No change Yes No Change
P2Y12 inhibitors
Clopidogrel (Plavix) 7 d No 12–24 h
Ticlopidine (Ticlid) 14 d No 12–24 h
Prasugrel (Effient) 7 d No 12–24 h
Ticagralor (Brilinta) 7 d No 12–24 h
Glycoprotein IIB/IIIA inhibitors
Eptifibatide 8 h No 8–12 h
(Integrilin)
Tirofiban 8 h No 8–12 h
(Aggrastat)
Abciximab 2–5 d No 8–12 h
Heparin derivatives
Heparin 8–10 h Yes 2 h
unfractionated
5000 U SQ Q12 h
Heparin 8–10 h Yes 2 h
unfractionated
5000 U SQ Q8 h
Heparin 8–10 h No 4 h
unfractionated
7500 U SQ Q8 h
Heparin IV 4 h No 4 h
Dalteparin 12 h Must wait 8 h after 4 h
(Fragmin) 5000 U catheter is placed
SQ QD before giving a dose
Enoxaparin Must wait 12 h after
(Lovenox) 40 mg the last dose before
SQ QD removing the catheter
Enoxaparin 30 mg 24 h No 4 h
SQ Q12
XA inhibitors
Fondaparinux 3 d No 24 h
(Arixtra) 2.5 mg SQ
QD
Apixaban (Eliquis) 3 d 24 h
Rivaroxaban 3 d 24 h
(Xarelto)
Warfarin (Coumadin) 5 d (normal INR) No (remove the Immediately
catheter while INR is
below 1.5)
51 MRI Spine 277
Table 51.1 (continued)
Time before needle/ Time to restart
catheter placement Epidural catheter anticoagulant
Drug and manipulation maintenance therapy
Thrombin inhibitors
Dabigatran 3 d No 24 h
(Pradaxa) 6 d if renal
impairment
5. The risk factors for developing an epidural hematoma include “patient-specific”

factors or “surgery-related” issues. “Patient-specific factors” include advanced
age, needle size, presence of epidural catheter, females, trauma patients, spinal
cord and vertebral column abnormalities, preexisting spinal stenosis, organ func-
tion compromise, presence of underlying coagulopathy, traumatic or difficult
needle placement, as well as indwelling catheter in anticoagulated patient.
Spontaneous spinal epidural hematoma can sometimes occur with anticoagula-
tion, thrombolysis, blood dyscrasias, coagulopathies, thrombocytopenia, neo-
plasms, or vascular malformations. “Surgery-related factors” include prolonged
surgery and high intraoperative blood loss.
6. The practice guidelines put forth by the American Society of Regional

Anesthesia and Pain Medicine provide several preventive measures to avoid the
occurrence of epidural hematoma. The rarity of occurrence mandates that most
guidelines come from the collective experience of recognized experts in the field
of regional anesthesia and anticoagulation. They are based on case reports, clini-
cal series, pharmacology, hematology, and risk factors for surgical bleeding. The
timelines to stopping and restarting anticoagulants after neuraxial anesthesia are
summarized in Table 51.1. Multiple anticoagulants always pose an additional
risk even in the case of aspirin, selective serotonin reuptake inhibitors, and non-
steroidal anti-inflammatory medications [5, 6]. Several newer anticoagulants in
the past few years necessitate a thorough knowledge of these drugs and their
impact on neuraxial anesthesia. Optimal coagulation is necessary during needle
placement, maintenance, and removal of catheters. Close monitoring of anti-
coagulation status, frequent and regularly timed neurological checks, and the
use of low-concentration local anesthetics are necessary to avoid this dreaded
complication.
7. The treatment of epidural hematoma is timely diagnosis, consultation with a
neurosurgeon, and an emergency laminectomy to avoid persistent neurological
deficits. The prognosis is best when the laminectomy is done within 8 h.
Treatment delay greater than 24 h is associated with the worst prognosis [7].
278 G. Doulatram
References
1. Matsumura A, Namikawa T, Hashimoto R, Okamoto T, Yanagida I, Hoshi M, Noguchi K,

Takami M. Clinical management for spontaneous spinal epidural hematoma: diagnosis and
treatment. Spine J. 2008;8(3):534–7.
2. Rothfus WE, Chedid MK, Deeb ZL, Abla AA, Maroon JC, Sherman RL. MR imag-
ing in the diagnosis of spontaneous spinal epidural hematomas. J Comput Assist Tomogr.
1987;11(5):851–4.
3. Bateman BT, Mhyre JM, Ehrenfeld J, Kheterpal S, Abbey KR, Argalious M, Berman MF,
Jacques PS, Levy W, Loeb RG, Paganelli W, Smith KW, Wethington KL, Wax D, Pace NL,
Tremper K, Sandberg WS. The risk and outcomes of epidural hematomas after perioperative
and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes
Group Research Consortium. Anesth Analg. 2013;116(6):1380–5.
4. Ehrenfeld JM, Agarwal AK, Henneman JP, Sandberg WS. Estimating the incidence of sus-
pected epidural hematoma and the hidden imaging cost of epidural catheterization: a retrospec-
tive review of 43,200 cases. Reg Anesth Pain Med. 2013;38(5):409–14.
5. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia.
Anesth Analg. 1994;79:1165–77.
6. Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL,
Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional anesthesia in the patient
receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia
and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med.
2010;35(1):64–101.
7. Neal JM, Barrington MJ, Brull R, Hadzic A, Hebl JR, Horlocker TT, Huntoon MA, Kopp SL,
Rathmell JP, Watson JC. The second ASRA practice advisory on neurologic complications
associated with regional anesthesia and pain medicine: executive summary 2015. Reg Anesth
Pain Med. 2015;40(5):401–30.
Chapter 52
TEE I
Kofi B. Vandyck
An 82-year-old man with a history of hypertension, hyperlipidaemia and COPD

presented from a nursing home for an emergent laparotomy for a ruptured appendix.
A transoesophageal echocardiography (TEE) probe was placed intraoperatively for
diagnosis and monitoring after several attempts at managing hypotension proved
futile.
Questions
1. What are some of the benefits of using TEE in managing patients for non-cardiac
surgery?
2. What physics principles underlie the calculation of valve area, stroke volume and
cardiac output using TEE? (See Figs. 52.1, 52.2, 52.3, 52.4 and formula illustration)
3. Intraoperative echo showed a severely calcified aortic valve with a left ventricu-
lar outflow tract diameter (LVOT) of 2.59 cm, an LVOT VTI of 17.5, maximum
LVOT velocity (Vmax) of 69.2 cm/s, aortic valve VTI of 152 cm and an aortic
valve Vmax of 533 cm/s. The heart rate on the monitor was 97 beats/min. How
would you calculate the stroke volume and cardiac out?
K.B. Vandyck, MD

DOI 10.1007/978-3-319-55862-2_52
280 K.B. Vandyck
Answers
1. TEE can provide immediate and accurate haemodynamic measurement of car-
diac function including cardiac output and left ventricular filling pressure, cham-
ber preload, atrial interaction and pulmonary arterial pressures. Doppler
ultrasound principles are used to derive intracardiac flow across orifices and
valves in order to calculate orifice area, stroke volume and cardiac output.
Intraoperative cardiac output measurement provides a tool for assessing global
cardiac function. The information obtained from the cardiac output measurement
can be used in guiding therapeutic decision during cardiac and non-cardiac sur-
gery. The use of TEE for cardiac output measurement thus provides a simple and
reliable minimally invasive method of assessing cardiac function. Intraoperatively,
TEE can be used to diagnose or redefine the cause of haemodynamic instability
and detect new or unsuspected pathology like valvular (stenosis or regurgitation)
and other lesions.
2. Blood flow across valves and orifices of the heart can be obtained using the
Doppler capabilities of echocardiography and applying the basic principle of
physics and fluid dynamics.
According to the principles of physics and fluid dynamics,
Volume in a cylinder = cross-sectional area of the cylinder or vessel

´ length of cylinder or vessel = p r 2 ´ L,
where r is the radius of the cylinder or vessel and L is the distance between the
two point (or the length of the cylinder or vessels).
Also, flow rate (Q) is calculated as
volume Area ´ L p r 2 ´ L
Flow rate ( Q ) = = =
t t t
where t is time for fluid to traverse from point A to B.
r
Fig. 52.1 Illustration of a
cylinder with parameters used
in calculating area and flow
across two points in the
cylinder where r is cross-
sectional radius of cylinder
and L is distance between
point A and point B [1–3] Point A Point B
52 TEE I 281
Using the law of conservation of mass (continuity equation) and assuming lami-
nar flow,
QA = QB
(p r 2
´ L)
A
=
(p r 2
´ L)
B
t t
velocity = L / t
Therefore, the formula can be simplified to read;

(p r 2
´ v) = (p r2 ´ v)
A B
The velocity (and distance L) that blood travels in a blood vessel can be mea-
sured by TEE using continuous or pulse wave Doppler. Continuous wave uses
two crystals; one crystal continuously transmits ultrasound wave and the other
crystal continuously receives ultrasound waves thus allowing for measurement
of high-frequency Doppler velocities along the entire length of the ultrasound
beam [1]. In contrast to continuous wave measurement, pulse wave measure-
ments use one ultrasound crystal for both transmitting and receiving ultrasound
waves. This allows for measurement of low-frequency Doppler velocity (v) from
a specific region of blood flow.
Fig. 52.2 Continuous wave Doppler through the annulus of the aortic valve. Vmax = maximum
velocity through aortic valve; Vmean = mean velocity at aortic valve; max PG = maximum pressure
gradient at aortic valve; mean PG = mean pressure gradient at aortic valve; VTI = volume time
integral at aortic valve
282 K.B. Vandyck
Fig. 52.3 Pulse wave Doppler through the left ventricular outflow tract (LVOT). Vmax = maximum
velocity in LVOT; Vmean = mean velocity in LVOT; max PG = maximum pressure gradient in LVOT;
mean PG = mean pressure gradient; VTI = volume time integral; AVA = aortic valve area;
SV = stroke volume; CO = cardiac output
Fig. 52.4 Mid-esophageal aortic valve long (ME AVLAX) axis view of the left ventricular outflow
tract (LVOT) with measurement of the LVOT diameter and area
Using either continuous or pulse wave Doppler allows for the measurement of
velocity (v) and distance (measured by the echo machine as velocity time integral
(VTI)). The VTI and v are obtained by tracing the area under the Doppler signal
obtained. The VTI is also called the stroke distance that is the distance travelled
by the sampled volume per heartbeat. Therefore, the pulse wave VTI is the dis-
tance travelled by a blood sample at a specific point in the LVOT, while the
continuous wave VTI (usually measured across the aortic valve) is the longest
distance travelled by blood across the aortic valve [1–3].
52 TEE I 283
Blood volume at a point in a vessel can be measured using the formula;
Volume = p r 2 ´ VTI ( stroke distance )

The stroke volume (SV) across the left ventricular outflow tract (LVOT) is
therefore;
SVLVOT = p rLVOT2 ´ VTI LVOT

where rLVOT is the diameter of the left ventricular outflow tract proximal to the
aortic annulus
Cardiac output ( CO ) = Stroke volume ( SV ) ´ Heart Rate ( HR )

Therefore, the cardiac output (CO) at the LVOT is;

(
COLVOT = SVLVOT ´ HR = p rLVOT2 ´ VTI LVOT ´ HR )
Normal stroke volume is 60–100 mL per beat, and normal cardiac output is
4–8 L/min.
According to the continuity equation,
Cardiac output at LVOT = Cardiac output at Aortic valve
p rLVOT2 ´ VTI LVOT = Area AV ´ VTI AV

or,
p rLVOT2 ´ vLVOT = Area AV ´ vAV

where VTILVOT and vLVOT are the velocity time integral and the velocity respec-
tively at the LVOT and VTIAV and vLVOT are the velocity time integral and veloc-
ity, respectively, at the aortic valve.
Therefore;
p rLVOT2 ´ VLVOT
Area AV =
VAV

or,
284 K.B. Vandyck
3.
p rLVOT2 ´ VTI LVOT

Area AV =
VTI AV

SVLVOT = p rLVOT2 ´ VTI LVOT
= 3.14 ´ (1.25 ) 2 ´ 17.5 cm.
= 85.86 cm3 / beat or 85.86 mL / beat

( r is half of the measured diameter 2.5 cm = 1.25 cm ) .
COLVOT = SVLVOT ´ HR = 85.86 mL / beat ´ 90 beats /min
= 7727.4 mL / min or ~ 7.7L /min .
References
1. Darmon PL, Hillel Z, Mogtader A, et al. Cardiac output by transesophageal echocardiography

using continuous-wave Doppler across the aortic valve. Anesthesiology. 1994;80:796.
2. Katz WE, Gasior TA, Quinlan JJ, Gorcsan 3rd J. Transgastric continuous-wave Doppler to
determine cardiac output. Am J Cardiol. 1993;71:853.
3. Parra V, Fita G, Rovira I, et al. Transoesophageal echocardiography accurately detects car-
diac output variation: a prospective comparison with thermodilution in cardiac surgery. Eur
J Anaesthesiol. 2008;25:135.
Chapter 53
TEE II
Kofi B. Vandyck
A 60-year-old-patient with a history of right upper lobe lung cancer, peripheral

vascular disease, and chronic bronchitis is scheduled for a transthoracic echocar-
diography as part of workup for lung resection. Echocardiography evaluation
revealed a severely calcified aortic valve, severe left ventricular hypertrophy, and a
low normal ejection fraction (EF 50%):
1 . What is the etiology and pathophysiology of aortic stenosis?
2. How do you assess and grade aortic stenosis?
3. What is the natural history of patients with aortic stenosis?
4. What interventions are available for patients with aortic stenosis
K.B. Vandyck, MD

DOI 10.1007/978-3-319-55862-2_53
286 K.B. Vandyck
Answers
1. Causes of aortic stenosis (AS) in adults:
(a) Degeneration of tricuspid valve—commonest, seen after 60 years age,
caused by generalized atherosclerosis
(b) Degeneration of bicuspid valve—seen before 60, fusion of right and left
cusps resulting in large anterior and small posterior cusp, associated with
aortic dissection, aneurysm and coarctation
(c) Rheumatic—commonest cause worldwide, usually associated with mitral
disease as well
(d) Outflow obstruction:
• Subvalvular—either membrane or hypertrophic obstructive cardiomyop-
athy (HOCM)
• Supravalvular—Williams syndrome
Aortic sclerosis, defined as valve thickening without obstruction to LV out-
flow, is present in 25% of adults over 65 years of age. Predisposing factors com-
mon to both aortic stenosis and sclerosis are hypertension, smoking, serum
low-density lipoprotein, and diabetes mellitus. Aortic sclerosis usually pro-
gresses to aortic stenosis in the presence of progressive inflammatory atheroscle-
rosis. Ten percent of patients with aortic sclerosis progress to AS within 5 years.
In the 2014 ACC/AHA guidelines on valvular disease, aortic sclerosis is consid-
ered part of the AS continuum with sclerosis assigned stage A (at risk group).
2. Diagnosis and assessment of severity of AS made on the basis of history, physi-
cal exam, and echocardiographic findings. Patients with severe aortic stenosis
(AS) usually present with angina, syncope, sudden death, or heart failure.
Physical exam may reveal a crescendo-decrescendo ejection murmur. ECG will
show signs of left ventricular hypertrophy and left atrial enlargement.
Two-dimensional echocardiography with Doppler evaluation (TTE or TEE) is
the test of choice to confirm the diagnosis of AS and assess severity and also note
the presence of coexisting diseases such as aortic regurgitation, mitral stenosis,
mitral regurgitation, aortic root dilation, and coronary artery disease (Fig. 53.1).
The peak velocity and mean pressure gradient across the aortic valve are mea-
sured by means of Doppler interrogation of the aortic valve (Fig. 53.2). Accurate
Doppler measurement of aortic valve velocity (and pressure) requires a near par-
allel alignment of the ultrasound beam to the aortic valve. The normal aortic
valve area is approximately 3.0–4.0 cm2. The velocity and pressure gradients
across the aortic valve are flow dependent. In patients with low ejection fraction,
dobutamine or exercise stress echo may be needed to confirm the diagnosis. In
the 2014 guidelines, severity of AS was divided into 4 stages (A, B, C, and D)
based on valve anatomy, valve hemodynamics, hemodynamic consequence, and
symptoms [1] (Table 53.1).
3. Patients with aortic stenosis usually present when symptoms become severe enough
to disrupt normal daily activity. Prior to that, morbidity and mortality are very low.
The rate of progression to severe aortic stenosis varies, but in general it has been
53 TEE II 287
a b
c d
e f
Fig. 53.1 Normal AV in ME AV SAX view (a and b), severely stenotic AV in ME AV SAX (c) and
ME AV LAX views (d), color Doppler (e) of severely stenotic AV showing turbulent flow at the
aortic valve and root. Aortic sclerosis (f)
shown that in patients with at least moderate aortic stenosis, jet velocity across the
aortic valve increases by 0.3 m/s per year, mean gradient increases by 7 mmHg per
year, and AVA decreases by 0.1 cm2 per year [2]. Patients with symptomatic or
severe aortic stenosis present with angina, dyspnea, lightheadedness, syncope, and
heart failure. Sudden death is a feared complication of severe aortic stenosis, and,
although rare, it has been reported to occur without symptoms. Average survival in
patients with symptomatic aortic stenosis is 30–50% at 2 years. Patients with
asymptomatic severe AS require close monitoring in order to detect sudden changes
in symptoms. Patients with mild-to-moderate aortic stenosis will not have symp-
toms of the disease, but due to the unpredictable disease progression, it is mandatory
for these asymptomatic patients to have regular clinical follow-up and evaluation for
development of symptoms and disease progression. During these follow-ups,
288 K.B. Vandyck
Fig. 53.2 Continous wave interrogation of stenosed aortic valve with measurement of maximum
and mean pressure gradient and transvalvular velocity across aortic valve
Table 53.1 Stages of valvular aortic stenosis (Adapted from the Nishimura et al., 2014 ACC/AHA
Practice Guidelines for the Management of Patients with Valvular Heart Disease)
Stage Symptoms Valve anatomy and hemodynamics
A Asymptomatic but at risk Bicuspid AV
Aortic sclerosis (vmax < 2 m/s)
B Asymptomatic but Mild-moderate leaflet calcification, some reduction in
progressive systolic motion (vmax 2–3.9 m/s, Pmean < 20–39 mmHg)
C Asymptomatic severe AS
C1 Asymptomatic severe AS Severe leaflet calcification or stenosis with severely
reduced leaflet opening (vmax ≥ 4 m/s;
Pmean ≥ 40 mmHg, AVA ≤ 1 cm2)
C2 Asymptomatic severe AS Severe leaflet calcification or stenosis with severely
with LV dysfunction reduced leaflet opening (vmax ≥ 4 m/s;
Pmean ≥ 40 mmHg, AVA ≤ 1 cm2, LVEF < 50%)
D Symptomatic severe AS
D1 Symptomatic severe Severe leaflet calcification or stenosis with severely
high-gradient AS reduced leaflet opening (vmax ≥ 4 m/s;
Pmean ≥ 40 mmHg, AVA ≤ 1 cm2, LV hypertrophy,
LVEF > 50%)
low-flow/low-gradient AS reduced leaflet opening (Resting vmax ≥ 4 m/s or
with reduced LVEF Pmean ≥ 40 mmHg; AVA ≤ 1 cm2, LVEF < 50%)
low-gradient AS with normal reduced leaflet opening (vmax < 4 m/s or
LVEF Pmean < 40 mmHg; AVA ≤ 1 cm2
Stroke Vol Index < 35 m/m2, LVEF ≥ 50%, small LV
size
53 TEE II 289
patients should be educated on the signs and symptoms of disease progression such
as exercise intolerance, exertional chest discomfort, dyspnea, and syncope.
4. Appearance of symptoms is the most important indication for intervention in patients
with aortic stenosis. There are no specific medical therapies to treat or slow the pro-
gression of aortic stenosis [1, 2]. It is recommended to treat hypertension in patients
with increased risk of developing AS (stages B and C) [1, 2]. Hypertension is preva-
lent in patients with AS and has been shown to be a risk factor for AS and also
increase the morbidity and mortality risk associated with AS [1, 3]. The treatment is
started at low dose, and patients should be monitored closely by experienced cardi-
ologist to avoid complications associated with the disease state or treatment in these
high-risk patients. Angiotensin-converting enzyme (ACE) inhibitors, diuretics, and
vasodilators can be used in the acute setting in patients with severe decompensated
AS. The use of these medications may require invasive hemodynamic monitoring.
Aortic valve replacement (AVR) is the only definite treatment for patient with
AS. Early surgical intervention has been shown to decrease mortality in patients with
severe AS [1]. Decision to operate should be based on symptoms, valve anatomy, and
hemodynamics [1]. The ACC/AHA guideline recommends surgical AVR for all
patients who meet an indication for AVR with low or intermediate surgical risk. Major
indications for surgical AVR (class I recommendation) are severe symptomatic AS,
asymptomatic severe AS with LVEF <50%, asymptomatic severe AS in patients
undergoing CABG, other heart surgeries or surgery on the aorta. In patients with mod-
erate AS undergoing other cardiac surgery, it is reasonable to perform surgical AVR if
the aortic velocity is between 3 and 3.9 m/s or the mean pressure gradient is between
20–39 mmHg (class IIa recommendation). These patients are likely to have symptoms
of the disease within 5 years due to the progressive nature of aortic stenosis [2].
Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgi-
cal procedure for replacing the aortic valve. At present, it is indicated in patients
with severe AS who are high risk for open surgical replacement of the aortic
valve. It involves placing a valve mounted on balloon at the tip of a catheter over
a diseased native aortic valve. The catheter is fed through either the femoral
artery or through the apex of the heart which require a small incision to be made
on the left chest wall. According to the ACC/AHA 2014 guidelines on valvular
disease, TAVR is recommended in AS patients with indications for AVR who
have a high risk for open AVR, or a prohibitive surgical risk and a predicted post
TAVR risk greater than 12 months.
References
1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin III JP, Guyton RA, American
College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Guidelines, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart
disease: a report of the American College of Cardiology/American Heart association task force
on practice guidelines. J Am Coll Cardiol. 2014;63:e57–18.
290 K.B. Vandyck
2. Saric M. Decompensated valvular disease in the cardiac care unit. In: Herzog, E. The cardiac
care unit: survival guide. 1st ed. Lippincott Williams and Wilkins, Philadelphia, PA 2012.:
Chapter 25. p. 253–257.
3. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger
MA, Joint Task Force on the Management of Valvular Heart Disease of the European Society
of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), et al. Joint
task force on the management of valvular heart disease of the European Society of Cardiology
(ESC); European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the man-
agement of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.
4. Skubas NJ, Shernan SK, Bollen B. An overview of the American College of Cardiology/
American Heart Association 2014 valve heart disease practice guidelines: what is its relevance
for the anesthesiologist and perioperative medicine physician? Anesth Analg. 2015;121(5):
1132–8.
Chapter 54
Echo: Doppler I
Kofi B. Vandyck
A 45-year-old Caucasian female with a recent history of breast cancer status post-
chemotherapy and radiation therapy was admitted with high-grade fever, slurred
speech, back pain, and petechial rash. Surveillance cultures had been inconclusive
with one of three samples being positive for coagulase-negative Staphylococcus
aureus. Transthoracic echocardiography, performed as part of initial workup,
showed no valvular vegetation, preserved ejection fraction (55%), and mild aortic
Fig. 54.1 Mid-esophageal short axis view of aortic valve showing vegetation on aortic leaflets.
Arrows showing vegetation on aortic valve leaflets
K.B. Vandyck, MD

DOI 10.1007/978-3-319-55862-2_54
292 K.B. Vandyck
Fig. 54.2 Mid-esophageal long axis view of aortic valve showing mobile vegetation on aortic
valve. Arrow showing vegetation on aortic valve leaflet. Valve viewed in long axis
Fig. 54.3 Mid-esophageal long axis view with color Doppler in a patient with aortic valve endo-
carditis showing severe regurgitation at the aortic valve
regurgitation. A diagnosis of infective endocarditis was suspected, and despite treat-

ment with antibiotics, the patient continued to have intermittent high-grade fever
and signs and symptoms of congestive heart failure. Transesophageal echocardiog-
raphy performed 7 days’ post-presentation showed a large mobile mass on the aortic
valve, severe aortic regurgitation with a depressed ejection fraction of 40% (see
Figs. 54.1, 54.2, and 54.3). Therefore, cardiothoracic surgery was consulted for
evaluation for possible valve replacement surgery.
54 Echo: Doppler I 293
Questions
1 . What are the risk factors for infective endocarditis?
2. Explain the pathophysiology of infective endocarditis?
3. Describe the clinical manifestations of infective endocarditis?
4. How do you diagnose infective endocarditis?
5. What is the role of TTE and TEE in the diagnosis of infective endocarditis?
6. What are the treatment options for patients with infective endocarditis?
7. Which are the guidelines on managing high-risk patients presenting for surgery?
294 K.B. Vandyck
Answers
1. The following patients present a high risk for infective endocarditis [1–9]:
(a) Male, elderly (age > 60)
(b) Prior history of prior IE
(c) Poor dental hygiene
(d) Patient undergoing dental procedures involving gingival tissues
(e) Patients with valvular heart disease (e.g., rheumatic valvular disease)
(f) Patients with uncorrected or partially corrected congenital heart disease
(g) IV drug use
(h) Prosthetic valves
(i) Immunosuppressed patient
(j) Patients with history of diabetes
(k) Patients with intracardiac devices
(l) Patients undergoing hemodialysis
2. Pathophysiology:
(a) IE occurs when bacteria or fungi invade sterile platelet-rich thrombus at sites
of injury in the endocardium.
(b) Sources of bacteria include the skin, oral cavity, mucosal surfaces, or sites of
focal infection.
(c) Infection results in invasion of the thrombus and destruction of the underly-
ing valvular and endocardial tissues.
(d) Bacteria usually resistant to the complement system of the body.
(e) Common bacterial species: Staphylococcus, Streptococcus, Enterococci,
and HACEK group (Haemophilus, Actinobacillous, Corynebacterium,
Eikenella, and Kingella).
3. Infective endocarditis can affect all organ systems of the body [1–9]:
(a) Nonspecific symptoms: fever (most common symptoms), chills, sweats, head-
aches, weight loss, back pain, myalgia arthralgia, cough, and pleuritic chest pain
(b) Other symptoms highly specific for IE: cardiac murmur (85% of patients),
splinter hemorrhage in nail beds, petechiae on skin and mucous membranes,
Janeway lesions (nontender macules on palm and sole), Roth spots (hemor-
rhagic lesions on retina), and Osler nodes (tender nodules on fingers and toes)
(c) Cardiac complications: valvular insufficiency, congestive heart failure (30–
40% of IE patients), and periannular and intraventricular abscesses (can
result in intracardiac fistulas), cardiac arrhythmias (usually the result of peri-
annular abscesses)
(d) Vascular-embolic complications: septic emboli (15–35% of IE patients),
mycotic aneurysm, and vertebral osteomyelitis
(e) Neurologic complications (mostly from vascular embolic events): brain
abscess, embolic stroke, and cerebral hemorrhage
(f) Renal complications: kidney infarct from septic emboli and glomerulone-
phritis (caused by immune complexes)
(g) Pulmonary complications (commonly seen in right heart IE): septic pulmo-
nary emboli and pyopneumothorax
4. The modified Duke Criteria is the most common guideline used in the diagnosis
of infective endocarditis. Pathological and clinical information obtained during
workup have been divided into major and minor criteria (adapted with permis-
sion from the ACC/AHA 2014 Guidelines for Management of Valvular Heart
Disease) [8]:
(a) Major criteria:
• Blood culture positive for IE: at least two positive cultures of blood sam-
ples drawn >12 h apart or all three or a majority of ≥4 separate cultures
of blood (with first and last sample drawn at least 1 h apart)
• Single positive blood culture for Coxiella Burnetii or anti-phase 1 IgG
antibody titer ≥1:800
• Evidence of endocardial involvement
• Echocardiogram positive for IE
(b) Minor criteria
• Predisposing heart condition
• IV drug use
• Fever (temperature > 38 °C)
• Vascular phenomena including major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hem-
orrhages, and Janeway lesions
• Immunological phenomena including glomerulonephritis, Osler nodes,
Roth spots, and rheumatoid factor
• Positive blood culture but does not meet a major criterion as noted above
(c) The criteria further stratify the diagnosis of IE into definite, possible, or
rejected based on whether a patient exhibits a set of major and/or minor
clinically defined characteristics (adapted with permission from the ACC/
AHA 2014 Guidelines for Management of Valvular Heart Disease):
• Definite IE:
Pathological criteria: culture demonstrated microorganism or histology
showing intracardiac abscess
Clinical criteria: two major criteria or one major and three minor criteria
or five minor criteria
• Possible IE:
One major criterion and one minor criterion or three minor criteria.
• Rejected IE:
Firm alternative diagnosis.
No pathological evidence of IE was found at surgery or autopsy after
antibiotic therapy for 4 days or less.
Resolution of clinical manifestations occurs after ≤4 days of antibiotic
therapy.
Clinical criteria for possible or definite infective endocarditis are not
met.
5. Echocardiography is a major criterion in the diagnoses of infective endocarditis,
and therefore it should be performed in all patients with suspected IE [8]:
(a) Echocardiographic evidence of IE includes (see Figs. 54.1, 54.2, and 54.3):
296 K.B. Vandyck
• Valvular vegetation
• Associated valvular regurgitation
• Intracardiac mass
• Periannular abscess
(b) Transthoracic echocardiogram (TTE):
• Initial test of choice to identify vegetation and quantify hemodynamic
effect of IE.
• Good sensitivity and specificity (75% and ~100%, respectively).
• Absence of lesions on TTE does not rule out IE when there is high suspi-
cion of IE.
• Suboptimal TTE images may be seen in patients with chronic obstructive
pulmonary disease, previous thoracic and cardiovascular surgery, and
morbid obesity.
(c) Transesophageal echocardiogram (TEE):
• Generally, more sensitive for the diagnosis of TEE especially for pros-
thetic valves, paravalvular abscess, fistulas, and intracardiac devices.
• Specificity is slightly lower than TTE.
• Recommended as the initial test of choice when feasible.
• Recommended in cases of negative TTE but high suspicion of IE.
• Recommended for follow-up of patients with IE, small left-sided heart IE
and patients who develop progressive disease despite institution of anti-
microbial therapy.
6. Treatment: The mainstay of treatment for infective endocarditis is antibiotic,
often over weeks, with regular surveillance to gauge effectiveness of treatment.
(a) Factors that present a challenge during antibiotic treatment:
• Focal infection with high bacterial density
• Impaired immunity in the patient
• Slow rate of bacterial growth within a biofilm
• Low microorganism metabolic activity
(b) Choice of antibiotics must be based on the knowledge of the susceptibility
profile of the microorganism in the vegetation.
(c) Systemic antibiotics must be in concentrations high enough to counteract the
high density of bacterial in the vegetation.
(d) An expected infectious disease must be directly treated with antimicrobials
in IE patient.
(e) Valve replacement is recommended in the following cases:
• Large mobile vegetation greater than 10 mm in diameter
• Vegetation with associated regurgitation
• Paravalvular infection and/or annular abscess
• Penetrating intracardiac lesion
• Endocarditis with associated heart block and/or malignant arrhythmia
• Fungal vegetation
• Persistent bacteremia despite antibiotic treatment
7. Antibiotic prophylaxis is recommended in the following highest-risk patients

only:
(a) Prosthetic heart valve
(b) Prior history of IE
(c) Dental procedures involving break in oral mucosa and gingival tissue
(d) Procedures in infected gastrointestinal and genitourinary tract
(e) Procedures on infected skin and integument
(f) Biopsy of the respiratory tract
(g) Unrepaired cyanotic congenital heart disease
(h) Repaired congenital heart disease with residual defects
Antibiotics for Recommendation for Dental Procedures [1]
(a) Patients who can take oral meds:
• Oral amoxicillin (adults 2 g, children 50 mg/kg)
(b) Patients unable to take oral meds:
• Ampicillin IV or IM (adults 2 g, children 50 mg/kg)
• Cefazolin IV (adults 1 g, children 50 mg/kg)
• Ceftriaxone IV (adults 1 g IV or IM, children 50 mg/kg)
(c) Patients allergic to penicillin (anaphylaxis, angioedema, urticaria):
• Oral azithromycin or clarithromycin (adult 500 mg, children 15 mg/kg)
• Oral clindamycin (adults 600 mg, children 20 mg/kg)
(d) Patients allergic to penicillin and unable to take oral medications:
• Clindamycin IV or IM (adults 600 mg, children 20 mg/kg)
• Vancomycin IV (adults 15 to 20 mg/kg, children 15 mg/kg)
References
1. Baddour LM, Wilson WR, et al. Infective endocarditis in adults: diagnosis, antimicrobial ther-
apy, and management of complications. Circulation. 2015;132:1435–86.
2. Brusch J. Infective endocarditis: management in the era of intravascular devices. New York,
NY: Informa Healthcare; 2007.
3. Durante-Mangoni E, Bradley S, Selton-Suty C, et al. Current features of infective endocarditis
in elderly patients: results of the International Collaboration on Endocarditis Prospective
Cohort Study. Arch Intern Med. 2008;168:2095.
4. Gould FK, Denning DW, Elliott TS, et al. Guidelines for the diagnosis and antibiotic treatment
of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial
Chemotherapy. J Antimicrob Chemother. 2012;67:269.
5. Habib G, Lancellotti P, Antunes MJ, et al. ESC guidelines for the management of infective
endocarditis: the task force for the management of infective endocarditis of the European
Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery
(EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015.
2015;36:3075.
6. Michel PL, Acar J. Native cardiac disease predisposing to infective endocarditis. Eur Heart
J. 1995;16(Suppl B):2.
298 K.B. Vandyck
7. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infec-
tive endocarditis in the 21st century: the International Collaboration on Endocarditis-
Prospective Cohort Study. Arch Intern Med. 2009;169:463.
8. Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC guideline for the management of
patients with valvular heart disease: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;e57:63.
9. Wilson W, Taubert KA, Gewitz M, Lockhart PB, et al. Prevention of Infective Endocarditis.
Guidelines from the American Heart Association. A Guideline from the American Heart
Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group. Circulation. 2007;116:1736. Copyright © 2007 Lippincott
Williams & Wilkins
Chapter 55
Echo: Doppler II
Talla A. Rousan
Fig. 55.1 Color flow Doppler imaging of mitral valve regurgitation from the transesophageal
echocardiographic Four-chamber mid-esophageal view with zoom-in on the mitral valve. Vena
contracta (black double arrow) and proximal isovelocity surface area radius (the distance between
the “+” signs) are shown
Questions
1 . What do Figs. 55.1, 55.2, and 55.3 represent?
2. Define color flow Doppler and its application in mitral valve regurgitation.
3. What is continuous wave Doppler?
4. Describe the different grades of mitral valve regurgitation.

Veteran Affairs Medical Center, 800 Stanton L. Young Blvd, COM 5400,

DOI 10.1007/978-3-319-55862-2_55
300 T.A. Rousan
Fig. 55.2 Continuous wave Doppler sampled across the mitral valve
Fig. 55.3 Pulsed wave Doppler sampled at the mitral valve

55 Echo: Doppler II 301
Answers
1. The figures show still echocardiographic frames for a patient with mitral valve
regurgitation. Figure 55.1 is color flow Doppler with transesophageal echocar-
diography, and Figs. 55.2 and 55.3 demonstrate continuous wave Doppler sam-
pled across the mitral valve and pulsed wave Doppler sampled at the mitral valve
using transthoracic echocardiography (TTE).
2. Color flow Doppler displays intracavity blood flow in colors (red, blue, green, or
their combinations) depending on the velocity, direction, and extent of turbulence
[1]. Color flow Doppler is a widely used method for the detection of regurgi-
tant valvular heart disease. This technique provides visualization of the origin
and width (vena contracta) of the regurgitation jet, spatial orientation of the jet
area in the receiving chamber, and flow convergence into the regurgitant orifice
[2]. The area of the regurgitant jet can provide a rapid quantitative assessment
of the severity of the regurgitation; generally speaking, a large area may indi-
cate a more significant regurgitation [2]. Vena contracta or regurgitant jet width
(black double arrow in Fig. 55.1) is the narrowest portion of a jet that occurs at/
or just downstream from the orifice of the valve, and it is an indirect measure of
the regurgitant orifice [3]. Proximal isovelocity surface area (PISA) or flow
convergence is another method to quantify the severity of mitral valve regurgita-
tion. It is based on the continuity equation and the principle of flow conversation
[1, 2]. As blood in the left ventricle approaches the mitral regurgitant orifice,
there is convergence and flow acceleration. This is seen in hemispheric waves of
decreasing area but of equal velocity (hence, the term isovelocity) [1, 2]. PISA
is identified by color flow Doppler as the “red-blue” aliasing interface (PISA
radius is the distance between the “+” signs in Fig. 55.1). PISA radius is used to
calculate the effective regurgitant orifice area (ERO), which is the cross-sectional
area of the vena contracta, and regurgitant volume (which is the volume of the
blood that is leaking back to the left atrium during systole) [1]. ERO and the
regurgitant volume can also be calculated using the volumetric method [1]. In the
absence of significant aortic valve regurgitation, the regurgitant volume is equal
to the flow across the mitral valve minus the flow across the left ventricular out-
flow tract (systemic stroke volume) [1]. These calculations are made by obtaining
the LVOT and mitral valve diameters and LVOT and mitral valve time-velocity
integral (TVI) [1]. Figure 55.3 shows pulsed wave Doppler at the mitral valve
which depicts the TVI of the mitral valve.
3. Doppler echocardiography measures blood flow velocities in the heart chambers
as well as in the great vessels [1]. Continuous wave Doppler measures the
changes in velocities along the beam path and is used to record the highest flow
velocity available [1]. Analysis of continuous wave Doppler signal by noting the
shape, contour, density, and velocity of the signal can provide an insight on the
severity of mitral valve regurgitation [4].
4. Mitral valve regurgitation is graded into mild, moderate, and severe. This is
based on quantitative as well as qualitative assessment, and it involves the use of
302 T.A. Rousan
Table 55.1 Grades of mitral valve regurgitation severity

Jet/left Effective
Jet atrium Vena Regurgitant regurgitant
area area Regurgitant contracta volume (mL/ orifice area
Severity (cm2) (cm2) fraction width (cm) beat) (cm2)
Mild <4 <20% <30% <0.3 <30 <0.20
Moderate 4–10 20–40% 30–49% 0.3–0.69 30–59 0.20–0.39
Severe >10 >40% ≥50% ≥0.7 ≥60 ≥0.40
Doppler echocardiography. The visualization of the jet area and jet area to left
atrium area ratio by color flow Doppler provides a quick assessment tool of the
severity of mitral valve regurgitation [3]. This method tends to underestimate
eccentric jets and overestimate the severity of mitral regurgitation in ventral jets
[3]. Mitral valve regurgitation can be quantitatively assessed by measuring the
vena contracta width, effective regurgitant orifice area, the regurgitant volume,
and the regurgitant fraction (the ratio between the regurgitant volume and the
flow across the mitral valve) [1, 3]. Table 55.1 illustrates the different grades of
mitral valve regurgitation using the different variables [3]. Based on the data
provided in the figures, this case represents severe mitral valve regurgitation
(vena contracta 0.7 cm and regurgitant volume of 63 mL).
References
1. Oh JK, Seward JB, Tajik AJ. The echo manual. 3rd ed. Philadelphia: Lippincott Williams &
Wilkins; 2007.
2. Zoghbi WA, et al. Recommendations for evaluation of the severity of native valvular regurgita-
tion with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr.
2003;16(7):777–802.
3. Grigioni F, et al. Clinical use of doppler echocardiography in organic mitral regurgitation: from
diagnosis to patients’ management. J Cardiovasc Ultrasound. 2015;23(3):121–33.
4. Fadel BM, et al. Spectral Doppler interrogation of mitral regurgitation -spot diagnosis.
Echocardiography. 2015;32(7):1179–83.
Chapter 56
Echo: Doppler III
Nicole T. Tran
Fig. 56.1
N.T. Tran, MD
Department of Cardiology, University of Oklahoma Health Sciences Center,

DOI 10.1007/978-3-319-55862-2_56
304 N.T. Tran
Fig. 56.2
56 Echo: Doppler III 305
Fig. 56.3
Fig. 56.4
I. A 48-year-old male with history of uncontrolled hypertension and end-stage

renal disease on hemodialysis presents for TTE as part of preoperative risk stratifi-
cation prior to possible renal transplant. He has NYHA Class III symptoms at base-
line. 2D images show moderately to markedly increased left ventricular wall
thickness. LVEF calculated by the biplane Simpson’s method is 56%. The remain-
der of his diastolic parameters are as shown in Figs. 56.1, 56.2, 56.3, and 56.4.
306 N.T. Tran
Questions
1 . Describe what happens in normal diastole.
2. What are the causes of diastolic dysfunction? What is the difference between
diastolic dysfunction and heart failure with preserved ejection fraction (HF-pEF)?
3. How do you use echocardiography to grade diastolic dysfunction?
4. What do Figs. 56.1, 56.2, 56.3, and 56.4 show?
5. Does this patient have normal or abnormal diastolic function? How would you
grade it?
6. What are the key considerations for managing diastolic dysfunction in the preop-
erative period?
Answers
1. Diastole is defined as the portion of the cardiac cycle between aortic valve clo-
sure and mitral valve closure. It is normally divided into four phases: isovolumic
relaxation, rapid early diastolic filling, diastasis, and atrial contraction.
Isovolumic relaxation occurs between aortic valve closure and mitral valve
opening. Through an active, calcium-dependent process, left ventricular pressure
decreases, while volume remains the same [1]. When left ventricular e nd-diastolic
pressure falls below left atrial pressure, the mitral valve opens and rapid early
diastolic filling begins. This usually accounts for 70% of left ventricular filling
[1, 2]. As pressures equalize between the left atrium and left ventricle, a small
amount of filling continues via passive flow from the pulmonary veins; this is
diastasis. Diastasis generally accounts for 5% of left ventricular filling and is
only present at slower heart rates. If the patient is in sinus rhythm, atrial systole
follows diastasis. Left atrial pressure again transiently increases, and there is
further filling of the left ventricle. Atrial contraction generally accounts from
25% of left ventricular filling in the normal heart. Diastolic function is influ-
enced by volume status, properties of the left ventricle (stiffness, recoil), atrial
properties, and catecholamines.
2. Aging, hypertension, diabetes, obesity, coronary artery disease, renal disease,
valvular heart disease, and infiltrative processes all affect left ventricular mechan-
ics/stiffening and thus diastolic function. In the presence of systolic dysfunction,
diastolic function is always abnormal. HF-pEF is defined as the presence of dia-
stolic dysfunction accompanied by signs/symptoms of clinical heart failure in
patients with an ejection fraction of at least 50% [3].
3. In the 2016 American Society of Echocardiography/European Association of
Cardiovascular Imaging guidelines, there are four main echocardiographic
parameters used to assess diastolic dysfunction: mitral inflow pulse wave (PW)
Doppler, annular tissue Doppler imaging (TDI), peak tricuspid regurgitant (TR)
velocity, and left atrial end-systolic volume index (LAESVi).
Mitral inflow PW Doppler is measured in the apical four chamber (A4C) view
with the Doppler cursor placed at the mitral leaflet tips [2, 4]. The initial wave of
early diastolic filling is labeled the E wave. The second wave represents filling
due to atrial contraction and is labeled the A wave (Fig. 56.1). In normal hearts
the E/A ratio is typically between 0.9 and 1.5 [2]. As relaxation becomes
Table 56.1 Grading diastolic dysfunction

Normal Grade I Grade II Grade III/IV
E/A 0.9–1.5 <0.9 0.9–2.0 ≥2.0
Average E/e′ ratio <14 <14 >14 >>14
Peak TR velocity <2.8 m/s <2.8 m/s ≥2.8 m/s ≥2.8 m/s
LAESVi <34 mL/m2 <34 mL/m2 ≥34 mL/m2 ≥34 mL/m2
308 N.T. Tran
impaired, but before left atrial pressures (LAP) rise, there is an increased reliance
on atrial contraction to maintain diastolic filling, and the E/A ratio is <0.9 [2]. As
LAP continues to rise, there is again more filling happening in early diastole due
to the increased pressure gradient between the left atrium (LA) and left ventricle
(LV), and the E/A ratio becomes “pseudo normal.” As left ventricular compliance
decreases and LAP rises further, there is initial brief filling in early diastole with
relatively little filling happening during atrial contraction, and the E/A ratio
increases to ≥2. Mitral inflow PW Doppler varies with volume status, mitral
valve disease, and atrial arrhythmias.
Annular TDI velocities are measured with PW Doppler in the A4C view with the
cursor placed at both the septal and at the lateral mitral annulus (Fig. 56.2).
Myocardial relaxation in early diastole is labeled e′. Septal and lateral e′ veloci-
ties are normally >7 cm/s and >10 cm/s, respectively [3]. As myocardial relax-
ation becomes impaired, annular tissue Doppler velocities decrease. The ratio of
mitral inflow during early diastolic filling (E) and tissue Doppler early myocar-
dial relaxation (e′) has been shown to correlate with LAP. Specifically, an aver-
age E/e′ ratio > 14, a septal E/e′ ratio > 15, and a lateral E/e′ ratio > 13 are
consistent with elevated LAP [2]. Annular TDI velocities are not dependent on
volume status but are unreliable in the presence of significant mitral annular
calcification, a mitral prosthesis, or a mitral annuloplasty ring.
The peak TR velocity (Fig. 56.3) also positively correlates with LAP and pulmo-
nary capillary wedge pressure (PCWP) in the absence of pulmonary vascular or
pulmonary parenchymal disease. It should be measured using continuous wave
(CW) Doppler in multiple views with an attempt to get the cursor as parallel as
possible to the direction of regurgitant flow. A peak TR velocity > 2.8 m/s is
consistent with elevated LAP [3].
Finally, left atrial size is related to chronic elevations in LAP (in the absence of
mitral valve disease, atrial arrhythmias, or post-cardiac transplant). Left atrial size
is best assessed by the left atrial end-systolic volume index (LAESVi), with left
atrial area traced in atrially focused A4C, and apical 2-chamber (A2C) views one
to two frames before mitral valve opening. Left atrial volume is calculated using
either Simpson’s method of disks or the area-length method (0.85 × A1 × A2)/
(L1–L2/2) and is indexed to body surface area (BSA). A LAESVi >34 mL/m2 is
consistent with chronic elevations in left atrial pressure [2].
Currently, the main purpose in grading diastolic dysfunction is to evaluate whether
LAP is elevated as elevated LAP is modifiable and correlates with symptoms and
outcomes. Grade I diastolic dysfunction is characterized by impaired left ventricu-
lar relaxation with normal filling pressures. There is a decrease in early diastolic
filling and an increase in filling with atrial contraction. Filling pressures are ele-
vated in grades II–IV diastolic dysfunction. In grade II diastolic dysfunction, the
left atrium remodels and left atrial pressures increase to compensate for elevated
left ventricular end-diastolic pressures. Grades III–IV diastolic dysfunction repre-
sent restrictive filling where left ventricular filling only occurs in the setting of
markedly elevated left atrial pressures due to reduced left ventricular compliance
(exaggerated change in pressure for a small change in volume). Grade III is revers-
ible; grade IV is irreversible [1–3]. Table 56.1 summarizes the findings for each of
the four key variables in grades I–IV diastolic dysfunction.
4. Figure 56.1 shows the mitral inflow PW Doppler from our patient. The 2D image
(above) shows the PW Doppler cursor placed at the mitral valve leaflet tips. The
Doppler waveform (below) shows left ventricular filling. E represents early diastolic
filling and A represents atrial contraction. Figure 56.2 shows annular TDI with the
PW Doppler cursor placed at the medial (septal) annulus (left) and lateral annulus
(right). e′ (myocardial relaxation in early diastole) is labeled on the Doppler tracing
below. This and the mitral inflow data from Fig. 56.1 are used to calculate the average
E/e′ ratio. Figure 56.3 shows a CW Doppler TR signal. The 2D image (top) shows the
Doppler sampling line going through tricuspid regurgitation (blue signal). The peak
TR velocity is marked on the Doppler waveform. Figure 56.4 shows a zoomed in
view of the left atrium in an A2C view. The LAESVi is shown being calculated using
the Simpson’s method of disks. This would be combined with the A4C tracing of the
left atrium to calculate left atrial volume and then divided by BSA to get the LAESVi.
5. With our patient, the mitral inflow PW Doppler E/A ratio is 1.2 (Fig. 56.1). This
is either normal or pseudo normal. Therefore, we need to assess his average E/e′
ratio, his peak TR velocity, and his LAESVi. His average E/e′ ratio is >14 at 19.3
(Fig. 56.2). His peak TR velocity is >2.8 m/s at 4.19 m/s (Fig. 56.3). His LAESVi
is >34 mL/m2 at 66.5 mL/m2 (Fig. 56.4). As all three parameters are abnormal,
LAP is elevated, and he has grade II diastolic dysfunction.
6. The data is mixed on how anesthesia affects diastolic function. It used to be
thought that isoflurane and desflurane prolonged isovolumic relaxation; how-
ever, further studies have had opposite findings [5]. Ketamine can reduce left
ventricular compliance, and propofol can prolong isovolumic relaxation; how-
ever, propofol can also decrease preload, which improves left atrial pressures [5].
The important thing is to recognize which patients have diastolic dysfunction as
these patients will be more sensitive to changes in preload, tachycardia, and
arrhythmias. Volume overload/increased preload will further increase already
elevated left atrial pressures and can precipitate pulmonary edema. Atrial
arrhythmias (atrial fibrillation, atrial flutter) result in loss of coordinated atrial
systole. In patients with impaired relaxation who rely on atrial contraction to fill
the ventricle, this can result in sudden impaired filling and elevation of
LAP. Diastole is shorter at higher heart rates, and tachycardia can worsen already
impaired diastolic dysfunction by further limiting diastolic filling.
References
1. Galderisi M. Diastolic dysfunction and diastolic heart failure: diagnostic, prognostic and thera-
peutic aspects. Cardiovasc Ultrasound. 2005;3:9.
2. Otto CM. Textbook of clinical echocardiography. 5th ed. Philadelphia, PA: Elsevier/Saunders;
2013.
310 N.T. Tran
3. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ven-
tricular diastolic function by echocardiography: an update from the American Society of
Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc
Echocardiogr. 2016;29:277–314.
4. Nagueh SF, Appleton CP, Gilbert TC, et al. Recommendations for the evaluation of left ven-
tricular diastolic function by echocardiography. J Am Soc Echocardiogr. 2009;22:107–33.
5. Deng Y, John S, Mangunta V. Perioperative diastolic dysfunction for the anesthesiologist.
Anesthesiology News. New York, NY: McMahon Publishing; 2016.
Chapter 57
Echo IV
Abbreviations
BKA Below-knee amputation

BP Blood pressure
CVP Central venous pressure
EKG Electrocardiogram
HR Heart rate
IVC Inferior vena cava
PA-pressure Pulmonary artery pressure
pRBC Packed red blood cells
RA Right atrium
RR Respiratory rate
SO2 Oxygen saturation
TTE Transthoraccic echocardiography

DOI 10.1007/978-3-319-55862-2_57
Fig. 57.1 TTE image
A 70-year-old male presents to the ED after an industrial accident causing a trau-

matic below-knee amputation on the right side. The patient has been obtunded and
dyspneic since arrival. A total of six pRBC units and 5 L of crystalloids have been
given in the last hour. You have been asked to evaluate this patient prior to operative
BKA. HR, 120; BP, 90/60; RR, 35; SpO2, 84%.
Questions
1 . What is the view shown in the picture and how do you obtain it (See Fig. 57.1)?
2. Is it accurate to measure fluid status and fluid responsiveness with TTE?
3. How do you interpret the following images?
4. Would you change this patient’s management, based on the ultrasound findings,
and how?
5. How would you confirm your suspicion?
57 Echo IV 313
Fig. 57.1A Probe placement
Xyphoid
Probe
Umbilicus
Answers
1. This is a longitudinal view of the subcostal inferior vena cava.
In the supine position, if possible with the knees bent, (relaxes abdominal wall)
the probe is placed in the midline 2 or 3 cm below the xyphoid perpendicular to the
abdominal wall with the orientation marker pointing toward the 3 o’clock position
(See Fig. 57.1A). Focusing on the right atrium the probe is turned counterclock-
wise until the orientation marker is pointing toward the patient’s head or until the
IVC is seen merging into the RA. The IVC diameter is best-measured 2–3 cm
before the IVC-RA junction, where the IVC walls are parallel [1].
2. IVC diameter and dynamic measurements of the IVC diameter have been used
as surrogates for CVP, fluid status, and responsiveness to fluid therapy. Several
difficulties may be encountered when using this technique. It maybe difficult to
obtain the appropriate image; the liver or diaphragm may tend to splint open the
IVC in the most proximal portions. Tricuspid valve dysfunction, right heart
structural abnormalities, and variation in the diameter of the IVC among normal
patients may also confound the matter [2].
As recommended by the American society of echocardiography, in the con-
text of focused cardiac ultrasound, IVC diameter and plethora are useful as sur-
rogates of fluid status, when formal transthoracic echocardiography is not
practical or readily available [3].
The IVC diameter and respiratory variation should be used along with other
indicators of volume status for clinical correlation. The interpretation of this
image alone should not be used for clinical decision-making.
3. The following ultrasound images are obtained from the patient:
Figure 57.2 shows a longitudinal view of the subcostal inferior vena cava.
Figure 57.3 shows a longitudinal view of the subcostal inferior vena cava in
M-mode measuring the IVC diameter during inspiration and expiration.
Fig. 57.2 Subcostal TTE

longitudinal view of the
subcostal inferior vena
cava
Fig. 57.3 Subcostal TTE

longitudinal view of the
subcostal inferior vena
cava, M-mode measuring
the IVC diameter at
inspiration and expiration.
(With permissions from
American College of
Emergency Physicians [4])
Ultrasound images of the IVC could be interpreted using the following crite-
ria [1]:
(a) Hypovolemia: a reduced IVC diameter (<2.5 cm) and collapse with inspira-
tion greater than half or complete collapse
(b) Hypervolemia: an increase in IVC diameter (>2.5 cm) and minimal collapse
with inspiration.
• Other situations that can cause this appearance are cardiac tamponade, mitral
regurgitation, or aortic stenosis.
Interpretation of IVC Diameter [5]:
(a) By measuring IVC diameter (normal 1.5–2.5 cm):
• Less than 1 cm: Very possible large blood loss necessitating blood
transfusion
• Less than 1.5 cm: Possible hypovolemia
• More than 2.5 cm: Possible hypervolemia
57 Echo IV 315
(b) By measuring IVC diameter collapse with inspiration (Caval Index) prefer-
ably in M-mode as shown in Fig. 57.3:
( IVC diameter in expiration - IVC diameter in inspiration )
• Caval index = ´100
IVC diamter in expiration
• Caval index >50% suggests fluid responsiveness.
(c) Central venous pressure estimated by IVC imaging.
• CVP of 0–5 cm H2O: Findings include an IVC diameter of less than
1.5 cm and a total collapse with inspiration.
• CVP of 5–10 cm H2O: Findings include an IVC diameter between 1.5 and
2.5 cm, and a caval index of >50%.
• CVP of 11–15 cm H2O: Findings include an IVC diameter between 1.5
and 2.5 cm, and a caval index of <50%.
• CVP of 16–20 cm H2O: Findings include an IVC diameter larger than
2.5 cm, and a caval index of <50%.
• CVP larger than 20 cm H2O: Findings include an IVC diameter larger
than 2.5 cm, and no changes in the diameter with inspiration.
The dynamic image of the IVC ultrasound obtained in this case shows volume
overload in the patient based on criteria discussed.
4. The ultrasound images (see answer to question 3) appear to show a patient that
could be in acute congestive heart failure, secondary to massive transfusion of
blood products/crystalloids (flash pulmonary edema).
This finding needs to be confirmed (see answer to question 5).
If congestive heart failure is strongly suspected continuing fluid resuscitation
will worsen the situation. A more precise measurement of his fluid status and
cardiac function is necessary to guide further therapy. Other supportive measures
like ventilatory support, forced diuresis, and inotropic support might be neces-
sary [6].
5. Clinical examination of the patient followed by further testing which should
include EKG, chest X-Ray, and formal transthoracic echocardiography. Invasive
tests include CVP and PA pressure measurement and cardiac catheterization.
Laboratory tests include N-terminal pro-B-type natriuretic peptide and markers
of cardiac ischemia.
References
1. Goldflam K, Lewiss R. Focus on: inferior vena cava ultrasound. Irving, TX. 2011. http://www.
acep.org/Content.aspx?id=80791. Accessed 31 Mar 2016.
2. De Lorenzo RA, Morris MJ, Williams JB, Haley TF, Straight TM, Holbrook-Emmons VL, et al.
Does a simple bedside sonographic measurement of the inferior vena cava correlate to central
venous pressure? J Emerg Med. 2012;42(4):429–36. doi:10.1016/j.jemermed.2011.05.082.
3. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac
ultrasound: recommendations from the American Society of Echocardiography. J Am Soc
Echocardiogr. 2013;26(6):567–81. doi:10.1016/j.echo.2013.04.001.
4. Goldflam K, Saul T, Lewiss R. Focus on: inferior vena cava ultrasound. ACEP News. June
2011.
5. Scott Moses M. Inferior vena cava ultrasound for volume status. Minneapolis-St Paul, Minnesota.
2013. http://www.fpnotebook.com/cv/rad/InfrVnCvUltrsndFrVlmSts.htm. Accessed 31 Mar
2016.
6. Chen HH, Schrier RW. Pathophysiology of volume overload in acute heart failure syndromes.
Am J Med. 2006;119(12 Suppl 1):S11–6. doi:10.1016/j.amjmed.2006.09.012.
Chapter 58
Ultrasound I
Abbreviations
PECS Pectoralis nerves
A 50 kg patient receives a supraclavicular peripheral nerve block in the preoperative

area for anesthesia and postoperative pain for open reduction and internal fixation
of an ulnar fracture on the left arm. The patient received a total of 20 cc of 0.5%
ropivacaine during the block (See Fig. 58.1). 55 min later, the surgery starts and the
patient complains of pain in the area of the surgery.

DOI 10.1007/978-3-319-55862-2_58
Fig. 58.1 Ultrasound image of the brachial plexus in the supraclavicular location, a needle is seen
injecting a pool of local anesthetic
Questions
1. Based on the ultrasound image above what is the most likely cause of the patient’s
pain?
2. How would you supplement the block?
3. Are there other reasons for pain during surgery?
4. Should a continuous nerve catheter been placed?
5. Do additives in the block mixture have a role?
58 Ultrasound I 319
Answers
1. Most probably this patient experienced ulnar sparing due to poor distribution of
the injection to the lower trunk [1]. This occurs commonly when the injection is
made superficial to the plexus and does not cover the lower trunk (in the “eight
ball corner pocket,” which is the area formed by the angle between the brachial
plexus and first rib).
These patients will report adequate motor and sensory block over the median,
radial, and musculocutaneous distribution; however, the area of the ulnar nerve,
and medial cutaneous nerve of the forearm retain sensation and function.
2. Time permitting, the block could be supplemented by placing more local anes-
thetic in the “eight ball corner pocket,” since the patient could safely still receive
more local anesthetic [2].
The maximum dose of ropivacaine in this patient is 150 mg (3 mg/kg). So we
could safely repeat the block targeting the area of interest and inject up to another
10 cc of ropivacaine 0.5%.
Awake patients might complaint of tourniquet pain. All patients experience
neuropathic pain after a few minutes of a tourniquet being inflated to 100 mmHg
above the systolic blood pressure. With enough time this manifests as pain,
sometimes severe in awake patients, or a sympathetic response in patients under
general anesthesia.
Other reasons for pain are due to surgical stimulation in the area covered by
the intercostobrachial nerve, the upper, inner aspect of the upper arm, which is
not routinely covered by brachial plexus blocks. This area can be anesthetized
with a field block of the medial side of the arm or a PECS II (pectoralis nerves)
block.
3. A catheter is indicated if it’s expected that the patient will require continuous
analgesic coverage beyond the first 24 h after surgery, would need strenuous
physical therapy, and has unresolved trauma or a chronic pain syndrome among
others.
A peripheral nerve catheter placed under ultrasound guidance has a better
chance of success, with fewer complications, than the one placed with stimula-
tion alone [3, 4]. It also prolongs the pain relief in the postoperative setting,
which might contribute to better patient satisfaction and active participation in
rehabilitation with selective sensory blockade [5].
In this particular case, a catheter is not indicated since the pain of the trauma
and surgery is expected to decrease after surgery; there is no need for strenuous
physical therapy, and the patient has no chronic pain.
4 . Some additives might have a role. The effects of these additives are:
Epinephrine: Delays the entry of local anesthetics into plasma. This effect is noted
with lidocaine, mepivacaine, prilocaine, and bupivacaine, but not on ropivacaine
[6].
Dexamethasone: Increases the duration of motor and sensory blockade at a recom-

mended dose of 4–8 mg. The mechanism is unknown. It may act by increasing
the activity of inhibitory potassium channels on nociceptive C fibers via gluco-
corticoid receptors, thereby decreasing the fibers’ activity, and it appears that the
same effect is achieved with intravenous use [6].
Clonidine: Prolongs motor and sensory blockade with all local anesthetics except
mepivacaine. However, it might cause hypotension, sedation, bradycardia, and
fainting possibly due to systemic absorption [6].
Buprenorphine: Perineural 150–300 μg of buprenorphine significantly prolongs
the duration of blocks. Intravenous or intramuscular use provides only partial
benefit [6].
In this case, dexamethasone would be an adequate choice as it will help prolong the
duration of the block, and it has a long history of safe use in the epidural space.
Patients may show modest temporary increases in blood glucose levels, espe-
cially in patients with diabetes mellitus.
References
1. Fredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of ‘corner pocket supracla-
vicular’ and infraclavicular ultrasound guided brachial plexus block: a randomised observer-
blinded comparison. Anaesthesia. 2009;64(7):738–44. doi:10.1111/j.1365-2044.2009.05918.x.
2. Morfey DH, Brull R. Finding the corner pocket: landmarks in ultrasound-guided supraclavicu-
lar block. Anaesthesia. 2009;64(12):1381. doi:10.1111/j.1365-2044.2009.06141_17.x.
3. Liu SS, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, et al. A prospective, ran-
domized, controlled trial comparing ultrasound versus nerve stimulator guidance for intersca-
lene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth
Analg. 2009;109(1):265–71. doi:10.1213/ane.0b013e3181a3272c.
4. Mariano ER, Loland VJ, Bellars RH, Sandhu NS, Bishop ML, Abrams RA, et al. Ultrasound
guidance versus electrical stimulation for infraclavicular brachial plexus perineural catheter
insertion. J Ultrasound Med. 2009;28(9):1211–8.
5. Axley M, Horn JL. Indications and management of continuous infusion of local anesthetics at
home. Curr Opin Anaesthesiol. 2010;23(5):650–5. doi:10.1097/ACO.0b013e32833e27bc.
6. Bailard NS, Ortiz J, Flores RA. Additives to local anesthetics for peripheral nerve blocks: evi-
dence, limitations, and recommendations. Am J Health Syst Pharm. 2014;71(5):373–85.
doi:10.2146/ajhp130336.
Chapter 59
Ultrasound II
Abbreviations
ACLS Advanced cardiac life support

ASRA American Society of Regional Anesthesia and Pain Medicine
CNS Central nervous system
LAST Local anesthetic systemic toxicity
NSAID Nonsteroidal anti-inflammatory drugs
TENS Transcutaneous electrical nerve stimulation
Figure 59.1 image is obtained from a patient (80yo M, 60 kg) in the PACU after a
repeat femoral peripheral nerve block for postoperative pain of a knee arthroplasty.
The patient received a total of 30 cc of 0.5% bupivacaine and 20 cc of 0.5% ropiva-
caine. Patient is complaining of persistent pain in the area of the surgery.
Department of Anesthesia, Oklahoma University Health and Science Center, 800 NE 10th
Street, Oklahoma City, OK 73102, USA

DOI 10.1007/978-3-319-55862-2_59
Fig. 59.1 Ultrasound view of

the groin area at the level of
the inguinal crease
Questions
1 . What are the structures labeled a, b, and c?
2. What are the possible causes of persistent postoperative pain?
3. Would you repeat the block?
4. If the patient develops seizures how would you treat him?
5. If the patient develops hypotension and asystole how would you treat him?
6. What other options are available to treat this patient’s pain?
59 Ultrasound II 323
Answers
1. a, femoral vein; b, femoral artery; c, femoral nerve.
2. Persistent pain might be due to:
(a) Inadequate distribution of the local anesthetic in the correct plane, possibly
due to difficult and distorted anatomy after multiple attempts
(b) Lack of coverage of the sciatic nerve area on the back of the knee or the
obturator nerve on the medial aspect of the thigh
3. This patient has received a large amount of local anesthetic after the two attempts;
a repeat one is inadvisable as we are over the maximum safe dose for local
anesthetic.
In this patient, the maximum safe dose of ropivacaine (3.5 mg/kg) is 280 mg
and bupivacaine (2 mg/kg) is 160 mg.
In the case of combined local anesthetics, the proportional maximum dose of
each agent should be calculated, and the sum should not exceed 100%.
This patient has received 100 mg of ropivacaine and 150 mg of bupivacaine.
The proportion of the maximum safe dose per agent is calculated as follows:
Dose given in mg
Proportion of the maximum dose = ×100
Maximum safe dose in mg

In this patient the proportion for each agent is calculated as follows:
100mg
Proportion of the max dose of Ropivacaine = × 100 =36%
280mg
150 mg
Proportion of the max dose of Ropivacaine = × 100 =94%
160 mg
The total dose of local anesthetic in this patient exceeds the 100% (94 + 36)
of the maximum safe dose. Further use of local anesthetic is unadvisable.
4. Seizures in this setting would be very suspicious for local anesthetic systemic
toxicity (LAST). According to the American Society of Regional Anesthesia and
Pain Medicine (ASRA), management in this setting should include [1]:
(a) Airway management: ventilate with 100% oxygen.
(b) Seizure suppression: benzodiazepines are preferred; avoid propofol in

patients having signs of cardiovascular instability.
(c) Alert the nearest facility having cardiopulmonary bypass capability.
(d) Lipid emulsion therapy (not propofol):

• Bolus 1.5 mL/kg.
• Continuous infusion at 0.25 mL/kg/min.
• Bolus may be repeated and the infusion raised to 0.5 mL/kg/min for per-
sistent hypotension.
• Continue treatment for 10 min after attaining stability.
• Maximum dose of lipid—10 mL/kg in first 30 min.
(e) Other possibilities of seizure activity in this setting are pseudo-seizures,
cryptogenic, metabolic insult, toxic insult, CNS infection, stroke, brain
trauma, cerebral hemorrhage, and alcohol or drug withdrawal.
5. Management of cardiovascular collapse in this setting differs from the one
caused by other etiologies and current recommendations by ASRA are [1]:
(a) Advanced Cardiac Life Support (ACLS):
• Avoid vasopressin, calcium channel blockers, beta-blockers, or local
anesthetics.
• Reduce individual epinephrine doses to <1 mcg/kg, to avoid onset of
malignant arrhythmias.
(b) Lipid emulsion (20%) therapy:
• Bolus 1.5 mL/kg (lean body mass) intravenously over 1 min.
• Continuous infusion 0.25 mL/kg/min.
• Repeat bolus once or twice for persistent cardiovascular collapse.
• Double the infusion rate to 0.5 mL/kg/min if blood pressure remains low.
• Continue infusion for at least 10 min after attaining circulatory stability.
• Recommended upper limit: Approximately 10 mL/kg lipid emulsion over
the first 30 min.
(c) Consider placing the patient on cardiopulmonary bypass if prolonged resus-
citation with no return of cardiac function is present.
6. Preoperatively patients should be counseled on postoperative goals and expec-
tations of pain control; patients with medical and psychiatric comorbidities
will especially benefit from preoperative optimization as well. For persistent
pain, before repeating the femoral nerve block, patient assessment to determine
the pain location would help in distinguishing between a failed femoral nerve
block and pain in an area not covered by a femoral block. If the latter is the
case, then the patient would benefit with supplementation of sciatic and obtura-
tor nerve blocks.
Acute postoperative pain requires a multimodal approach. The patient will
benefit from the use of acetaminophen, NSAIDs, antidepressants, and/or antiepi-
leptic medications. Continuous evaluation of pain and titration of opioids, if
needed, is recommended which may also be administered as a patient-controlled
option [2, 3]. Other options available in the postoperative period are topical
application of local anesthetics and the use of TENS.
59 Ultrasound II 325
References
1. Neal JM, Mulroy MF, Weinberg GL, American Society of Regional A, Pain M. American
Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic
systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37(1):16–8. doi:10.1097/
AAP.0b013e31822e0d8a.
2. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The prevention of
chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and
meta-analysis. Anesth Analg. 2012;115(2):428–42. doi:10.1213/ANE.0b013e318249d36e.
3. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al.
Management of postoperative pain: a clinical practice guideline from the American Pain
Society, the American Society of Regional Anesthesia and Pain Medicine, and the American
Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and
Administrative Council. J Pain. 2016;17(2):131–57. doi:10.1016/j.jpain.2015.12.008.
Chapter 60
Lung Ultrasound
Marcos E. Gomes
An ultrasound of the chest/lung is obtained on a multi-trauma patient with chest

drains and on a ventilator in the ICU.
SEASHORE SIGN STRATOSPHERIC SIGN SEASHORE SIGN
Fig. 60.1 Lung ultrasound, M-mode method
M.E. Gomes, MD

DOI 10.1007/978-3-319-55862-2_60
328 M.E. Gomes
Questions
1 . What is lung sliding?
2. What is the difference between lung sliding and lung pulse?
3. What is the best ultrasound method to detect lung sliding?
4. What is the differential diagnosis for absence of lung sliding?
5. What is lung point?
6. Besides lung sliding, what other two common artifacts can help with differential
diagnosis?
60 Lung Ultrasound 329
Answers
1. Lung sliding is the movement of the pleural interface in a synchronous fashion
with spontaneous or mechanical ventilation. The parietal and visceral pleura
constitute the pleural interface, which is a hyperechoic structure between two
ribs on bidimensional ultrasound. It is maximized in the lower lung fields, as the
lung descends toward the abdomen. Lung sliding identification is the most com-
monly used artifact in the exclusion of pneumothorax as well as in the confirma-
tion of endotracheal intubation [2].
2. Lung pulse artifact is a small to-and-fro movement of the visceral on the parietal
pleura induced by the heartbeat rather than respirations. It is more prominent on
the left side, closer to the heart. In order for it to be visualized, ventilation and,
consequently, lung sliding must be absent. It implies an intact pleural interface,
and its presence excludes a pneumothorax.
3. M-mode ultrasound is the preferred method for lung movement imaging, produc-
ing the characteristic “seashore sign” (Fig. 60.1). This image has two portions. The
superficial part (top of the figure) is typically composed of multiple horizontal lines
that correspond to motionless soft tissue. It ends on the pleural line. The other por-
tion corresponds to the motion of the normal lung. This motion generates an arti-
fact that originates from the pleural line and looks like sand on a beach. The image
on its entirety looks like water waves in the ocean touching the sand on a beach.
4. Lung sliding becomes vague in pulmonary overexpansion, parietal emphysema,
pneumonia, and severe ARDS. It disappears in pneumothorax, complete atelec-
tasis, pleural fibrosis, and apnea.
5. On two-dimensional ultrasound, lung point is the transition point between the
presence and absence of a lung sliding. It represents the border of the pneumo-
thorax and the intact pleural interface. In M-mode, the absence of lung sliding
will create a series of black and white horizontal lines called the “stratospheric
Fig. 60.2 A-lines
330 M.E. Gomes
Fig. 60.3 B-lines
or barcode” sign. In this mode, the lung point can be identified by the transition
of a seashore sign to a stratospheric sign (Fig. 60.1). This is a pathognomonic
sign for the presence of pneumothorax, with 100% specificity [3].
6. A-lines are multiple horizontal regularly spaced hyperechogenic lines which
represent reflections of the pleural interface. Each A line is separated by a dis-
tance equivalent to the thickness of the subcutaneous tissue between the ultra-
sound probe and the pleural interface (Fig. 60.2). They are present in a normal
lung as well as in the presence of pneumothorax.
B-lines, also known as comet tails or lung rockets, are artifacts created by
repetitive reflections of the ultrasound wave within the lung parenchyma because
of a higher concentration of physiologic or pathologic fluid. They are vertical
white lines, originating from the visceral pleura and reaching the bottom of the
screen (Fig. 60.3). B-lines will erase the A-lines on their passage. A few B-lines
(less than 3) may be seen in a healthy lung and more so in the dependent regions.
Their presence is utilized in the diagnosis of alveolar interstitial syndrome (pul-
monary edema, ARDS) and exclusion of pneumothorax [4].
References
1. Barillari A, et al. Lung ultrasound: a new tool for the emergency physician. Intern Emerg Med.
2010;5:335–40.
2. Xirouchaki N, et al. Lung ultrasound in critically ill patients: comparison with bedside chest
radiography. Intensive Care Med. 2011;37:1488–93.
3. Piette E, et al. Basic concepts in the use of thoracic and lung ultrasound. Curr Opin Anesthesiol.
2013;26:20–30.
4. Lichtenstein DA, et al. Relevance of lung ultrasound in the diagnosis of acute respiratory fail-
ure: the blue protocol. Chest. 2008;134:117–25.
Chapter 61
Abdominal X-Ray
Diaphragm
Gas bubble in
stomach
Post pyloric
feeding tube
Fig. 61.1 X-ray of an appropriately placed feeding tube
A.S. Madamangalam, MBBS, MD

Department of Anesthesiology and Perioperative Medicine, Augusta University Medical
Center, 1120 15th Street, BI-2144, Augusta, GA 30912, USA

DOI 10.1007/978-3-319-55862-2_61
332 A.S. Madamangalam
Questions
1 . What are the indications for a feeding tube placement?
2. Name some methods available to confirm appropriate placement of a feeding
tube, and what are the drawbacks of the most definite methods of confirming
feeding tube placement?
3. What preconditions need to be met for placement of a feeding tube?
4. Are there complications associated with feeding tube placement?
61 Abdominal X-Ray 333
Answers
1. Early records note that Capivacceus placed a tube to deliver nutrients into the
foregut [1]. The practice became more common during the seventeenth century.
The tubes are inserted to decompress the stomach or for intestinal ileus or
obstruction [2, 3]. Patients that most frequently need a naso-enteric tube (NET)
are in surgical intensive care settings. Other indications include prematurity, fail-
ure to thrive (or malnutrition), neurologic and neuromuscular disorders, inability
to swallow, anatomical and postsurgical malformations of the mouth and esopha-
gus, cancer and digestive disorders. The feeding tubes could be for short-term or
even long-term use [2]. Feeding tubes are placed in patients either through the
nose or percutaneously.
2. Appropriate placement of an NET is not always successful. Misplacement is said
to occur about 13–20% in adults and in 39–55% of pediatric patients [3]. Many
different methods have been used to confirm proper placement. These include:
(a) Auscultation—injecting air into the feeding tube and listening for the rush of
air over the stomach
(b) Bubbling—placing the end of the tube under water to look for bubbling
which would indicate misplacement into the tracheobronchial tree
(c) Appearance and pH of aspirate from NET
(d) Endoscopy and fluoroscopy—expensive and time consuming
(e) Capnometry—to detect CO2 from the tracheobronchial tree in misplaced
NET
(f) Detection of a copper wire in the stylet of the feeding tube with a locator
device placed over the chest
(g) The gold standard—radiography of the chest and abdomen which should
visualize the entire feeding tube within the gastro intestinal tract to identify
proper positioning.
None of these methods ensure that the incidence of misplacement is reduced to
zero [4].
To date, two “gold standard” methods of confirming the appropriate place-
ment of the feeding tube are recognized: the radiographic (or fluoroscopic) and
the endoscopic method. Both these modalities provide confirmation of appropri-
ate placement with great accuracy.
Fluoroscopy exposes the patient to radiation, which is avoided by endoscopy.
Both procedures are expensive in terms of finances and time. There is the issue of
ready availability of equipment as well as the technical difficulty of interpreting the
images reliably with both methods. Quite often when a method other than the radio-
graphic method is used for the confirmation of the location of the tip of the NET, an
X-ray of the abdomen is performed to additionally verify location of the tip of the
NET. This further adds a cost to the process as well as exposing the patient to
radiation.
3. The process of placing the NET is noted to be simple and safe. Ideally the patient
is not on an anticoagulant. Patients are also required to be fasting for about
6 hours, if the feeding tube is placed percutaneously; in such situations the
patient may require moderate sedation or even a general anesthetic for NET
placement.
4. There are a few risks associated with the placement of the NET such as bleeding,
infection, dislodgement of the tube, as well as bloating and nausea. Undetected
placement of the NET in the respiratory tract may lead to pneumonia, lung punc-
ture, pneumothorax, empyema, and even death.
References
1. Chernoff R. An overview of tube feeding: from ancient times to the future. Nut Clin Pract.
2006;21(4):408–10.
2. Kirby DF, et al. American gastroenterological association technical review on tube feeding for
enteral nutrition. Gastroenetrology. 1995;108(4):1282–301.
3. Huffman S, et al. Methods to confirm feeding tube placement: application of research in prac-
tice. Pediatr Nurs. 2004;30(1):10–3.
4. Institute ECRI. Confirming feeding tube placement; old habits die hard. Pa Patient Saf Auth.
2006;3(4):23–30.
Chapter 62
Angio I
Fig. 62.1
A.V. Pakala, MD
Section of Cardiovascular Disease, Department of Medicine, University of Oklahoma College
of Medicine, Oklahoma City, OK, USA

DOI 10.1007/978-3-319-55862-2_62
336 A.V. Pakala
Fig. 62.2
Questions
1 . What do these images show?
2. How does one assess the pretest probability for this finding?
3. How does imaging play a role in diagnosis?
4. What are the acute therapeutic options in this situation?
5. When is thrombolytic therapy used?
6. What is the role of catheter based therapy?
62 Angio I 337
Answers
1. Figure 62.1 is computed tomography showing a large pulmonary embolism (PE)
involving the right pulmonary artery (red arrow). Figure 62.2 is pulmonary angi-
ography of the same patient showing the same finding.
2. Wells score (Table 62.1) is used to calculate the pretest probability of PE.
3. In patients with high pretest probability for PE, imaging is the test of choice.
Pulmonary arteriography is the gold standard for diagnosis of PE. Current gen-
eration multi-detector helical computed tomography (CT) has high sensitivity
and specificity, comparable to pulmonary arteriography, in detection of PE [2].
Helical CT is the most widely used modality in current clinical settings and
would be the diagnostic test of choice in this case. However, in patients with high
pretest probability for PE (as in our case) and a negative CT, further investigation
in the form of duplex ultrasound of lower extremities or pulmonary arteriogra-
phy should be considered [3].
4. In patients with high pretest probability for PE, therapeutic anticoagulation
should be initiated immediately while awaiting further diagnostic testing (CT,
duplex ultrasound, etc.) [4]. Treatment for PE has evolved with the introduction
of novel oral anticoagulants or non-warfarin oral anticoagulants (NOAC).
Treatment for acute PE can be one of the following:
(a) Weight-based low-molecular-weight heparin (LMWH) for 5 days followed
by dabigatran, edoxaban, or warfarin (NOACs)
(b) Rivaroxaban or apixaban without initial LMWH
The treatment for acute PE is divided into the following treatment phases:
acute phase of 5–10 days, short-term phase 3–6 months, and long-term phase
beyond 6 months. The duration of therapy depends on the underlying cause for
the PE and the risk to benefit ratio of anticoagulation.
Table 62.1 A score of <2 indicates a low probability of pulmonary embolism

Clinical characteristic Score
Active cancer 1
Surgery or bedridden for 3 days or more during the past 1.5
4 weeks
History of deep venous thrombosis or pulmonary 1.5
embolism
Hemoptysis 1
Heart rate > 100 beats/min 1.5
Pulmonary embolism judged to be the most likely 3
diagnosis
Clinical signs and symptoms compatible with deep 3
venous thrombosis
A score of 2–6 indicates an intermediate probability of PE. A score > 6 indicates a high probability
of pulmonary embolism [1]
338 A.V. Pakala
Table 62.2 PESI score, a Predictors Points assigned

total point score for a given
Age, in years Age, in years
patient, is obtained by
summing the patient’s age in Altered mental status +60
years and the points for each Systolic blood pressure < 100 mmHg +30
applicable predictor History of cancer +30
Arterial O2 saturation < 90% +20
Temp <36°C +20
Respiratory rate > 30/min +20
Pulse >110 bpm +20
Male sex +10
History of heart failure +10
History of chronic lung disease +10
Points’ assignments correspond with the following risk
classes: class 1 (very low risk), <65; class II (low risk),
65–85; class III (intermediate risk), 86–105; class IV (high
risk), 106–125; class V (very high risk), >125
Outcomes in PE patients depend on the clinical presentation. Based on clini-

cal presentation, they can be further classified into [5]:
(a) Massive PE: Acute PE with sustained hypotension (systolic BP < 90 mmHg
sustained for over 15 min or requiring ionotropic support) in the absence of
any other cause, pulselessness, or profound bradycardia (highest risk of
adverse outcomes).
(b) Sub-massive PE: Acute PE without sustained hypotension, with signs of
hypoperfusion, right ventricular dysfunction on echocardiography, elevated
cardiac troponins, and elevated brain natriuretic peptide (intermediate risk of
adverse outcomes).
(c) Low-risk PE: Acute PE with normal blood pressures, normal cardiac bio-
markers, and normal RV function (low risk of adverse outcomes).
Further risk stratification using Pulmonary Embolism Severity Index (PESI)
scores (Table 62.2), signs of cardiovascular decompensation, and signs of shock-
like state allows for consideration of inpatient versus outpatient treatment setting
for further management and for the consideration for advanced therapies includ-
ing thrombolytic therapy [6].
5. The role of systemically administered thrombolysis in acute PE is reserved for
patients with clinically massive PE who are not at risk for major bleeding. As
mentioned above, massive PE is defined as PE with resulting hypotension
(SBP < 90 mmHg) [7].
In low-risk PE, antithrombotic therapy is sufficient. Thrombolytic therapy
may be considered down the road in these patients if they acutely develop hypo-
tension while on antithrombotic therapy. Thrombolysis may also be considered
in those patients who were initially stable, if blood pressure decreases but is still
>90 mmHg, and they develop a shock-like state along with supplemental signs
of cardiac decompensation including acute right ventricular failure, elevated car-
diac troponins, and brain natriuretic peptide levels (sub-massive PE) [4].
62 Angio I 339
Table 62.3 Contraindications for systemic thrombolytic therapy [8]

Absolute contraindications for thrombolytic therapy
Prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months (excluding stroke within 3 h)
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head trauma or facial trauma within 3 months
Relative contraindications for thrombolytic therapy
Severe uncontrolled hypertension on presentation (SBP >180 mmHg or DBP >110 mmHg)
History of ischemic stroke more than 3 months prior
Major surgery less than 3 weeks
Recent (within two to 4 weeks) internal bleeding
For streptokinase—Prior exposure (more than 5 days ago) or prior allergic reaction to these
agents
Pregnancy
Active peptic ulcer
Current use of anticoagulant (e.g., warfarin sodium) that has produced an elevated
international normalized ratio (INR) >1.7 or prothrombin time (PT) >15 s
Contraindications to systemic thrombolysis are mentioned in Table 62.3.

Thrombolytic agents approved by the FDA are alteplase (100 mg infusion over
2 h), urokinase (4400 U/kg as a loading dose given at a rate of 90 mL/h over a
period of 10 min, followed by continuous infusion of 4400 U/kg/h at a rate of
15 mL/h for 12 h), and streptokinase (250,000 U as a loading dose over 30 min,
followed by 100,000 U/h over 12–24 h).
6. Patients who are not candidates for systemic thrombolysis should be monitored
closely for development of shock-like state (hypotension, worsening tachycar-
dia, gas exchange, oliguria, mentation, etc.) [4]. If there is concern for clinical
deterioration, catheter-based thrombectomy may be considered over systemic
thrombolysis especially in the presence of a relative contraindication for sys-
temic thrombolysis) [9]. Catheter-based thrombectomy consists of catheter-
directed thrombolysis (reduced dose of thrombolytic administered directly to the
thrombus) or mechanical thrombectomy without thrombolysis (endovascular
catheter is used to mechanically disrupt the thrombus).
References
1. Kearon C, Ginsberg JS, Douketis J, Turpie AG, Bates SM, Lee AY, et al. An evaluation of
D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med.
2006;144(11):812–21.
2. Winer-Muram HT, Rydberg J, Johnson MS, Tarver RD, Williams MD, Shah H, et al. Suspected
acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction
pulmonary arteriography. Radiology. 2004;233(3):806–15.
340 A.V. Pakala
3. Quiroz R, Kucher N, Zou KH, Kipfmueller F, Costello P, Goldhaber SZ, et al. Clinical validity
of a negative computed tomography scan in patients with suspected pulmonary embolism: a
systematic review. JAMA. 2005;293(16):2012–7.
4. Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, et al. Guidance for the
treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis.
2016;41(1):32–67.
5. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al.
Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombo-
sis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the
American Heart Association. Circulation. 2011;123(16):1788–830.
6. Jimenez D, Aujesky D, Yusen RD. Risk stratification of normotensive patients with acute
symptomatic pulmonary embolism. Br J Haematol. 2010;151(5):415–24.
7. Meyer G, Vicaut E, Konstantinides SV. Fibrinolysis for intermediate-risk pulmonary embo-
lism. N Engl J Med. 2014;371(6):581–2.
8. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al.
Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis,
9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest. 2012;141(2 Suppl):e419S–94S.
9. Kucher N, Boekstegers P, Muller OJ, Kupatt C, Beyer-Westendorf J, Heitzer T, et al.
Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute
intermediate-risk pulmonary embolism. Circulation. 2014;129(4):479–86.
Chapter 63
Angio II
A sixty-one-year-old male with known descending thoracic aortic aneurysm with

Stanford-type B aortic dissection underwent thoracic endovascular aortic repair
(TEVAR) due to ongoing pain and rapidly expanding aneurysm. The procedure was
complicated due to significant curvature of the thoracic aorta; patient was subse-
quently discharged home.
Fig. 63.1
A.V. Pakala, MD

DOI 10.1007/978-3-319-55862-2_63
342 A.V. Pakala
Fig. 63.2
Patient was readmitted 2 weeks later with worsening chest pain, back pain, and
dizziness. At the time of presentation, patient was in distress.
Examination revealed sinus tachycardia HR 120 bpm, no obvious cardiovascular
exam findings were noted, pulses were equal in all four extremities, and serum
chemistry was unremarkable except for mild renal insufficiency.
Due to recent TEVAR procedure, CT angiography was obtained; images are dis-
played below.
Questions
1 . What is seen in the images?
2. How is the above complication classified?
3. What are the treatment options?
4. What is the recommended surveillance to detect this complication?
63 Angio II 343
Answers
1. Figure 63.1 is a triple phase computed tomographic image (CT) showing a type
III endoleak in the descending thoracic aorta originating from the stent graft.
Figure 63.2 is also a triple phase CT image of the same patient showing the
extension of the type III endoleak proximally. This patient underwent a thoracic
endovascular aortic repair (TEVAR) procedure for urgent repair of acute type B
thoracic aortic dissection with ongoing chest pain and rapid aneurysmal
expansion. TEVAR is the procedure of choice in patients with complicated type
B dissections [1]. The CT images are consistent with an endoleak. Endoleak is
defined as blood collection outside the stent graft but within the aneurysm sac.
This is a known complication following TEVAR. According to reported data, it
occurs in about 5–20% of cases [1].
2. The most widely used method classifies endoleaks depending on the mechanism
of formation of the endoleak [2]:
(a) Type I endoleak: Proximal or distal reperfusion of the aneurysmal sac. This
occurs due to malapposition of the stent graft to the aortic wall. This is an
early complication following TEVAR and needs urgent intervention. This is
considered to be a form of treatment failure.
(b) Type II endoleak: Retrograde reperfusion of the aneurysmal sac from
branch vessels. These have a benign course and usually need surveillance
only.
(c) Type III endoleak: Leak into the aneurysmal sac due to structural damage to
the stent graft in the form of tears, fractures, or junctional separation. This
requires urgent intervention and is considered to be a form of treatment
failure.
(d) Type IV endoleak: Leakage into the aneurysmal sac due to endograft

porosity.
(e) Type V endoleak: Increase in the aneurysm sac in the absence of leak (endo-
tension). This is poorly understood.
3. Type I endoleaks are caused by malapposition of the proximal or the distal end
of the stent graft to the aortic wall leading to a direct communication of the lumi-
nal blood to the aneurysmal sac and potential for rupture. Treatment involves
securing the proximal and distal ends of the stent graft using endovascular
approach, usually with balloon angioplasty. If endovascular repair fails, open
repair is recommended [3, 4]. Type III endoleaks are caused by structural dam-
age to the stent graft leading to direct communication of the luminal blood to the
aneurysmal sac, leading to expansion and rupture of the aneurysmal sac. Initial
treatment strategy is endovascular stent graft placement or extension; if this fails,
then open repair is recommended [3, 4].
344 A.V. Pakala
4. Lifelong surveillance is recommended following TEVAR since complications

like type III endoleaks can occur many years down the line [4]. Triple phase CT
(images obtained before, during, and after contrast administration) angiography
is the modality of choice in many centers. As in our case, endoleak on a triple
phase CT angiography will show up as contrast outside the stent graft structure
in delayed imaging after the contrast has cleared the aortic lumen [3]. Patients
receive CT angiography immediately post procedure, then at 1 month, 6 month,
and then yearly with clinical follow-up. Magnetic resonance imaging (MRI)
can be used as an alternative modality to reduce cumulative radiation in cases
where MRI compatible grafts have been used. Ultrasound is not as reliable in
the setting of TEVAR due to chest wall interference. Transesophageal echocar-
diography as a follow-up tool has some disadvantages due to its invasive nature.
References
1. Grabenwoger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, et al. Thoracic

Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement
from the European Association for Cardio-Thoracic Surgery (EACTS) and the European
Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous
Cardiovascular Interventions (EAPCI). Eur Heart J. 2012;33(13):1558–63.
2. Veith FJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, et al. Nature and sig-
nificance of endoleaks and endotension: summary of opinions expressed at an international
conference. J Vasc Surg. 2002;35(5):1029–35.
3. Criado FJ, Abul-Khoudoud OR, Domer GS, McKendrick C, Zuzga M, Clark NS, et al.
Endovascular repair of the thoracic aorta: lessons learned. Ann Thorac Surg. 2005;80(3):857–
63; discussion 63.
4. Stavropoulos SW, Carpenter JP. Postoperative imaging surveillance and endoleak management
after endovascular repair of thoracic aortic aneurysms. J Vasc Surg. 2006;43(Suppl
A):89A–93A.
Chapter 64
Angio III
A 46-year-old male presents to the ER after a syncopal event. The patient developed
severe precordial chest pain while lifting weights, immediately followed by synco-
pal event lasting 30 seconds. Currently in the ER, he continues to have chest pain
that radiates to the back. He describes it as a tearing sensation. Pain does not respond
to nitroglycerine. On exam patient appears in distress, diaphoretic, HR 120 bpm, BP
150/70 mmHg on right, and 120/60 mmHg on left; chest exam is within normal
limits.
EKG is consistent with sinus tachycardia and ST depressions anterolaterally.
CXR reveals widened mediastinum.
Creatinine 2.0 ng/ml (0.0–0.399 ng/ml)
Troponin 0.2 ng/ml (0.0–0.399 ng/ml)
D-dimer 800
BNP 240 pg/ml (0–100 pg/ml)
Echocardiography is performed next and a couple of images are displayed below.
A.V. Pakala, MD

DOI 10.1007/978-3-319-55862-2_64
346 A.V. Pakala
Fig. 64.1
Fig. 64.2
Questions
1 . What do the images show?
2. How is this condition created?
3. What are the presenting features of this condition?
4. How is this condition classified?
5. What end organ complications can we expect?
6. What is the role of imaging and laboratory testing?
7. What is the treatment of choice?
64 Angio III 347
Answers
1. Figure 64.1 shows a transthoracic echocardiographic image of a Stanford type A
acute aortic dissection. Figure 64.2 shows a transesophageal echocardiographic
image of the same patient confirming the same finding.
2. Acute aortic syndromes have very high mortality and need a very high index of
suspicion for diagnosis. Acute aortic dissection, intramural hematoma, and pen-
etrating aortic ulcer are all considered to be acute aortic syndromes [1].
Aortic dissection is a disruption of the medial layer of the aortic wall with
bleeding within or along the wall of the aorta. The blood may tear through the
adventitia or back into the intima creating a dissection flap. Acute aortic dissec-
tion is rapidly fatal, 40% patients die immediately, about 20% patient die during
or immediately after surgery, and only about half the patients are alive 5 years
out from surgery [2, 3].
Conditions that place extreme stress on the aortic wall (hypertension, decel-
eration injury, weight lifting) or lead to degeneration of the aortic media (genetic
syndromes, inflammatory vasculitides, bicuspid aortic valve) can increase the
risk of aortic dissection.
3. Presenting symptoms are sudden onset and severe chest, back, or abdominal pain
that is described as tearing or ripping in quality [4, 5]. Some patients with acute
aortic dissections may not have any chest pain at all and may present with syn-
cope and shock like state. Patients also present with perfusion defects and end
organ damage depending on the extension of the dissection flap, with resulting
neurological deficits, myocardial ischemia, renal insufficiency, mesenteric isch-
emia, or limb ischemia.
On physical exam, patients may demonstrate perfusion deficits in the form of
a pulse deficit and systolic blood pressure deferential. Vascular examination of
all four extremities should be conducted in all patients with suspected aortic dis-
section [6].
4. Thoracic aortic dissections are classified according to the involvement of the
various segments of the thoracic aorta. Accurate classification is necessary to
decide on surgical versus medical management. Two classification schema have
been proposed: DeBakey and Stanford. The Stanford classification is more
widely used, it classifies thoracic aortic dissections based on the involvement of
the ascending aorta into:
(a) Stanford A: involving ascending aorta (before the brachiocephalic artery).
Urgent surgery is recommended.
(b) Stanford B: involving the descending aorta only (after the left subclavian
artery). Surgery usually not recommended.
Classification of Aortic Dissection
348
Percentage 60% 10–15% 25–30%
Type DeBakey 1 DeBakey 11 DeBakey 111
Stanford A (Proximal) Stanford B (Distal)

A.V. Pakala
Fig. 64.3 DeBakey and Stanford classification of thoracic aortic dissections

64 Angio III 349
Table 64.1 End organ Type End-organ complication

complications of acute
Cardiovascular Aortic regurgitationPericardial tamponade
thoracic aortic dissection [1]
Coronary artery dissection
Congestive heart failure
Neurological Ischemic stroke
Ischemic spinal injury
Pulmonary Aortopulmonary fistula
Gastrointestinal Mesenteric ischemia
Nephrology Acute renal failure
Limb Acute limb ischemia
The DeBakey classification:

(a) Type I: Originates in ascending aorta and propagates distally. Urgent surgery
is recommended.
(b) Type II: Dissection is limited to the ascending aorta only. Urgent surgery is
recommended.
(c) Type III: Originates in the descending thoracic aorta and propagates distally.
Surgery is usually not recommended.
5. As mentioned previously, acute thoracic aortic dissections carry high morbidity
and mortality. This is largely due to the end organ complications that arise due to
obstruction to blood flow via the dissection flap. The various end organ compli-
cations are listed in (Table 64.1).
6. The role of D-dimer testing in the screening of aortic dissection has been reported
in literature. In patients with low to intermediate pretest probability for aortic
dissection, D-dimer test may have a role in ruling out dissection and avoiding
further imaging. However, the guidelines do not recommend the use of D-dimer
testing in patients with suspected aortic dissection [1, 7].
First step in the algorithm for managing patients with suspected aortic dissec-
tion is to determine the pretest probability of aortic dissection. In patients who
have a high pretest probability (severe chest pain, known risk factors, and high-
risk exam features), the first step is immediate surgical consultation followed by
imaging in the form of transesophageal echocardiography, computed tomogra-
phy, or magnetic resonance imaging. Transesophageal echocardiography has
several advantages including quick access, absence of radiation, and ability to be
performed in patients who are unstable [1].
7. Stanford type A dissection is rapidly fatal due to high rate of complications.
Immediate surgical consultation should be obtained. Urgent surgery is the treat-
ment of choice in unstable patients. In patients who are relatively stable, preop-
erative cardiovascular evaluation and coronary angiography should be considered
prior to surgery.
350 A.V. Pakala
While awaiting surgery or in patients who are not considered surgical candi-
dates, intravenous beta blockers should be initiated to reduce heart rate to
<60 bpm. Non-dihydropyridine calcium channel blockers can be used in patients
who cannot tolerate beta blockers. If blood pressure remains elevated
(>120 mmHg) despite adequate heart rate control, vasodilators can be initiated.
Intraoperative transesophageal echocardiography to evaluate for acute aortic
regurgitation should be performed. In presence of aortic valve involvement or
significant coronary artery disease, valve replacement surgery or bypass grafting
is performed in addition. The surgery involves replacing the entire dissected seg-
ment with a Dacron graft. If the aortic valve is not involved, it is resuspended
onto the graft.
References
1. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/
AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and manage-
ment of patients with thoracic aortic disease. A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines, American
Association for Thoracic Surgery, American College of Radiology, American Stroke
Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular
Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic
Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55(14):e27–e129.
2. Masuda Y, Yamada Z, Morooka N, Watanabe S, Inagaki Y. Prognosis of patients with medically
treated aortic dissections. Circulation. 1991;84(5 Suppl):III7–13.
3. Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dis-
section of ascending aorta. Should the arch be included? J Thorac Cardiovasc Surg.
1992;104(1):46–59.
4. Januzzi JL, Eagle KA, Cooper JV, Fang J, Sechtem U, Myrmel T, et al. Acute aortic dissection
presenting with congestive heart failure: results from the International Registry of Acute Aortic
Dissection. J Am Coll Cardiol. 2005;46(4):733–5.
5. Miller DC, Stinson EB, Oyer PE, Rossiter SJ, Reitz BA, Griepp RB, et al. Operative treatment
of aortic dissections. Experience with 125 patients over a sixteen-year period. J Thorac
Cardiovasc Surg. 1979;78(3):365–82.
6. Yagdi T, Atay Y, Engin C, Mahmudov R, Tetik O, Iyem H, et al. Impact of organ malperfusion
on mortality and morbidity in acute type A aortic dissections. J Card Surg. 2006;21(4):363–9.
7. Marill KA. Serum D-dimer is a sensitive test for the detection of acute aortic dissection: a
pooled meta-analysis. J Emerg Med. 2008;34(4):367–76.
Chapter 65
CXR: Pediatric I
Frederic J. Sage and Frederick van Damme
Fig. 65.1 Normal
pediatric chest X-ray
F.J. Sage, MD, FRCA, FFICM (*) • F. van Damme, MB, ChB (Stell), FRCA
Department of Anaesthesia, East Surrey Hospital, Canada Avenue,
Redhill, RH1 5RH, UK

DOI 10.1007/978-3-319-55862-2_65
352 F.J. Sage and F. van Damme
Questions
1 . How do pediatric chest X-rays differ from those of an adult?
2. Consider this normal chest X-ray of an infant (Fig. 65.1). Is there a system for
interpreting the image?
3. What points do you look for?
4. What is specific to each age group?
5. What should you not expect to see on an infant chest X-ray?
6. Do not forget?
65 CXR: Pediatric I 353
Answers
1. Pediatric chest X-Ray differ from those of adults because:
(a) They are difficult to obtain as cooperation is limited [1].
(b) Chest X-rays change with age.
(c) Children present with different conditions.
(d) There are specific areas to review when interpreting a pediatric chest
X-ray.
(f) The thymus can cause confusion.
2. There are many ways of reading a CXR [2]. Adopt a method that suits you and
stick to it. Here is an example:
(a) Check ID and quality
(b) Bone structure
(c) Tracheobronchial tree and mediastinum
(d) Heart silhouette
(e) Contours of thorax
(f) Lung fields
(g) Abdomen
(h) Soft tissues
(i) Lines, tubes, and artefacts
3. Points to look for:
(a) Check ID and quality:
• Age will guide you in your interpretation.
• Quality of the picture: rotation, inspiration, and exposure [2]. Over- or
underexposed films will impair your judgement on parenchymal density
and vascularity.
• Position: AP, PA, and supine. Particularly important in neonates where
lung mechanics are different such as the angle of the ribs. This can be
affected by poor positioning of the child.
• Also, ensure the orientation markers are correct (R and L). This is an
opportunity to detect situs inversus or dextrocardia.
(b) Bone structure:
• Check skeleton integrity. Premature neonates have an absence of humeral
head ossification [3].
• Is the spine visible behind the mediastinum reflecting correct exposure?
• Rotation can be excluded if the clavicles are symmetrical either side of
the midline.
• Ribs direction will vary with age. Flatter in neonates. Rib notching of
coarctation is not usually visible until the age of 5.
• Trauma of delivery: shoulders and clavicles. Non-accidental injuries
(NAI) in older children: fractured ribs, upper limbs, etc.
• In infants, a higher proportion of the skeleton is visible including head
and neck, upper limbs, pelvis, and hips. These should all be checked.
(c) Tracheobronchial tree and mediastinum:

• Position and integrity of trachea and main bronchi.
• Presence of a foreign body either directly visible or indirectly by its effect
on ventilation.
• The thymus is routinely visible until the age of 3. It is readily identifiable
but can make the heart shadow difficult to analyze.
• Some lines should be visible within the mediastinum in particular the
esophagus. Look for possible esophageal atresia if the nasogastric tube
curls up before reaching the stomach.
• There are some common mediastinal tumors in children including lym-
phomas, neurogenic tumors (ganglioneuromas), thymomas, teratomas,
and lipoblastomas.
(d) Heart silhouette and hila:
• This area can provide a number of clues in cases of cardiovascular mal-
formations. A clinical suspicion is likely and it is useful to know if the
child has a cyanotic or non-cyanotic condition.
• Points to consider are heart size, shape, and position.
• Special attention needs to be given to the lung vasculature from the pul-
monary vessels in the hila to the overall vascularity of the lung fields up
to the periphery of the thoracic cavity. Do the lungs appear hypo- or
hypervascularized? Correct X-ray exposure is crucial [1].
(e) Contours of the thorax:
• A systematic review of all the peripheral regions of the thoracic cavity is
necessary.
• Check the apices for pneumothoraces but remember that the child could
be supine.
• Inspect the margins of the mediastinum and heart silhouette, the costo-
diaphragmatic angles, and the position and shapes of the two hemidia-
phragms. Note the fissures if visible.
(f) Lung fields:
• Compare symmetrically: lung translucency, inflation, parenchyma, vas-
cularization, and lung markings. Diaphragmatic hernias usually occur on
the left side [1].
• A good quality X-ray is needed to identify and distinguish parenchymal
disease or abnormal vasculature. You need to decide whether the p athology
involves the lung or the cardiovascular system. If it is unilateral, a local
process may be involved. A bilateral symmetrical aspect is more likely
due to a systemic condition whether respiratory or cardiac.
(g) Abdomen:
• This must be included in the neonatal X-ray [1]. Look for the presence of
air in the bowel. In esophageal atresia, air will be absent unless there also
is a tracheoesophageal fistula (TOF) below the level of the atresia.
• In older children, check the size of solid organs: grossly enlarged liver,
spleen, and kidneys can be visible.
• Check for free air under the diaphragm from trauma or ruptured viscus.
65 CXR: Pediatric I 355
Fig. 65.2 Chest X-ray of a

neonate. Note: the presence
of ET tube, NG tube and
well positioned umbilical
arterial catheter. The
umbilical vein catheter is
not deep enough with its
tip below the diaphragm
(h) Soft tissues:

• Check body fat (absent in premature children), edema (hydrops fetalis),
or surgical emphysema.
(i) Artefacts:
• Children in PICU or NICU will have a number of lines inserted which
need to be checked for correct position (Fig. 65.2): umbilical artery or
vein catheters, central venous catheter, PICC, nasogastric (NG) tube,
endotracheal (ET) tube, shunts, and drains [3].
• Artifacts include umbilical clips, skin folds, monitoring equipment, cots,
or ventilator parts.
4. In every case, knowledge of the clinical presentation should guide the interpre-
tation [2]. Furthermore, some pathologies will be more common at different
ages.
For example, the following conditions should be sought in the chest X-ray of:
A premature baby or a neonate:
Remember X-ray will be AP and supine. Check fetal maturity—ossification
of humeral heads. Check lines and tubes [1].
Look for acute cardiopulmonary conditions—respiratory distress in prema-
ture babies, transient tachypnea of the newborn, and meconium aspiration.
Congenital malformations, cardiovascular anomalies, and hypoperfusion of the
lung fields.
Rarer anomalies include:
Diaphragmatic hernia: abdominal content in the chest cavity.
Esophageal atresia: NG tube curling up and absence of intraabdominal gas
unless TOF is also present [1]. Dextrocardia: check that labelling has been cor-
rectly done.
Infants: respiratory tract infections, NAI, tumors: mediastinal but also chest
wall and metastatic tumors. Foreign bodies. Rib notching of coarctation (not in
under 5).
Children: trauma, NAI, and infections.
5. A tension pneumothorax: this is a life-threatening condition which should be

managed clinically without X-ray confirmation.
6. Do not forget: the elephant in the room [2].
If something is obvious and appears important, notice and mention it early.
It is then up to you to prioritize your interpretation according to the clinical
situation.
References
1. Arthur R. The neonatal chest X-ray. Paediatr Respir Rev. 2001;2:311–23.

2. Radiologymasterclass.co.uk. http://www.radiologymasterclass.co.uk/. Accessed 25 Dec 2016.
3. Radiopaedia.org. https://radiopaedia.org/. Accessed 25 Dec 2016.
Chapter 66
CXR: Pediatric II
Frederick van Damme and Frederic J. Sage
An 11-month-old boy presented to our emergency department (ED) with a history

of choking on a biscuit he was eating. He had one episode of cyanosis on choking.
In the ED, he had episodes of coughing and his observations were as follows:
HR 145/min, RR 45/min, SpO2 93% on air, SpO2 99% on high flow oxygen (O2).
No FB was apparent on the CXR shown below. After discussion with the otorhi-
nolaryngologist and pediatricians, it was decided to admit this boy for observation.
Fig. 66.1 CXR of our patient
F. van Damme, MB, ChB (Stell), FRCA • F.J. Sage, MD, FRCA, FFICM (*)
Department of Anaesthesia, East Surrey Hospital,
Canada Avenue, Redhill, RH1 5RH, UK

DOI 10.1007/978-3-319-55862-2_66
358 F. van Damme and F.J. Sage
Questions
1 . What is the initial prehospital management of a choking child? [1]
2. Describe the presentation of a foreign body (FB) aspiration in a child? [2–5]
3. What does the CXR in our patient show?
4. What is the management of aspirated and ingested FB? [1–6]
5. What is the incidence and complication rate of FB in children? [2, 6]
66 CXR: Pediatric II 359
Answers
1. Assess severity of choking episode [1].
(a) Effective cough (crying or verbal response to questions, loud cough, able to
breath before coughing, normal GCS)
• Encourage cough—unless patient deteriorates or until obstruction is
relieved.
Transport to ED if indicated!
(b) Ineffective cough (unable to breath, cyanosis, decreasing GCS, unable to
vocalize) [1]
• Conscious—blind oropharyngeal finger sweep is not recommended.
Alternating five back blows with five chest thrusts (infants) or five
abdominal thrusts (child >1 year). Repeat until object comes out or child
becomes unconscious.
• Unconscious—start CPR.
2. History of aspiration from a witness (not always available).
Presentation can range from complete obstruction with hypoxia and cardiac
arrest to partial obstruction with symptoms described below to being asymp-
tomatic and presenting later [2].
Symptoms: coughing, choking, stridor or wheezing, drooling, vomiting,
chest discomfort, difficulty in swallowing, reduced appetite or refusal to eat, and
gagging on eating and drinking.
Signs: tachypnea, intercostal muscles retraction, use of accessory muscles,
nasal flaring, or cyanosis.
Sometimes asymptomatic with no physical signs even with a reliable his-
tory of aspiration. Sometimes the presentation is with repeated pneumonias or
lung abscesses.
Physical examination:
Persistent stridor—high-pitched inspiratory stridor usually a result of supra-
glottic obstruction.
Biphasic stridor: indicates an obstruction at glottic or subglottic region.
Expiratory stridor: indicates a tracheal or bronchial obstruction.
Decreased breath sounds and wheezing can be indicative of an aspirated FB.
X-rays: AP (Antero Posterior) and lateral x-rays of the chest including the neck
must be obtained. Inspiratory and expiratory films will help in lateralizing (radio-
lucent) FB by emphasizing air trapping. Left and right lateral films are used in
young, uncooperative children (the side with the FB will not deflate when placed
dependent). Over 50% of X-rays are normal within 24 hours of aspiration.
Fig. 66.2 FB (ring) at level of thoracic inlet
Fig. 66.3 FB (coin) in mid esophagus

Radiopaque FB:
It is important to distinguish between a battery/magnet and simple coin. Battery will
have a double halo on X-ray and should be removed as a matter of urgency if
stuck in the esophagus [5].
Radiolucent FB:
The following indirect signs can be present:
Normal or air trapping with air bronchograms.

Atelectasis and partial or total collapse of affected lung.
Hyperinflation of affected lung +/− mediastinal shift.
Pneumothorax or air in the mediastinum.
Consolidation.
3. Hyperinflated right lung with increased translucency, flattened right hemidia-
phragm, wider spaced right ribs, and mediastinal shift to the left are the radio-
logical features of obstruction.
4. Management of these cases should involve a multidisciplinary team (MDT)
approach and good communication between the team members. The need for
special equipment, specialized skills with a pediatric otorhinolaryngologist, a
pediatric anesthesiologist, and a pediatric intensivist would warrant transfer of
these patients to a facility that can provide them.
(a) Esophageal FB. [2]

Several techniques have been described in the literature for the removal of
FB. Rigid and flexible esophagoscopy requires a general anesthetic (GA).
Balloon retrieval and bougienage of esophageal FB does not require a GA [4].
Bougienage relies on the rationale that if you push the coin into the stomach,
it will pass down the gastrointestinal tract. GA requires a rapid sequence
induction and intubation to prevent aspiration. A repeat esophagoscopy is
performed after removal of the FB to assess any mucosal injury.
(b) Button battery ingestion. [2]
We will consider this as a separate topic as the potential for significant
esophageal injuries is very high within 2 hours of ingestion of the battery.
Ingestion of the newer lithium button batteries are of great concern as the
generation of hydroxide radicals in the esophageal mucosa result in a caustic
injury from the high pH. This can lead to esophageal perforation, mediasti-
nitis, tracheoesophageal fistula or aorto-enteric fistulas, and life-threatening
bleeding. The most common battery that raises concern is the 3 V, 20/22 mm
lithium button battery (CR 2032) [2].
Ingested esophageal batteries should be removed as a matter of urgency
for the reasons mentioned above. Asymptomatic gastric batteries are allowed
to pass naturally but should be monitored with follow up X-rays. Symptomatic
gastric batteries or simultaneous ingested magnets should be removed
urgently. Children at greatest risk are those younger than 5 years of age and
those with ingested battery size >20 mm and multiple battery ingestions [3].
(c) Tracheal or bronchial FB.
The procedure planned may be a diagnostic flexible bronchoscopy (in cases
where the diagnosis is not certain) or a rigid bronchoscopy for FB retrieval
in symptomatic children.
As the surgeon and anesthesiologist share management of a potentially
obstructed airway, a clear communication of a detailed anesthetic and surgi-
cal plan and good cooperation between the two teams is essential.
Anesthetic Technique:
Preoperative assessment should determine where the FB has lodged, the
nature of the FB, and the time it occurred. FB in the trachea means there is a risk
for complete airway obstruction, and the risk is less if it is lodged beyond the
carina.
There are three main anesthetic issues—method of induction, ventilation, and
maintenance of anesthesia.
The optimal method of induction is not definitely established but maintaining
spontaneous ventilation during the induction of a patient with a proximal FB is
commonly practiced [2]. While spontaneous and controlled ventilation are fea-
sible for FB removal, positive pressure ventilation down the bronchoscope with
intermittent apnea while manipulating the object may be more suitable for distal
FB retrieval. Airway trauma and rupture are significant and potentially fatal com-
plications; hence, it is essential to avoid coughing and bucking secondary to the
intense stimulation from a rigid bronchoscope. Movement can be prevented with
neuromuscular blockade or deep anesthesia. In theory, there is a risk of positive
pressure ventilation causing air trapping due to a ball-valve effect but the litera-
ture does not support this concern. Maintenance can be with inhalational agents
or a total IV technique with propofol and remifentanil infusions with the advan-
tage of a constant level of anesthesia irrespective of ventilation [4, 6].
Ventilation—spontaneous, controlled, and manual jet ventilation (with the ven-
tilation catheter inserted separately from the bronchoscope) has been used and in
one series, the incidence of intraoperative hypoxemia was less with manual jet
ventilation.
To facilitate removal of the FB through the larynx, the vocal cords should be
well relaxed which can be achieved with a small dose of neuromuscular blocker
or propofol. If the FB occludes the trachea and cannot be removed, it can tempo-
rally be pushed down the left or right main bronchus to allow one-lung ventila-
tion. Rarely, a tracheostomy or a thoracotomy might be needed [4].
Once the procedure is finished, a tracheal tube is inserted if a full stomach is a
problem and the patient is woken up and extubated on return of protective reflexes.
The patient in our case report suffered several episodes of respiratory distress
and cyanosis and was rapidly transferred to the operating room for an emergency
rigid bronchoscopy. Adequate intravenous access was in situ (two cannulas mini-
mum). Anesthesia was induced with 100% O2 and sevoflurane after a period of
Fig. 66.4 Bronchoscopic view—FB in right main bronchus
preoxygenation with 100% O2. Once the patient was anesthetized and the airway
maintained, a rigid bronchoscope was inserted to examine the airways. The FB
(an orange pip) was located at the origin of the right main bronchus (Fig. 66.4).
After many difficulties, including transient occlusions of the lower trachea, the
pip was removed with a rigid sucker.
All secretions and FB material were removed and the underlying mucosa was
evaluated (Fig. 66.5). The child was allowed to slowly emerge from general
anesthesia and was closely observed for laryngo-/bronchospasm. After a period
of observation in post-anesthetic recovery area, the patient was allowed back to
the pediatric ward for further observation.
5. Asphyxiation due to FB is a leading cause of death in the pediatric population
aged 0–3 years in the European Union (EU) and in the United Status. During
2000, ingestion or aspiration of a foreign body (FB) was responsible for more
than 17,000 emergency department visits in children younger than 14 years in
the United States with a preponderance in males. In the United States, FB aspira-
tion was responsible for about 4800 deaths in 2013, or about 1 death per 100,000
children [5], aged 0 to 4 years. Estimates in the EU show 50,000 incidences [5,
7]a year with a 10% fatality rate.
26% of FB are food objects such as bones, nuts, or seeds. The remaining 74%
are non-food objects: coins, marbles, and toys. Coins make up 15% of FB. Acute
and chronic complications seem to occur in almost 15% of patients [2, 5, 7].
Fig. 66.5 Bronchoscopic view—FB removed. Edema and secretions visible, right main
bronchus
Complications: Complete obstruction can lead to cardiac arrest and death if

not treated promptly. In children in whom the diagnosis was delayed, most com-
mon complications included croup, pneumonia, pneumothorax, atelectasis, stric-
ture, and perforation. Less commonly, perforation of the bronchial tree and
fistula formation into surrounding structures can happen [2, 5].
Complications rate from rigid endoscopy and bronchoscopy is low (0.2–5%)
and mortality is less than 0.2% [2].
Acknowledgment Thanks to Robert Bunting and the X-ray department at East Surrey Hospital,
Redhill, United Kingdom, for providing the CXR’s and to Mr. Kapoor, Consultant ENT surgeon,
for the bronchoscopic images.
References
1. Resuscitation council (UK) – Paediatric Guidelines – Choking Child.

2. Berdan EA, Sato TT. Pediatric airway and esophageal foreign bodies. Surg Clin North Am.
2017 Feb;97(1):85–91.
3. Fortran F, Ballali S, et al. Foreign bodies in the airways: a meta-analysis of published papers.
Int J Pediatr Otorhinolaryngol. 2012;76:S12–9.
4. Heinzerling NP, Christensen MA, Swedler R, et al. Safe and effective management of esopha-
geal coins in children with bougienage. Surgery. 2015;158(4):1065–70.
5. Connors GP. Pediatric Foreign body ingestion. In Medscape. http://emedicine.medscape.com/
article/801821-overview#a4. Accessed 1 Dec 2016.
6. Fidkowski CW, et al. The anesthetic considerations of tracheobronchial foreign bodies in chil-
dren: a literature review of 12,979 cases. Anesth Analg. 2010;111:1016–25.
7. Susy Safe Working Group. The Susy Safe project overview after the first four years of activity.
Int J Pediatr Otorhinolaryngol. 2012;76(Suppl 1):S3–11.
Chapter 67
ECHO: 3D
Nicole T. Tran
Fig. 67.1 Mitral valve

systole

diastole
N.T. Tran, MD
Department of Cardiology, University of Oklahoma Health Sciences Center,

DOI 10.1007/978-3-319-55862-2_67
368 N.T. Tran
I. A 70-year-old male with long-standing history of a cardiac murmur presents for
evaluation of decreased exertion tolerance. He has no other significant past medical
or surgical history. He previously was very active and walked 2–3 miles daily but
recently has had to cut back to one mile due to fatigue and dyspnea. Physical exam
is notable for a 3/6 holosystolic murmur located at the apex and radiating to the
axilla, a laterally displaced apical impulse and an early diastolic rumble. A transtho-
racic echocardiogram (TTE) is obtained which prompts a transesophageal echocar-
diogram (TEE) for further evaluation.
Questions
1 . What is the normal anatomy of the mitral valve?
2. What do Figs. 67.1 and 67.2 demonstrate?
3. How is mitral regurgitation classified?
4. What is the role of 3D TEE in the evaluation of mitral regurgitation?
5. What are the advantages and disadvantages of three-dimensional (3D) echocar-
diography compared to two-dimensional (2D) echocardiography?
6. What are the indications for surgical treatment of mitral regurgitation?

systole

diastole
67 ECHO: 3D 369
Fig. 67.5 Mitral
regurgitation
II. A 40 year old female with hypertension, diabetes, and end-stage renal disease on
hemodialysis presents to the emergency room complaining of a 2 week history of
fevers, chills, night sweats and a 1 day history of rapidly progressive shortness of
breath. She is sitting upright, in moderate distress and appears dyspneic. Temperature
is 38.4°C. 2/2 blood cultures grow S. aureus. Physical exam reveals an S3 and an
early diastolic flow rumble.
Questions
7 . What do Figs. 67.3, 67.4, and 67.5 demonstrate?
8. Using the Carpentier classification, what is the mechanism of mitral

regurgitation?
9. What are additional key echocardiographic findings in the evaluation of this
condition?
370 N.T. Tran
Answers
1. The mitral valve is the left atrioventricular (AV) valve. It is a bileaflet valve com-
posed of anterior (aortic) and posterior (mural) leaflets. The anterior mitral valve
leaflet (AML) occupies 1/3 of the mitral annulus but is broader and occupies 2/3
of the surface area of the valve. It is in fibrous continuity with the left and non-
coronary cusps of the aortic valve. The posterior mitral valve leaflet (PML) occu-
pies 2/3 of the mitral annulus but only accounts for 1/3 of the surface area of the
valve [1]. It is divided into three scallops which Carpentier labeled P1, P2 and P3
going laterally to medially. By convention, the AML is similarly divided into
three segments (A1, A2, A3 from lateral to medial) which correspond to the PML
scallops. The mitral annulus is fibrous anteriorly, muscular posteriorly, and
changes shape during the cardiac cycle. The muscular posterior portion is more
prone to dilatation and calcification. On the ventricular aspect of the mitral valve,
there are three layers of chordae tendinae (primary, secondary and tertiary)
which attach to the papillary muscles. There are classically two papillary mus-
cles: posteromedial and anterolateral. The posteromedial papillary muscle is
connected via cords to the medial 1/2 of the mitral valve and the anterolateral
papillary muscle gives cords to the lateral 1/2 of the mitral valve. With normal
mitral valve function, there is a zone of coaptation where the leaflets close, as
well as a 4–5 mm zone of apposition where the two leaflets overlap.
2. Figures 70.1 and 70.2 show the classical 3D TEE surgeon’s view of the mitral
valve in systole (Fig. 67.1) and diastole (Fig. 67.2). In the surgeon’s view, the left
atrium has been opened and you are looking down at an en face view of the
mitral valve. The aortic valve by convention is at the top of the image. In this
view, the lateral commissure and left atrial appendage are to the left of the image,
and the medial commissure and tricuspid valve apparatus are to the right of the
image. PML scallops are labeled by the Carpentier convention, lateral to medial,
P1, P2 and P3. The adjacent segments of the AML are labeled A1, A2, A3 from
lateral to medial. These images show a flail P2 segment due to a ruptured cord
(arrow). A flail segment is defined as the tip of the leaflet pointing towards the
left atrium in systole and the left ventricle in diastole.
3. Mitral regurgitation (MR) is typically described by the Carpentier Classification
(adapted from Tsang et al.) [2]. This patient’s mitral regurgitation would be
described as type II (likely due to fibroelastic disease) with isolated flail P2 seg-
ment due to a ruptured cord (Table 67.1).
4. Echocardiographic evaluation of MR should seek to identify the origin of regur-
gitation (is it primary? secondary?), the specific lesion responsible for the
regurgitation, which aspects of the mitral valve apparatus are affected (leaflets?
annulus? chordae tendinae? papillary muscles?), the severity of the MR, and the
downstream effects of the MR. This complete evaluation aids in surgical planning
[2, 3]. TEE is indicated preoperatively or intraoperatively (class I recommenda-
tion) or when surgery is being considered (class IIa recommendation) to “estab-
lish the anatomic basis of severe MR and to assess the feasibility of and guide
67 ECHO: 3D 371
Table 67.1 Carpentier classification of mitral regurgitation (inserted with answer 3)

Type Leaflet motion Mechanism of MR
I Normal Perforation
Cleft
Dilated annulus without leaflet tethering
II Excess motion Fibroelastic diseasea
Barlow’s diseaseb
IIIa Restricted motion in systole and diastole Rheumatic/post-inflammatory
IIIb Restricted motion in systole only Due to symmetric or asymmetric (ischemic)
ventricular dysfunction
a
Fibroelastic disease usually characterized by a single prolapsing segment with prolapse due to
focal cord elongation or rupture
b
Barlow’s disease is due to classic myxomatous changes of both leaflets and multiple segments and
both leaflets may be involved. Leaflets are often thickened (>5 mm)
surgical repair” [4]. TEE is also indicated when TTE is technically inadequate or
non-diagnostic in the evaluation of severe MR (class I recommendation).
5. 3D TEE provides anatomic information from a typical surgeon’s viewpoint
which can be critical in communicating findings in an operative setting. It is
superior to 2D imaging in correctly identifying affected scallops. Changes in
annular size or adjacent anatomy can result in misidentification of scallops on
typical 2D TEE views. 3D TEE eliminates this source of error [5, 6]. 3D TEE is
also more sensitive and specific than 2D echocardiography for the identification
and characterization of commissural lesions. It provides additional information
on annular size and geometry as well as on adjacent anatomic structures without
necessitating mental 3D reconstruction. As a result, it is less operator dependent
than 2D TEE. Current 3D probes have the ability to do X-plane imaging (imag-
ing of simultaneous orthogonal planes), live (real-time) 3D imaging, 3D full
volume imaging (4–7 heartbeats are averaged to obtain a large volume image),
and 3D full color volume imaging, which with newer technology is useful in the
quantification of mitral regurgitation. The main limitations of 3D TEE are the
need for an adequate acoustic window, the need to minimize respiratory artifact
and translational motion when obtaining full-volume imaging to minimize stitch
artifacts, and the decrease in temporal resolution when compared to 2D TEE.
6. Surgery is indicated for severe acute MR (class I recommendation) [4]. For pri-
mary mitral valve pathology, surgery is indicated for chronic, severe, symptom-
atic MR as long as left ventricular ejection fraction (LVEF) is 30% or greater and
left ventricular end-systolic dimension (LVESD) is less than or equal to 55 mm
(class I recommendation). Surgery is indicated for chronic, severe, asymptom-
atic MR if the LVEF is between 30 and 60% and the LVESD is at least 40 mm
(class I recommendation). It is reasonable to send an asymptomatic patient with
chronic, severe MR, an LVEF >60%, and LVESD <40 mm for repair with an
experienced surgeon if the likelihood of successful repair is >90% (class IIa
recommendation). It is also reasonable to refer patients with chronic severe MR
and either new onset Atrial Fibrillation or pulmonary hypertension (pulmonary
372 N.T. Tran
artery systolic pressure > 50 mm Hg at rest or >60 mm Hg with exercise) for

surgery (class IIa recommendation). It should be noted that if at all possible,
mitral valve repair is preferred over mitral valve replacement. Patients should be
referred to a surgical center with expertise in mitral valve repair, where the likeli-
hood of successful repair is at least 90% (class I recommendation). It is recom-
mended that mitral valve surgeons do at least 25 repairs per year, and mitral
valve centers of excellence do at least 50 repairs per year. Isolated P2 prolapse is
the most easily repaired lesion. Repair success rates decrease with anterior or
multi-segment prolapse, mitral annular calcification, and significant billowing/
excess leaflet tissue.
7. These images show a 3D TEE surgeon’s view of the mitral valve in systole
(Fig. 67.3) and diastole (Fig. 67.4). The aortic valve is labeled at the top of the
screen (Ao). The lateral commissure is on the left by the left atrial appendage;
the medial commissure is on the right by the tricuspid valve (TV) apparatus. On
the atrial aspect of the P2 scallop of the PML, there is an irregular, shaggy, echo-
genic mass (arrow in Fig. 67.4) which involves the mitral valve annulus and is
associated with local destruction of the P2 scallop. The regurgitant orifice is
marked with an arrow in Fig. 67.3. Figure 67.5 shows the color doppler mitral
regurgitation through the perforated leaflet. The patient has positive blood cul-
tures for a typical organism (S. aureus), suggestive echocardiographic findings,
and is febrile. She has two major and one minor Duke criteria which is diagnostic
for infective endocarditis [7]. TEE confirmed severe MR which was likely acute
given her clinical presentation. Her lack of murmur is explained by rapid equili-
bration of left atrial and left ventricular diastolic pressures. If present, the mur-
mur of acute severe MR occurs in early systole and terminates in early to
mid-systole. An S3 is often present due to acute left ventricular volume overload
and a diastolic rumble flow murmur may be heard [8].
8. In this patient, mitral valve leaflet motion is normal. The mechanism of MR is
due to leaflet perforation from infective endocarditis (IE) (Carpentier class I)
(Table 67.1).
9. In this situation, 3D TEE was used to confirm the location and size of the vegeta-
tion (P2 scallop with extension into the muscular annulus), to evaluate for any
other associated valvular disease (in this case leaflet perforation), to evaluate the
shape/size of the mitral valve annulus for surgical planning, and to evaluate for
extension into adjacent structures. The anterior mitral valve leaflet is in fibrous
continuity with the left and non-coronary cusps of the aortic valve as well as the
right and left fibrous trigones. With IE involving the anterior mitral leaflet, it is
important to carefully examine for perivalvular or aortic valvular extension.
Perivalvular extension of IE is an indication for surgical intervention. It is also
important to accurately quantify the degree of regurgitation as severe, symptom-
atic regurgitation due to IE is an indication for surgical intervention. Large veg-
etations (>10 mm in size) associated with embolic phenomena, or recurrent
embolic phenomenon are also indications for surgical management of IE [9].
67 ECHO: 3D 373
References
1. McCarthy KP, Ring L, Rana BS. Anatomy of the mitral valve: understanding the mitral valve
complex in mitral regurgitation. Eur Heart J Cardiovasc Imaging. Dec 2010;11(10):3–9.
2. Tsang W, Lang RM. Three-dimensional echocardiography is essential for intraoperative
assessment of mitral regurgitation. Circulation. 2013;128:643–52.
3. Chandra S, Salgo IS, Sugeng L, et al. Characterization of degenerative mitral valve disease
using morphologic analysis of real-time three-dimensional echocardiographic images:
objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging.
2011;4:24–32.
4. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2008 focused updated incorporated
into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease:
a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines developed in collaboration with the Society of Cardiovascular
Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions
and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1–e142.
5. Zekly SB, Nagueh SF, Little SH, et al. Comparative accuracy of two-and three-dimensional
transthoracic and transesophageal echocardiography in identifying mitral valve pathology in
patients undergoing mitral valve repair: initial observations. J Am Soc Echocardiogr.
2011;24:1079–85.
6. Pepi M, Tamburini G, Maltagliati A, et al. Head-to-Head Comparison of two- and three-
dimensional trans thoracic and transesophageal echocardiography in the location of mitral
valve prolapse. J Am Coll Cardiol. 2006;48:2524–30.
7. Durack D, Lukes AS, Bright DK, et al. New criteria for diagnosis of infective endocarditis:
utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med.
1994;96(3):200–9.
8. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119:3232–41.
9. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation.
2010;121:1141–52.
Part IV
Physiologic Studies
Chapter 68
Pulmonary Function Testing
John B. Carter
Forty-two-year-old female is 61 inches and 98 lbs and has shortness of breath.

Figure 68.1 is her spirogram. FVC is 94% of predicted. FEV1 is 46% but post bron-
chodilator increases to 66%. FEV1/FVC was 39%.
Volume
4
0
–1 0 1 2 3 4 5 6 7 8
Time
Fig. 68.1 Patient’s spirometry, red curve after bronchodilator
J.B. Carter, MD
Department of Respiratory Therapy, Oklahoma University Medical Center Hospital,

DOI 10.1007/978-3-319-55862-2_68
378 J.B. Carter
Questions
1 . How is spirometry performed and what information does it provide?
2. When is spirometry indicated?
3. Describe normal and abnormal spirometry curves.
4. Describe spirometry in COPD.
5. What is bronchodilator reversibility testing?
6. How would you interpret this patient’s spirometry?
68 Pulmonary Function Testing 379
Answers
1. Spirometry: the patient inhales until the lungs are full and rapidly and forcefully
exhales. The test is dependent on patient effort, so it must be properly per-
formed. The test is repeated until three acceptable and consistent results are
obtained.
(a) Forced vital capacity or FVC. This is the total exhaled volume in liters
exhaled after full inspiration, typically in the first 6 s.
(b) Forced expiratory volume in liters during the first second or FEV1.
(c) The ratio of the FEV1/FVC as a fraction. Normal is between 0.7 and 0.8.
(d) The forced expiratory flow rate in the midportion of the FEV1, the FEF25–75.
(e) Normal values are obtained from tables, obtained in normal controls, and
vary by height, gender, and ethnicity. These data provide objective measure-
ments to determine the severity and follow the course of the pulmonary dis-
ease [1].
(f) These measurements are based on flow over time. Flow volume loops are
flow rates plotted against volume and are discussed in a separate chapter.
2. Spirometry can confirm the presence and severity of obstructive and restrictive
lung disease. The response to bronchodilator can assist to differentiate asthma
from COPD. It can be useful to assess progression and response to therapy.
Spirometry is not routinely necessary in preoperative testing for non-thoracic
surgery. In patients evaluated for lung resection, simple spirometry, FVC, and
FEV1 should be obtained. The predicted postoperative FEV1 is calculated as
ppoFEV1 = preop FEV1% × (1–% functional lung removed/100). A
ppoFEV1 < 40% indicates a higher risk of postoperative complications; these
patients may need additional testing, and/or a ppoFEV1 < 30% may require post-
op ventilation [2].
3. Figure 68.2 is a normal spirometry curve. Figure 68.3 demonstrates abnormal
spirometry curves. Three basic patterns are:
(a) Normal: FEV1 and FVC are >80% of predicted.
FVC1/FVC is >0.7.
(b) Obstructive: FEV1 < 80% of predicted
FVC normal or reduced, usually decreased to a lesser degree than FEV1
FEV1/FVC < 0.7. (Fig. 68.3)
An obstructive pattern is usually seen in COPD or asthma.
(c) Restrictive: FEV1 is normal or slightly reduced.
FVC < 80% of predicted.
FEV1/FVC > 0.7. (Fig. 68.4)
380 J.B. Carter
Fig. 68.2 Normal Normal spirogram: Volume-time curve

spirometry curve (with
permission from Global 5
FVC
Initiative for Chronic
Obstructive Lung Disease. 4
http://www.goldcopd.org) FEV1
Volume (L)
3
FEV1/FVC = 4.0/4.8 L (0.83)
1 2 3 4 5 6
Time (s)
Fig. 68.3 Obstructive Obstructive

pattern (with permission
from Global Initiative for
Chronic Obstructive Lung
Disease. http://www.
goldcopd.org)
Volume
Time
Normal Abnormal
Restrictive
Volume
Fig. 68.4 Restrictive
pattern (with permission
from Global Initiative for
Chronic Obstructive Lung Time
Disease. http://www. Normal Abnormal
goldcopd.org)
68 Pulmonary Function Testing 381
Fig. 68.5 Mixed pattern Mixed

(with permission from
Global Initiative for
Chronic Obstructive Lung
Disease. http://www.
goldcopd.org)
Volume
Time
Normal Abnormal
Restrictive pattern is seen in parenchymal disease such as pulmonary fibrosis.

Extraparenchymal causes include chest wall deformity such as scoliosis, obesity,
pleural effusion, and neuromuscular disorder. Further pulmonary testing with CO
diffusion capacity may help in the diagnosis.
If both FEV1 and FVC are reduced, the patient may have a mixed restrictive and
obstructive disorder (Fig. 68.5). Another possibility is that severe obstruction
may lead to air trapping. Measuring total lung capacity and residual volume will
show increased residual volume in air trapping [3].
4. Chronic obstructive lung disease COPD is common. Causes include cigarette

smoking, occupational exposure to particulates such as in coal miners, and α1
antitrypsin deficiency [4]. There is a progressive airflow limitation that is not
fully reversible. This is due to loss of elastic recoil in emphysema and airway
narrowing by secretions or inflammatory changes. Clinical features include pro-
ductive cough, progressing dyspnea, and prolonged expiration [5].
GOLD spirometric criteria for COPD severity
I. Mild FEV1/FVC < 0.7 May be asymptomatic
FEV1 ≥ 80% predicted
II. Moderate FEV1/FVC < 0.7 Dyspnea on exertion
50% ≤ FEV1 < 80% predicted
III. Severe FEV1/FVC < 0.7 Activity limited by SOB
30% ≤ FEV1 < 50% predicted Exacerbations begin
IV. Very FEV1/FVC < 0.7 Impaired quality of life
severe FEV1 < 30% predicted or Exacerbations may be severe
FEV1 < 50% predicted and chronic respiratory
failure
382 J.B. Carter
5. Bronchodilator testing demonstrates reversibility of obstruction, indicating ben-

efit from bronchodilator therapy, primarily beta2 agonists. FVC and FEV1 are
measured at baseline and after inhaled bronchodilator.
(a) FEV1 increases of at least 12% or 200 ml from baseline is considered signifi-
cant. This supports the diagnosis of asthma.
(b) Some patients with COPD respond to bronchodilators.
(c) In general spirometry that returns to normal after bronchodilator is not
COPD [1].
6. This patient’s spirometry has an FVC of >80%; thus, a restrictive component is
not present.
The marked decreased FEV1 at 46% predicted and FEV1/FVC of 39% indicate an
obstructive component that is severe. She shows responsiveness to bronchodila-
tors. The diagnosis of either COPD or asthma is based on the history and physi-
cal in addition to spirometry.
References
1. Spirometry for health care providers. Global Initiative for Chronic Obstructive Lung Disease.
Goldcopd.org.
2. Slinger P, Darling G. Preanesthetic assessment for thoracic surgery. In: Slinger P, editor.
Principles and practice of anesthesia for thoracic surgery. New York: Springer; 2011. p. 19.
3. Feyrouz A, Reena M. Interpreting pulmonary function tests. Cleveland Clin
J. 2003;70:866–81.
4. Al-Ruzzeh S, Kurup V. Stoelting’s Anesthesia and Co-existing Disease, Chapter 9, 6th ed.
2012.
5. West J. Pulmonary pathophysiology the essentials. Philadelphia: Lippincott Williams &
Wilkins; 2003.
Chapter 69
Stress Test
Sixty-five-year-old lady awaiting Whipple surgery presents to the preoperative

clinic. She has a past medical history of ischemic heart disease with percutaneous
coronary intervention in the past, prior ischemic stroke with left-sided hemiparesis,
diabetes mellitus well controlled on metformin, essential hypertension, and hyper-
lipidemia. Patient stated that she started noticing chest pressure over left precor-
dium with moderate exertion over the past 3 months. She is partially dependent.
Due to suspicion of ischemic heart disease and elevated risk surgery, cardiology
clinic referral is made, and surgery is postponed. Cardiologist orders a stress test.
Results are displayed below.
A.V. Pakala, MD

DOI 10.1007/978-3-319-55862-2_69
384 A.V. Pakala
Fig. 69.1
Fig. 69.2
69 Stress Test 385
Questions
1 . What do the images demonstrate?
2. What is the pathophysiologic basis of stress testing?
3. What factors influence the choice of stress testing?
4. What is the role of stress testing in the preoperative setting?
386 A.V. Pakala
Answers
1. Patient underwent a dobutamine stress echocardiogram. Figures show still

frames of the left ventricle in end systole, at rest, and at peak stress (Figs. 69.1
and 69.2). Findings are consistent with stress-induced wall motion abnormality
involving the left anterior descending coronary artery distribution (anterior and
anterolateral myocardium).
2. Functional stress testing is the test of choice for detecting myocardial ischemia.
Stress testing is based on the principle of “the ischemic cascade”; according to
which, as the severity of ischemia increases, the ischemic manifestations
worsen progressively from diastolic dysfunction, reduced epicardial perfusion,
regional wall motion abnormalities, global systolic dysfunction, and finally
EKG changes [1].
The aim of a stress test is to activate the ischemic cascade with either exercise
or drugs and demonstrate the resulting ischemic manifestations via EKG, echocar-
diography, myocardial perfusion imaging (MPI), or magnetic resonance imaging.
Exercise stress is preferred over pharmacological stress because of the higher
physiological stress levels achieved via exercise. Exercise stress also provides
additional prognostic information like functional capacity. However, not all
patients are candidate for exercise stress testing, especially those who have sig-
nificant disabilities or disabling comorbidities.
3. The sensitivity and specificity of a stress test depend upon the pretest probability
of ischemic heart disease (IHD); sensitivity of the stress test to detect disease
increases in patient populations with high pretest probability of IHD (65-year-
old male with typical chest pain); on the other hand the specificity of the stress
test to detect the absence of disease increases in populations with low pretest
probability of IHD (35-year-old female with atypical chest pain). The clinical
utility of a stress test in diagnosing or ruling out IHD is best in those with inter-
mediate pretest probability of IHD (45-year-old male with atypical chest pain).
The choice of stress testing depends on patient’s ability to exercise, body
habitus, and baseline EKG. According to the ACC-AHA guidelines, exercise
stress EKG testing is recommended in symptomatic patients with intermediate
pretest probability for ischemic heart disease (IHD), moderate functional capac-
ity, and interpretable EKG at baseline. Exercise stress with MPI or echocardiog-
raphy is recommended in symptomatic patients with intermediate to high pretest
probability of IHD, moderate functional capacity, and uninterpretable EKG at
baseline. Pharmacological stress MPI or echocardiogram is recommended for
symptomatic intermediate to high pretest probability patients who have limited
functional capacity and are not able to exercise [1].
4. Routine stress testing for IHD in the preoperative setting is not recommended.
For patients who are scheduled for elevated risk surgery (>1% risk of major
adverse cardiovascular events) and have excellent functional capacity
(METS > 10), it is reasonable to proceed with surgery without stress testing.
Even in patients with intermediate functional capacity (METS 4–10), proceeding
with surgery without stress testing may be considered [2].
69 Stress Test 387
Fig. 69.3 Coronary
angiogram showing the left
anterior descending (LAD)
coronary artery and left
circumflex coronary artery
(LCX) with severe stenosis
in the proximal segment
(red arrow)
Patients who are scheduled for elevated risk surgery and have poor functional
capacity (<4 METS) or if functional capacity cannot be determined, stress test-
ing may be considered if results of the stress test would change preoperative
management. In our patient scheduled for elevated risk surgery, functional status
estimation is not possible due to hemiparesis and partially dependent status. As
per the ACC-AHA guidelines, stress testing may be considered as mentioned
above.
More importantly however, our patient should be scheduled for stress testing
independent of surgical status due to the fact that she has high pretest probability
for ischemic heart disease and is currently symptomatic. High-risk stress fea-
tures (as shown in this case) suggest a high ischemic burden which would benefit
with revascularization. Our patient underwent coronary angiogram that revealed
significant stenosis of the left anterior descending (LAD) coronary artery
(Fig. 69.3). After discussions between the patient, surgeon, anesthesiologist, and
cardiologist, multidisciplinary decision was made to postpone Whipple surgery
to allow for percutaneous coronary intervention with bare metal stent and dual
antiplatelet therapy for 30 days.
References
1. Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. ACC/AHA/
AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of
patients with stable ischemic heart disease: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines, and the American Association
for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular
Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014;130(19):
1749–67.
2. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al.
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. J Am Coll Cardiol. 2014;64(22):
e77–137.
Chapter 70
Flow Volume Loops
Edward Kosik
A 48-year-old male patient presents to the preanesthesia clinic to prepare for a knee
arthroscopy procedure. The patient has a history of COPD and is a 40-pack-year
smoker.
Vitals are HR 72, BP 140/74, SpO2 93% on room air, and temp 36.6, with height
of 64 inches and weight of 88 kilograms.
Pulmonary function tests, including a flow volume loop, were present in the
patient’s medical records from an outside hospital.
E. Kosik, DO

DOI 10.1007/978-3-319-55862-2_70
390 E. Kosik
Fig. 70.1 A normal FVL
Questions
1. Draw a normal flow volume loop. Label the x- and y-axes. Where is the residual
volume and total lung capacity located? Show where expiration and inspiration
are represented.
2. Regarding patient effort, what is required from the patient for a flow volume loop
to be accurate? What type of patients might have difficulty with a FVL?
3. Where is the peak expiratory flow rate (PEFR) located on the FVL? What are the
normal values for PEFR for adult females and males? Besides a respiratory prob-
lem, what are major influences on the PEFR?
4. Where does an FVL start? What direction does the FVL follow?
5. Draw an FVL for a patient with mild COPD. Describe some key characteristics.
Explain what happens to the FVL whenever there is severe COPD.
6. Draw an FVL for a patient with vocal cord paralysis.
7. Explain what an FVL for a patient with a fixed obstruction such as a goiter looks like.
8. What does an FVL typically look like for restrictive lung disease?
70 Flow Volume Loops 391
Answers
1. Refer to Fig. 70.1a. The y-axis represents the flow rate. On this same axis exhala-
tion is found in the area above the x-axis, and inhalation is represented below the
x-axis. The lung volume is plotted on the x-axis and the value decreases from left
to right. In other words, the x-axis starts at total lung capacity at the left end, and
the volume decreases progressively until residual volume is reached at the far right.
2. A flow volume loop requires the patient to provide maximal ventilatory effort.
This might be difficult to obtain in pediatric patients and patients who might be
in acute respiratory distress.
3. A normal peak expiratory flow rate (PEFR) is located at the highest point on a
flow volume loop. A PEFR averages between 440 and 740 L/min in men and 340
and 530 L/min in women. Age and height are the major influences on PEFR [1].
Fig. 70.1a Normal flow (Normal)

volume loop with labels
Exhalation
Flow (L/s)
Volume
TLC RV
Inhalation
392 E. Kosik
4. The flow volume loop begins on the left of the x-axis and follows a clockwise
direction.
5. In mild COPD, the PEFR usually decreases slightly so that the initial expiratory
flow is not affected significantly (Fig. 70.2). Instead of the almost linear decrease
in expiratory flow, there is a “scooping” of the loop soon after the PEFR. This
scooping represents the decreased amount of flow secondary to difficulty in
expelling the volume of gases left in the distal airways.
In severe COPD, the PEFR is affected more drastically. The expiratory flow
does not come close to the flow of a normal subject.
6. This FVL depicts a paralyzed vocal cord adducting during inspiration resulting
in decreased airflow, but expiration is not affected (Fig. 70.3).
7. The peak flow of the FVL will be decreased during exhalation and inhalation.
Exhalation and inhalation flows will typically mirror each other. Since the patient
is providing maximal effort, residual lung volume and total lung volume remain
the same (Fig. 70.4) [2].
8. While there are many variations for FVLs representing restrictive lung diseases,
typically the TLC and RV are decreased. However, the peak flows remain almost
normal although for a shorter time (Fig. 70.5).
Obstructive lung disease

Normal FV loop
Exhalation
Flow (L/s)
Volume
Inhalation
Fig. 70.2 Significant
obstructive lung disease
70 Flow Volume Loops 393
Fig. 70.3 Variable (Variable extrathoracic)

extra-thoracic obstruction
Exhalation
Flow (L/s)
Inhalation
Flow volume loop

(Fixed obstruction)
Exhalation
Flow (L/s)
Inhalation
Fig. 70.4 Fixed
obstruction
394 E. Kosik
Fig. 70.5 Restrictive lung Normal FVL

disease Restrictive FVL
Exhalation
Flow (L/s)
Inhalation
References
1. Leiner GC, Abramowitz S, Small MJ, et al. Expiratory peak flow rate. Standard values for nor-
mal subjects. Use as a clinical test of ventilatory function. Am Rev Respir Dis. 1963;88:644.
2. Miller RD, Hyatt RE. Evaluation of obstructing lesions of the trachea and larynx by flow-
volume loops. Am Rev Respir Dis. 1973;108(3):475–81.
Chapter 71
Cath Report
Talla A. Rousan
Fig. 71.1 Coronary
angiogram of the left
coronary artery with caudal
angulation showing the left
anterior descending artery
and the left circumflex
coronary artery (arrow)

Veteran Affairs Medical Center, 800 Stanton L. Young Blvd, COM 5400,

DOI 10.1007/978-3-319-55862-2_71
396 T.A. Rousan
Fig. 71.2 Coronary
angiogram of the left
coronary artery with
cranial angulation showing
the left anterior descending
artery (arrow) and the left
circumflex coronary artery
Fig. 71.3 Coronary
angiogram of the right
coronary artery
Questions
1 . What do Figs. 71.1, 71.2, and 71.3 show?
2. Describe the normal coronary anatomy.
3. List some indications and contraindications for cardiac catheterization.
4. What are the complications of cardiac catheterization?
5. What are the determinants of myocardial demand and supply?
6. What defines a significant stenosis?
7. What are the main components of a “cath report”?
71 Cath Report 397
Answers
1. The images represent coronary angiography in different angiographic angula-
tions. Coronary angiography is defined as the radiographic visualization of the
coronary arteries after the injection of radiopaque iodinated contrast media [1].
This procedure is typically performed as a part of the cardiac catheterization
procedure which may also include hemodynamic assessment or imaging of other
cardiac chambers (usually the left ventricle). Coronary angiography is performed
of both the left and right coronary arteries and bypass grafts, if present, using
specialized catheters. Images are obtained in different angulations to accurately
delineate the coronary anatomy. Figures 71.1 and 71.2 delineate the anatomy of
the left coronary system. Figure 71.1 is a caudal angulation and best shows the
left circumflex artery and its branches (arrow). Figure 71.2 is a cranial angulation
view, and it best shows the left anterior descending artery and its branches
(arrow). Figure 71.3 shows the right coronary artery.
2. There are two major epicardial arteries: the left main and the right coronary
arteries originating typically from the left and right sinuses of Valsalva at the
base of the ascending aorta [2]. The left main coronary artery further divides to
the left anterior descending (LAD) and the left circumflex (LCX) coronary arter-
ies. In some instances, the left main coronary artery also gives a third branch
termed the ramus intermedius artery. The LAD and LCX further subdivide to
diagonal and obtuse marginal arteries. The dominance of the coronary c irculation
is determined based on the origin of the posterior descending artery (PDA) which
supplies the posterior part of the interventricular septum. The PDA arises from
the right coronary artery in 70% of the patients rendering the circulation right
dominant and from the left circumflex artery in 15% of the cases which makes
the circulation left dominant. In the remainder of the cases, the PDA arises from
both the right coronary and the left circumflex arteries, in which cases the circu-
lation is termed codominant [3].
The nomenclature of the different segments of the coronary artery tree has
been described by the Bypass Angioplasty Revascularization Investigation
(BARI) group, and detailed description is beyond the scope of this chapter [4].
Table 71.1 summarizes the main branches of the coronary arteries.
3. The main indication of cardiac catheterization in adults is to delineate the coro-
nary anatomy and the severity of stenoses for suspected coronary artery disease.
The procedure may be performed on elective or urgent basis [5]. Table 71.2 sum-
marizes the main indications of coronary angiography. There are no absolute
contraindications (apart from patient refusal) for cardiac catheterization.
Table 71.3 summarizes the major relative contraindications.
4. Cardiac catheterization is a relatively safe procedure; however, there are a number
of complications that may be associated with it, and the patient needs to be well
informed about them prior to proceeding with this invasive procedure. The main
complications [5, 6] encountered in this procedure are summarized in Table 71.4.
398 T.A. Rousan
Table 71.1 The main branches 1. Left main coronary artery

of the coronary arteries (in a
(a) Left anterior descending artery
right dominant system)
• Diagonal arteries
• Septal perforator arteries
(b) Left circumflex artery
• Obtuse marginal artery
• Left posterolateral artery
• Left posterior descending arterya
(c) Ramus intermedius arteryb
2. Right coronary artery
(a) Sinus node arteryc
(b) Conus arteryd
(c) Acute marginal arteries
(d) Posterior descending arterye
(e) Posterolateral arteries
a
Arises from the left circumflex artery in a left- or mixed-
dominant coronary circulation (30% of the cases)
b
Not present in all cases
c
Arises from the proximal right coronary artery in 50–70%
of the cases
d
Arises from a separate ostium close to the right coronary
artery ostium in 30–50% of the cases
e
Arises from the right coronary artery in a right- or mixed-
dominant coronary circulation
Table 71.2 Indications of 1. Suspected coronary artery disease

cardiac catheterization (a) Stable angina
(b) Unstable angina
(c) Abnormal stress test
2. Acute myocardial infarction
(a) ST segment elevation myocardial infarction
(b) Non-ST segment elevation myocardial infarction
3. History of resuscitated sudden cardiac death
4. Valvular heart disease
5. Congenital heart disease
6. Cardiomyopathy
7. Cardiac transplant (initial assessment or follow-up)
5. The balance and interrelation between myocardial oxygen demand and supply is
complex and is governed my multiple factors. The determinants of myocardial oxy-
gen demand include the heart rate, myocardial contractility, preload (end-diastolic
pressure or volume), afterload (arterial impedance), and muscle mass. The main
determinants of myocardial oxygen supply include coronary blood flow and arterial
oxygen content [7]. Coronary blood flow is directly proportional to coronary perfu-
sion pressure (aortic diastolic pressure—left ventricular end-diastolic pressure) and
inversely proportional to microvascular resistance (left ventricular wall tension). If
demand exceeds supply, myocardial ischemia ensues with its deleterious effects.
6. A significant coronary artery stenosis is defined as an angiographic stenosis of
70% or more in a major epicardial artery. An angiographic stenosis of 50% or more
71 Cath Report 399
Table 71.3 Contraindications 1. Renal failure (acute of chronic)

to cardiac catheterization
2. Active gastrointestinal bleeding
3. Bleeding diathesis
4. Severe anemia
5. Infection or fever
6. Recent stroke (less than 1 month)
7. Severe electrolyte imbalance
8. Severe uncontrolled hypertension
9. Severe decompensated heart failure
10. D
ocumented allergy (anaphylactoid reaction) to iodinated
contrast media
11. Uncooperative patient
12. Pregnancy
Table 71.4 Complications of cardiac 1. Stroke (<0.05%)

catheterizations (incidence)
2. Myocardial infarction (<0.07%)
3. Death (<0.2%)
4. Serious ventricular arrhythmia (<0.5%)
5. Contrast-induced nephropathy (incidence
varies based on baseline kidney function)
6. Contrast allergic reaction (<5%)
7. Vascular injury (<1%)
8. Access-related complications
(a) Pseudoaneurysm (0.5–9%)
(b) Arteriovenous fistula (0.2–2%)
(c) Arterial occlusion (0.8%)
(d) H
emorrhage (hematoma (5–23%);
retroperitoneal bleeding (0.1%))
(e) Infection (0.1%)
of the left main coronary artery is considered to be significant. In many instances,

the stenosis does not reach the cutoff of angiographic significance, and further test-
ing is needed. There are multiple modalities that can be used to assess the signifi-
cance of an intermediate angiographic stenosis including fractional flow reserve
(FFR) and intravascular ultrasound (IVUS). FFR is defined as the maximal blood
flow to the myocardium in the presence of a stenosis in the supplying coronary
artery, divided by the theoretical normal maximal flow in the same distribution [8].
A value of 0.80 or less indicates that a stenosis is hemodynamically significant and
thus may be a cause of ischemia and would benefit from revascularization [9].
IVUS can be used to image the coronary artery and better characterize a stenosis.
An area of less than 4.0 mm2 (this value varies based on the different studies) in an
epicardial artery or 6.0 mm2 in the left main coronary artery is considered to be
significant [10].
7. At the conclusion of cardiac catheterization, a comprehensive report is key to
help in the management of the patient and for future reference. Table 71.5
summarizes the key components of the report.
400 T.A. Rousan
Table 71.5 Components of the 1. Patient’s demographics

cardiac catheterization report
2. Operator(s)
3. Indication(s) of the procedure
4. Procedure(s) performed
5. Detailed narrative of the procedure including:
(a) Coronary anatomy
(b) Hemodynamics
(c) Description of intervention (if done)
(d) Medications used
• Sedation
• Anticoagulants
• Contrast media volume
6. Complications
7. Estimated blood loss
8. Final impression
9. Recommendations
References
1. Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, et al. ACC/AHA
guidelines for coronary angiography. A report of the American College of Cardiology/
American Heart Association Task Force on practice guidelines (Committee on Coronary
Angiography). Developed in collaboration with the Society for Cardiac Angiography and
Interventions. J Am Coll Cardiol. 1999;33(6):1756–824.
2. Angelini P. Normal and anomalous coronary arteries: definitions and classification. Am Heart
J. 1989;117(2):418–34.
3. Allwork SP. The applied anatomy of the arterial blood supply to the heart in man. J Anat.
1987;153:1–16.
4. Protocol for the Bypass Angioplasty Revascularization Investigation. Circulation.
1991;84(6):1–27.
5. Kern MJ. The cardiac catheterization handbook. 5th ed. Kern MJ, editor. Philadelphia:
Elsevier; 2011.
6. al. A-FMe. Arterial and venous access in the cardiac catheterization lab. 1st ed. M. A-F, editor.
New Jersey: Rutgers University Press; 2016.
7. Burkhoff D, Naidu SS. The science behind percutaneous hemodynamic support: a review and
comparison of support strategies. Catheter Cardiovasc Interv. 2012;80(5):816–29.
8. Pijls NH, De Bruyne B, Peels K, Van Der Voort PH, Bonnier HJ, Bartunek JKJJ, et al.
Measurement of fractional flow reserve to assess the functional severity of coronary-artery
stenoses. N Engl J Med. 1996;334(26):1703–8.
9. Kern MJ, Lerman A, Bech JW, De Bruyne B, Eeckhout E, Fearon WF, et al. Physiological
assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific
statement from the American Heart Association Committee on Diagnostic and Interventional
Cardiac Catheterization, Council on Clinical Cardiology. Circulation. 2006;114(12):1321–41.
10. Jasti V, Ivan E, Yalamanchili V, Wongpraparut N, Leesar MA. Correlations between fractional
flow reserve and intravascular ultrasound in patients with an ambiguous left main coronary
artery stenosis. Circulation. 2004;110(18):2831–6.
Chapter 72
CIED: Interrogation
Fig. 72.1

UTMB, Galveston, TX 77555, USA

DOI 10.1007/978-3-319-55862-2_72
402 R. Govindaraj
You are contacted about a 61-year-old female patient who is starting a course of
electroconvulsive therapy (ECT) for depression the following day. She has been a
nursing home resident for the prior 2 years, has not seen a cardiologist in that time,
and is a poor historian. Her comorbidities include hypertension and coronary artery
disease treated with angioplasty and stents 5 years ago. A chest X-ray was done
2 days prior to rule out pneumonia and is shown below. No other information is
available and there is no family.
1 . What does the X-ray demonstrate?

2. What needs to be done next?
3. What is the information that needs to be communicated with the CIED team?
4. What information does the CIED team communicate with the anesthesiologist?
5. Name some sources of electromagnetic interference (EMI).
6. What are the adverse effects of EMI on CIED?
7. Is it necessary to interrogate this device? If so, why?
8. What is the effect of ECT on CIED?
9. How is anesthesia managed?
72 CIED: Interrogation 403
Answers
1. The chest X-ray shows what appears to be a pacemaker device over the right
chest with a single lead in the right atrium. Pacemakers have one or two thin
leads, and the tip of the lead can be in the atrium, right ventricle, and/or left ven-
tricle as opposed to an ICD which will have two radiodense shock coils with one
in the SVC area and the second in the right ventricle.
2. Apart from the routine pre-anesthesia assessment, the CIED needs to be

addressed. ECT is an elective procedure and is a source of electromagnetic
interference (EMI). As per the guidelines, before an elective procedure, the
patient’s cardiologist, if known, is contacted for recommendations. If not known,
then the CIED team (cardiologist, cardiac electrophysiologist, device clinic
nurses and staff) from the same or a neighboring hospital is involved.
3. Information that need to be communicated with the CIED team [1, 4]:
(a) Intended surgical procedure and its anatomic location
(b) Location of the pulse generator
(c) Patient position during the procedure
(d) Type of electrocautery to be used whether monopolar or bipolar
(e) Presence of other sources of EMI
(f) Cardioversion or defibrillation during the procedure
(g) Venue for the procedure
(h) Postoperative plan: Day case/inpatient with telemetry bed
(i) Surgical procedure that can cause mechanical damage the leads to CIED
4. Information that the CIED team communicates with the Anesthesiologist [1, 4]:
(a) Details of the settings in the CIED and their functioning status.
(b) Date of last device interrogation (should be 6 months for AICD and 1 year
for pacemaker).
(c) Device type, manufacturer, and model
(d) Indication for device placement.
(e) Life of the battery.
(f) Age of the leads (should be >3 months).
(g) Current programming mode.
(h) Is the patient pacemaker dependent?
(i) Response of the device to magnet placement.
(j) Any alert status on the device.
(k) Pacing threshold on the last occasion.
(l) Individualized prescription or perioperative recommendation based on
patient information, device characteristics, and surgical factors.
5. Sources of EMI in a hospital setting [2]:
(a) Electrocautery (especially monopolar electrocautery).
(b) Evoked potential monitors.
(c) Nerve stimulators.
(d) Fasciculations.
404 R. Govindaraj
(e) External defibrillation.

(f) Magnetic resonance imaging (MRI).
(g) Radiofrequency ablation.
(h) Extracorporeal shock wave lithotripsy (ESWL).
(i) Electroconvulsive therapy (ECT).
(j) Other sources of interference include large tidal volumes and shivering.
Sources of EMI in daily life [3]:
(a) Digital music players
(b) Magnets in stereo speakers, headphones, toys, jewelries, and some clothes
(c) Metal detectors
(d) Tasers
(e) Cellular phones
(f) Portable home phones
(g) Auto engines
(h) Arc welding equipment
(i) Cockpits
(j) RFID equipment
(k) High-voltage power coils
6. Adverse effects of EMI [1, 4]:
(a) Damage to the CIED circuitry.
(b) Failure to pace, defibrillate, or both.
(c) Asynchronous pacing.
(d) Arrhythmia detection and AICD shocks.
(e) Rate-adaptive sensor activation.
(f) Electrical reset is a very rare occurrence that can happen when an energy
surge directly contacts the CIED generator and results in major hardware/
software failure. The reset mode is a safety backup, and depending on the
manufacturer, the device will go to a preset rate and then has to be repro-
grammed or replaced. The most common cause is therapeutic ionizing radia-
tion rather than electrocautery or cardioversion.
(g) EMI could produce enough current to flow from the generator to the pacing
electrode and damage the tissue-lead interface. Acute injury may lead to loss
of sensing and pacing.
7. For reasons mentioned in answer 4 and as there has not been a cardiology con-
sultation in 2 years, this device needs to be interrogated/checked.
8. In ECT, a brief electrical current (duration 1–2 s), although sometimes a more
prolonged stimulus, is delivered to the head triggering a seizure. Transient ECG
changes such as increased P wave amplitude, altered QRS shape, and ST-T wave
abnormalities may occur. The physiological stresses of ECT which include bra-
dycardia, hypotension followed by tachycardia, and hypertension may provoke
cardiac failure in patients with marginal cardiac function. With the brief shocks,
hemodynamically significant pacing inhibition is unlikely. Similarly, with ICDs
on standard programming, inappropriate shocks from this brief electrical therapy
72 CIED: Interrogation 405
are also unlikely. If a more prolonged stimulus is used, then there is a potential
for significant bradycardia and ICD shocks. A prolonged, intense seizure may
cause myopotential inhibition of the device in pacemaker-dependent patients [1].
9. Monitoring should include continuous ECG and continuous peripheral pulse. In
pacemaker-dependent patients, a magnet is placed over the generator, and in oth-
ers it is made available. For an AICD, a magnet is kept handy. It is also advisable
to know the ICD tachycardia detection rate and be prepared to use the magnet if
the heart rate, post-ECT, approaches that level. Temporary pacing systems and
external cardioversion devices should be made available. Postoperatively, if the
device was programmed pre-procedure, then the patient should not leave a moni-
tored area until reprogramming and device function have been restored.
Otherwise, recommendation for the follow-up assessment and reprogramming
needed after surgery and the timing of postoperative CIED evaluation are based
on the CIED recommendations [1, 4].
References
1. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society
of Anesthesiologists (ASA) expert consensus statement on the perioperative management of
patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and
patient management. Heart Rhythm. 2011;8(7):1114–54. PMID: 21722856. doi:10.1016/j.
hrthm.2010.12.023.
2. Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable
electronic devices. Br J Anaesth. 2011;107(Suppl 1):i16–26. doi:10.1093/bja/aer354.
3. Beinart R, Nazarian S. Effects of external electrical and magnetic fields on pacemakers and defi-
brillators: from engineering principles to clinical practice. Circulation. 2013;128(25):2799–809.
4. American Society of Anesthesiologists. Practice advisory for the perioperative management of
patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-
defibrillators. An updated report by the American Society of Anesthesiologists Task Force on
perioperative management of patients with cardiac implantable electronic devices.
Anesthesiology. 2011;114:247–61.
Chapter 73
Pressure–Volume Curves
Marcos E. Gomes
The image below is a snapshot of a pressure–volume curve of a patient on a

ventilator in the ICU.
1000
900
800 Beaking
700
600
500
400
300
200
100
–100
–20 0 20 40
Fig. 73.1 Dynamic pressure–volume curve showing “beaking”
M.E. Gomes, MD

DOI 10.1007/978-3-319-55862-2_73
408 M.E. Gomes
1 . What does pressure–volume (P–V) curve describe?

2. What is the goal of using P–V curves?
3. Does it improve outcome?
4. What are inflection points on the P–V curve?
5. How can one select appropriate PEEP?
6. What are the benefits of adequate PEEP?
73 Pressure–Volume Curves 409
Answers
1. Pressure–volume curves describe the mechanical behavior of the lungs and chest
wall during inspiration and expiration, giving the clinician a sense of the patient’s
lung and chest wall compliance (Fig. 73.1). It has been studied in many disease
states but most extensively in patients with ARDS. Different than static pressure–
volume curves, dynamic pressure–volume curves are obtained during actual gas
flow through the respiratory cycle, and add the variable of airway resistance to
the equation [1]. Many ICU and OR ventilators currently come with the built-in
capability to record constant flow dynamic pressure–volume curves.
2. The reason clinicians initiated the analysis of pressure–volume curves in differ-
ent disease scenarios was to assess individual patient’s respiratory mechanics
and possibly customize the ventilator settings according to their findings.
Ultimately, the goal was to optimize the ventilator settings for each patient and
improve compliance, thus protecting them from ventilator-induced lung injury.
3. Despite the initial enthusiasm and excitement that the use of P–V curves could
improve morbidity and mortality, it has not been borne out in studies. Difficulties
in measurements and improper use of the information may have been contribu-
tors to the lack of evidence and have raised questions about the clinical useful-
ness of this method. Since the development of new ventilators with the built-in
capacity to measure dynamic pressure–volume curves, promising research has
been ongoing and hopefully will result in the initially desired clinical outcomes.
4. Lower inflection point (LIP) represents the lung volume at which some alveoli
close (closing capacity). The upper inflection point (UIP) represents the start of
overdistension or the stop of recruitment. Both lower and upper inflection points
can be identified on a static respiratory system compliance curve (static pres-
sure–volume curve, Fig. 73.2). In theory, the lungs should be ventilated between
these two inflection points, although no outcome study has shown significant
benefit with this approach. In fact, studies have considered the LIP to be the
UIP
Volume
P-flex
Fig. 73.2 Graphic
representation of static LIP
pressure–volume curve
showing the P-flex point Pressure
410 M.E. Gomes
minimal pressure above which mechanical ventilation should take place in

ARDS. Similarly, LIP is proposed as the starting point for PEEP titration in that
setting. Gattinoni et al. suggested that the calculation of what they called “P-flex”
could result in the optimal PEEP for a given patient. P-flex is the intersection
point between the slopes of the low-compliance segment and high-compliance
segment (Fig. 73.2) and corresponds roughly to the lower inflection point. Static
pressure–volume curves are difficult to obtain in routine care; therefore, dynamic
compliance curves, available in most ventilators, are being used instead
(Fig. 73.1). Typically, inflection points are not easily identified on dynamic
curves, but when visible, the presence of a lower inflection point may indicate
insufficient PEEP because it represents a sudden increase in lung volume at a
certain pressure. In an optimized and recruited lung, achieving a given pressure
should not be required to open several alveoli at once, which makes LIP more
visible. Instead, alveoli should be gradually, slowly, and uniformly opened,
making LIP less visible. In Fig. 73.3, it is easier to identify the LIP and under-
stand how recruitment (change in tidal volume) only happens after 10 cmH2O of
pressure is applied to the airway. This high pressure requirement in order to
promote a change in volume implies insufficient PEEP. On the other hand, the
presence of an upper inflection point may indicate excessive PEEP, over infla-
tion, or overall excessive pressure in the respiratory system. The latter is termed
“beaking” (Fig. 73.1) [2, 3].
5. The importance of selecting an adequate level of PEEP stems from the goal of
not only lung recruitment for improved compliance and oxygenation but also
optimization of respiratory mechanics and avoidance of the development of
ventilator-induced lung injury. This type of injury can occur from different
mechanisms: barotrauma (high alveolar pressure), volutrauma (alveolar overdis-
1000 ml
Volume
0 ml
Fig. 73.3 Graphic
representation of a dynamic LIP
pressure–volume curve
showing easy visualization
of the LIP, suggesting 5 10 15 20 25
insufficient PEEP Pressure
73 Pressure–Volume Curves 411
tension), atelectotrauma (cyclic opening/closing of alveoli), and biotrauma

(release of inflammatory mediators). Ideal ventilator settings imply a combina-
tion of PEEP and small tidal volume that causes the least insult to the lung. The
only ventilator setting that has been associated with improved outcome is avoid-
ing a plateau pressure above 30 cmH2O. Stepwise algorithms for PEEP incre-
ments and other methods suggesting specific PEEP values for certain clinical
scenarios have been questioned by investigators, mostly due to lack of benefit in
survival statistics. Examples of such methods are staircase recruitment maneu-
ver, adjusting according to FiO2 requirements, adjusting higher than the lower
inflection point on a pressure–volume curve, adjusting to maximize static com-
pliance (TV/Pplat-PEEP), adjusting to maintain plateau pressure of 28–30 cmH2O,
and adjusting by measurement of transpulmonary pressures with esophageal bal-
loon, titration to lowest intrapulmonary shunt (highest SvO2) [3].
6. Adequate PEEP increases FRC, recruits atelectatic and collapsed lung areas, opti-
mizes ventilation/perfusion ratio, reduces right to left shunt, and avoids end-
expiratory alveolar collapse. Potential disadvantages are reduction of cardiac
output by diminished venous return, reduction of renal/hepatic/splanchnic circula-
tions, overdistension/rupture of alveoli, and increase of intracranial hypertension.
References
1. Jonson B, et al. Pressure–volume curves and compliance in acute lung injury. Am J Respir Crit
Care Med. 1999;159:1172–8.
2. Harris S. Pressure–volume curves of the respiratory system. Respir Care. 2005;50(1):78–99.
3. Pestana D, et al. Adjusting positive end-expiratory pressure and tidal volume in acute respira-
tory distress syndrome according to the pressure–volume curve. Acta Anaesthesiol Scand.
2003;47:326–34.
Part V
Conceptual Images
Chapter 74
Dissociation Curve
100%
Left shift
80%
Percent saturation
60%
Right shift
40%
20%
0%
0 10 20 30 40 50 60 70 80 90 100
P50 = 26.5 mmHg PO2 (mm Hg)
Fig. 74.1
1 . What does the above image in Fig. 74.1 depict?

2. What is P50?
3. How do you determine the oxygen content?
4. At what point can cyanosis be detected?
R. Ganta, MD, FRCA (*)


DOI 10.1007/978-3-319-55862-2_74
5. What variables shift the curve to the left and to the right and how does that affect
oxygen transport?
6. What is Fick equation?
7. What is Bohr effect?
8. What is Haldane effect?
74 Dissociation Curve 417
Answers
1. This is the oxyhemoglobin dissociation curve which demonstrates the mea-
sured relationship between the partial pressure of oxygen (PO2) on the
x-axis and the oxygen saturation (SaO2) on the y-axis. The graph is sigmoid
or S shaped. Initially, in the steep portion of the curve, the hemoglobin’s
affinity for oxygen increases with maximum O2 loading, and then the graph
levels off around PO2 of 60 mmHg with little change even when the PO2 is
increased significantly.
2. P50 is the oxygen tension at which hemoglobin is 50% saturated which is typi-
cally around 26 mm Hg and is a measure of hemoglobin’s affinity for oxygen.
3. The blood oxygen content (CaO2) is calculated as the sum of the oxygen bound
by hemoglobin (Hb) and the oxygen dissolved in the plasma.
O2 content = oxygen bound to hemoglobin + oxygen dissolved in blood.
CaO2 = (1.39 × Hb × SaO2/100) + (PaO2 × 0.003).
For example, if Hb is 15 g/dL, SaO2 is 100%, and PaO2 is 100 mm Hg, then
CaO2 = (15 × 1.39 × 1) + (100 × 0.003)
= 20.85 + 0.3
= 21.15 mL/dL.
Increased O2 affinity (left shift)

100%
Hemoglobin F
CO2
pH
80% temperature
Percent saturation
Decreased O2 affinity (right shift)

60%
Hemoglobin A
CO2
pH
40% temperature
20%
0%
0 10 20 30 40 50 60 70 80 90 100
P50 = 26.5 mm Hg
PO2 (mm Hg)
Fig. 74.2 Factors that shift the oxyhemoglobin dissociation curve

Left shift Right shift

Alkalosis Acidosis
Hypothermia Hyperthermia
Decreased 2,3-DPG Increased 2,3-DPG
Abnormal hemoglobin (fetal) Abnormal hemoglobin
Carboxyhemoglobin Increased CO2
Methemoglobin
4. Cyanosis can be detected at an SaO2 of approximately 80%. Clear cyanosis can

appear at an SaO2 of approximately 67%. The appearance is also affected by skin
perfusion, skin pigmentation, and hemoglobin concentration.
5. Variables shifting the oxyhemoglobin dissociation curve.
Diseases or other conditions (Fig. 74.2) could shift the dissociation curve either to
the right (increasing P50) or to the left (decreasing P50). A rightward shift indicates
that a higher PO2 is required for the same 50% Hb saturation. This means lower
oxygen affinity. This is seen in the peripheral tissues where oxygen “unloading”
happens. Conversely, a leftward shift increases hemoglobin’s affinity for oxygen
[1, 2]. This is seen in the lungs where oxygen “loading” happens.
Five variables affect tissue oxygenation [3]:
1. Hemoglobin concentration.
2. Hemoglobin oxygen saturation (SaO2).
3. Hemoglobin affinity for oxygen (P50).
4. Cardiac output.
5. Tissue oxygen consumption.
6. The Fick equation expresses the relationship between oxygen consumption
(VO2), arteriovenous oxygen content difference (CaO2 − CvO2), and cardiac out-
put (QT):
Fick equation: VO2 = QT × (CaO2 − CvO2)
CaO2 = arterial oxygen content = 20 m/dL
CvO2 = mixed venous oxygen content = 15 mL/dL
CaO2 − CvO2 = normal extraction for oxygen = 5 mL/dL
The arteriovenous difference is a good measure of the overall adequacy of
oxygen delivery.
With a normal oxygen consumption of approximately 250 mL/min and a car-
diac output of 5000 mL/min, the normal arteriovenous difference by this equa-
tion is 5 mL O2/dL blood. Note that the normal extraction ratio for oxygen
(CaO2 − CvO2)/CaO2 is 5 mL/20 mL or 25%; thus, the body normally consumes
only 25% of the oxygen carried on hemoglobin.
7. The Bohr effect is a physiological phenomenon, and it describes the inverse rela-
tionship of the hemoglobin’s affinity for oxygen to acidity and to the concentra-
tion of carbon dioxide. An increase in CO2 (which reacts with water to form
carbonic acid) increases acid and lowers pH which leads to O2 unloading by
74 Dissociation Curve 419
hemoglobin. This effect facilitates the oxygen transport as hemoglobin binds to

oxygen in the lung (less CO2 and acid) and releases it in the tissues (more CO2
and acid).
8. Oxygenated hemoglobin has a reduced capacity for CO2, and conversely reduced
Hb has an increased capacity. This is known as Haldane effect, which is of physi-
ologic importance in governing CO2 transport [4]. Reduced Hb in the tissues
facilitates CO2 “pickup,” and in the oxygen-rich capillaries of the lung, this prop-
erty promotes dissociation of CO2 from the Hb and thereby elimination.
References
1. Morgan GE Jr. Clinical anesthesiology. 3rd ed. New York: Lange Medical Books/McGraw-Hill
Medical Publishing Division; 2002.
2. Collins J-A, Rudenski A, Gibson J, et al. Relating oxygen partial pressure, saturation and con-
tent: the haemoglobin-oxygen dissociation curve. Breathe. 2015;11:194–201.
3. Faust RJ. Anesthesiology review. 4th ed. New York: Churchill Livingston; 2014.
4. Linda CS. Physiology. 5th ed. Philadelphia: Saunders/Elsevier; 2014.
Suggested Reading
Lumb AB. Nunn’s applied respiratory physiology. 5th ed. Boston: Butterworth-Heinemann; 2000.
West JB. Respiratory physiology—the essentials. 6th ed. Philadelphia: Lippincott Williams &
Wilkins; 2000.
Chapter 75
Frank-Starling Curve
Deepinder Mann
Increased
inotropy
B
A2
Baseline
A
Cardiac output A1
C
Decreased
inotropy
D D2
Failing
ventricle
Preload
Fig. 75.1
Depicted above is a family of cardiac function curves representing a ventricle

under various conditions. Point A represents baseline cardiac function with normal
preload; points A1 and A2 show states of decreased and increase preload, respec-
tively. After reviewing this figure, please answer the following questions.
D. Mann, DO
301 University Blvd, Galveston, TX 77555, USA

DOI 10.1007/978-3-319-55862-2_75
422 D. Mann
Questions
1. What is Frank-Starling mechanism? Intracellularly, how can it cause a more
forceful contraction?
2. For the Frank-Starling curves depicted in Fig. 75.1, what are other parameters
that can be substituted for the cardiac output label on the y-axis?
3. What parameters can replace preload on the x-axis?
4. What physiological changes might cause the system to move from:
(a) Point A to A2
(b) Point A to A1
(c) Point A to B
(d) Point A to D
5. Graphically, which direction(s) will adding a beta-blocker shift a ventricle on
Fig. 75.1?
6. Following a premature ventricular contraction in a normal ventricle, how will the
force generated by the next contraction change?
7. After a single bolus dose of phenylephrine, what effect can be expected on car-
diac output?
8. If starting at point D2 on Fig. 75.1, would a fluid bolus be expected to increase
cardiac output? If not, what interventions could increase output?
75 Frank-Starling Curve 423
Answers
1. The Frank-Starling mechanism describes a relationship where increasing ven-
tricular filling increases cardiac output. Increased preload increases sarcomere
stretch inside cardiac myocytes which generate more force during contraction
and thereby allows the heart to eject more blood. However, there is a limit to
which this relationship can be maintained. In failing ventricles, overstretch can
limit or decrease cardiac output. In these cases, reducing myocyte stretch to a
more optimal length can improve overall cardiac function. Although the cellular
basis has not been definitively determined, the most widely accepted mechanism
is that as sarcomeres are stretched, there is a length-dependent reduction in the
spacing between thick and thin filaments. As the filaments are stretched and get
closer together, tropomyosin on the thin filament becomes more sensitive to cal-
cium. When contraction occurs, the sarcoplasmic reticulum releases calcium.
The more sensitive tropomyosin now allows more actin-myosin cross-bridges to
form yielding greater force generation [1–3].
2. Multiple measurements have been developed to describe how well or efficiently
a cardiac ventricle can pump. Essentially any measure that varies directly to
cardiac output can be substituted on the y-axis. Some of the more popular met-
rics include venous return, stroke volume, cardiac index, and stroke work.
3. Measurements that are essentially synonyms for preload on a cardiac function
curve include end-diastolic volume, end-diastolic pressure, right atrial pressure,
and pulmonary capillary wedge pressure.
4. Cardiac output can change by moving between different points on a single curve
or changing to different curves. Physiologic changes altering preload can cause
movement along the same cardiac curve, while changes in inotropy can cause
shifts to different curves. On the steep, positively sloped portion of a cardiac
function curve (sometimes called the preload dependent segment), cardiac out-
put increases as ventricular stretch increases. If preload continues to increase, the
point of overstretch is reached and eventually passed. Cardiac output plateaus
and then begins to fall. The plateaued segment is sometimes called the preload
independent portion.
(a) Moving from A to A2 shows an increase in cardiac output that is the result
of increasing preload. Fluid resuscitation, passive leg raise, and decreasing
PEEP are examples of interventions that can cause such a change.
Point A2 also represents the end of the preload-dependent and the start of
the preload-independent portion of the cardiac function curve. Cardiac out-
put levels off beyond A2 and eventually drops as overdistension is reached.
(b) Decreasing preload shifts the systems leftward. As ventricular filling

approaches 0, so does the cardiac output. Physiologically, anything that
decreases venous return will cause a move from A to A1. Examples include
hemorrhage, dehydration, obstructive shock, and high levels of PEEP.
(c) With preload being constant, moving from point A to B requires either an
increase in cardiac inotropy or a decrease in afterload. Catecholamines (such
424 D. Mann
as epinephrine or dobutamine) that stimulate beta-1 adrenergic receptors in

the heart can cause a more forceful contraction by a stretch-independent
mechanism. Increasing intracellular calcium levels can also increase inot-
ropy independent of preload. Administering calcium or a phosphodiesterase-
3 inhibitor (PDE3), like milrinone, is a clinical way of achieving this.
Afterload is the pressure the ventricle must overcome in order to eject
blood. Therefore, reducing afterload will also increase cardiac output inde-
pendent of myocyte stretch. Clinically there are many pharmacologic agents
that decrease afterload. Example drug classes include the following: nitric
oxide inducers (such as nitroglycerin, nitroprusside, and isosorbide), alpha-1
adrenergic antagonists (such as prazosin), beta-2 adrenergic agonists, and
PDE3 inhibitors.
Exercise, through multiple mechanisms including beta-1 and beta-2
receptor agonism, increases preload and decreases afterload simultaneously.
(d) Shifting to a lower cardiac function curve, such as from A to D, indicates
that inotropy has dropped significantly independent of stretch. A clinical
example of this is myocardial infarction causing myocyte damage or death.
Fewer sarcomeres will be present, so less force will be generated. The result
is a downward shift in the cardiac function curve as well as a decreased slope
in the preload dependent portion.
5. Beta-1 adrenergic antagonists decrease cardiac chronotropy and inotropy. The
overall effect will be a shift toward the right and toward a lower curve. Depending
on the starting point, this can result in an increase or decrease in cardiac output:
(a) Pure inotropy reduction will lead to less cardiac output at any fixed preload.
Graphically, this will be a shift to a lower curve (such as from A to C).
(b) However, there are situations when beta-1 antagonism can yield a net

increase in cardiac output. If the ventricle is still in the preload-dependent
segment of a given curve, a lower heart rate can allow for more time in dias-
tole and therefore more filling. Also, beta-blockers can calm some cardiac
arrhythmias. Better atrial-ventricular coordination preserves the function of
atrial kick, which increases ventricular filling.
(c) If starting at point A1, more preload will shift the ventricle toward point
A. Inotropy reduction will drop the ventricle to a lower curve. Will it be as
low as point C (or lower)? It depends on how sensitive the myocytes are and
how much they are relying on beta stimulation in their current state. The
final position will be lower than point A, but the net result could be a higher
cardiac output than the original A1 starting point.
6. Following a PVC, there is a longer than usual time for diastole, more ventricular
filling and myocyte stretch. More force will be generated during the next con-
traction, and the extra blood that entered the ventricle will be ejected.
7. Phenylephrine causes vasoconstriction via alpha-1 adrenergic agonism. This can
cause an increase in afterload, which can decrease cardiac output. However,
vasoconstriction can also shift pooled blood from peripheral and splanchnic
75 Frank-Starling Curve 425
venous beds into central circulation; this can increase preload. The resulting net
effect is controversial and may depend on the starting point on the cardiac func-
tion curve. Porcine models suggest that starting on the steep (preload dependent)
part of a cardiac function curve causes a net increase in cardiac output [4]. While
giving phenylephrine on the flatter (preload independent) part of the cardiac
function curve causes a net decrease in cardiac output.
8. At point D2, the ventricle is overdistended and in failure. Additional fluid will
not improve stroke volume. Decreasing myocyte stretch so that sarcomeres can
get closer to their optimal length would be more helpful. Diuretics or hemocon-
centration is more appropriate; the result will be moving from point D2 toward
D. Adding inotropic support or significantly decreasing afterload with vasodila-
tors can also improve cardiac output. These changes can shift the entire curve
closer to curve C.
References
1. Hall J. Cardiac muscle: the heart as a pump and function of the valves. In: Hall J, editor. Guyton
and Hall textbook of medical physiology. 13th ed. Philadelphia: Elsevier; 2016. p. 245–258
2. Noble MI. The Frank—Starling Curve. Clinical Science. 1978 Jan 1;54(1):1–7.
3. Kobirumaki-Shimozawa F, Inoue T, Shintani SA, et al. Cardiac thin filament regulation and the
Frank–Starling mechanism. J Physiol Sci. 2014;64:221.
4. Maxime C, Zhongping J, et al. Effects of phenylephrine on cardiac output and venous return
depend on the position of the heart on the Frank-Starling relationship. J Appl Physiol.
2012;113(2):281–9.
Chapter 76
West’s Zones
Fig. 76.1
Upper Zone 1
zone PA > Pa > Pv
Middle Zone 2
zone Pa > PA > Pv
Zone 3
Lower
Pa > Pv > PA
zone
1 . What does the above image depict, and what are the pressure profiles in the zones?
2. Describe the factors that affect pulmonary vascular resistance [1].
3. What are the clinical implications of the zones of west?
A.S. Madamangalam, MBBS, MD (*)


DOI 10.1007/978-3-319-55862-2_76
428 A.S. Madamangalam and T.D. Raj
Answers
1. The image above depicts West’s zones of the lung which describe the effects of
gravity and the differing pressures within the alveoli, pulmonary arteries, and
veins on ventilation and perfusion.
When one views the vascular resistance in an upright individual, three lung
perfusion zones are identified. The hydrostatic pressure in the pulmonary vascu-
lar system of an upright individual varies from the apex to the base of the lungs
and therefore the perfusion characteristics vary as well. Pulmonary arterial pres-
sure is 5 mmHg at the apex and 25 mmHg at the base, and pulmonary venous
pressure is −5 mmHg at the apex and +15 mmHg at the bases.
Zone 1 is not seen in normal lungs. It may be seen in positive pressure ventila-
tion or after hemorrhage. Alveolar pressure exceeds pulmonary vascular pres-
sures. Hence the pulmonary vessels are collapsed, and no flow occurs causing
alveolar dead space.
Zone 2 occurs about 3 cm above the level of the heart. Pv (venous pressure) is
subatmospheric, and therefore the higher PA (aveolar pressure) tends to compress
the vessels on the venous side of the pulmonary circulation. Blood flow is driven
by the gradient (Pa = arterial pressure) Pa − PA. Flow occurs in pulses-starling
resistor or waterfall effect.
Zone 3 is in the bottom of the lungs below the level of the heart. When the
pulmonary arterial and venous pressures are greater than the alveolar pressure,
the alveolar pressure has no effect on circulation [2].
2. The pulmonary vascular circuit is a very low-resistance system. Many factors
contribute to the control of this resistance. The largest contributor to the pulmo-
nary vascular resistance (PVR) on the arterial side is from the capillaries. These
vessels, at their most diminutive size are very thin walled and can therefore be
affected by pressure exerted on them, either intra or extravascular pressure. The
extravascular pressures are alveolar and interstitial pressures in the lung. PVR is
lowest at functional residual capacity (FRC); at high lung volumes, the intra-
alveolar vessels are compressed, and at low lung volumes, the extra-alveolar
vessels are compressed.
Large changes in cardiac output produce only small changes in PVR due to
recruitment and distension of pulmonary vessels. Both acute and chronic lung
diseases increase PVR. Other factors that influence PVR include autonomic fac-
tors (alpha-adrenergic, vasoconstriction; beta-adrenergic, vasodilatation) and local
metabolic factors (vasodilators such as Nitric Oxide (NO) and prostacyclin; vaso-
constrictors such as serotonin, histamine, noradrenaline and hypercapnia). Low
PAO2 produces vasoconstriction (HPV-hypoxic pulmonary vasoconstriction).
3. During measurement of the pulmonary wedge pressure, an assumption is made
that there is a clear unobstructed communication between the pulmonary artery
and veins, as the wedge pressure is measured from the right side of the heart. For
the wedge pressure to be an accurate reflection of the left atrial pressure, the
measurement needs to be performed in west’s zone 3. If the wedge pressure is
measured in west’s zone 2, then the values reflect the pressure in the alveoli or
extra-alveolar vessels and not the actual pulmonary venous pressure.
76 West’s Zones 429
References
1. West, J.B. Ventilation/blood flow and gas exchange. 1st ed. Oxford: Blackwell Scientific
Publications; Philadelphia: Lippincott; 1990. (5th ed., 1965).
2. West J, Dollery C, Naimark A. Distribution of blood flow in isolated lung; relation to vascular
and alveolar pressures. J Appl Physiol. 1964;19:713–24.
Chapter 77
Spirometry
Daniel A. Biggs
The following are the results of spirometry testing performed on a patient:
Volumes Capacities
2 8
4 4
Fig. 77.1 Questions 1–8
D.A. Biggs, MD, MSc


DOI 10.1007/978-3-319-55862-2_77
432 D.A. Biggs
Volumes Capacity
Inspiratory
reserve
volume
Inspiratory
capacity
Vital
capacity
Total
Tidal lung
volume capacity
Expiratory
reserve
volume
Functional
residual
capacity
Residual Residual
volume volume
Fig. 77.2 Spirometry with labels
Questions
1–8. Label Fig. 77.1 and define each volume and capacity.
9. Which lung volume cannot be measured by spirometry and how can it be
obtained?
10. What is the significance of the FRC and what factors influence it?
11. Define closing volume and closing capacity and what is their importance?
77 Spirometry 433
Answers
1. Inspiratory reserve volume (IRV)—maximum amount of air that can be inhaled
after normal tidal inhalation [1].
2. Tidal volume (TV)—amount of air moved during breathing at rest [1].
3. Expiratory reserve volume (ERV)—maximum amount of air that can be exhaled
after normal tidal exhalation [1].
4. Residual volume (RV)—amount of air in the lungs after complete expiration [1].
5. Inspiratory capacity (IC)—TV + IRV [1].
6. Functional residual capacity (FRC)—ERV + RV—the volume at the end of
tidal expiration when the chest is at rest and inward lung and outward chest wall
elastic recoil forces are equal [1].
7. Vital capacity (VC)—IRV + TV + ERV—total amount of air that can be moved
into the lungs [1].
8. Total lung capacity [1].
9. The residual volume (RV) cannot be measured by spirometry. Radiographic
planimetry, nitrogen washout, helium dilution, and body plethysmography may
all be used to calculate residual volume [1].
10. FRC acts as the O2 reserve when a patient becomes apneic. Factors that decrease
the FRC include pregnancy, obesity, supine position, restrictive lung disease,
general anesthesia, and muscle relaxants [2].
11. Closing volume (CV)—amount of gas remaining in the lungs, above the resid-
ual volume, when the bronchioles begin to collapse during expiration.
Closing capacity (CC)—CV + RV [1].
Fig. 77.3 Closing volume

and capacity [3]
Total lung
capacity Airway closure begins
Closing volume
Functional
residual Closing capacity
capacity Residual volume
434 D.A. Biggs
CV increases with increasing age, lung disease, and supine positioning. Airway
closure usually occurs first in the dependent portions of the lungs. The closing
capacity is usually less than FRC. In some patients, the closing volume can
exceed the FRC. This produces a V/Q mismatch and may cause hypoxemia.
Closing volume is measured by nitrogen washout.
References
1. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R. Clinical anesthesia.
7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.
2. Miller RD. Miller’s anesthesia. 8th ed. Philadelphia: Elsevier Saunders; 2015.
Chapter 78
Autoregulation Curves
80
Autoregulation zone
Cerebral blood flow (ml/100mhg/min)
70
constant cerebral perfusion
60
Below
autoregulation zone
50 ischemia Above
autoregulation zone
40 vasogenic edema
30
30
10
0
0 50 100 150 200
Blood pressure (mmHg)
Fig. 78.1
A.S. Madamangalam, MBBS, MD


DOI 10.1007/978-3-319-55862-2_78
1 . What does the above graph (Fig. 78.1) depict?

2. Define cerebral perfusion pressure, and how is it derived?
3. How is cerebral autoregulation achieved during normal states?
4. What are the conditions in which this balance of cerebral perfusion is upset?
78 Autoregulation Curves 437
Answers
1. The image depicts a normal cerebral autoregulation. The brain maintains a con-
stant blood flow to itself despite changes in cerebral perfusion pressure. The
ability of the organ to achieve this is called cerebral autoregulation.
2. Cerebral perfusion pressure (CPP) is defined as the difference between the mean
arterial pressure (MAP) and intracranial pressure (ICP) {CPP = MAP − ICP}.
If the central venous pressure (CVP) is greater than the ICP, then
CPP = MAP − CVP. The cerebral flow is then modulated by the greater of the
two pressures—CVP or ICP. The classic understanding is that autoregulation is
maintained between MAPs of 50–150 mmHg [1]. As the ICP is generally in the
range of 5–12 mmHg, MAP then becomes the main determinant of the cerebral
blood flow. This can be affected by various factors such as sympathetic neural
activity, the renin-angiotensin system, and changes in the arterial carbon dioxide
partial pressure.
3. The primary mechanism of cerebral autoregulation is not clearly defined.

Currently, it is believed to result from the interplay between the myogenic and
metabolic responses of the vessels. The perivascular nerves and the vascular
endothelium are also said to impact autoregulation.
4. Autoregulation is disrupted in both chronic and acute disease states. Severe head
injury or acute ischemic stroke may disrupt autoregulation and expose the brain
to further ill effects of altered blood pressure. Similarly, space-occupying lesions
may impair autoregulation around the mass. Asphyxia and hypoxic injury as well
as infections can disrupt the phenomenon [2].
In chronic hypertension the autoregulatory curve is right shifted toward higher
blood pressure. But in acute hypertension, there is failure of the autoregulation.
Microvascular disease such as microangiopathy of long-standing diabetes can
lead to a chronic loss in autoregulation.
Several anesthetic drugs can affect autoregulation. Inhaled anesthetics tend to
impair autoregulation, and the degree of the effect is dependent not only on the
agent but also the partial pressure of the drug. Among the inhaled anesthetic agents,
sevoflurane appears to preserve autoregulation at all doses [3]. In healthy individu-
als, propofol and remifentanil tend to maintain cerebral autoregulation [4].
References
1. Paulson OB, et al. Cerebral autoregulation. Cerebrovasc Brain Metab Rev. 1990;2(2):161–92.
2. Dagal A, et al. Cerebral autoregulation and anesthesia. Curr Opin Anaesthesiol. 2009;22(5):547–
52. doi:10.1097/ACO.0b013e32833020be.
3. Pires PW, et al. The effects of hypertension on the cerebral circulation. Am J Physiol Heart Circ
Physiol. 2013;304(12):h1598–614. doi:10.1152/ajpheart.00490.2012.
4. Morgan EG, Mikhail SM. Clinical anesthesiology. In: Neurophysiology and anesthesia. 4th
ed. New York: McGraw-Hill; 2006.
Chapter 79
Anesthesia Circuits
Alberto J. de Armendi
Breathing System Questions

1 . Identify the breathing systems labeled above as 1–5.
2. By what names are Mapleson systems also known as?
3. Name the components of the Mapleson breathing system?
4. What are the advantages of the Mapleson A system and how does it work?
5. Are there disadvantages of the Mapleson A system?
6. What are the advantages and disadvantages of the Mapleson D system?
7. What is the hardest system to scavenge anesthetic gases?
8. Are there advantages and disadvantages of the Mapleson F system?
9. What are the advantages and disadvantages of the circle system?
A.J. de Armendi, MD, PhD, MBA

Sciences Center, 750 NE 13th Street, Suite 200, PO Box 5318, Oklahoma City,
OK 73104, USA

DOI 10.1007/978-3-319-55862-2_79
440 A.J. de Armendi
APL valve
FGF
1
Bag Mask
APL FGF
2 Bag
Mask
FGF
Mask
FGF
APL
4 Valve Bag
Mask
FGF
CO2
5 canister
Patient
Ventilator
Pressure release valve
Fig. 79.1 Breathing systems

79 Anesthesia Circuits 441
Answers/Discussion
1. They are Mapleson systems A, D, E, and F and the circle system (see Fig. 79.1)
[1–5].
2. Mapleson systems are also known as carbon dioxide washout [depend on fresh gas
flow (FGF) to wash out carbon dioxide] or flow-controlled breathing systems.
3. Components of the Mapleson breathing systems are (1) fresh gas flow, (2) breathing
tube (corrugated for flexibility and kinking resistance), (3) mask, (4) reservoir bag
(antistatic or low charged, monitors respiration, accommodates fresh gas flow dur-
ing expiration, protects from excessive pressure generation), (5) connectors
(increase dead space and resistance), (6) adaptors, and (7) adjustable pressure-lim-
iting (APL) expiratory valve (spring-loaded adjustable one-way valve, and also
known as pop-off valve, exhaust valve, overspill valve, pressure relief valve, scav-
enger valve, and expiratory valve).
4. The Mapleson A system is best for spontaneous respiration with the advantage of
less waste of fresh gas flows. The APL valve is open during spontaneous respira-
tion. Fresh gas flows equaling minute ventilation (75–100 ml/kg/min) are required
for maximal efficiency. Higher fresh gas flows than minute ventilation will force
alveolar gas to be vented, whereas lower fresh gas flows than minute ventilation
will allow for rebreathing of alveolar gases to occur. Once the reservoir bag is full
of fresh gas flow, the APL valve opens and the alveolar gas is vented [3].
5. The Mapleson A system should not be used for controlled ventilation. If the
Mapleson A breathing systems are used during controlled ventilation, the APL
valve is partially closed. Disadvantages of the Mapleson A system include (1)
carbon dioxide must be monitored when used for controlled ventilation, (2) more
waste of fresh gas flows, (3) scavenging is poor as the APL valve is near the
patient, and (4) more operating room/atmospheric pollution [3].
6. In the Mapleson D breathing system, during spontaneously breathing with the
APL valve open, the patient inhales mostly fresh gas flows delivered from the
anesthesia machine. During exhalation, alveolar gases are vented at the APL
valve. During controlled ventilation, the APL valve is partially closed, fresh gas
flows are set at 1.5–2 times the minute ventilation, and alveolar gases are vented
during inspiration as the reservoir bad is squeezed or the ventilator is activated
(rates of 12–14 breaths/minute). The major disadvantage of the Mapleson D over
the Mapleson A breathing system is that the fresh gas flows are set higher in
order to avoid rebreathing of alveolar gases. Therefore, the Mapleson D system
is less efficient (more costly) and causes more operating room/atmospheric pol-
lution [3].
442 A.J. de Armendi
7. With an open end, the Mapleson E system is the most difficult for scavenging
gases. The FGF depends not only on the patient’s respiratory rate and minute
volume but also on the capacity of the expiratory limb. If the latter is equal to the
tidal volume, then an FGF rate of 2.5 times the patient’s MV is sufficient. If the
capacity is less, then the FGF should be increased.
8. The Mapleson F, also known as the Jackson Rees modification, helps monitor
and assists ventilation. Major advantages of the Mapleson F breathing system are
(1) can be used in neonates, (2) inexpensive, (3) lack of barotrauma potential,
and (4) low resistance without any valves. During spontaneous respiration, the
reservoir bag is left open and serves as a monitor by demonstrating breathing.
During controlled ventilation, the open end of the reservoir bag is occluded and
squeezed. Disadvantages of the Mapleson F system include (1) not efficient as
high fresh gas flows are needed (1.5–3 times the minute ventilation), (2) increased
rebreathing from the mixture of fresh gas flows and exhaled gas collection in the
reservoir bag, (3) loss of heat, (4) lack of humidification, and (5) greater operat-
ing room/atmospheric pollution.
9. Advantages of the circle breathing system include (1) absorber and absorbent
(carbon dioxide absorption, less fresh gas flows, diffuse rather than columnar gas
spread, less turbulence, reduced resistance, bypass mechanism allows for carbon
dioxide accumulation, and less canister dust), (2) improved economy, (3) less
operating room and atmospheric pollution, (4) conservation of heat, (5) conser-
vation of moisture, (6) controlled use of flammable gases/vapors, and (7) con-
stant inhaled gas mixture deliveries (oxygen and gas analyzers). Disadvantages
of the circle breathing system include (1) toxic product production (compound A
due to CO2 absorbent which can be reduced with calcium hydroxide free soda
lime), (2) carbon monoxide production from desiccated soda lime, and (3) unidi-
rectional valve problems (resistance, sticking, wetting, electrostatic, leaks).
References
1. Mapleson WW. The elimination of rebreathing in various semiclosed anaesthetic systems. Br

J Anaesth. 1954;26:323–32.
2. Dorsch JA, Dorsch SE. Mapleson breathing system. In: Understanding anaesthesia equipment.
5th ed. New Delhi: William and Wilkins; 2008. p. 209–21.
3. Jonsson LO, Zetterstrom H. Fresh gas flow in coaxial Mapleson A and D systems during spon-
taneous breathing. Acta Anaesthesiol Scand. 1986;30:588–93.
4. http://www.anaesthesia.med.usyd.edu.au/resources/lectures/gas_supplies_clt/breathingsys-
tems.html.
5. Kaul TK, Mittal G. Mapleson’s breathing systems. Indian J Anaesth. 2013;57(5):507–15.
doi:10.4103/0019-5049.120148.
Chapter 80
Flowmeters
John B. Carter
Fig. 80.1 Anesthesia flowmeter
Liters/minute
0.8
0.6
0.4
1 . What are the physical principles of the anesthesia flowmeter?

2. Describe the components of the flowmeter assembly.
3. What are the concerns about flowmeter leaks?
4. List the causes of inaccuracy in flowmeters.
J.B. Carter, MD

DOI 10.1007/978-3-319-55862-2_80
444 J.B. Carter
Answers
1. Operating principles of the conventional flowmeter
(a) The anesthesia flowmeter is described as a constant pressure, variable orifice
flow meter. Newer anesthesia machines may have electronic flowmeters;
however, auxiliary O2 flowmeters of the conventional type may be present.
(b) The glass flowmeter or Thorpe tube is tapered, smaller at the bottom and
wider at the top (Fig 80.1). Gas flows under the float raising it until the bob-
bin or ball stops as its weight is supported by the pressure difference above
and below.
(c) Flow tubes are specific to the physical characteristics of each gas.
(d) Gas flow at low rates is laminar and viscosity of the gas is important. Laminar
flow is predicted by the Hagen-Poiseuille formula:
π Pr 4
Q=
8η l
where Q is flow, ∆P is the pressure gradient (unchanged), R is the radius
(variable as tube widens), ῃ is the viscosity (characteristic of each individual
gas), and l is the length of the tube.
At higher flow rates, flow becomes turbulent as the Reynolds’ number
exceeds 2000. With turbulent flow, the density becomes more important than
viscosity:
υρ r
Reynolds number =
η
υ, fluid linear velocity; r, radius; ρ, density; and ῃ, viscosity [1]
(e) Floats are meant to rotate, minimizing friction.
2. Components of flowmeter assembly
(a) The flow control valve is manually controlled, turning counterclockwise. A
needle valve disengages releasing the gas flow into the flowmeter. All gas
flow from the flowmeter distally to the common gas outlet is in the low pres-
sure circuit of the anesthesia machine.
(b) The oxygen flow control is physically different; it is larger, has a fluted edge,
and is color coded.
(c) If a single gas has two flow tubes, they are placed in series and controlled by
one valve.
(d) The flow rate is read at the top of a bobbin and the middle of a ball. Float
stops at the top and bottom of the tube to keep the float visible at high flows,
giving an indication when flow is turned off, and prevent the float from
becoming stuck at the top of the gas outlet.
(e) Flowmeter scales are individually calibrated to the specific float and are gas
specific. The tube, float, and scale are an inseparable unit [2].
80 Flowmeters 445
3. Leaks
(a) Flowmeter leaks are downstream from the oxygen failure cutoff valve or
“fail safe” valve. Hypoxic gas mixtures from a leak in the flowmeter may be
detected by the O2 monitor, which is placed downstream.
(b) Flowmeters are fragile and may leak from cracks or the O rings at either end.
In the presence of a flowmeter leak, hypoxic mixtures are less likely when
the oxygen flowmeter is placed downstream of the others. This is now the
standard position. See Figs. 80.2 and 80.3. A crack in the O2 flowmeter, even
placed last, may still result in a hypoxic gas mixture.
(c) Being in the low pressure circuit, specific tests may be necessary to detect
leaks. In general, if the machine does not have a check valve at the common
gas outlet, the low pressure circuit may be tested with a positive pressure
leak test. Machines with a check valve must be tested with a negative pres-
sure leak test [3].
Fig. 80.2 Flowmeter leak Unsafe

with oxygen upstream of
other gases Outlet
O2 Air N2O
Safe
Outlet
Fig. 80.3 Flowmeter leak

with oxygen downstream
of other gases N2O Air O2
446 J.B. Carter
4. Causes of inaccuracy include:

(a) The tube that is not vertical distorts the annular flow.
(b) Back pressure from ventilator may cause the float to drop, measuring less
than the actual flow.
(c) A float may become sticky from either a dirty flow tube or static electricity.
(d) Flowmeters are calibrated at 20 °C and 760 mm Hg. The effect of tempera-
ture is minor; however at decreased atmospheric pressure, the density will be
less, and with higher, turbulent flow, the actual flow will be greater than the
set flow.
References
1. Aitkenhead AR, Moppett IK, Thompson JP. Smith & Aitkenhead’s textbook of anesthesia. 6th
ed. Churchill Livingstone Elsevier; 2013.
2. Morgan EG, Mikhail MS. Clinical anesthesiology, Chapter 4, 4th ed.
3. Barash PG, Cullen BF. Clinical anesthesiology, Chapter 26, 6th ed. 2009.
Chapter 81
Cardiac Bypass Machines
A 75-year-old white male is undergoing aortocoronary bypass grafting. On initia-

tion of cardiopulmonary bypass (CPB), the alarm on the CPB machine goes off
indicating high pressure in the arterial circuit.
1 . Name some causes of high pressure on the arterial side.
2. List the components and functions of a CPB circuit.
3. What is extracorporeal circulation?
4. What are the types of oxygenators, their advantages, and disadvantages?
5. What types of filters are used on a bypass machine? Where are the filters located?
6. What is partial and total bypass?
7. What is left ventricular (LV) venting and why is it necessary?
8. What are the types of flow? What is the advantage of using pulsatile flow?
9. Name some complications during cardiopulmonary bypass.

UTMB, Galveston, TX, USA

DOI 10.1007/978-3-319-55862-2_81
448 R. Govindaraj
S
V
C
P
V
Left
Right P atrium
A Aorta
atrium
Cannula
Cannula
Right Left
ventricle ventricle
I
V
C
Filter
LV vent
Reservoir filter
Oxygenator
.............
Heat exchanger
Bubble catcher
& filter
Fig. 81.1 Schematic diagram of Cardio pulmonary bypass machine
Answers
1. Systemic hypertension in the patient, occlusion and malposition of the aortic can-
nula and dissection of the aortic wall, an inadvertent clamp or kink in the line, and
an obstructed arterial line filter can all cause high pressure on the arterial side.
2.
Components [1]:
(a) Venous reservoir
(b) Membrane oxygenator bundle
(c) Venous and arterial blood line/cannula
(d) Arterial filter purge line
(e) Arterial line filter
(f) Venous blood pump (also called the arterial pump head; this pump forces
venous blood through the membrane oxygenator and arterialized blood to
the patient’s aortic root)
(g) Cardiotomy suction pump
(h) Ventricular vent (left ventricular vent)
81 Cardiac Bypass Machines 449
(i) Cardioplegia pump

(j) Crystalloid cardioplegia
(k) Water inlet line
(l) Water outlet line
(m) Gas inlet line
Functions:
(a) Oxygenation and carbon dioxide elimination
(b) Circulation of blood
(c) Systemic cooling and rewarming
(d) Diversion of blood from the heart to provide a bloodless surgical field
3. Extracorporeal circulation or extracorporeal life support is mechanical cardiopul-
monary support. When it is used in the operating room to provide total support of
heart and lung function to facilitate cardiac surgery, the technique is commonly
called cardiopulmonary bypass (CPB). When used with extrathoracic cannula-
tion for respiratory support, the technique is called extracorporeal membrane
oxygenation (ECMO), and for renal support it is termed as hemodialysis [2].
4. There are two common types of oxygenators—bubble and membrane oxygenators.
Bubble oxygenators are simple, low-cost oxygenators with greater efficiency
that require lower priming volumes and are easy to assemble. The disadvantages
are the production of microemboli and increased blood cell trauma as a result of
turbulence and foaming which is created by bubbling oxygen through a column
of blood.
In a membrane oxygenator, gas exchange takes place through a thin mem-
brane; hence there is minimal cellular trauma, but it requires a greater surface
area and a larger priming volume. It is very expensive and difficult to clean.
5. There are two common types of filters used for blood filtration during CPB: depth
and screen filters. Depth filter consists of packed fibers of Dacron with a signifi-
cant amount of thickness but no defined pore size. Hence filtration depends on the
thickness and tightness of the packing of the material. Screen filter is made of a
woven mesh of polyester fibers with a defined pore size. The arterial line has a
screen type filter, while the cardiotomy reservoir has a combination of both
depth- and screen-type filters. Depth filters remove gaseous emboli and microem-
boli efficiently. The disadvantage with depth filter is it removes a lot of platelets.
Screen filters, on the other hand, remove less platelets but also remove gaseous
and microemboli less efficiently. Filters can also be placed in a number of other
locations, including the ventilating gas line and the cardioplegia delivery circuit.
6. Partial bypass occurs when only a portion of systemic venous blood drains to
the pump oxygenator while the remaining blood passes through the right heart
and lungs to be ejected by the left ventricle. Partial bypass is employed in
descending thoracic aortic surgery in order to provide perfusion to distal organs
(spinal cord and visceral organs) while the aorta is cross-clamped. This is to
decrease ischemia time especially to the spinal cord thereby minimizing the risk
of neurologic complications (paraplegia).
450 R. Govindaraj
Total bypass occurs when all the venous return from the right side of the
heart is diverted into the pump oxygenator.
7. During CPB surgery, either no venting or LV venting via the cardioplegia cannula
in the aortic root is practiced. The purpose of left ventricular venting is to prevent
distension of the left ventricle and prevent cardiac ejection of air. Prevention of
distension of the left ventricle is desirable to prevent mechanical damage to the
muscle from excessive stretching, decreasing myocardial oxygen demand, facili-
tating subendocardial perfusion, and preventing pulmonary venous hypertension.
8. Pulsatile and nonpulsatile flows are the types used while on bypass. Pulsatile
flow improves the quality of microcirculation and prevents systemic inflamma-
tory response. But it has been calculated that very little of the pulsatile energy is
actually delivered into the patient’s arterial system.
9. The incidence of complications on CPB is about 1% with a death rate of about
0.04%.
Aortic dissection. Best diagnosed by TEE or epi-aortic scanning.
High arterial line pressure has already been discussed.
Massive air embolism. On a smaller scale, air can entrain in some situations and
can cause embolism in the arterial circuits. Microthrombi and air which cannot
be filtered by the filters on the arterial side can embolize and cause postoperative
confusion and delirium [3].
Oxygenator failure. If the heart is still functioning, separation from CPB, or if
the heart is arrested, the oxygenator needs replacing which requires interruption
to circulation (consider cooling).
Arterial pump failure either due to electrical or mechanical failure. Hand crank
should be available.
Clotting of the circuit from inadequate anticoagulation or inadvertent prot-
amine administration while on bypass.
Obstruction of venous return and air lock.
Electrical failure. All CPB machines have a backup battery. If that fails, then
hand cranking of the arterial pump is the option (not to forget the pump that oper-
ates the suction and vent).
Hemolysis from trauma to the cells. This is increased when the pump run is long.
Exsanguination due to disconnection of the tubing while on bypass.
References
1. Machin D, Allsager C. Principles of cardiopulmonary bypass. Contin Educ Anaesth Crit Care
Pain. 2006;6(5):176–81. doi:10.1093/bjaceaccp/mkl043.
2. Hensley FA, Martin DE, Gravlee GP. A practical approach to cardiac anesthesia. 5th ed.
Philadelphia: Lippincott Williams and Wilkins; 2013.
3. Stehouwer MC, Boers C, de Vroege R, C Kelder J, Yilmaz A, Bruins P. Clinical evaluation of
the air removal characteristics of an oxygenator with integrated arterial filter in a minimized
extracorporeal circuit. Int J Artif Organs. 2011;34(4):374–82. doi:10.5301/IJAO.2011.7749.
Chapter 82
Line Isolation Monitor
Ground
Main
Primary Secondary Line 1
power
supply coil coil
Line 2
to OR Grounded Ungrounded
Wall outlet
Fig. 82.1
1 . What does the image show? Describe its function.

2. What are leakage currents?
3. What are line isolation monitors (LIM)?
4. List the locations where line-isolated electrical systems are required in a health-
care facility.
5. What are the effects of differing current strengths?
6. Explain situations that enhance risks of electrical shock.
A.S. Madamangalam, MBBS, MD (*)


DOI 10.1007/978-3-319-55862-2_82
452 A.S. Madamangalam and T.D. Raj
Answers
1. It shows an isolation transformer whose function is to allow electric power trans-
mission between two circuits without a direct connection. On the left is the main
power supply which is grounded and looped around the primary coil of the isola-
tion transformer. The current flowing through this generates a magnetic field
which creates an electrical potential difference in the secondary coil allowing
current to flow from the primary to the secondary coil. By this arrangement an
electrical fault on one side cannot spread to the other side. The isolation trans-
former transmits only the potential difference across the primary coil and not the
absolute voltage. Hence a fault in a device plugged into the isolated power sup-
ply, which is not grounded, does not lead to an electric shock.
2. Perfectly working electrical equipment may yet produce leakage currents. This
is defined as any current, not intended to be applied to a patient, but may pass
from exposed metal parts of equipment to ground or to other parts of the
instruments.
3. LIM detects electrical potential and leakage currents between the two lines of the
isolated secondary system and ground. It is designed to alarm with audible and
visual warnings when the secondary system degrades to the extent that there
would be a 5 mA or greater electric shock with the next electric fault.
Things to remember:
• An alarm does not mean there is imminent danger to the patient or anyone else.
The alarm therefore simply calls attention to the fact that the system has con-
verted to a partially grounded system [1]. This is a situation that needs correction
as soon as possible. No ongoing procedures need be halted.
• The LIM does not interrupt electrical service. All ungrounded systems will con-
tinue to work as usual [1, 2].
• An active alarm does not mean that there is a hazardous current flowing. It pre-
dicts that a current of at least 5 mA could flow from one conductor of the isolated
system to ground if a path is provided. Therefore, a second fault or electric fail-
ure needs to occur before a true hazardous condition exists [2].
If the alarm on the LIM goes off, the last electrical equipment plugged into the
system in an area is likely suspect and should be unplugged.
4. Electrically isolated systems are required in all wet locations [1]:
(a) Intensive care units (ICUs)
(b) Coronary care units (CCUs)
(c) Emergency departments
(d) Special procedure rooms
(e) Electrophysiology laboratories
(f) Dialysis locations
82 Line Isolation Monitor 453
(g) Various other wet locations that involve patient care, such as GI labs
5. The human body is a large resistor to the flow of current. The flow which is
dependent on the mass and the moisture content of the body.
Macroshock
1 mA—threshold of perception, a slight tingling at the fingertips.
5 mA—maximum harmless current.
10–20 mA—muscle contracture may prevent release of an electrode.
50 mA—pain, fainting, and exhaustion.
100 mA—ventricular fibrillation (VF) will likely result.
Microshock
As little as 100 μA can cause VF.
6. Patients undergoing thoracic surgery are at highest risk of electric shock as are
those when cardiac catheters and dye injectors are being used. This is due to
direct leakage of current in the circulatory system. A patient is most at risk when
the heart is exposed directly to the conducting agent such as diagnostic catheters
or pacing wires.
Patients that are anesthetized or immobilized through illness or have restraints,
or those on drug therapy are considered more susceptible to electrical hazards
than normal individuals. These patients cannot disconnect themselves in the
event of an electric shock. Thus they can be at a high risk for the ill effects of
electrical leakage.
Electrolyte imbalance, hypoxemia, elevated catecholamine levels, and some
drugs such as digitalis also enhance the risk. Infants are at greater risk owing to
their smaller body mass.
References
1. Barash PG, Cullen BF, Stoelting RK. Clinical anesthesia fundamentals. Wolters Kluwer
Health; 2015. p. 803–5.
2. Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s clinical anesthesiology. 5th ed.
McGraw-Hill; 2013. p. 17–9.
Chapter 83
Machine: Schematic
Section A Section C
N2O Pipeline
supply Calibrated
vaporizers
Pipeline Flowmeters
Cylinder pressure
pressure gauge
gauge
*Fail-safe*
valve
Pressure
regulator Oxygen Flow-control
N2O valve
supply
failure
alarm
Check valve
O2
Second stage
O2 pressure
regulator
O2
Oxygen
O2 Cylinder flush
supply valve Machine outlet
& check valve (common gas outlet)
O2 Pipeline supply Section B
Fig. 83.1 Schematic diagram of an anesthesia machine

Associate Professor for Anesthesia and Pain, Department of Anesthesiology, UTMB,
Galveston, TX, USA
Director for Ultrasound Guided Regional Anesthesia, , Galveston, TX 77555, USA

DOI 10.1007/978-3-319-55862-2_83
456 R. Govindaraj
1. What is section A and what are its components?

2. What are the safety systems in the high-pressure system, and what is the pres-
sure for the different gases in the high-pressure system?
3. What is section B and what are its components?
4. What is section C and what are its components?
5. What is a fail-safe valve and what is its function?
6. What are the mechanisms used to prevent delivering a hypoxic mixture at the
fresh gas outlet?
7. What is the oxygen flush valve? What are the properties of the oxygen coming
through the oxygen flush activation and what are the disadvantages?
8. How is the leak test performed?
9. How do we determine the presence of an oxygen pressure failure safety device
or fail-safe valve?
10. What is an oxygen supply failure alarm?
83 Machine: Schematic 457
Answers
1. This is the high-pressure system (cylinder to pressure regulators) in the anesthe-
sia machine. Its components are:
Hanger yoke, which includes the filter and unidirectional valve
Yoke block
Cylinders with safety features and pressure gauge
Cylinder pressure regulators
2. Cylinder pressure can increase due to defective overfilling or when cylinders are
exposed to high temperature. The increase in pressure can cause the cylinder to
explode. Rupture disk device in the cylinder plays a safety role by rupturing the
disk when the pressure in the cylinder increases beyond the safety range e xpelling
the contents thereby avoiding an explosion. Thermally controlled fusible plug
melts and releases the gas under high pressure due to expansion of gases when
cylinders are exposed to higher temperature [1].
Working pressure for the different gases in the high-pressure system are:
Oxygen 1900 psig
Nitrous Oxide 745 psig
Air 1900 psig upstream of the pressure reducing valve
3. This is the intermediate pressure system (from pressure regulators to the flowme-
ter). Components include:
Pipeline inlets for oxygen, nitrous oxide and air.
Pipeline check valves and pressure gauges.
Oxygen fail-safe (pressure-failure) valve.
Oxygen flush valve.
Second-stage pressure regulators in the Ohmeda machine but absent in the
Narkomed machine.
Flowmeter control valves.
Pipeline pressure for oxygen is 50–55 psi, air 50–55 psi, and nitrous oxide 50 psi.
The pipeline pressure of gases is usually slightly higher than cylinder pres-
sure in order to preferentially enable use of pipeline gases. The intermediate
zone working pressure for the gases ranges from 37 to 55 psig. When the pipe-
line pressure of oxygen falls below 30 psig, the low-pressure alarm gets acti-
vated. The second-stage pressure regulator in the Ohmeda machine reduces the
pressure to 26 psig for nitrous oxide and 14 psig for oxygen.
4. It is the low-pressure system (flowmeters to the common gas outlet). The gases
flow through flowmeters, vaporizers, and oxygen analyzer then through the fresh
gas outlet to the patient.
Components are:
Flow meter tubes
Vaporizer and its manifold
Safety devices to prevent hypoxia (proportioning device)
Check valve
458 R. Govindaraj
Pressure relief devices like APL valve

Common gas outlet
Pressure in this section of the machine is slightly above atmospheric and not
constant.
5. Fail-safe valve is located in the intermediate pressure zone of the machine. It
prevents delivery of low FiO2. When the oxygen pressure falls, the fail-safe
valve which is kept open by the working pressure of oxygen gradually shuts
off the other gas which is usually nitrous oxide. It then opens another valve due
to the low pressure and directs the oxygen to an oxygen low pressure alarm.
This safety facility is not available when oxygen and air mixture is being used.
6. Different machines use different mechanisms to prevent delivery of hypoxic
mixtures such as:
Mandatory minimum oxygen flow, minimum oxygen ratio settings, and
proportionating systems are the different principles employed to prevent
delivering hypoxic mixture.
Ohmeda uses a Link-25 system, and the Narkomed uses an oxygen ratio mon-
itor controller with a pneumatic oxygen/nitrous oxide interlock system to facili-
tate the process.
7. Oxygen flush valve is an emergency source of oxygen with high flows at high
pressure. Flows of 30–70 l per minute are produced at a pressure of 60 psig
(400 kPa):
Oxygen flush can be activated regardless of whether the master switch is
turned on or off. Oxygen flush activation may or may not result in other gas flows
being shut off and may result in either a positive or negative pressure in the
machine circuitry, depending on the design of the inlet and the flush line into the
common gas outlet [2].
Disadvantages associated with the oxygen flush include accidental activation
and internal leakage, which can result in an oxygen-enriched mixture being
delivered. The flush valve may stick in the on position. It may also stick and
obstruct flow from the flowmeters. Barotrauma and awareness during anesthesia
have resulted from its activation [3].
8. Low-pressure leak test checks the integrity of the back bar from the flow control
valve to the common gas outlet. Methods used are:
Common gas occlusion test to test high-pressure leaks
Oxygen flush leak test for high-pressure leaks
The abovementioned tests are good for North American Drager and Ohmeda 8000.
Ohmeda-negative pressure leak test later came to be universal on every
machine since 1993 and is known as the FDA universal negative pressure leak
test. This test holds good on all anesthetic machines in current use. It does not
require the presence or absence of check valves. The device used is a simple suc-
tion bulb to provide negative pressure [3].
Machine master switch, flow control valves, and vaporizers are turned off.
Suction bulb is attached to the common gas outlet and squeezed repeatedly until
83 Machine: Schematic 459
it is fully collapsed. This action creates low pressure in the circuit. Machine is
leak free if the bulb remains collapsed for 10 s. A leak is present if the bulb rein-
flates within 10 s. Test is repeated with each vaporizer individually turned on.
9. The flow meter of oxygen and nitrous oxide is switched on, and as soon as the
flows are registered, the oxygen source should be cut off. A proper functioning
fail-safe valve will shut the flow of nitrous oxide immediately. Restoration of
oxygen flow will restore the flow of nitrous oxide as well.
10. An oxygen supply pressure alarm will sound within 5 s of the oxygen pressure
falling below 38 psig. In earlier machines, this was a pneumatic device called
Ritchie whistle and is electronic in the present-day machines.
References
1. Gurudatt C. The basic anaesthesia machine. Indian J Anaesth. 2013;57(5):438–45.

doi:10.4103/0019-5049.120138.
2. Dorsch JA, Dorsch SE. Hazards of anesthesia machines and breathing systems. In: Dorsch JA,
Dorsch SE, editors. Understanding anesthesia equipment. 4th ed. Baltimore: Williams &
Wilkins; 1999. p. 399.
3. Myers JA, Good ML, Andrews JJ. Comparison of tests for detecting leaks in the low-pressure
system of anesthesia gas machines. Anesth Analg. 1997;84:179–84. PMID:8989021.
Index
A Airway pressure release ventilation (APRV),

Abdominal X-ray, 331–334 250–251
ABG analysis. See Arterial blood gas (ABG) Alanine transaminase (ALT), 152
analysis Albumin, 153
Abnormal placenta, 227–230 A-line
Accreta, 229 arterial waveform, 19
Acid-base disorders, 195, 197 components, arterial waveform, 20
Acidosis, 193, 220, 221 damping and affect, 21
acid–base disorders, diagnosis of, 195, 197 indications, 20–21
anion gap, 196–197 monitoring affect, site of, 22
delta gap, 197 pulse contour analysis, 23
metabolic acidosis, causes of, 197–198 lung sliding, 328, 329
respiratory acidosis, 198 Alkaline phosphatase (AP), 152–153, 215
Winter’s formula, 197 Allen test, 21
Acute aortic syndromes, 347 α-stat, 210–211
Acute cardiopulmonary conditions, 355 ALT. See Alanine transaminase (ALT)
Acute coronary syndrome, 189 Alveolar–arterial gradient, 201
Acute postoperative pain, 324 Anemia, 215
Acute renal failure (ARF), 177–178 Anesthesia circuits, 439–442
Acute respiratory distress syndrome Anesthesia machine, 455, 457–459
(ARDS), 410 Anesthetic technique
APRV, 250–251 bronchoscopic view, 363, 364
Berlin definition, 249 maintenance, 362
ECMO, 252 optimal method of induction, 362
HFOV, 250–251 preoperative assessment, 362
nitric oxide and prostaglandins, 252 ventilation, 362
prone ventilation, 251 Angiography, 341–344
protective lung strategy, 249–250 pulmonary embolism
risk factors, 249 acute, 337
steroids, statins/NMB, 250 clinical presentation, 338
Acute traumatic coagulopathy (ATC), long-term phase, 337
140–141 low-risk, 338
Acute tubular necrosis (ATN), 176, 177 massive, 338
Advanced cardiac life support (ACLS), 324 risk stratification, 338
AICD, 403–405 short-term phase, 337
Airway management, 323 sub-massive, 338

DOI 10.1007/978-3-319-55862-2
462 Index
Angiography (cont.) B
treatment, 336–337 Barbiturate, 184
Wells score, 336, 337 Basic metabolic panel (BMP), 147–150,
thoracic aortic dissections 202–204
D-dimer testing, 349 clinical presentation with EKG, 149
DeBakey and Stanford classification, hypokalemia, 149–150
347, 348 arrhythmias, 150
end organ complications, 349 causes, 149
patient management, 349 monitoring, 150
surgical consultation, 349 potassium deficit, 149
symptoms, 347 treatment, 149–150
transesophageal echocardiography, 349 postoperative confusion, 143–145
transthoracic echocardiography, 347 drowsiness, 143
Angiotensin-converting enzyme (ACE) hyponatremia, 144
inhibitors, 289 management, 145
Anion gap, 196–197 osmolality, 145
Annular TDI velocities, 308 osmolarity, 145
Anterior mitral valve leaflet (AML), 370 Bazzett’s formula, 15
Antithrombotic therapy, 338 Beaking, 405, 410
Aortic aneurysm, 341–344 Beer-Lambert law, 45, 48
Aortic dissection, 450 Benzodiazepines, 184
Aortic regurgitation, 292 Benzoylecgonine, 183
Aortic stenosis (AS), 193 Betablockers (BBs), 92
causes of, 286 Beta-receptor agonists, 71
diagnosis and assessment, 286–288 Biliary tree, 152
interventions, 289 Bilirubin, 152
patient history, 286–287, 289 Bioreactance, 87
stages of, 286, 288 BIS monitor. See Bispectral index (BIS)
Aortic valve, 285 monitor
interrogation, 286, 288 Bispectral index (BIS) monitor, 67–71
peak velocity and mean pressure Biventricular pacemaker, 109
gradient, 286 B-lines, 330
stenotic atrioventricular, 287 Blood gas
Aortic valve replacement (AVR), 289 ABG, 210
Apgar score, 221–223 acidosis, 193
Applied Fick principle, 87 acid–base disorders, diagnosis of,
ARDS. See Acute respiratory distress 195, 197
syndrome (ARDS) anion gap, 196–197
ARF. See Acute renal failure (ARF) delta gap, 197
Arterial blood gas (ABG) analysis, 48, metabolic acidosis, causes of, 197–198
204–206, 209 respiratory acidosis, 198
Arterial pump failure, 450 Winter’s formula, 197
Aspartate transaminase (AST), 152 DKA
Atrial depolarizations, 14 abnormal laboratory values, 204
Atrial fibrillation (AF), 193 differential diagnosis, 204–205
incidence, 91 electrolytes, trending changes for,
neuraxial anesthesia and, 93 205–206
precipitants of, 92 initial diagnosis, 203, 204
rhythm, 91 perioperative management, 206–207
treatment, 91 treatment of, 205
types of, 91 fetal, 221
Atrial relaxation, 4 American Congress of Obstetricians
Autoregulation curves, 435–437 and Gynecologists, 223
Awake craniotomy, 270–271 Apgar score, 222–223
A wave, 4 fetal acid–base balance, 222
Index 463
implication, acidosis, 223 phases of, 36, 37

outcome, 223 uses of, 38
umbilical artery/vein, samples, 222 Capnometry, 36
value and acidosis, 222 Carbon monoxide, 50
hypoxia, 199, 200 Carboxyhemoglobin (CoHb), 48
alveolar gas equation, 199 Carboxyhemoglobinemia, 50
hypoventilation, 200 Carboxy tetrahydrocannabinol
pH-stat, 210, 211 (THCCOOH), 183
α-stat, 210, 211 Cardiac catheterization
Blood pressure, 20, 23 adults, 397
Blood product transfusion, 158 complications, 397, 399
BMP. See Basic metabolic panel (BMP) contraindications, 397, 399
BNP. See B-type natriuretic peptide (BNP) incidence, 397, 399
Bohr effect, 418–419 indications, 398
Brachial plexus, supraclavicular location, 318 patient management, 399
Brain tumors, 267, 269–270 report components, 399, 400
awake craniotomy, 270–271 Cardiac function curve, 419–425
classification, 269 Cardiac index, 9
craniopharyngioma, 270 Cardiac oscillations, 41
GBM, 270 Cardiac output (CO), 9, 83–87, 418–425
gliomas, 270 Cardiac resynchronization therapy, 240
medulloblastoma, 270 Cardiopulmonary bypass (CPB), 323,
meningiomas, 270 447–450
metastatic brain disease, 270 Cardiovascular collapse management, 324
steroids, 270 Cardioversion, 91, 93
Brain-type natriuretic peptide, 192 Carpentier classification, mitral
Bronchial obstruction, 359 regurgitation, 370
Bronchodilator testing, 382 Catheter-based thrombectomy, 339
Brugada’s sign, 122 Cath report, 395
B-type natriuretic peptide (BNP), 192 CBC. See Complete blood count (CBC)
heart failure, diagnosis, 191–194 Central venous pressure (CVP), 3–4
limitations, 193 contraindications, 6
normal levels and conditions, 191 determinants of, 5
prognostic information and elevated factors, 5
levels, 192 indications, 5–6
Bubble oxygenators, 449 Cerebral blood flow (CBF), 27, 28, 437
Buprenorphine, 320 Cerebral desaturation, 54
Burst suppression pattern, 60 Cerebral oximetry (CO), 51, 52
Button battery ingestion, 361–362 beach chair position, 53
Bypass Angioplasty Revascularization cardiac surgery, 52–53
Investigation (BARI), 397 cerebral oxygen supply, 52
cerebral vascular surgery, geriatric surgery
and thoracic surgery, 53
C FDA-approved cerebral oximetry
Calorimetric CO2 detector, 38 devices, 55
Cannabinoids, 184 heart failure and ECMO, 53
Capnogram, 36 interventions, 54–55
Capnography near-field photodetection, 54
abnormal capnograms, 39–42 NIRS, 51, 55
tracing mechanism, 35–36 trauma, 53
calorimetric CO2 detector, 38 Cerebral oxygen supply, 52
capnometers, types of, 36 Cerebral palsy, 223
capnometry and capnogram, 36 Cerebral perfusion pressure (CPP), 26–28,
A and D denote, 36 264, 437
ETCO2, 37 CHADS2 score, 92
464 Index
CHA2DS2-VASc score, 92 tension pneumothorax, 233

CHB. See Complete heart block (CHB) treatment, 233
Chemistries, late pregnancy, 213 of premature baby, 355
alkaline phosphatase, 215 of soft tissues, 355
anemia, 215 of thoracic cavity, 354
hemoglobin range, 215 of tracheobronchial tree
plasma proteins, 215 and mediastinum, 354
platelet count, 215 Child-Pugh score, 153
pregnancy, affecting bicarbonate level, 215 Cholecystectomy, 116, 122
renal function tests, 214 Chronic obstructive pulmonary disease
WBC count, upper limit of, 214 (COPD), 117, 122, 381,
Chest pain 389, 390, 392
IHD, 386 CIED, 401–405
precordial, 345 CIN. See Contrast-induced nephropathy (CIN)
Chest tube, 233 Circle system
Chest x-ray (CXR), 233, 234, 247 advantages, 439–442
of abdomen, 354 disadvantages, 439, 441, 442
ARDS Cirrhosis, 178
APRV, 354–355 Clonidine, 320
Berlin definition, 249 Closing capacity (CC), 433
ECMO, 252 Closing volume (CV), 433
HFOV, 250–251 Clot lysis, 164
nitric oxide and prostaglandins, 252 Clotting, of circuit, 450
prone ventilation, 251 Coagulation
protective lung strategy, 249–250 DIC
risk factors, 249 clinical states, 155
steroids, statins/NMB, 250 complications, blood product
artefacts, 355 transfusion, 158
bone structure, 353 diagnosis, 156
children vs. adults, 353 management, 157–158
diagnosis, mediastinal shift, 238 pathophysiology, 157
differential diagnosis, 248, 249 prothrombin time, 158–159
etiology, 238 thrombocytopenia, 156
FB aspiration (see Foreign body (FB) Cocaine, 182, 183
aspiration) Cognitive dysfunction, 53
of heart silhouette and hila, 354 Color flow Doppler, 301
ICD Complete blood count (CBC), 139–141,
BiV ICD, 240 213, 217
diagnosis, 242 epigastric/subcostal pain, 219
electrocautery, 242 HELLP syndrome, 219
indications, 240 late pregnancy
intraoperative device functioning, alkaline phosphatase, 215
measurement, 243–244 hemoglobin range, 214
magnet, effect, 241–242 plasma proteins, 215
radiation therapy, 242 platelet count, 214
radiofrequency, 242 pregnancy, affecting bicarbonate
of lungs, 354 level, 214
of neonates, 355 renal function tests, 214
pneumothorax, 231, 232 WBC count, upper limit of, 214
causes and the clinical preeclampsia
presentation, 231 BUN, creatinine, and uric acid
classification, 232 levels, 218
surgical intervention, indications diagnosis, laboratory work-up, 218
for, 233 DIC panel, 219
Index 465
proteinuria, 218 radiographic visualization, 397

thrombocytopenia, 218 of right coronary artery, 396, 397
Complete heart block (CHB) Coronary artery stenosis, 398–399
atrioventricular conduction, 103 Coronary heart disease, 193
causes, 103–104 CO2 sensor, 36
signs/symptoms, 103 CPP. See Cerebral perfusion pressure (CPP)
ventricular rate, 103 Craniopharyngioma, 269, 270
Computed tomography (CT), 248 Curare cleft, 41, 43
ARDS Cushing’s Triad, 29
APRV, 250–251 CVP. See Central venous pressure (CVP)
Berlin definition, 249 C wave, 4
ECMO, 252 CXR. See Chest x-ray (CXR)
HFOV, 250–251 Cyanosis, 415, 418
nitric oxide and prostaglandins, 252 Cytotoxic edema, 270
prone ventilation, 251
protective lung strategy, 249–250
risk factors, 249 D
steroids, statins/NMB, 250 Damping, 21
brain tumors, 267, 269–270 Defibrillation, 98
awake craniotomy, 270–271 Deflation, balloon, 127, 129
classification, 269 Dehydration, 204, 205
craniopharyngioma, 270 Delta gap, 197
GBM, 270 Dexamethasone, 320
gliomas, 270 Dexmedetomidine, 70
medulloblastoma, 270 Diabetic ketoacidosis (DKA)
meningiomas, 270 abnormal laboratory values, 204
metastatic brain disease, 270 differential diagnosis, 204–205
steroids, 270 electrolytes, trending changes for,
differential diagnosis, 248 205–206
mediastinal mass initial diagnosis, 203, 204
anesthesia, 255–256 perioperative management, 206–207
physical ramifications, 255 treatment of, 205
symptoms, 255 Diastole, 306
techniques, 256 augmentation, 126, 127
TBI dysfunction, 20, 302–305, 308
abnormal findings, 260, 267 abnormal diastolic function, 309
GCS, 259–262 anesthesia, 309
management, guidelines for, 262–264 causes of, 306
perioperative anesthetic care, 264 diastole, 306
trauma, 262 echocardiography, 306–308
types of, 262 and HF-pEF, 306
Congenital diaphragmatic hernia, 232 pressures, 8
Congestive heart failure, 92, 315 Dicrotic notch, 20
Conjugated hyperbilirubinemia, 152 Diffuse axonal injury (DAI), 262
Conscious sedation, 70 Diltiazem, 120, 122
Continuous wave Doppler, 301 Disseminated intravascular coagulation
Contrast-induced nephropathy (CIN), 177 (DIC), 219
Contusion, 262 clinical states, 156
Cooximetry, 47–50 complications, blood product
COPD. See Chronic obstructive pulmonary transfusion, 158
disease (COPD) diagnosis, 156
Coronary angiography management, 157–158
caudal angulation, 395, 397 pathophysiology, 157
cranial angulation, 396, 397 prothrombin time, 158–159
466 Index
Dissociation curve, 415 Electrical bioimpedance, 87

blood oxygen content, 417–418 Electrical failure, 450
Bohr effect, 418–419 Electrical hazards, 453
cyanosis, 418 Electrically isolated systems, 452–453
Fick equation, 418 Electrocardiogram (ECG)
Hb concentration, 419 atrial fibrillation
P50, 417 incidence, 91
variables shift, 418 neuraxial anesthesia and, 93
Diuretics, 149, 289 precipitants of, 92
DKA. See Diabetic ketoacidosis (DKA) rhythm, 91
Doppler treatment, 91
IE, 291–292 types of, 91
antibiotic prophylaxis, 297 CHB
clinical manifestations, 294 atrioventricular conduction, 103
Duke Criteria, 295 causes, 103–104
echocardiography, 295–296 signs/symptoms, 103
pathophysiology, 294 ventricular rate, 103
risk for, 294 cholecystectomy, 116, 122
treatment, 296 chronic obstructive pulmonary disease,
mitral valve regurgitation, 299–301 117, 122
color flow Doppler, 301 diabetes mellitus type II
continuous wave Doppler, 301 and hypertension, 119, 122
grades of, 302 ischemic heart disease and, 117, 122
ultrasound, 280, 281 electrolyte abnormalities, 111–113
Double-burst stimulation, 134 end-stage renal disease, 121, 123
Drug testing heart axis, 15–16
cocaine abuse, 183 heart failure and reduced systolic function,
fentanyl, 183 119, 122
illicit drugs, 183–184 hypertension, 118, 122
Level I Trauma Centers, 183 and COPD, 116, 122
marijuana drug, 183 diltiazem for, 120, 122
substance abuse, anesthesiology, 183 ischemic heart disease and diabetes
Dynamic pressure–volume curve, 405, 409 mellitus type II, 117, 122
LBBB, 16–17
maternal cardiac arrest
E anesthetic toxicity treatment, 98
ECG. See Electrocardiogram (ECG) causes of, 97
Echocardiography, 295–296, 386 etiologies, 97
diastole dysfunction, 306–309 management, 98
Doppler, 301 myocardial ischemia and infarction, 79–82
infective endocarditis, 295–296 electrocardiographic findings, 78, 79
TEE, 300, 301, 368, 370 management, 79–80
aortic stenosis, 285–289 perioperative management, 81
benefits of, 279 prognosis, 80
cardiac output, 279–280 Osborn wave, 16
infective endocarditis, 295 pacemaker, 106–109
intraoperative echo, LVOT, 279 palpitations, 118, 122
physics principles, 280–283 PR interval, 14–15
three-dimensional, 367–372 p-waves, 13
two-dimensional, 286 QT interval, 15
EEG. See Electroencephalogram (EEG) rate modulation, pacemaker, 108
Effective regurgitant orifice area (ERO), 301 RBBB, 16
Eight ball corner pocket, 319 routine screening colonoscopy, 120, 122
Ejection fraction, 285 ventral hernia repair, 121–123
Elective procedure, 403 Electrocautery
Index 467
ICD, 242 endoscopic confirmation, 333

pacemaker, 242 under fluoroscopy, 333
Electrocautery unit (ECU), 71 indications, 333
Electroconvulsive therapy (ECT), 402–404 preconditions, 334
Electroencephalogram (EEG), 59 Femoral peripheral nerve block, 321
beta and alpha frequencies, 59 Fentanyl, 183
channels, 59 Fetal acid–base balance, 222
characteristics of, 59 Fetal acidemia, 75
montage, 59 Fetal heart rate monitoring, 73–75
significance, 59 decelerations, 74
Electrolyte abnormalities, 111–113 fetal acidemia, 75
Electromagnetic interference (EMI), 242, 243, variability, 74
402, 403 FEUrea, 177
Electronic fetal monitoring (EFM), 75 Fiber-optic PACs, 11
Emergency laminectomy, 277 Fick equation, 416, 418
EMI. See Electromagnetic interference (EMI) Fixed obstruction, 393
End-diastolic pressure, 20 Flash pulmonary edema, 315
Endograft, 343 Flow meters, anesthesia, 443
Endoleaks, types, 343 components of, 444
Endotracheal tube (ETT), 255 hypoxic gas mixtures, leaks, 445
End-stage renal disease, 121, 123 inaccuracy causes, 446
Ephedrine, 184 operating principles, 444
Epicardial arteries, 397 Thorpe tube, 444
Epidural anesthesia, 275 Flow volume loops
Epidural hematoma, 262, 275 fixed obstruction, 393
American Society of Regional Anesthesia maximal ventilatory effort, 391
and Pain Medicine, 276, 277 normal, 390
anticoagulant drugs, 276, 277 patient’s medical records, 389
differential diagnosis, 275 peak expiratory flow rate, 390, 391
incidence, 275 peak flow, 394
risk factors, 275 restrictive lung disease, 392
symptoms, 275 Fluid resuscitation, 315
treatment, 277 Fluid therapy, 313
Epigastric/subcostal pain, 219 Forced expiratory volume (FEV), 379
Epinephrine, 319 Forced vital capacity (FVC), 379
Esophageal foreign body, 361 Foreign body (FB) aspiration
Esophageal intubation, 42, 44 asphyxiation, 363
ETCO2, 37, 38, 41, 42 in children, 358
Etomidate, 64 complication rate, 358
Exercise stress, 386 complications, 364
Expiratory reserve volume (ERV), 433 history, 359
Exsanguination, 450 incidence, 358
External ventricular drainage (EVD) system, 33 management, 358
Extracorporeal circulation, 447, 449 in mid esophagus, 360
Extracorporeal membrane oxygenation radiolucent, 361–362
(ECMO), 53, 251 radiopaque, 361
Extracorporeal oxygenation (ECO), 256 thoracic inlet, 360
Fractional excretion of sodium (FENa),
176–177
F Fractional flow reserve (FFR), 399
FB aspiration. See Foreign body (FB) Frank-Starling mechanism, 87, 421–425
aspiration Fresh gas flow (FGF), 441
Feeding tube placement Functional residual capacity (FRC), 428
complications, 334 Functional stress testing, 386
disadvantages, 333 F waves, 91
468 Index
G Hypoxia, 199, 200

Gamma-glutamyl transferase (γGT), 152–153 alveolar gas equation, 199
Gas chromatography coupled with mass hypoventilation, 200
spectrometry (GC-MS), 183
Glasgow Coma Scale (GCS), 27, 29, 259–261
Glioblastoma multiforme (GBM), 270 I
Gliomas, 270 IABP. See Intra-aortic balloon pump (IABP)
GOLD spirometric criteria, 381 ICD. See Implantable cardio-defibrillator (ICD)
IHD. See Ischemic heart disease (IHD)
Illicit drugs, 182, 183
H Impaired relaxation, 5
Haldane effect, 416, 419 Implantable biventricular cardio-defibrillator
Hallucinogens, 183 (BiV ICD), 239–242
Heart axis, 15–16 Implantable cardio-defibrillator (ICD)
Heart block, 122 BiV ICD, 240
Heart failure, 53, 191–193 diagnosis, 242
Heart failure with preserved ejection fraction electrocautery, 242
(HF-pEF), 306 indications, 240
HELLP syndrome, 218 intraoperative device functioning,
Hemithorax, 232 measurement, 243–244
Hemolysis, 450 magnet, effect, 241–242
Hemorrhagic shock, 140 radiation therapy, 242
Henry’s law, 210 radiofrequency, 242
Hepatic cell death, 152 Increta, 229
Hepatorenal syndrome (HRS), 177–178 Infective endocarditis (IE), 372
Herniation, 27 antibiotic prophylaxis, 297
HF-pEF. See Heart failure with preserved clinical manifestations, 294
ejection fraction (HF-pEF) Duke Criteria, 295
High arterial line pressure, 450 echocardiography, 295–296
High-frequency oscillatory ventilation pathophysiology, 294
(HFOV), 250–251 risk for, 294
High-pressure system, 456, 457 treatment, 296
High-risk stress, 387 Inferior vena cava (IVC)
His bundle, 103, 104 Caval index, 315
Hodgkin’s disease, 254 clinical examination, patient, 315
HRS. See Hepatorenal syndrome (HRS) dynamic measurements, 313
Hydration, 205 interpretation, 313
Hyperkalemia, 113 respiratory variation, 313
Hypertension, 118–123, 289 subcostal, 313, 314
Hypertonic saline, 33 ultrasound images, 313, 315
Hypervolemia, 314 Inflation, balloon, 127, 128
Hypokalemia, 149 Inflection point, 409–410
arrhythmias, 150 Inspiratory capacity (IC), 433
causes, 149 Inspiratory reserve volume (IRV), 433
maintenance, 150 Insulin therapy, 205
monitoring, 150 International sensitivity index (ISI), 159
potassium deficit, 149 International 10–20 system, 59
treatment, 149–150 Interrogation, 401–405
Hyponatremia, 144 Intra-aortic balloon pump (IABP), 125
Hypotension, 64, 264 abnormal timing, balloon and
Hypothermia, 64 consequences, 126, 128–129
Hypoventilation, 41, 200 complication, 127
Hypovolemia, 314 consequences, therapy, inflation and
Hypoxemia, 46, 199, 200 deflation, 126
Index 469
console, 126 LiDCOrapid system, 86

contraindications, 127 Lidocaine, 98
early deflation, 129 Line isolation monitors, 451, 452
early inflation, 128 Lipid emulsion therapy, 324
helium and carbon dioxide, 127 Liquid chromatography coupled with a mass
IABP-SHOCK II trial, 127 spectrometry (LC/MS), 183
late deflation, 129 Liver function testing, 151
late inflation, 128 Alkaline phosphatase and γGT, 152–153
lumens, 126 aspartate transaminase and ALT, 152
triggers, balloon counterpulsation, prothrombin time, 153
126–127 risk scoring systems, 153
Intracranial pressure (ICP), 25, 264, 437 total bilirubin, 152
causes, 27–28 Local anesthetic systemic toxicity
herniation, 27 (LAST), 323
indications, 29–30 Lone atrial fibrillation, 91
management, 32–34 Long-standing persistent atrial fibrillation, 91
Monro-Kellie hypothesis and Cushing’s Lower inflection point (LIP), 409–410
Triad, 29 Low pressure leak test, 458–459
significance, 28 Low-pressure system, 457
types of, 30–32 Lundberg A waves, 31
values for, 27 Lung point, 329
Intraparenchymal/intracerebral Lung pulse artifact, 329
hemorrhage, 262 Lung sliding, 329
Intravascular ultrasound (IVUS), 399 Lung ultrasound, 327–329
Intraventricular hemorrhage, 262
Ischemia, 5
Ischemic heart disease (IHD), 117, 122, 383, M
386, 387 Magnetic resonance imaging (MRI), 229
Isosbestic points, 45 brain tumors, 267, 269–270
IVC. See Inferior vena cava (IVC) awake craniotomy, 270–271
classification, 269
craniopharyngioma, 270
J GBM, 270
Jackson Rees modification, 442 gliomas, 270
J wave, 15, 16 medulloblastoma, 270
meningiomas, 270
metastatic brain disease, 270
K steroids, 270
Ketamine, 64, 70 epidural hematoma, 275
Ketone bodies, 204–206 American Society of Regional
Knee arthroscopy procedure, 389 Anesthesia and Pain Medicine,
276, 277
anticoagulant drugs, 276, 277
L differential diagnosis, 275
Large-bore needle, 233 incidence, 275
Left anterior descending (LAD) coronary risk factors, 275
arteries, 395, 397 symptoms, 275
Left atrial end-systolic volume index treatment, 277
(LAESVi), 307 Mannitol, 33
Left bundle branch block (LBBB), 16–17, 122 Mapleson breathing system
Left circumflex (LCX) coronary arteries, 397 advantages, 439–442
Left ventricular outflow tract (LVOT), 279, disadvantages, 439, 441, 442
282, 283 Marijuana, 183
LiDCOplus monitor, 86 Massive air embolism, 450
470 Index
Massive transfusion, blood products/ myocardial oxygen supply-demand

crystalloids, 315 imbalance, 190
Maternal cardiac arrest, 97 perioperative, 190
anesthetic toxicity treatment, 98 troponins, 188
causes of, 97 universal classification, 188
etiologies, 97 management, 79–80
management, 98 perioperative management, 81
Mean arterial pressure (MAP), 20 prognosis, 80
Mechanomyography (MMG), 135 Myocardial ischemia
Meconium aspiration, 355 electrocardiographic findings, 78, 79
Mediastinal mass management, 79–80
anesthesia, 255–256 perioperative management, 81
physical ramifications, 255 prognosis, 80
symptoms, 255 Myocardial oxygen demand and supply, 398
techniques, 256 Myocardial oxygen supply-demand
Mediastinal shift, 238 imbalance, 190
Medulloblastoma, 270 Myocardial perfusion imaging (MPI), 386
Membrane oxygenator, 449
Meningiomas, 270
MEP. See Motor evoked potential (MEP) N
Metabolic acidosis, 197, 222 Natriuretic peptide receptor type A (NPR-A), 192
Metastatic brain disease, 270 Near-field photodetection, 54
Methemoglobin, 45 Near-infrared spectroscopy (NIRS), 52, 55
Methemoglobinemia, 49 Neonatal depression, 222
Methylene blue (MB), 50 Neuromuscular blockade (NMB), 65, 248, 250
Minimally invasive cardiac output monitor Nexfin monitor, 86
FloTrac system, 84–85 Nitric oxide, 251, 252
pulse contour analysis, 86 Nitrous oxide, 64, 65
Mitral inflow PW Doppler, 307–308 Non-ketotic hyperosmolar hyperglycemia
Mitral valve (NHH), 204
diastole, 367, 368 NPR-A. See Natriuretic peptide receptor type
leaflet motion, 372 A (NPR-A)
physical examination, 369 N-terminal proBNP (NT-proBNP), 192
regurgitation, 286, 299–301, 368, 369
color flow Doppler, 301
continuous wave Doppler, 301 O
grades of, 302 Obstruction, venous return and air lock, 450
systole, 367, 368 Obstructive lung disease, 380, 392
Mixed acidosis, 222 Ohmeda-negative pressure leak test, 458
Mixed pattern, 379, 381 Opioid, 64, 65, 183, 184
Mixed venous oxygen saturation (SvO2), 11 Osborn wave, 16
M-mode method, 327–330 Osmolality, 145
Model for End-stage Liver Disease (MELD) Osmolarity, 145
score, 153 Osmotic therapy, 33
Monitored anesthesia care (MAC), 256 Oxygenated hemoglobin, 419
Monro-Kellie hypothesis, 29 Oxygenator failure, 450
Motor evoked potential (MEP), 65 Oxygen
MRI. See Magnetic resonance imaging (MRI) consumption, 418
Myocardial infarction (MI) content, 415, 417
electrocardiographic findings, 78, 79 delivery, 418
elevated troponins and perioperative, 188 fail safe valve, 458
acute coronary syndrome, 189 saturation, 45
cardiology team, 190 supply pressure alarm, 459
causes, troponin elevation, 189 Oxyhemoglobin, absorption spectra, 43
Index 471
P PiCCO plus monitor, 86

Pacemaker, 106–108, 239, 241, 403, 405 Placenta, abnormal, 227–230
AOO, VOO, and DOO, 107 Placenta accreta, 229
dependency, 107 Plasma osmolality, 144
electrocautery, 242 Platelet mapping, 165
radiation therapy, 242 PlateletMapping® assay, 172, 173
radiofrequency, 242 Platelets, 156
Pain control, 324 Pleth variability index (PVI), 46
Palpitations, 118, 122 Pneumothorax, 231, 232
PAOP. See Pulmonary artery occlusion causes and the clinical presentation, 231
pressure (PAOP) classification, 232
Paroxysmal atrial fibrillation, 91 exclusion of, 329
Partial bypass, 449 lung sliding, 329
Peak expiratory flow rate (PEFR), 391 surgical intervention, indications for, 233
Peak systolic pressure, 20 tension pneumothorax, 233
Peak TR velocity, 307, 308 treatment, 233
Pediatric patients, CXR Positive end expiratory pressure (PEEP),
of abdomen, 354 249–250, 408, 410
artefacts, 355 Posterior descending artery (PDA), 397
bone structure, 353 Posterior mitral valve leaflet (PML), 370
children vs. adults, 353 Postoperative confusion, 143–145
FB aspiration (see Foreign body (FB) drowsiness, 143
aspiration) hyponatremia, 144
of heart silhouette and hila, 354 management, 145
of lungs, 354 osmolarity, 145
of neonates, 355 osmorarity, 145
of premature baby, 355 Posttetanic count stimulation, 133–134
of soft tissues, 355 Potassium deficit, 149
of thoracic cavity, 354 Preeclampsia, 218–219
of tracheobronchial tree Preload, 105–424
and mediastinum, 354 Prerenal azotemia, 177
Pediatric pneumothorax, 232 Pressure-passive flow, 28
PEEP. See Positive end expiratory pressure Pressure recording analytical method
(PEEP) (PRAM), 86
Pentobarbital, 33–34 Pressure–volume curves, 405–411
Percreta, 229 PR interval, 14–15
Perfusion index (PI), 46 ProAQT sensor, 86
Perimortem C-section, 98 Probe placement, 313
Peripheral nerve block, 317 Prone ventilation, 251
Peripheral nerve catheter, 319 Propofol, 33, 70
Peripheral nerve stimulator, 132 Prostaglandins, 252
electrical stimulus, 132 Prosthetic valve, 294
neuromuscular function, 132 Protective lung strategy, 249–250
patterns of, 132–134 Proteinuria, 217
quantitative monitoring techniques, 135 Prothrombin time (PT), 153, 158–159
ulnar and fascial nerves, 134 Proximal isovelocity surface area (PISA), 301
Permanent atrial fibrillation, 91 Pulmonary artery catheters
Permanent pacemaker placement (PPP), 104 fiber-optic PACs, 11
Persistent atrial fibrillation, 91 indications, 11–12
P-flex, 409, 410 PAOP overestimates/underestimates, 10
Pharmacological stress, 386 ventricular diastolic pressure estimation,
Phonomyography (PMG), 135 8–9
pH-stat, 209–210 v waves, 10
Physical therapy, 319 waveform, 7, 8
472 Index
Pulmonary artery occlusion pressure Restrictive lung disease, 379, 390, 392, 394
(PAOP), 9 Resynchronization therapy, 193
overestimation, 10 Return of spontaneous circulation
underestimation, 10 (ROSC), 40, 42
Pulmonary capillary wedge pressure (PCWP), Right atrium, 8
8, 308 Right bundle branch block (RBBB), 16, 122
Pulmonary edema, 315 Right ventricle, 8
Pulmonary embolism (PE) Rigid bronchoscopy (RB), 255
acute, 337 Rotational thromboelastometry (ROTEM®),
angiography, 337 165–166
antithrombotic therapy, 338 Routine stress testing, 386–387
clinical presentation, 338
long-term phase, 337
low-risk, 338 S
massive, 338 Saturation percentage, 417, 418
risk stratification, 338 Seashore sign, 329, 330
short-term phase, 337 Seizure suppression, 323
sub-massive, 338 Signal quality index (SQI), 69, 71
therapeutic anticoagulation, 337 Signals, SSEP, 64
thrombolysis, 338 Single-twitch stimulation, 132
treatment, 337–338 Sodium polystyrene sulfonate, 113
Wells score, 337 Somatosensory evoked potentials (SSEP),
Pulmonary Embolism Severity Index (PESI) 61–65
scores, 338 amplitude, 64
Pulmonary function testing, 377, 389 anesthetic agents, 64
bronchodilator testing, 382 latency, 64
COPD, 381 MEP, 65
FEV1/FVC, 377, 379, 381, 382 signals, 63
red curve after bronchodilator, 377 significant change, 64
spirometry, 378–381 waveforms, 61–63
Pulmonary vascular resistance (PVR), 428 Spirometry, 431–434
Pulmonary wedge pressure, 428 Spontaneous pneumothorax, 232
Pulsatile and nonpulsatile flows, 450 Square wave test, 21
Pulse Doppler technology, 86–87 SSEP. See Somatosensory evoked potentials
Pulse oximetry, 45–46 (SSEP)
PulsioFlex, 86 Statins, 248, 250
P-waves, 13 Steroids, 248, 250, 270
Stratospheric sign, 327, 330
Stress test, 383–387
Q Stroke index, 9
QT interval, 15 Stroke volume, 9
Quadriplegia, 275 Stroke volume variation (SVV), 84–87
ST segment, 15
elevation, 79–80
R Subarachnoid hemorrhage, 262
Radiation therapy, 242 Subcostal inferior vena cava, 313
Radiofrequency, 242 Subdural hematoma, 262
Radioimmunoassay, 183 Succinylcholine, 113
Radiolucent foreign body, 361–362 Sudden systolic pressure, 8
Radiopaque foreign body, 361 Supraclavicular nerve block, 317
Rebreathing, 41 Syndrome of inappropriate ADH (SIADH)
Residual volume (RV), 433 secretion, 145
Respiratory acidosis, 198, 222 Systemic hypertension, 448
Respiratory cycle, 87 Systolic decline, 20
Respiratory distress, premature babies, 355 Systolic phase, 20
Index 473
T Trachea, 255
Tachycardia, 79, 122 Tracheal/bronchial foreign body, 362
TBI. See Traumatic brain injury (TBI) Tracheal stenosis, 256
TEE. See Transoesophageal echocardiography Tracheomalacia, 256
(TEE) Train-of-four (TOF) stimulation, 133
TEG. See Thromboelastography (TEG) Transcatheter aortic valve replacement
Temporary transvenous pacemaker, 104 (TAVR), 289
Tension pneumothorax, 231–233, 356 Transcutaneous pacemaker, 104
Tetanic stimulation, 133 Transient tachypnea, newborn, 355
Tetrahydrocannabinol (THC), 183 Transoesophageal echocardiography (TEE),
Thermodilution method, 9 300, 301, 368, 370
Thoracic aortic dissections aortic stenosis
D-dimer testing, 349 causes of, 286
DeBakey and Stanford classification, 347, diagnosis and assessment, 286–288
348 interventions, 289
end organ complications, 349 patient history, 286, 287, 289
patient management, 349 stages of, 286, 288
surgical consultation, 349 benefits of, 279
symptoms, 347 cardiac output, 279–280
transesophageal echocardiography, 349 infective endocarditis, 295
transthoracic echocardiography, 347 intraoperative echo, LVOT, 279
Thoracic endovascular aortic repair (TEVAR), physics principles, 280–283
341–343 Transthoracic echocardiogram (TTE), 296,
Three-dimensional echocardiography, 368, 371
367–372 Trauma-induced coagulopathy (TIC), 141
Thrombectomy Traumatic below-knee amputation, 312
catheter-based, 339 Traumatic brain injury (TBI)
mechanical, 339 abnormal findings, 260, 267
Thrombocytopenia, 156, 218 GCS, 259–262
Thromboelastography (TEG), 161 management, guidelines for, 262–264
abnormal interpretation perioperative anesthetic care, 264
citrated kaolin tracing, 171, 173 trauma, 262
clot lysis, 164 types of, 262
hypercoagulability of factors, 170, Traumatic pneumothorax, 232
172–173 Triple phase CT, 343, 344
MA and G, 168, 172 Troponins, 188
platelet function, 172, 173 TTE. See Transthoracic echocardiogram
PlateletMapping® assay, 172, 173 (TTE)
primary fibrinolysis, 169, 172 Tube thoracotomy, 233
TEGACT, 168, 169, 172 Two-dimensional echocardiography, 286
conventional coagulation tests, 162
data, 161, 162
parameter, guide therapy, 164–165 U
phases, 162–164 Ultrasound, 317–324
platelet mapping, 165 abnormal placenta, 227, 229
ROTEM vs., 165–166 anesthesia, 227
Thrombolytic therapy, 338, 339 classification/grading and common
Tidal inhalation, 433 sonographic findings, 227
Tidal volume (TV), 433 frequency, 227, 229
Time-velocity integral (TVI), 301 implantation, 227
Tissue oxygenation, 418 pregnancy, coagulation change during,
Torsades, 15 227
Total bilirubin, 152 risk factors, 227
Total bypass, 450 Unconjugated bilirubin, 152
Total intravenous anesthesia (TIVA), 70 Upper inflection point (UIP), 409
474 Index
Urine testing, 175 Ventral hernia repair, 121–123

AKIN classification, 179 Ventricular compliance, 4–5
ARF, causes of, 177–178 Ventricular fibrillation, 97, 98
CIN, 177 Ventricular rate, 103
diagnostic tests, 176–177 Ventricular systole, 4
FEUrea, 177 Vital capacity (VC), 433
history and physical examination, 176 Vocal cord paralysis, 390, 392
HRS, 178 Volatile anesthetics, 70
RIFLE criteria, 178–179 VVI pacemaker, 107
Urobilinogen, 152 V wave, 4
Utero-placental gas exchange, 222
U waves, 149
W
West Lung zones, 427–428
V Whipple surgery, 383
Variable extra-thoracic obstruction, 393 Winter’s formula, 195
Vasodilators, 289 Wolff-Parkinson-White syndrome, 93
Vasogenic edema, 270
Velocity time integral (VTI), 281–283
Vena contracta, 301 Z
Venous return, 5 Zones of lungs, 427–428

Data Interpretation in Anesthesia 2017

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ISBN 978-3-319-55861-5 ISBN 978-3-319-55862-2 (eBook)

Library of Congress Control Number: 2017946757

© Springer International Publishing AG 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Edmond, OK Tilak D. Raj

12 SSEP’s and More��������������������������������������������������������������������������������������� 61

Part II Laboratory Testing

25 Complete Blood Count (CBC)���������������������������������������������������������������� 139

29 Coagulation Profile���������������������������������������������������������������������������������� 155

Part III Imaging

43 Ultrasound: Abnormal Placenta������������������������������������������������������������ 227

Part IV Physiologic Studies

68 Pulmonary Function Testing������������������������������������������������������������������ 377

Part V Conceptual Images

74 Dissociation Curve ���������������������������������������������������������������������������������� 415

Alberto J. de Armendi, MD, PhD, MBA Department of Anesthesiology, The

Edward Kosik, DO Department of Anesthesiology, University of Oklahoma Health

© Springer International Publishing AG 2017 3

Fig. 1.1 Central venous 1

Fig. 1.2 Normal CVP a

factors (e.g., impaired relaxation, ischemia, and pharmacologic manipula-

RAP = RVEDP = LAP = LVEDP

Raised CVP with abrupt x and y descent

Steep x descent & Absent y descent

Fig. 2.1 Pulmonary artery catheter normal waveform

© Springer International Publishing AG 2017 7

Fig. 2.2 Waveforms encountered during PAC advancement

3. PA catheter data may be unreliable due to intrathoracic pressure variations.

6. Fiber-optic PACs can be used to measure mixed venous oxygen saturation

Evidence, Outcome: UK National Health Service PAC-Man (PAC in patient

1. Jean Louis Vincent A. Clinical review: update on hemodynamic monitoring – a consensus of

© Springer International Publishing AG 2017 13

Fig. 3.1 Normal EKG

Fig. 3.2 Normal EKG (components labeled)

Fig. 3.3 J wave

Causes Hypothermia (temp <30°C)

Fig. 3.4 Bundle branch block

delay is followed by mechanical asynchrony, regional workload differences,

© Springer International Publishing AG 2017 19

( b) Use of intraoperative deliberate hypotension

4. The arterial waveform is the summation of numerous harmonic waves to form a

5. The arterial line waveform is different at different sites of measurement due to

A 27-year-old male involved in a motorcycle accident. He presented to emergency

© Springer International Publishing AG 2017 25

1 . What are normal values for intracranial pressure?

toxic-­metabolic encephalopathies. Additionally, an increase in venous pressure

0 50 100 150 200

Fig. 5.3 Compliance curve

6. Normal or abnormal ICP is a function of the volume and compliance of each

• GCS 3–8 and abnormal CT scan.

Fig. 5.4 Normal ICP

analysis. Prognosis of survival following head injury and optimization of CPP-­

Fig. 5.5 ICP waveform

Fig. 5.6 ICP waveform 50

Lundberg B waves are rhythmic oscillations, sharply peaked occurring every

slowly. Vasogenic edema from brain tumors, abscesses, or noninfectious

suppression, and paralytic ileus. Pupillary reactivity is the only neurologic

Fig. 6.1 Inhalation begins

Edmond, OK Tilak D. Raj

12 SSEP’s and More�� 61

25 Complete Blood Count (CBC)�� 139

29 Coagulation Profile�� 155

43 Ultrasound: Abnormal Placenta�� 227

68 Pulmonary Function Testing�� 377

74 Dissociation Curve �� 415

toxic-metabolic encephalopathies. Additionally, an increase in venous pressure

analysis. Prognosis of survival following head injury and optimization of CPP-