Miller's Anesthesia 2/2

1 1 - The Scope of Modern Anesthetic Practice Introduction Forces That Will Change Practice (Fig. 1.1) Changing Patient Populations Changing Locations of Care Changes in the Anesthesia Workforce Increasing Costs of Care Increasing Focus on Safety and Quality New Opportunities and Challenges in Research Increasing Availability of Data Conclusions Acknowledgment References 2 2 - Anesthesia and Analgesia in the Global Context Introduction Section 1: Anesthesia and “Global Health” Scope and Scale of the Global Anesthesia, Surgery, and Pain Crises Global Burden of Surgical Disease Global Burden of Pain Disparities in Access, Affordability, and Safety Global Anesthesia, Surgery, and Pain Crises: Origins and Areas for Intervention Misperceptions and Limited Data Advocacy and Policy Workforce Shortages and Strategies for Expansion Infrastructure Challenges Inequities in Analgesia Section 2: Evolution of Anesthesia Care Models and Challenges Around the World Africa Uganda (Mary T. Nabukenya and Sarah Hodges) South Africa (Hyla Kluyts) North America Canada (Tyler Law) Mexico (Gerardo Prieto) United States (Ronald D. Miller and Adrian W. Gelb) Europe Norway (Jannicke Mellin-Olsen) Romania (Daniela Filipescu) Asia and The Middle East India (Bala Krishnan Kanni) Lebanon and The Middle East (Patricia Yazbeck) Pakistan (Fauzia Khan) China (Yugaung Huang) Vietnam (Thi Thanh Nguyen and Thang Cong Quyet) South America Paraguay (Rodrigo Sosa Argana) Colombia (Pedro Ibarra) Oceania Australia and New Zealand (Rob McDougall) Fiji and Pacific Island Nations (Sereima Bale) Section 3: Essentials for Practice in Resource-Constrained Settings Clinical and Technical Skills Global Health Competencies Conclusions Acknowledgments References Appendix 1 Links and Useful Resources References 3 3 - Perioperative Medicine Introduction The Anesthesiologist and Perioperative Medicine Perioperative Management Preoperative Assessment and Management Intraoperative (Intraprocedural) Management Postoperative Management Coordinated Perioperative Management Strategies Models of Perioperative Care Patient-Centered Medical Home Surgical Hospitalist Enhanced Recovery After Surgery Perioperative Surgical Home Conclusion References 4 4 - Informatics in Perioperative Medicine Introduction Computer Systems Computer Networks The Internet Information Security Standards for Healthcare Data Exchange Regulation of Electronic Data Exchange The Nature of Healthcare Information in the Anesthesia Encounter Development and Deployment of Anesthesia Information Management Systems Anatomy of an Anesthesia Information Management System Advantages of Implementation of an Anesthesia Information Management System Integration of Anesthesia Care Information with Operating Room Information Systems Development of Decision Support Tools Passive Decision Support Systems Active Decision Support Systems Impact of Decision Support in Anesthesia Care Integration with the Enterprise Electronic Health Record Billing System Interactions Challenges in Anesthesia Information Management System Implementation Additional Uses for Collected Data Use for Medical Research Measurement of Quality of Care Interactions of Electronic Devices with the Delivery of Anesthesia Care Conclusion Acknowledgment References 5 5 - Quality Improvement in Anesthesia Practice and Patient Safety Definition of Quality Aims of Quality in Health Care Deming’s System of Profound Knowledge Approaches to Quality Assessment Quality Assurance Versus Continuous Quality Improvement Frameworks for Improvement Model for Improvement Lean Methodology and Six Sigma The Value Framework in Health Care Quality Improvement Measures and Tools Process and Outcome Measures Analysis and Display of Quality Improvement Data Run Charts and Control Charts Failure Modes and Effects Analysis Putting It All Together: An Example Quality Improvement Project Dashboards and Scorecards Additional Quality Improvement Evaluation and Communication Tools Improvement Intervention Tools Daily Goals Sheet Checklists Briefings and Debriefings Sources of Quality Improvement Information Incident Reporting Published Literature National Initiatives and Quality Metrics Outcomes Research Internal or External Institutional Reviews Examples of Quality Improvement Programs Collaborative Programs Institute for Healthcare Improvement Breakthrough Series Collaboratives Comprehensive Unit-Based Program Challenges and Barriers to Quality Improvement Projects Related concepts: improvement science and implementation science The Future: Research, Education, and Ethics Summary Acknowledgments References 6 6 - Avoiding Patient Harm in Anesthesia: Human Performance and Patient Safety What this Chapter is About:An Overview Readers Will Learn WHAT THIS CHAPTER IS NOT ABOUT Human Performance and Patient Safety in Anesthesia: Why is this Important Nature of the Anesthesia Professional’s Operational Domain: A Dynamic and Complex Environment Anesthesiology by its Nature Involves Crises Criteria defining a complex and dynamic world Production Pressure Resulting in Asymmetry Between Safety and Production Nature of the Anesthesia Professional’s Work: Task Variation and Workload Management Procedural Tasks of Anesthesia Professionals and Related Vulnerabilities Preoperative Planning Induction Maintenance Phase of Anesthesia Emergence Pre-Use Checkout of Equipment/Anesthesia Machine Checkout Cognitive Tasks of Administering Anesthesia AND RELATED VULNERABILITIES Introduction of the Anesthesia Professional’s Core Cognitive Process Model Management and Coordination of the Core Cognitive Process: Supervisory Control and Resource Management Anesthesia Professional’s Workload and Methodologies to Measure It Assessing the Performance of Anesthesia Professionals Performance as a function of task density Performance as a Function of Teaching, Delegation, and Supervision Performance as a Function of Experience What are the practical implications of performance assessment in Anesthesia Benefits and Challenges of Assessing Performance Benefits of the Scientific Study of Tasks and Performance in Anesthesia Challenges of the Scientific Study of Tasks and Performance in Anesthesia Patient Safety on the Individual and Team Level Human Performance, Human Factors, and NonTechnical Skills Human Performance and Human Factors Human Factors and Nontechnical Skills Human Factors on the Individual Level Task Management Situation Awareness Decision Making Performance-Shaping Factors on the Individual Level Distractions and Interruptions in the Operating Room Sleep Deprivation and Fatigue Rest Breaks, Strategic Napping at Work, and Use of Caffeine Aging Anesthesiologists Illness and Drug Use Professionals’ Attitudes as a Crucial Part of Human Performance and Patient Safety Human Factors AT the Team Level Effective Communication and Delegation of Tasks Status and Hierarchy: Speaking Up Teamwork Leadership Patient Safety Strategies AT the Individual and Team Level: Crisis Resource Management and Other Training Curricula Crisis/Crew Resource Management Other Curricula for Team Training: TeamSTEPPS and Clinical Team Training Patient Safety on the Organizational Level Systems Thinking Human Failure: Human Error and Violations Active Errors Evolution and Investigation of Accidents: One Error is not the Cause of an Accident Evaluation of Errors and Accidents: Hindsight Bias—“I knew it all Along” and Outcome Bias—“No Harm no Foul” System Error Models: Normal Accident Theory and High Reliability Organization Theory Safety I and Safety II: Ensuring that as Few Things as Possible go Wrong or that as Many Things as Possible go Right… Resilience and Uncertainty Management: Safety is a Dynamic State, not all Risks can be Eliminated Normalization of Deviance and Flirting with the Margin Achieving High Reliabilty and System Thinking: Fundamental Elements for a Systematic Safety Approach Culture of Safety Organizational Learning Characteristics of Successful Incident Reporting Systems Continuous Training including simulation . A pocket card of the 15 CRM key points is shown in Fig. 6.17 Continuous Optimization of Safety-Relevant Structures and Processes The Bigger Picture: Patient Safety Efforts on the U.S. National and International Level Patient Safety Milestones and Movements Institutions Engaging in Patient Safety Raising the Awareness for Patient Safety Certified Education in Patient Safety for Health Care Professionals National and International Evaluation of the Benefits of Patient Safety Programs Patients for Patient Safety Conclusion and Outlook Acknowledgment References References 7 7 - Patient Simulation What This Chapter Is About: An Overview Readers will Learn What this Chapter is not About Simulation in Anesthesia: Why Is It Important Application of Simulation in Anesthesia and Health Care Use of Patient Simulation for Training and Education Use of Patient Simulation for System Probing and Protocol Testing Use of Patient Simulation for Testing Equipment and Supplies Use of Patient Simulation for Performance Assessment Use of Patient Simulation for Research Other Uses of Patient Simulation History, Development, and Types of Simulators and Simulation Simulation Fidelity and Classification of Simulators Sites of Simulation Dedicated Simulation Center Training and Probing Where Clinicians Work In Situ Simulation Peri-situ or Off-site Simulation Sequential Location Simulation Mobile Simulation: “Have Simulator, Will Travel” Simulation Team Training Participants: Who Should Be Trained and in What Composition Training Individuals Training Crews: Interprofessional Single-Discipline Team Training Training Teams: Interprofessional Multidiscipline Team Training Cross Training: Changing Roles EN-BLOC Training: Avoiding Sub-Threshold Training Effects Patient Simulation Timing: Announced in Advance Versus Unannounced in Advance Scopes of Simulation in Health Care: The 12 Dimensions of Simulation Crisis Resource Management (ACRM; CRM): Part of Modern Patient Simulation Team Training The Roots of Anesthesia Crisis Resource Management Training Anesthesia Crisis Resource Management Curricula Benefits of Crisis Resource Management-Based Simulation Training Anatomy of a Patient Simulation Team Training Exercise Scenario Design and Execution: Knowing the Learning Objectives and Making It Real Goal Oriented: Establishing Learning Objectives Cognitive Load Theory: Not too much, not too Little Constraints and Limitations of Scenario Design Ideas Scenario Design Templates AND Scenario Templates Reality Versus Realism Simulation Realism and Simulation Relevance in-Scenario Information and Guiding Debriefing: Heart and Soul of Patient Simulation Simulators (Devices) Don’t Teach Instruction Versus Facilitation—A New Way of Teaching Debriefing Techniques Use of Recorded Audio-Video Sequences in Debriefings Excursion: Debriefing Techniques For Discussion of Real Clinical Cases Excursion: Debriefing Techniques for Morbidity and Mortality Conferences Debriefing in Different Cultures Qualification and Certification of Simulation Instructors Tasks of Simulation Instructors—Learning Objectives for Simulation Instructor Courses Education, Training, AND Continuous Development of Simulation Instructors Instructor Education and Training Continuous Faculty Development Certification of Simulation Instructors Accreditation of Simulation Programs, Sites, and Centers Benefits, Effectiveness, and Ecological Validity of Simulation Training Benefits Effectiveness Ecological Validity of Patient Simulation: Is there Transferability to the Real World Cost of Patient Simulation and Simulation Centers Cost of Patient Simulation Cost of Simulation Centers Using Simulation for Assessment of Clinical Performance Benefits Of Simulation-Based Performance Assessment Pitfalls of Simulation-Based Performance Assessment Using Simulation for the Evaluation and Testing of Anesthesia Professionals Simulation Societies and Simulation Journals The Future of Patient Simulation in Anesthesia Appendix 7.1 Online Links and Useful Resources Acknowledgment References 8 8 - Ethical Aspects of Anesthesia Care Clinical Ethics Informed Consent and Informed Refusal Competence and Capacity Disclosure Legal Implications of Informed Consent Informed Refusal Special Issues in Informed Consent and Informed Refusal The Jehovah’s Witness Patient The Pediatric Patient and Other Patients With Impaired Competence Ethical Challenges of Preoperative Testing Routine Preoperative Testing Protocols Routine Preoperative Pregnancy and Human Immunodeficiency Virus Testing Ethics of Anesthesia Involving Pregnant Women Maternal-Fetal Conflicts Informed Consent in Laboring Women The Uncooperative Patient—Coercion and Restraint Truth Telling—Disclosure of Errors and Apology Advance Directives and Surrogate Decision Makers Medical Decisions That May Require a Court Order Do-Not-Attempt-Resuscitation Orders in the Operating Room End-of-Life Decision Making Withdrawal or Withholding of Medical Therapies Terminal Sedation Neuromuscular Blocking Drugs Implantable Cardiac Devices Physician-Assisted Suicide and Euthanasia Ethical Issues in Organ Transplantation Brain Death Donation after Cardiac Death Research Ethics Human Subject Research Children as Research Subjects Ethics of Animal Research Physician Participation in Executions Moral Integrity—can the Physician be a Conscientious Objector in Medicine References 9 9 - Consciousness, Memory, and Anesthesia Introduction Scientific and Clinical Importance Consciousness Definitions Subcortical Nuclei Regulating Arousal Brainstem Hypothalamus Role of the Thalamus Cortical-Subcortical Connectivity Cortical Connectivity and Dynamics Memory History and Terminology Organization and Function of Normal Memory Multiple Memory Systems Long-Term Potentiation, Synaptic Tagging, and the Consolidation Model of Memory Reconsolidation Phase Synchronization and Coupling Effects of Anesthetic Drugs on Declarative Memory Function in Humans Behavioral Studies of Retrograde Memory Effects Mathematical Modeling of Anesthetic Amnesia Anesthetic Effects on Attention and Arousal as Modulators of Encoding Neuroimaging Studies of Cortical Encoding Processes Neuroimaging Studies of Medial Temporal Lobe Function Studies of Cortical Event-Related Potentials Anesthetic Effects on Medial Temporal Lobe Plasticity Human and Nonhuman Studies of Anesthetic Effects on Fear Memory Systems The Amygdala-Dependent Fear System Studies of Anesthetic Effects on Fear Systems in Nonhumans Studies of Anesthetic Effects on Fear Systems in Humans Clinical Relevance Anesthetic Effects on Implicit Memory Function References 10 10 - Sleep Medicine Physiology Evolution Circadian Rhythms Sleep Stages and Sleep Cycles Neuroanatomy of Sleep Sleep-Promoting and Arousal Pathways How to Assess Sleep Questionnaires Actigraphy Respiratory Polygraphy Polysomnography Sleep Laboratory Testing Out-of-Center Testing Scoring of Sleep and Sleep Disordered Breathing Sleep and Breathing Respiratory Regulation During Sleep Sleep-Disordered Breathing Obstructive Sleep Apnea Central Sleep Apnea Obesity Hypoventilation Syndrome Sleep and Anesthesia: Two Unequal Twins Influencing Perioperative Medicine Clinical Picture of Sleep and Anesthesia Activation of Sleep-Promoting Pathways During Anesthesia Perioperative Interactions Between Anesthesia and Sleep Sleep-Disordered Breathing and Airway Patency During Anesthesia Perioperative Management in Patients with Sleep-Disordered Breathing Preoperative Screening Perioperative Management of Patients with Possible Sleep-Disordered Breathing Knowledge Gaps and Future Research Sleep and Sedation in the Intensive Care Unit Noise and Light Exposure Medication and Medical Procedures Sleep and Sedation in the Intensive Care Unit Pharmacological Treatment of Sleep Disturbances in Intensive Care Unit Patients Consequences of Sleep Disturbance in ICU Patients Perioperative Management of Other Sleep Disorders Narcolepsy Restless Legs Syndrome and Periodic Limb Movement Disorder Acknowledgment References 11 11 - Cerebral Physiology and the Effects of Anesthetic Drugs The Anatomy of the Cerebral Circulation Cerebrospinal Fluid Formation and Circulation Regulation of Cerebral Blood Flow Myogenic Regulation (Autoregulation) of Cerebral Blood Flow Chemical Regulation of Cerebral Blood Flow Cerebral Metabolic Rate Neurogenic Regulation of Cerebral Blood Flow Effects of Blood Viscosity on Cerebral Blood Flow Cardiac Output An Integrated Contemporary View of Cerebral Autoregulation Vasoactive Drugs Systemic Vasodilators Catecholamine Agonists and Antagonists Age Effects of Anesthetics on Cerebral Blood Flow and Cerebral Metabolic Rate Intravenous Anesthetic Drugs Barbiturates Propofol Etomidate Narcotics Benzodiazepines Droperidol Ketamine Lidocaine Inhaled Anesthetics Volatile Anesthetics Nitrous Oxide Muscle Relaxants Nondepolarizing Relaxants Succinylcholine Other Effects of Anesthetics on Cerebral Physiology Cerebrospinal Fluid Dynamics Blood-Brain Barrier Epileptogenesis Volatile Anesthetics Methohexital Ketamine Etomidate Propofol Narcotics Neonatal Anesthetic Neurotoxicity Cerebral Physiology in Pathologic States Cerebral Ischemia—Pathophysiologic Considerations Critical Cerebral Blood Flow Thresholds Models of Cerebral Ischemia Energy Failure and Excitotoxicity The Nature of Neuronal Death Timing of Neuronal Death Brain Protection Considerations Relevant to Complete Global Ischemia (Cardiac Arrest) Considerations Relevant to Focal (Incomplete) Ischemia Cerebral Ischemia: Influence of Physiologic Variables Anchor 1081 Summary of Anesthetics and Neuroprotection Deferring Elective Procedures After Stroke Chronic Arterial Hypertension Intracranial Hypertension Brain Tumors Coma and Epilepsy References 12 12 - Neuromuscular Physiology and Pharmacology Neuromuscular Transmission Morphology Quantal Theory Neuromuscular Junction Formation of Neurotransmitter at Motor Nerve Endings Nerve Action Potential Synaptic Vesicles and Recycling Process of Exocytosis Acetylcholinesterase Postjunctional Acetylcholine Receptors Synthesis and Stabilization of Postjunctional Receptors Basic Electrophysiology of Neurotransmission Drug Effects on Postjunctional Receptors Classic Actions of Nondepolarizing Muscle Relaxants Classic Actions of Depolarizing Muscle Relaxants Nonclassic and Noncompetitive Actions of Neuromuscular Drugs Desensitization Block Channel Block Phase II Block Biology of Prejunctional and Postjunctional Nicotinic Acetylcholine Receptors Postjunctional Conventional Acetylcholine Receptors in Muscle Versus Neuronal Acetylcholine Receptors in Muscle Maintenance of Mature Neuromuscular Junctions Re-Expression of Immature (Fetal) γ-Subunit and α7-Subunit Acetylcholine Receptors in Adult Life Prejunctional Acetylcholine Receptors Neuromuscular Junction at Extremes of Age Newborn Old Age References 13 13 - Respiratory Physiology and Pathophysiology Respiratory Physiology Is Central to the Practice of Anesthesia Pulmonary Physiology in Health Respiration in the Cell Transport of O2 in the Blood Transport of Co2 in the Blood Oxygenation in the Pulmonary Artery Ventilation Alveolar Ventilation Dead Space Ventilation Static Lung Volumes—Functional Residual Capacity Respiratory Mechanics Compliance of the Respiratory System Resistance of the Respiratory System Airways Tissue Inertia or Acceleration of Gas and Tissue Distribution of Inspired Gas Airway Closure Diffusion of Gas Perfusion Distribution of Lung Blood Flow Distribution of Blood Flow in the Lung: the Effect of Gravity Distribution of Blood Flow in the Lung: Influence of Factors Not Related to Gravity Hypoxic Pulmonary Vasoconstriction Clinical Assessment of Lung Function Spirometry—Total Lung Capacity and Subdivisions Diffusing Capacity (DLCO)—Diffusion Across Alveolar-Capillary Membranes Surface Area Membrane Thickness Pressure Gradient Molecular Weight and Solubility Intraoperative Respiratory Events Respiratory Function During Anesthesia Lung Volume and Respiratory Mechanics During Anesthesia Lung Volume Compliance and Resistance of the Respiratory System Atelectasis and Airway Closure During Anesthesia Prevention of Atelectasis During Anesthesia Positive End-Expiratory Pressure Recruitment Maneuvers Minimizing Gas Resorption Maintenance of Muscle Tone Atelectasis Following Surgery Airway Closure Distribution of Ventilation and Blood Flow During Anesthesia Distribution of Ventilation Distribution of Lung Blood Flow Hypoxic Pulmonary Vasoconstriction Ventilation-Perfusion Matching During Anesthesia Dead Space, Shunt, and Ventilation-Perfusion Relationships CO2 Elimination Oxygenation Factors that Influence Respiratory Function During Anesthesia Spontaneous Breathing Increased Oxygen Fraction Body Position Age Obesity Preexisting Lung Disease Regional Anesthesia Causes of Hypoxemia and Hypercapnia Hypoventilation Ventilation-Perfusion Mismatch Effect of on CO2 Elimination Impaired Diffusion Right-to-Left Shunt Respiratory Function During One-Lung Ventilation Pneumoperitoneum Lung Function After Cardiac Surgery Protective Ventilation Postoperative Physiotherapy Intraoperative Hyperoxia Effect of Sleep on Respiration References 14 14 - Cardiac Physiology Physiology of the Intact Heart CARDIAC CYCLE Electrical Events and the Electrocardiogram Mechanical Events Ventricular Structure and Function Ventricular Structure Ventricular Function Cardiac Output Cellular Cardiac Physiology Cellular Anatomy Cardiomyocyte Structure and Function Excitation System Excitation-Contraction Coupling Contractile System Control of Cardiac Function Neural Regulation of Cardiac Function Hormones Affecting Cardiac Function Sex Steroid Hormones and the Heart Cardiac Reflexes Baroreceptor Reflex (Carotid Sinus Reflex) Chemoreceptor Reflex Bainbridge Reflex Bezold-Jarisch Reflex Valsalva Maneuver Cushing Reflex Oculocardiac Reflex Acknowledgment References 15 15 - Gastrointestinal Physiology and Pathophysiology Introduction Gastrointestinal Anatomy and Function Transit Time in Health and Disease Methods of Evaluating Colonic Motility The Effects of General Anesthesia on Bowel Function Effect of Opioids on Bowel Function Effect of Open Abdominal Surgery, Ischemia, Stomas, and Bowel Anastomosis on Gastrointestinal Physiology and Function Gastrointestinal System Nociception Abdominal Viscera Innervation Celiac Plexus Anatomy Abdominal Visceral Pain Visceral Pain Treatment Visceral Pain Block Techniques Visceral/Celiac PLEXUS Block Intraperitoneal Regional Anesthesia or Peritoneal Lavage Celiac Plexus Block—Posterior and Trans-Crural Approach Celiac Plexus Block—Anterior Approach Endoscopic Ultrasound-Guided Celiac Plexus Block Technical Aspects of Visceral Plexus Blocks Complications of Visceral Pain Blocks Indications for a Visceral Pain Block Post-Laparatomy Pain Relief Cancer Pain Effects of Regional Anesthesia on Gastrointestinal Physiology Effect on Gastrointestinal Motility and Postoperative Ileus Effect on Enteric Anastomosis Dehiscence Effect on Nutrition Effect on Postoperative Nausea and Vomiting Effect on Gastrointestinal Blood Flow and Volume Enhanced Recovery After Surgery for Gastrointestinal Procedures— Physiologic Basis Physiologic Basis of Eras Perioperative Pain Control Preoperative Carbohydrate Loading and Early Postoperative Feeding Temperature Control Nasogastric Tubes Bowel Preparation Drains Fluid Management Mobilization and Early Ambulation Acknowledgment References 16 16 - Hepatic Physiology, Pathophysiology, and Anesthetic Considerations Surgical Anatomy, Hepatic Blood Flow, and the Biliary Tree Cellular Anatomy Liver Lobule and Acinus Hepatocytes Hepatic Stellate Cells Myeloid Cells Lymphocytes Hepatic Physiology Drug Metabolism Protein Metabolism Carbohydrate Metabolism Lipid Metabolism Bile and Enterohepatic Circulation Role of the Liver in Coagulation Heme Metabolism, Bilirubin, and Porphyrias Hepatic Regulation of Hormones Evaluation of the Liver Clinical Assessment Standard Laboratory Tests Detection of Hepatocellular Injury Aminotransferases Lactate Dehydrogenase Glutathione-S-Transferase Detection of Cholestatic Disorders Alkaline Phosphatase Serum Bilirubin Assessment of Hepatic Protein Synthesis Serum Albumin Prothrombin Time Testing for Diagnosis of Specific Diseases Testing in Management and Prognosis of Liver Disease Noninvasive Serum Testing for Fibrosis Quantitative Liver Tests Measurement of Hepatic Blood Flow Clearance Techniques Indicator Dilution Techniques Direct Measurements Radiologic Methods Hepatic Pathophysiology Cholestatic Disease Primary Biliary Cholangitis Primary Sclerosing Cholangitis Cirrhosis Ascites Renal Failure and Hepatorenal Syndrome Hepatic Encephalopathy Pulmonary Complications Hepatocellular Carcinoma Hepatic Effects of Anesthetic Agents Inhalational Anesthetics Nonhepatic Surgery in Patients With Liver Disease Anesthetic Considerations for Procedures Involving the Liver Strategies for Minimizing Blood Loss Low Central Venous Pressure Other Approaches to Reduce Blood Loss Anesthetic Management Enhanced Recovery After Surgery and Liver Resection Acknowledgment References 17 17 - Renal Anatomy, Physiology, Pharmacology, and Evaluation of Function Introduction Organization of the Kidney The Nephron The Renal Tubules Formation of Urine Glomerular Filtration Mediator Control of the Glomerular Filtration Rate The Dopaminergic System Adenosine Nitric Oxide Renal Tubular System Physiology The Loop of Henle Distal Tubules and Macula Densa Collecting Tubules Collecting Ducts Renal Autoregulation Autoregulation of Renal Blood Flow The Myogenic Mechanism of the Renal Blood Flow Autoregulation Tubuloglomerular Feedback Maintenance of Plasma Osmolality Definition Regulation of Osmolality Role of Proximal Tubules and Loop of Henle Medullary Interstitium Vasa Recta The Role of Urea Renal Control of Intravascular Volume Hypovolemia Hypervolemia Clinical Tests for Renal Function46,47 Urine Output Creatinine Blood Urea Nitrogen Renal Clearance Techniques Measurement of Tubular Function Effect of Anesthetics on Renal Function Effects of Mechanical Ventilation on Renal Function Induced Hypotension Acknowledgment References 18 18 - Basic Principles of Pharmacology Introduction Fundamental Pharmacokinetic Concepts Volume of Distribution Clearance Physiologic Model for Clearance Hepatic Biotransformation Pharmacokinetic Models Physiologic Models Compartmental Models Zero Versus First-Order Kinetics One-Compartment Model Multicompartment Models Special Interests in Anesthetic Pharmacokinetics Front-End Kinetics Back-End Kinetics Hysteresis Pharmacodynamic Principles Potency and Efficacy Effective Versus Lethal Doses Anesthetic Drug Interactions Drug Displays Special Populations Influence of Obesity on Anesthetic Drugs Propofol Opioids Remifentanil Dosing Scalars Remifentanil Kinetic Models for Target-Controlled Infusions Fentanyl Other Opioids Inhaled Anesthetics Influence of Age on Anesthetic Drug Pharmacology Summary References 19 19 - Inhaled Anesthetics: Mechanisms of Action History The Unified Paradigm of Anesthetic Theories Minimum Alveolar Concentration―A Bridge Between Past and Present Shift From Lipid- to Protein-Centered Mechanisms Diversity of Potential Anesthetic Targets Anesthesia: A Composite Neuropharmacologic State Integrated Effects on Central Nervous System Function Immobility Unconsciousness Learning and Memory Sedation Identification of Molecular Sites of Anesthetic Action Criteria for Identifying Sites Relevant to Anesthesia Physicochemical Properties of Anesthetic Binding Sites From Model Proteins to Receptors Molecular Targets of Inhaled Anesthetics Ligand-Gated ION Channels Potentiation of Inhibitory GABAA and Glycine Receptors Inhibition of Excitatory Acetylcholine and Glutamate Receptors Voltage-Gated and other ION Channels Na+ Channels Ca2+ Channels K+, HCN, and TRP Channels Intracellular Signaling Mechanisms G-Protein–Coupled Receptors Protein Phosphorylation Gene Expression Cellular Mechanisms Neuronal Excitability Presynaptic Versus Postsynaptic Effects on Synaptic Transmission Simple Circuits and Complex Networks Simple Circuit Phenomena Synaptic Plasticity Spontaneously Active Circuits Rhythms and Simulations δ-Rhythms and Other Slow Rhythms θ-Rhythms γ-Rhythms Models and Simulations Research Strategies for the Future Pharmacologic Approaches Agonists, Antagonists, and Experimental Anesthetics Nonimmobilizers Photoreactive Anesthetics Genetic Approaches Whole-Organism Genetics Molecular Genetics Knockout and Knockin Animals Forward and Population Genetics Functional Imaging and High-Density Electroencephalography Summary References 20 20 - Inhaled Anesthetic Uptake, Distribution, Metabolism, and Toxicity Introduction Uptake and Distribution of Inhaled Anesthetics Biophysical Properties of Inhaled Anesthetics: Partial Pressure, Hydrophobicity, and Partition Coefficients Anesthetic Delivery, Uptake, and Distribution: a Multicompartmental Model Upstream and Downstream Compartments and Anesthetic Transfer: Bulk Flow and Pressure Gradients Rate of Wash-In of the Circuit: Equilibration Between Vaporizer and Circuit Equilibration Between Circuit and Pulmonary Airspace The Alveolar Anesthetic Concentration Alveolar Uptake of Anesthetic into Pulmonary Blood Other Factors That Affect the Rate of Rise of Palv Distribution of Anesthetic into Tissues The Mixed Venous Anesthetic Partial Pressure Synthesis of the Model and Inhaled Anesthetic Induction: PK/PD Pharmacodynamic Effects of Anesthetics on Uptake and Distribution The Effect of Nitrous Oxide on Gas-Filled Spaces Recovery from Anesthesia Similarities and Differences to Induction Context Sensitive Recovery from Anesthesia Percutaneous and Visceral Anesthetic Loss Effect of the Anesthetic Circuit Clearance via Metabolism of Anesthetics Additional Considerations and Possibilities Diffusion Hypox