Theodore H. Stanley, M.D. W. Clayton Petty, M.D. Anesthesiology 1986 contains the Refresher Course manuscripts of the presentations of the 31st Annual Postgraduate Course in Anesthesiology which took place at the Westin Hotel Utah Convention Center in Salt Lake City, Utah, February 14-18, 1986. The chapters reflect recent and future developments in anesthetic techniques, monitoring instruments and devices, and anesthetic drugs. The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting, and 2) serve as a vehi cl e to bri ng many of the 1 atest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesi a expressed at the conference. Thi s book and its chapters should not be considered complete treatises on the subjects addressed but rather attempts to summarlze the most salient points. This textbook is the fourth in a continuing series documenting the proceedings of the Postgraduate Course in Salt Lake City. We hope that this and the past and future volumes reflect the rapid and continuing evolution of anesthesiology in the late twentieth century. TABLE OF CONTENTS PHARMACOLOGY The New Neuromusucular Blocking Agents D. Ryan Cook, M.D.

Brain injury is one of the most unacceptable complications sustained during heart surgery. This book presents the current results and thinking of a number of leading clinical investigators in this area. Nearly all have been active in serious studies designed to define various aspects of brain physiology, patho physiology, or protection during cardiac operations performed with cardio pulmonary bypass. We were particularly interested in obtaining contributions from younger investigators. Brain injury is a problem which has long troubled those involved with perioperative care of the cardiac surgical patient. The first chapter by Dr. Torkel Aberg presents a summary of his extensive investigations into this problem. It is intended both to present the perspective of a surgeon interested in this problem, and to serve as an introduction to the overall issue of avoiding brain injury during heart surgery. The next three chapters discuss the problem of perfusion pressure, outcome, and brain blood flow. Dr. Sarnquist's contribution stems from his extensive experience with low flow bypass as practiced at Stanford University and the results of the studies he performed in collaboration with Dr. Fish. Drs. Govier and Reves discuss in some detail the general effects of anesthetic agents upon brain metabolic needs as well as their important data demonstrating preserva tion of brain blood flow autoregulation during cardiopulmonary bypass (CPB) as practiced at the University of Alabama. Finally Dr."

This treatise commemorates the 32nd anniversary of the first successful allogenic kidney transplant in a human being and the beginning of a con tinuing challenge for well over a generation of anesthesiologists. If compari sons can be permitted, this epoch-making event can be ranked with the first pulmonary lobectomy and subsequently the initial ligation of a patent ductus arteriosus in the late 1930s when thoracic and cardiac surgery began. Was it merely a coincidence that brought these events to the fore so close upon one another after many years of ideation and frustration? Not so, according to Lewis Thomas, for this was the time of medicine's second revolution-its transformation from an empirical art into a powerfully effective science. The remote Galenic conception of disease with its emphasis on disturbed body humors was about to be supplanted by effective therapeutics, as signified by the introduction of the sulfonamides and antibiotics for the specific treatment of infection. Anesthesiology had been dormant up to that era, still relying upon a few agents, more or less utilized from the beginning, and purveyed by a handful of specialists who had not yet begun to ask the scientific questions necessary for their maturation into a bona fide discipline. However, anesthesiology was in evitably caught in the ferment, for as Peter Caws observed, "It serves to re mind us that the development of science is a step-wise process: nobody starts from scratch and nobody gets very far ahead of the rest."

Patients with pain disorders pose many clinical challenges for the attending physician. Even experienced clinicians occasionally arrive at the point where diagnostic, work-up, treatment, or prognostic thinking becomes blocked.
Pain teaches the reader to recognize and appropriately treat a variety of pain disorders using a case study format. Divided into three section, chronic pain conditions, chronic pain and related disorders, and treatment overview, and derived from consultation requests from providers in medical practice, the cases are written in a format that encourages the reader to formulate a differential diagnosis and treatment plan for a variety of pain problems. Succinct in its presentation and logical in its layout, Pain is the perfect resource for the busy practitioner on the go.

The diagnosis of cancer inspires fear, in part because of the high mortality rate associated with most malignancies, and in part because of the perception that cancer is a painful disease. Recently compiled statistics tend to support patients' fears. Pain is a major symptom in 70% of patients with advanced cancer [1]. Half of all patients undergoing anticancer therapy experience pain [2]. It has been estimated by members of the World Health Organization that 3. 5 million people worldwide suffer from cancer pain. One study of the severity of cancer pain estimates that pain is moderate to severe in 50% of cancer pain patients, very severe or excruciating in 30% [3]. An analysis of several reports of patients in developed countries estimates that 50-80% of patients had inadequate relief [2]. In underdeveloped countries, adequacy of treatment may be far lower because of lack of availability of medical facilities and legal constraints on the use of potent narcotics. The picture need not be this bleak. The reality is that, for most patients, cancer pain is relatively easy to control with simple, inexpensive measures. Several studies have indicated that cancer pain can be well controlled with oral morphine in over 90% of patients [4,5]. Long-acting orally effective opiate preparations such as time release morphine, methadone, and levorphanol allow patients to sleep comfortably through the night. When the oral route is impossible, narcotics can be administered rectally or by intravenous or subcutaneous infusion.

A definitive, comprehensive text on the technological developments and clinical applications of this critical subject matter. Written for the entire heart surgery team, this volume covers the physiology of cardiopulmonary bypass, mechanics and components of the heart-lung machine, the conduct of cardiopulmonary bypass in cardiac surgery, non-cardiac applications of cardiopulmonary bypass, and mechanical assistance of the failing heart and lung. The authors also give special consideration to such areas as blood conservation in cardiac surgery, religions objections to blood transfusions, medical-legal aspects and cardiopulmonary bypass, as well as warm blood cardioplegia and normothermic cardiopulmonary bypass.

One of the most exciting developments in medicine in this century has been the discovery of opioid receptors and their pharmacology. The breadth of know- edge derived from such discovery has truly changed the practice of medicine today. The acceptance by the clinicians of the research data obtained by the basic scientist on spinal opioids is truly amazing. The clinical sequelae of the discovery of opioid receptors has been the development of the technique of intraspinal administration of opioids. In the last decade much has been written about indications, effects, and side effects of intraspinal opioids. The technique has become commonplace for cancer and postoperative pain. However, no standards of care and management of patients with spinally administered opioids have been developed. We need these standards to be developed and universally followed. The monograph was conceived to update clinicians on the applied pharma cology of spinal opioids. We were fortunate to have Drs. N. Rawal and D. Coombs agree to edit this monograph. They have been able to assemble world-renowned experts as contributing authors. It is our hope that the con tents of this book will be stimulating, informative, and useful to the reader. PREFACE Much has been written about the subject of spinal opioid analgesia, includ ing several notable reviews. We were stimulated to assemble this particular volume in this important series on pain management initiated by Dr. Raj for a number of reasons."

Theodore H. Stanley, M. D. What's New in, Anesthesiology in 1988 contains the Refresher Course manuscripts of the presentations of the 33rd Annual Postgraduate Course in Anesthesiology which took place at the Marriott Hotel Convention Center in Salt Lake City, Utah, February 19-23, 1988. The chapters reflect new data, ideas and concepts within the general framework of most recent developments in "evaluation and monitoring cardiac function before, during and after surgery," "new anesthetics and their actions on the heart and peripheral vasculature, and other organ systems," "metabolism and elimination of anesthetics and anesthetic adjuvants," and "recent developments in the anesthetic management of patients with congenital heart disease, renal and pulmonary dysfunction, and diabetes insipidus. " In addition, there are chapters on new developments in "obstetrics," "regional anesthesia," and "anesthetic management of the newborn. " The purposes of the textbook are to 1) act as a reference for the anesthesio logists attending the meeting, and,2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference. This book and its chapters should not be considered complete treatises on the subjects addressed but rather attempts to summarize the most salient points. This textbook is the sixth in a continuing series documenting the proceedings of the Postgraduate Course in Salt Lake City."

On 16 October 1846, an itinerant New England dentist named William T. G. Morton proved the anesthetic effect of diethyl ether in a public demonstration in the "ether dome" of the Bulfinch Building of the Massachusetts General Hospital in Boston. The patient, Gilbert Abbott, suffered no pain, and the surgeon, Dr. John C. Warren, was able to complete a suture ligature of a vas cular tumor of the jaw without the hurry that until then was so necessary. The operation proved a failure, since the tumor recurred; but the demonstration of ether's anesthetic effect was a great success. Operative pain was conquered, and surgery could advance from a crude and unscientific practice where speed was paramount, and the major body cavities could not be entered, into the unique blend of science and art that it is now. "Gentlemen, this is no hum bug," supposedly muttered Warren, perhaps the last noncontroversial assess ment of anesthesiology to be made by a surgeon. The screams of resisting patients in pain were stilled, and quiet entered the operating room for the first time. But the new science of pain relief was quickly wrapped in controversy. An argument immediately arose as to who could legitimately claim primacy for the discovery. Morton's attempt to hide the true nature of his anesthetic agent, coupled with an effort to patent the discovery, clouded his reputation and stimulated other claimants to push themselves forward."

The pain center/clinic is in the stage of transition. It has come a long way since chronic pain was a nonexistent entity and patients with difficult pain problems did not receive well-deserved attention or were lost in the busy practices of vari ous specialty clinics. Thirty-five years ahead of the rest of us, John]. Bonica was the first physician who had a clear vision of a pain center's potential. Twenty years later, in response to loud public demands for relief of chronic pain, this idea was put into practice by a number of others on a somewhat larger scale. A team of specialists from various disciplines, trained in the management of chronic pain, now offer approaches ranging from simple outpatient care to inpatient hospital ization for comprehensive care including drug detoxification, behavior modi fication, and total rehabilitation of these patients. Hospitals have entered this arena with renewed enthusiasm. The pain center/clinic is now an established, ac cepted, and expanding method of providing care for chronic pain patients. The chapters in this book are based on examples of multidisciplinary projects that deal comprehensively with management of chronic pain. Aimed primarily at the pain center/clinic in the university hospital setting, this book ranges from his torical perspectives to current pain centers with their less orthodox methods of re lieving chronic pain to the future of algology as a specialty."

It is a pleasure to have the privilege of writing the foreword for a book edited by Dr. Francis F. Foldes. Dr. Foldes has collected in one convenient place a discussion and description of enzyme systems of use to the anesthesiologist and to those other individuals, such as undergraduate and graduate students in related basic sciences, who will profit by and can make use of this body of information. The practicing anesthesiologist and those who work in related fields have become increasingly aware of the need to understand enzyme activities which influence the uptake, distribution, and excretion of those substances that are used in the anesthetic management of surgical patients. A variety of such is obvious when one considers that such diverse substances as activities and muscle re analgesic drugs, tranquilizers, hypnotics, anesthetic agents, laxants are strongly affected by these systems and have an influence over the basic understanding of how these drugs operate and act in the body, as well as providing a safety measure so necessary to the proper conduct of clinical anesthesia. The editor and his colleagues have rendered us a great service in collecting information that deals with the basic activity of enzymes including their structure, their kinetics, and to the degree that knowledge permits, mechanism of actions."

Second only to the common cold, pain is the most common reason for health care visits. It results in significant personal and social costs to individuals, and economic costs to society. Chronic pain has been estimated to cost more than 100 billion annually in the United States, and its estimated annual cost to European countries ranges from 1.1 to nearly 50 billion Euros (nearly 1.5 billion to over 60 billion dollars). In order to treat pain, clinicians need to be able to assess pain and its effects on functioning. However, 100s, if not 1000s, of different measures of pain and pain-related domains exist. Surprisingly, despite the fact that much is known about the psychometrics strengths and weaknesses of existing measures, there does not yet exist a simple pain assessment guide that describes the most useful and psychometrically sound pain measures for health care providers. This book fills this need.

Ronald Brisman, M.D. This book will discuss three areas where the The multiplicity of procedures with varying neurosurgeon may provide an important degrees of risks and benefits sometimes re contribution to the relief of intractable pain: quires a sequential approach, but always an trigeminal and other facial neuralgias, chronic individual one, matching an appropriate treat noncancer pain, and cancer pain. By one ment plan or procedure for a particular patient intervention, the neurosurgeon often may pro at a specific time in his or her illness. vide long-lasting pain relief. New techniques, The neurosurgical chapters in this book which have developed since the 1970s and represent my experience with several hundred continue to evolve, dominate the neurosur patients during a 12-year period from 1975 gical armamentarium because they are not only through 1987. I have relied heavily on the effective, but safe. These include percutaneous works of others, which have been quoted from radio frequency electrocoagulation for trigem the neurosurgical literature, but this book is inal neuralgia, spinal stimulation for chronic not meant to be encyclopedic. noncancer pain, and intraspinal morphine in At least as important as knowing when to fusion for cancer pain. operate is knowing when not to do so, and this Sometimes a procedure relieves pain but the is particularly true of the treatment of pain. pain recurs; it may be necessary to repeat the Most patients with pain do not require neuro procedure, which in the case of radiofrequency surgical intervention."

This handbook is an up-to-date, evidence based quick, easy reference guide for expert regional anesthesia providers. It will also be an invaluable tool and a great entry point for amateurs' sonographers who wish to understand the basics of ultrasound, its uses for diagnosis and treatment, current guidelines and standards of care. It presents in details challenges, stratification of risks, techniques, and approaches to facilitate effective ultrasound use in perioperative pain control and emergency room pain management. This uses an outline, schematic approach for easy understanding and retention. The applications of ultrasound are vast and cover the full spectrum of ultrasound guided regional anesthesia. This book concentrates and encompasses the most clinically relevant information as a first aid use of perioperative ultrasound. The chapters are concise, focusing on clinical presentations, diagnosis, differential diagnosis which will help you to deliver patient care in a timely and skillful manner. This compact book is packed with relevant, remarkable information related to ultrasound guided techniques and evidence-based protocols and latest guidelines for regional anesthesia, nerve blocks, and opioid-reducing analgesia to promote early recovery after surgery. Concise, practical, and clinically applicable for various specialties, this book fills the unmet need for understanding the usefulness and techniques of ultrasound and its application in perioperative pain management, in particular regional anesthesia and nerve blocks. This handbook enables every physician, nurse, resident and all medical staff to understand the essentials of ultrasound and regional anesthesia, its evolving techniques, and the use of modern equipment to provide patient care safely.

All anesthesiologists eventually face the fear of a "near miss," when a patient's life has been put at risk. Learning from the experience is crucial to professionalism and the ongoing development of expertise. Drawing on forty-plus years of practice in major metropolitan hospitals in the United States, Norway, and South Africa, John Brock-Utne, MD presents 80 carefully selected cases that provide the basis for lessons and tips to prevent potential disaster. The cases emphasize problem-centered learning and span a broad range of topics-from an outbreak of operating room infection (could it be the anesthesia equipment?), complications of fiberoptic intubations, and problems with epidural drug pumps, to performing an urgent tracheostomy for the first time, working with an aggressive surgeon, and what to do when a patient falls off the operating table during surgery.80 true-story clinical "near misses" never before published, ideal for problem-centered learning, recommendations, references, and discussions accompany most cases, rich basis for teaching discussions both in or out of the operating room, settings include sophisticated as well as rudimentary anesthetic environments, complements the author's other case book, "Clinical Anesthesia: Near Misses and Lessons Learned" (Springer, 2008).

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Mechanical ventilation is an essential life-sustaining therapy for many critically-ill patients. As technology has evolved, clinicians have been presented with an increasing number of ventilator options as well as an ever-expanding and confusing list of terms, abbreviations, and acronyms. Unfortunately, this has made it extremely difficult for clinicians at all levels of training to truly understand mechanical ventilation and to optimally manage patients with respiratory failure. Mechanical Ventilation was written to address these problems. This handbook provides students, residents, fellows, and practicing physicians with a clear explanation of essential physiology, terms and acronyms, and ventilator modes and breath types. It describes how mechanical ventilators work and explains clearly and concisely how to write ventilator orders, how to manage patients with many different causes of respiratory failure, how to "wean" patients from the ventilator, and much more. Mechanical Ventilation is meant to be carried and used at the bedside and to allow everyone who cares for critically-ill patients to master this essential therapy.

Thoracic anaesthesia is regarded as a post fellowship sub-speciality within anaesthesia, and can be daunting. This handbook provides an easily accessible, informative, and palatable guide to this often complex subject. The text is sub-divided into basic sciences, pre-operative assessment, diagnostic procedures, and an anaesthetist's walk-through of key thoracic surgical procedures. It concludes with an emergency section covering thoracic anaesthesia emergencies, critical care, and the thoracic surgical patient, and ends with essential guidance on the relevant practical procedures necessary to manage cases. The text provides an essential reference for the core curriculum of the Fellowship of the Royal College of Anaesthetists and for the day-to-day practice of post fellowship anaesthetists alike. The discussions of the surgical procedures are simple, highlighting the poignant stages that can affect the anaesthetic management of the patient. The authors use the very latest evidence in order to keep the reader up to speed with developments in the field. Whether on-call, running day-to-day lists or working within critical care, this indispensable guidebook will optimise the preparedness of all staff in dealing with any case, whether simple or complex.

Advances over the past two decades have enabled physicians to revolutionize the manner in which they can assess and manage children's pain. Thirty years ago it was thought that young children did not experience pain and therefore it was not necessary to treat it. Today professionals from a variety of disciplines have contributed data that have revolutionized medical perspectives. Technological advances now enable doctors to treat acute pain in fetuses, premature neonates, infants, toddlers, children, and adolescents with increasing precision and efficacy. Research highlighting the context of chronic pain has moved them away from a mind-body dichotomy and toward an integrated, holistic perspective that leads to substantial improvement in children's adaptive functioning as well as subjective discomfort.

This book covers these topics and is intended for anyone who provides medical care to children. Each chapter provides an overview of the problem, followed by a "hands on" description of relevant assessment and intervention strategies. The role of the primary care practitioner is highlighted, both as a front-line resource as well as a consumer of specialized pediatric pain treatment services. Each chapter ends with a summary and specific bullet points highlighting the most central elements, making for quick and easy reference.

A panel of prominent clinician-scientists comprehensively reviews the latest developments in pediatric pain management, with special emphasis on the setting in which pain is detected and managed. The authors explore the cutting-edge of children's pain care in inpatient, outpatient, palliative care, school, and residential settings, and describe alternate approaches, including complementary and alternative medicine, pain management via the internet and information technology, and pain care in developing countries.

Ankylosing Spondylitis in Clinical Practice is a concise, practical guide on the diagnosis and management of this debilitating condition. This book is aimed at clinicians who treat Ankylosing Spondylitis. It provides an authoritative, accessible guide to the diagnosis, management and treatment of ankylosing spondylitis.

Neuromodulation implants are currently one of the most successful techniques in the treatment of chronic pain, a condition that affects more and more patients each year, leading to reduced quality of life as well as economic losses.Neuromodulation implants for pain are a relatively new technique and are being increasingly used around the globe. However, technical training is not available for every implanter as there are relatively few centers in the world. Further, refresher courses for low-rate implanters are not available. This book fills that gap by offering an update on the best techniques currently used, providing a step-by-step guide on how to perform these procedures correctly. Based on the experiences of leading physicians in the field, it also discusses how to manage both major and minor complications. Lastly, it covers the neuromodulatory intervention techniques used to treat chronic pain in various clinical areas. As such it is a valuable resource for pain physicians as well as neurosurgeons, orthopedists and anesthetists.