Title Page

Clinical Anesthesia Procedures of the Massachusetts General Hospital, 9th Edition

Editors
Contributors
Preface
Notices and Disclaimers

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Editors

Senior Editor
Richard M. Pino, MD, PhD, FCCM

Associate Editors
Meredith A. Albrecht, MD
Edward A. Bittner, MD, PhD, FCCP, FCCM
Hovig V. Chitilian, MD
Wilton C. Levine, MD
Susan A. Vassallo, MD

Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Contributors

Paul H. Alfille, MD
Chief, Division of Thoracic, Vascular and Neuroanesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Richard W. Anderson, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Keith Baker, MD, PhD
Associate Professor of Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Xiaodong Bao, MD, PhD
Instructor in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Peter L. Bekker, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Clinical Fellow
Harvard Medical School
Boston, Massachusetts

William Benedetto, MD
Instructor in Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Sheri Berg, MD
Instructor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Somaletha Bhattacharya, MD, FFARCSI
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Edward A. Bittner, MD, PhD, FCCP, FCCM
Assistant Professor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Program Director, Critical Care-Anesthesiology Fellowship
Associate Director, Surgical Intensive Care Unit
Massachusetts General Hospital
Boston, Massachusetts

Emery N. Brown, MD
Warren M. Zapol Professor of Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Harvard Medical School

Edward Hood Taplin
Professor of Medical Engineering
Institute for Medical Engineering and Science
Professor of Computational Neuroscience
Department of Brain and Cognitive Sciences
Massachusetts Institute of Technology
Cambridge, Massachusetts

Jessie L. Cassada, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Khan Chaichana, MD
Resident in Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jonathan E. Charnin, MD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Hovig V. Chitilian, MD
Assistant Professor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Director, Liver Transplant Anesthesia
Massachusetts General Hospital
Boston, Massachusetts

Naida Cole, MD, MM
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jessica A. Cox, DACCPM
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Lane C. Crawford, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Negin Daneshpayeh, MD
Resident in Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Mitchell Donner, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Dan Drzymalski, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Harvard Medical School
Boston, Massachusetts

Oleg V. Evgenov, MD, PhD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Stuart A. Forman, MD, PhD
Associate Professor of Anesthesia
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

David G. Frazer, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Margaret Gargarian, MD
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Edward E. George, MD, PhD
Assistant Professor
Harvard Medical School
Medical Director of Post Anesthesia Care Unit
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Matthew C. Gertsch, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Gregory Ginsburg, MD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jeremy Goldfarb, MD
Director
Post Anesthesia Care Unit
Director
Preoperative Medical Evaluation Center
Chief, Inpatient Hospitalist Service, Staff Anesthesiologist
Massachusetts Eye and Ear Infirmary
Clinical Instructor
Harvard Medical School
Boston, Massachusetts

Gaganpreet Grewal, MD
Resident in Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

George M. Hanna, MD
Instructor of Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

P. Grace Harrell, MD
Assistant Professor
Harvard Medical School
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Ryan J. Horvath, MD, PhD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Caroline B. G. Hunter, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Christina Anne Jelly, MD, MSc
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Rebecca Kalman, MD
Instructor in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Tara L. Kelly, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Cindy Kim, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

David J. Kim, MD, MS
Resident in Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

William R. Kimball, MD, PhD
Assistant Professor of Anesthesia
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Michael R. King, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Stephanie L. Lee, MD, PhD
Associate Professor of Medicine
Boston University School of Medicine
Director
Thyroid Health Center
Boston Medical Center
Boston, Massachusetts

Jason S. Lee, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Alexander Y. B. Lee, MD, MBA
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Yiuka Leung, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Wilton C. Levine, MD
Assistant Professor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Associate Medical Director
Perioperative Services
Massachusetts General Hospital
Boston, Massachusetts

Jason M. Lewis, MD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Amber Liu, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Ayumi Maeda, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Solmaz Poorsattar Manuel, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

John J. A. Marota MD, PhD
Assistant Professor
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Courtney Maxey-Jones, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Matthew J. Meyer, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Rebecca D. Minehart, MD, MSHPEd
Assistant Professor of Anesthesia
Harvard Medical School
Assistant Program Director, Anesthesia Residency
Program Director, Obstetric Anesthesia Fellowship
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Alexander D. Moore, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Robert A. Peterfreund, MD, PhD
Associate Professor of Anesthesia
Harvard Medical School
Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

May C. M. Pian-Smith, MD, MS
Associate Professor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Director of Quality and Safety
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Richard M. Pino, MD, PhD, FCCM
Associate Professor of Anesthesia
Harvard Medical School
Vice Chairman for Clinical Affairs
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Michael P. Puglia, MD, PhD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jason Z. Qu, MD
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

James P. Rathmell, MD
Professor of Anesthesia
Harvard Medical School
Executive Vice Chairman
Chief, Division of Pain Medicine
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jessie D. Roberts, Jr., MD
Associate Professor of Anesthesia
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jamie Rubin, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Adeola Sadik, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

William J. Sauer, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Puneet Sayal, MD, MSc
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Ulrich Schmidt, MD, PhD, FCCM
Associate Professor of Anesthesia
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

William B. Schoenfeld, MD
Instructor in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Laurie Shapiro, MD
Assistant Professor
Harvard Medical School
Director
Perioperative Inpatient Evaluation Service
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Milad Sharifpour, MD, MS
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Tao Shen, MBBS
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Kenneth E. Shepherd, MD
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Assistant Professor of Anesthesia
Harvard Medical School
Boston, Massachusetts

Bryan Simmons, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Ken Solt, MD
Associate Professor of Anesthesia
Harvard Medical School
Assistant Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Katherine A. Sparger, MD
Department of Pediatrics
Harvard Medical School
Neonatal and Newborn Medicine Unit
Massachusetts General Hospital
Boston, Massachusetts

Genevieve Staudt, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Michele Szabo, MD
Assistant Professor
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Andrea Torri, MD
Assistant Professor of Anesthesia
Harvard University School of Medicine
Attending Anesthesiologist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Becky Ying Ki Tsui, MD, MPH
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Samuel M. Vanderhoek, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Susan A. Vassallo, MD
Assistant Professor of Anesthesia
Harvard Medical School
Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Rafael Vazquez, MD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Olof Viktorsdottir, MD
Instructor in Anesthesia
Harvard Medical School
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Lisa Warren, MD
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Elizabeth Cox Williams, MD
Instructor in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Zhongcong Xie, MD, PhD
Professor of Anesthesia
Harvard Medical School
Associate Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Marc D. Yelle, MD, PhD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Preface

In the late 1970s, Dr. Richard Kitz, as the Anaesthetist-in-Chief at Massachusetts General Hospital, had a vision for a “manual of anesthetic
practice, written primarily by recent house staff ” that was “intended to be the foundation of practical knowledge for the inexperienced or incompletely
trained anesthetist.” The ninth edition of Clinical Anesthesia Procedures of the Massachusetts General Hospital continues this tradition. It was written by
residents and attending staff of the Department of Anesthesia, Critical Care, and Pain Medicine at the Massachusetts General Hospital. Often, the senior author, now a board certified anesthesiologist, was the “resident author” for the previous edition. For almost 40 years and with the help of over 200 peo-
ple, the Clinical Anesthesia Procedures of the Massachusetts General Hospital has been routinely updated to meet the needs of our ever-changing field.

Similar to the past editions, this manual continues to emphasize the clinical fundamentals needed for the safe administration of anesthesia and perioperative care for our patients. The suggestions reflect the current clinical practice at MGH, represent the foundation of the educational programs for our residency and fellowship programs, and complement more extensive readings in other published works and Internet sources. It is designed to be an easily accessible and accurate source of information for practicing anesthesiologists, nurse anesthetists, anesthesia assistants, trainees in anesthesia and other disciplines, medical students, and health care professionals interested in perioperative care. It is intended to augment experienced clinical teaching and inspire more detailed study stimulated by updated references for each chapter.

I wish to gratefully acknowledge the many past editors of, and contributors to, the previous editions of this handbook. I have enjoyed working with Ms. Nicole Dernoski and her talented editorial staff at Lippincott Williams & Wilkins. I am indebted to Richard J. Kitz, MD, and Hassan Ali, MD, for their mentorship and friendship over the years and to Jeanine Wiener-Kronish, MD, Anesthetist-in-Chief, for her ongoing support. Mack Thomas, MD, inspired me to start on the path to anesthesia and critical care when I was a medical student at LSUMC and purchased the third edition of the handbook. I never remotely dreamed that I would eventually be given the privilege of being one of the editors.

I hope that you find this edition helpful as you pursue the very rewarding and evolving field of anesthesia.

Finally, this handbook could not have been revised without the endless love, support, and patience of my wife, Patti, and son, Daniel.

Richard M. Pino, MD, PhD, FCCM

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