Title Page

Handbook of Clinical Anesthesia Procedures of the Massachusetts General Hospital, Tenth Edition

Copyright © 2022 Wolters Kluwer. All rights reserved.
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Editors

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

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

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

Contributors

Mark Abraham, MD*
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Christopher M. Aiudi, MD, PharmD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Daniel Ankeny, MD, PhD
Instructor in Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

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

Xiaodong Bao, MD, PhD
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Diana Barragan-Bradford, MD
Fellow in Critical Care
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Gloria Nadayil Berchmans, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Sheri M. Berg, MD
Assistant Professor of Anesthesia
Harvard Medical School
Director of PACU
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Juan M. Cotte Cabarcas, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachussets General Hospital
Boston, Massachusetts

Shika Card, MD, MA
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Andrew N. Chalupka, MD
Assistant Professor of Anesthesia
Senior Associate Consultant
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic
Rochester, Minnesota

Marvin G. Chang, MD, PhD
Instructor of Anesthesia
Harvard Medical School
Assistant Program Director, Critical Care Anesthesiology Fellowship
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Frances K. W. Chen, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jenny Zhao Cheng, MD
Resident 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
Department of Anesthesia, Critical Care and Pain Medicine
Neurosurgical, Vascular, and Thoracic Division Chief
Massachusetts General Hospital
Boston, Massachusetts

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

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

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

Stephanie L. Counihan, MSN, CRNA
Staff Nurse Anesthetist
Massachusetts General Hospital
Department of Anesthesia, Critical Care, and Pain Medicine
Boston, Massachusetts

Jerome Crowley, MD, MPH*
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Adam A. Dalia, MD, MBA, FASE
Assistant Professor of Anesthesia
Harvard Medical School
Division of Cardiac Anesthesia
Department of Anesthesiology, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Michelle Dyrholm, DO
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

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

Gregory H. Foos, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

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

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

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

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

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

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

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

Ryan J. Horvath, MD, PhD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Omar Hyder, MD, MS
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Oluwaseun Johnson-Akeju, MD, MMSc
Anesthetist in Chief
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Alexander S. Kuo, MS, MD
Assistant Professor
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Jean Kwo, MD
Assistant Professor in Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Maximilian Frank Lang, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Stephanie Lankford, CRNA
Certified Registered Nurse Anesthetist
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Thomas J. Lavin, DO
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Johanna Lee, 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
Medical Director Perioperative Services
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Rupeng Li, MD, PhD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Lucy T. Li, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

James Taylor Lloyd, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Ying Hui Low, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital, Harvard Medical School
Boston, Massachusetts

Christopher J. Mariani, MD, PhD
Resident in Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Lukas H. Matern, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Joseph L. McDowell, MD
Instructor of Anesthesia
Harvard Medical School
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
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Miguel A. Patino Montoya, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Eleanor M. Mullen, MSN, CRNA
Staff CRNA
Department of Anesthesia, Critical Care, and Pain Medicine
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts

Alexander Nagrebetsky, MD, MSc
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

John H. Nichols, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Raissa Quezado da Nobrega, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Peter O. Ochieng, MD
Resident in Anesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Riccardo Pinciroli, MD
Instructor
Harvard Medical School
Research Staff
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
Division Chief, Critical Care
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Triffin J. Psyhojos, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Katarina Ruscic, MD, PhD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Kyan C. Safavi, MD, MBA
Assistant Professor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Aubrey Samost-Williams, MD, MS
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Kendrick Shaw, MD, PhD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Pain, and Critical Care Medicine
Massachusetts General Hospital
Boston, Massachussetts

Jamie L. Sparling, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Rachel Steinhorn, MD
Cardiovascular Fellow
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Matthew W. Vanneman, MD
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

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

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

Jeanine P. Wiener-Kronish, MD
Distinguished Professor
Henry Isaiah Dorr Professor of Anesthetics and Anesthesia
Harvard Medical School
Emeritus Chair
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

Shauna Williams, CRNA
Staff CRNA
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

Jared R. B. Wortzman, MD*
Instructor of Anesthesia
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

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

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

*Affiliation prior to publication.

Preface

Dr. Richard Kitz, as the Anesthetist-in-Chief at Massachusetts General Hospital, had a vision for a “manual of anesthetic practice that was written primarily by recent house staff ” that was “intended to be the foundation of practical knowledge for the inexperienced or incompletely trained anesthetist.” The goal was to have each chapter written by a resident mentored by a faculty member. Although Dick is no longer with us, the legacy that he started in the 1970’s continues today with the 10th edition of Clinical Anesthesia Procedures of the Massachusetts General Hospital. These chapters have been passed on from generation to generation with updating to meet the needs of our ever-changing specialty.

This 10th edition has several new features. Each senior author of the previous edition was given a choice to write a new chapter with the hope that new authors would significantly update each chapter as needed rather than just making minor edits of previous ones. Anesthesia at MGH is conducted as a care team of residents, CRNAs, fellows, and staff anesthesiologists. Several of the chapters in this edition are now coauthored by a CRNA who has expertise of the subject matter. Finally, this edition was written almost entirely during the COVID-19 pandemic. During this time, all of the authors were administering to the needs of incredibly sick patients with respiratory and multisystem organ failure.

The Tenth edition continues to focus on clinical fundamentals that are required for the safe administration of anesthesia and perioperative care. Each chapter reflects the current clinical practice at MGH that is the foundation of our residency and fellowship programs. It is designed to be an easily accessible and accurate source of information for practicing anesthesiologists, CRNAs, anesthesia assistants, learners in anesthesia and other disciplines, medical students, and healthcare professionals interested in perioperative care. The information should be augmented with consultation of other in-depth published works and online sources.

I wish to gratefully acknowledge the many past editors of, and contributors to, the previous editions of this handbook. I have enjoyed working with Sean Hanrahan, Ashley Fischer, Oliver Raj, and Keith Donnellan at Wolters Kluwer. My executive assistant, Amanda Bourgeois, has been indispensable throughout the planning and organization of this book, communicating with the publishing staff, and “gently reminding” my colleagues to submit the chapters on time.

During the writing of this book and the COVID-19 pandemic, the support of our families was essential for maintaining some semblance of normalcy. Thanks to my wife, Patti, and son, Daniel, for their continued love and support.

I have been privileged to work with my mentors and friends, Hassan Ali, MD, and Jeanine Wiener-Kronish, MD. Thirty years ago, I purchased the third edition of Clinical Anesthesia Procedures of the Massachusetts General Hospital during an anesthesia elective with Mack Thomas, MD, at LSUMC in New Orleans. I am forever grateful for his teaching, enthusiasm that inspired me to become an anesthesiologist and critical care physician, and his continued friendship.

Richard M. Pino, MD, PhD, FCCM

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