Preop cardiac clearance evaluation every anesthesiologist should know: by William L. Thompson MD, anesthesiologist

My first recommendation is to become very familiar with the ACC/AHA guidelines regarding Perioperative Management  for Noncardiac Surgery. I will provide a link below. In September 2024, the ACC/AHA updated recommendations for noncardiac surgery. The last guidelines 2014. These are the recommendations they brought forth, and I will summarize the most important anesthesia considerations.

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Adrenergic Receptort selectivity: By William L. Thompson MD

As you may have already been aware, the various adrengergic drugs at the anesthesiologist's disposal have different selectivity to the types of receptors they bind and stimulate.  We have obtained that knowledge, over time, to determine which agonist is best for the desired effect we wish to achieve. That being said the following diagram below illustrates the various agonists and the receptors they are known to bind to and stimulate. These are noteworthy to memorize. Have I missed any you would include?

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Sympathetic Nervous system review: by anesthesiologist William L. Thompson MD

As you may recall, the parasympathetic nervous system has a cranial-sacral distribution where as the sympathetic nervous system has a thoraco-lumbar distribution. The sympathetic nervous system secretes the neurotransmitter norepinephrine in the post ganglionic sympathetic nerve fibers. Norepinephrine binds to end-organ adrenergic receptors to exert various effects on the various adrenergic receptors as seen below. It is worth while to remember these actions.  Note: the neurotransmitter of the sympathetic preganglionic nerve fibers is acetylcholine.

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Choosing the right pressor at the right time: William Lee Thompson MD

I remember a case years ago in which I was the anesthesiologist for an Aortobifem bypass surgery. The patient was the usual vasculopath with a threatened limb, and surprisingly  had a normal appearing echo/electrocardiogram. The surgery was emergent and I warned the patient and his family that despite normal findings on ekg/echo, he was still very much at risk for intraoperative cardiovascular complications. Unfortunately, I was not in the postion to delay the surgery for a pharmacologic or exercise stress test. So the surgery proceeded.

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