, 6 TH EDITION
NURSE
ANESTHESIA
JOHN J. NAGELHOUT, PhD, CRNA, FAAN
Director, School of Anesthesia
Kaiser Permanente/California State University Fullerton
Southern California Permanente Medical Group
Pasadena, California
SASS ELISHA, EdD, CRNA
Assistant Director, School of Anesthesia
Kaiser Permanente/California State University Fullerton
Southern California Permanente Medical Group
Pasadena, California
,3251 Riverport Lane
St. Louis, Missouri 63043
NURSE ANESTHESIA, SIXTH EDITION ISBN: 978-0-323-44392-0
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Previous editions copyrighted 2014, 2010, 2005, 2001, and 1997.
Library of Congress Cataloging-in-Publication Data
Names: Nagelhout, John J., editor. | Elisha, Sass, editor.
Title: Nurse anesthesia / [edited by] John J. Nagelhout, Sass Elisha.
Other titles: Nurse anesthesia (Nagelhout)
Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2016032301 | ISBN 9780323443920 (hardcover : alk. paper)
Subjects: | MESH: Anesthesia | Anesthetics | Nurse Anesthetists | Nurses’ Instruction
Classification: LCC RD82 | NLM WO 200 | DDC 617.9/6–dc23 LC record available at https://lccn.loc.
gov/2016032301
Executive Content Strategists: Tamara A. Myers and Kellie White
Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Jeff Patterson
Project Manager: Lisa A. P. Bushey
Design Direction: Brian Salisbury
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
, Preface
Nurse anesthesia education and clinical practice continues to evolve at figures, and boxes. Effective anesthesia must be viewed as part of a
a rapid pace. Our professional degree has moved to the doctoral level, therapeutic continuum of care. For this reason, we have been especially
and the requisite knowledge needed to provide safe patient care is sensitive to include the latest medical and surgical information available
increasing exponentially. Due to the complexity of modern surgical from the specialties that impact our practice. Integrating new technol-
procedures, ensuring the highest-quality outcomes requires the need ogy and knowledge in the basic sciences into clinical practice has
for lifelong learning. Anesthesia practice has expanded beyond the allowed nurse anesthetists to continue to evolve as leaders in providing
traditional surgical settings to include interventional procedures, pain safe and comprehensive care. We have included additional new chapters
management, and non-operating room anesthetics. The objective of on a wide variety of topics, including patient-centered care; cultural
this new edition is to integrate the vast amount of current knowledge competence and nurse anesthesia practice; additional drugs of interest,
to help guide clinical practice. including antibiotics, psychiatric drugs, and antiemetics; goal-directed
Technological innovations that allow this textbook to be used in fluid therapy; blood and blood component therapy; anesthesia manage-
traditional, as well as various electronic formats, are now commonplace. ment for patients with cardiac devices; anesthesia for robotic surgery;
We approach the sixth edition of Nurse Anesthesia with a clear intent anesthesia for transplant surgery and organ procurement; and chronic
to bridge these platforms while remaining true to our educational pain: physiology and management. The chapter dedicated to research
objectives. Since the conception of the first edition of this text more in nurse anesthesia has been reconceptualized to focus on the integra-
than two decades ago, we continue to be guided by our original vision tion of evidence-based research into practice.
to fill the need for scientifically-based, clinically-oriented work on Producing an educational resource of this size and complexity
which anesthesia practitioners and learners can rely to deliver excellent would not be possible without the tireless efforts of our authors and a
patient care. broad array of experts. We would like to express our sincere gratitude
Our intent is to harness the vast knowledge that nurse anesthetists to Retta Smith, who assisted in the production and editing of this
bring to clinical practice and provide a comprehensive, evidence-based textbook, and Clinton Lee for designing graphics. We proudly carry
resource for continuous learning. We are tremendously gratified that over from the previous editions hundreds of anatomic figures that were
this textbook has become the seminal work for our specialty. This book specially hand drawn for this text by the renowned medical illustrator,
is included among the Library of Congress’s essential nursing textbooks William E. Loechel. We would like to express our gratitude to the staff
for medical libraries throughout the United States and in national at Elsevier who work tirelessly to produce this textbook. This book
digital resource databases such as Elsevier’s ClinicalKey for Nursing. would not exist without their knowledge, expertise, and enthusiasm. A
We reach an international audience of nurses and nurse anesthetists special thank you to Tamara Meyers, Executive Content Strategist;
and are always pleased when we hear of the positive impact we are Laura Selkirk, Senior Content Development Specialist; and Lisa
having on anesthesia practice worldwide. Bushey, Project Manager.
We are especially grateful to all of our new and returning authors We would also like to acknowledge the contributions of Karen
who bring a wealth of expertise and experience to their respective areas. Plaus, PhD, CRNA, FAAN, as the coeditor of the first five editions of
The majority of clinical anesthesia continues to be provided by nurse this text. Dr. Plaus has devoted her career to educating nurse anesthe-
anesthetists, and this textbook is a testament to the leadership we bring tists and advancing our specialty. Her decades-long achievements on
to academic and clinical nursing. Each chapter has been extensively the national and international level continue to be instrumental in
reviewed and revised to contain the most salient information available. making nurse anesthesia a vital specialty for delivering high-quality
The newest concepts, techniques, and areas of controversy in anesthesia healthcare.
are discussed in detail. This is the first edition to contain full color, John J. Nagelhout
which greatly enhances the readability of the hundreds of new tables, Sass Elisha
ix
NURSE
ANESTHESIA
JOHN J. NAGELHOUT, PhD, CRNA, FAAN
Director, School of Anesthesia
Kaiser Permanente/California State University Fullerton
Southern California Permanente Medical Group
Pasadena, California
SASS ELISHA, EdD, CRNA
Assistant Director, School of Anesthesia
Kaiser Permanente/California State University Fullerton
Southern California Permanente Medical Group
Pasadena, California
,3251 Riverport Lane
St. Louis, Missouri 63043
NURSE ANESTHESIA, SIXTH EDITION ISBN: 978-0-323-44392-0
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Previous editions copyrighted 2014, 2010, 2005, 2001, and 1997.
Library of Congress Cataloging-in-Publication Data
Names: Nagelhout, John J., editor. | Elisha, Sass, editor.
Title: Nurse anesthesia / [edited by] John J. Nagelhout, Sass Elisha.
Other titles: Nurse anesthesia (Nagelhout)
Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2016032301 | ISBN 9780323443920 (hardcover : alk. paper)
Subjects: | MESH: Anesthesia | Anesthetics | Nurse Anesthetists | Nurses’ Instruction
Classification: LCC RD82 | NLM WO 200 | DDC 617.9/6–dc23 LC record available at https://lccn.loc.
gov/2016032301
Executive Content Strategists: Tamara A. Myers and Kellie White
Content Development Manager: Lisa Newton
Senior Content Development Specialist: Laura Selkirk
Publishing Services Manager: Jeff Patterson
Project Manager: Lisa A. P. Bushey
Design Direction: Brian Salisbury
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
, Preface
Nurse anesthesia education and clinical practice continues to evolve at figures, and boxes. Effective anesthesia must be viewed as part of a
a rapid pace. Our professional degree has moved to the doctoral level, therapeutic continuum of care. For this reason, we have been especially
and the requisite knowledge needed to provide safe patient care is sensitive to include the latest medical and surgical information available
increasing exponentially. Due to the complexity of modern surgical from the specialties that impact our practice. Integrating new technol-
procedures, ensuring the highest-quality outcomes requires the need ogy and knowledge in the basic sciences into clinical practice has
for lifelong learning. Anesthesia practice has expanded beyond the allowed nurse anesthetists to continue to evolve as leaders in providing
traditional surgical settings to include interventional procedures, pain safe and comprehensive care. We have included additional new chapters
management, and non-operating room anesthetics. The objective of on a wide variety of topics, including patient-centered care; cultural
this new edition is to integrate the vast amount of current knowledge competence and nurse anesthesia practice; additional drugs of interest,
to help guide clinical practice. including antibiotics, psychiatric drugs, and antiemetics; goal-directed
Technological innovations that allow this textbook to be used in fluid therapy; blood and blood component therapy; anesthesia manage-
traditional, as well as various electronic formats, are now commonplace. ment for patients with cardiac devices; anesthesia for robotic surgery;
We approach the sixth edition of Nurse Anesthesia with a clear intent anesthesia for transplant surgery and organ procurement; and chronic
to bridge these platforms while remaining true to our educational pain: physiology and management. The chapter dedicated to research
objectives. Since the conception of the first edition of this text more in nurse anesthesia has been reconceptualized to focus on the integra-
than two decades ago, we continue to be guided by our original vision tion of evidence-based research into practice.
to fill the need for scientifically-based, clinically-oriented work on Producing an educational resource of this size and complexity
which anesthesia practitioners and learners can rely to deliver excellent would not be possible without the tireless efforts of our authors and a
patient care. broad array of experts. We would like to express our sincere gratitude
Our intent is to harness the vast knowledge that nurse anesthetists to Retta Smith, who assisted in the production and editing of this
bring to clinical practice and provide a comprehensive, evidence-based textbook, and Clinton Lee for designing graphics. We proudly carry
resource for continuous learning. We are tremendously gratified that over from the previous editions hundreds of anatomic figures that were
this textbook has become the seminal work for our specialty. This book specially hand drawn for this text by the renowned medical illustrator,
is included among the Library of Congress’s essential nursing textbooks William E. Loechel. We would like to express our gratitude to the staff
for medical libraries throughout the United States and in national at Elsevier who work tirelessly to produce this textbook. This book
digital resource databases such as Elsevier’s ClinicalKey for Nursing. would not exist without their knowledge, expertise, and enthusiasm. A
We reach an international audience of nurses and nurse anesthetists special thank you to Tamara Meyers, Executive Content Strategist;
and are always pleased when we hear of the positive impact we are Laura Selkirk, Senior Content Development Specialist; and Lisa
having on anesthesia practice worldwide. Bushey, Project Manager.
We are especially grateful to all of our new and returning authors We would also like to acknowledge the contributions of Karen
who bring a wealth of expertise and experience to their respective areas. Plaus, PhD, CRNA, FAAN, as the coeditor of the first five editions of
The majority of clinical anesthesia continues to be provided by nurse this text. Dr. Plaus has devoted her career to educating nurse anesthe-
anesthetists, and this textbook is a testament to the leadership we bring tists and advancing our specialty. Her decades-long achievements on
to academic and clinical nursing. Each chapter has been extensively the national and international level continue to be instrumental in
reviewed and revised to contain the most salient information available. making nurse anesthesia a vital specialty for delivering high-quality
The newest concepts, techniques, and areas of controversy in anesthesia healthcare.
are discussed in detail. This is the first edition to contain full color, John J. Nagelhout
which greatly enhances the readability of the hundreds of new tables, Sass Elisha
ix
