Anticoagulation is mandatory for any form of extra-corporeal circulation to prevent activation of the coagulation system through contact between blood and artificial surfaces and through blood stasis. The absence of sufficient anticoagulation is likely to result in clot formation within minutes of aortic cannulation and commencement of CPB, with detrimental consequences for the patient. This chapter briefly outlines the history of heparin before discussing its pharmacology, intraoperative hemostasis monitoring, the management of heparin resistance and Heparin Induced Thrombocytopenia (HIT) and the outlook for anticoagulation on CPB.

Neurological complications after a cardiac surgery are common and have a large impact on patient outcomes. They are the result of a combination of numerous factors, many of them associated with cardiopulmonary bypass (CPB). Blood pressure control is essential to reduce the incidence of cerebral hypoperfusion and ischemic stroke during and after cardiac surgery. Cerebral oxygen saturation can be tracked using near infrared spectroscopy to assess cerebral perfusion and oxygenation. Careful temperature management plays a key role in preventing cerebral morbidity. Despite multiple attempts to find pharmacologic strategies to prevent neurologic injury, no such solution has been found to reduce the burden of neurologic complications associated with cardiac surgery.

Over the last decade there has been a significant increase in the utilization of mechanical circulatory support (MCS) devices. Advanced MCS devices are commonplace in the cardiothoracic intensive care. The indications for their use have broadened to include the prophylactic use in high-risk percutaneous coronary interventions or surgery, as an adjunct to cardiopulmonary and as part of the routine management of intractable cardiogenic shock. MCS are typically classified as either temporary or durable and will be discussed in this chapter.

The composition of the fluid used to prime cardiopulmonary bypass (CPB) circuits has been a source of great interest and debate ever since the inception of cardiopulmonary bypass in 1953. There has been significant progress in our understanding, but the ideal priming solution has still to be agreed upon and practice continues to vary widely between cardiac units. Circuits must be carefully de-aired with a compatible priming solution in order to prevent gas emboli from passing into the patient’s circulation at the commencement of CPB. Crystalloid and colloid priming solutions are now commonplace.

Deep hypothermic circulatory arrest (DHCA), either alone or in combination with other perfusion strategies, has become the mainstay of vital organ protection for a variety of pathologies and surgical procedures that necessitate the complete cessation of blood flow. DHCA provides a near blood-less operating field, albeit of limited duration, while ameliorating the major adverse consequences of vital organ ischemia.Cooling of the brain – the organ at greatest ischemic risk – reduces cerebral metabolic rate, extending the period of "safe" ischemia from 3-4 minutes at normothermia to >20 minutes.

This chapter explores temperature regulation and how it can be managed perioperatively. First, it addresses the components and mechanisms that control and regulate temperature in humans. Second, it explores the abnormalities that may occur due to pathologies, surgery, and anaesthesia. Lastly, it addresses how perioperative practitioners can regulate temperature effectively using a range of methods.

This chapter explores some of the new roles that have been introduced into perioperative care over the last couple of decades. These are the surgical first assistant, surgical care practitioner, and anaesthetic associate. It highlights the history, educational pathways, role boundaries, scope of practice, and the professional and legal implications of each of the extended or advanced roles.

General anaesthesia is the reversible loss of consciousness induced by pharmacological agents. Surgeries were previously often limited to superficial procedures and amputations due to significant patient discomfort. This chapter provides an overview of the conduct of general anaesthesia, and its various phases: induction, maintenance, and emergence. Core concepts such as depth of anaesthesia and perioperative care will also be reviewed. Anaesthetic adjuncts, drugs, and equipment will also be discussed due to their crucial role in ensuring patient safety during general anaesthesia.

The conduct of a general anaesthetic is more than just the administration of a drug to induce anaesthesia – a wide variety of agents are available, and they can be used pre-, intra-, and postoperatively. They will also be used for different purposes in different situations. This chapter discusses many of the common drugs used during a general anaesthetic, with a brief description of the effects, mechanism of action, and different routes of administration.

Regional anaesthesia is the use of local anaesthetic drugs to block sensations of pain from a large area of the body. It is used to allow surgery to proceed either without general anaesthesia or combined with general anaesthesia to provide superior pain relief than can be achieved with analgesic drugs alone. It is broadly divided into two categories. Neuraxial blocks involve injection of local anaesthetic close to the spinal cord, such as in the subarachnoid (intrathecal) space (known as a spinal) or in the epidural space (known as an epidural). Peripheral nerve blocks involve injection of local anaesthetic near peripheral nerves or plexuses. This can be performed either using landmark technique, a nerve stimulator, or with ultrasound guidance depending on the chosen block. Common equipment and techniques used to perform regional anaesthesia are discussed in this chapter, as well as advantages, potential risks, and the patient preparation and monitoring that is required.

This chapter discusses the management of obstetric patients undergoing anaesthesia and surgery. First, it outlines the distinct challenges of emergency obstetric anaesthesia and surgery. Second, it discusses pregnancy related changes to anatomy and physiology, common obstetric procedures, and drugs specific to the obstetric speciality. Finally, it highlights the advancements in care and medical technology and draws upon some of the moral and legal dilemmas faced by multidisciplinary teams in the obstetric setting.

Safe and effective health care underpinned by a sound evidence base is considered the gold standard of quality and compassionate care. Evidence-based practice remains a broad term that is frequently used but not always understood. This chapter explores what evidence-based practice is, why it matters, and the barriers that can hinder its implementation in practice. It is vital that operating department practice is informed, supported, and guided by evidence-based practice.

In acknowledging that ethics should be regarded as the cornerstone of healthcare practice and the significance of professional regulation for healthcare practitioners providing patient care, it is vital to develop an understanding of how and why this is the case. This chapter has been written to support all perioperative practitioners in developing this knowledge in the context of the operating theatre. The chapter includes discussion of some of the key moral theories and frameworks that may be used to guide reflective, ethical decision making before moving on to consider the role of professional codes and regulation in prescribing and enforcing standards of professional conduct and directing ethical decision making.

This chapter explains the fundamentals of basic patient monitoring for patients undergoing general anaesthesia. Monitoring provides information and feedback of a patient’s physiological state in response to any therapeutic interventions or stimuli during anaesthesia and surgery. It is vital that perioperative practitioners understand the underlying principles of basic patient monitoring. This includes understanding how and what is being measured, how the monitoring is assembled, and how to problem solve to ensure optimal functionality and accuracy.

This chapter explains the challenges involved with bariatric surgery and how they can be navigated to optimise patient care. Due to the increasing global rates of obesity, increasing numbers of bariatric patients are presenting for surgery. Obesity is associated with several physiological and psychological effects, and it is essential that these are considered in order to plan and deliver safe, effective, patient-centred perioperative care.