This chapter discusses the diagnosis, evaluation and management of chronic obstructive pulmonary disease (COPD). Airflow restriction may be severe, leading to patients presenting in an upright or tripod position, with cyanosis, altered mental status, and respiratory arrest. Patients should be placed on supplemental oxygen therapy as needed to maintain adequate oxygen saturations of 88-92%. Over-oxygenating the COPD patient can lead to worsening ventilation-perfusion mismatch and apnea. Patients must be monitored for signs of impending respiratory failure. CPAP and BiPAP may be considered for certain patients with moderate to severe COPD exacerbations. The goal of ventilator management in the COPD patient is to oxygenate and ventilate without causing barotrauma and hemodynamic instability. If patients acutely decompensate while receiving invasive or noninvasive positive pressure ventilation, the possibility of pneumothorax and intrinsic positive end-expiratory pressure (auto-PEEP) should be considered.

Pediatric surgical patients present special anesthetic challenges including induction without intravenous (IV) access, a higher incidence of airway complications, and a greater incidence of hemodynamic instability due to surgical blood loss. Supratentorial tumors are the second most common location and include low-grade astrocytoma, malignant and mixed glioma, ependymoma, ganglioglioma, oligodendroglioma, choroid plexus tumor, and meningioma. This chapter presents a case study of a 8-year-old child presented with partial complex seizures characterized by staring spells accompanied by oral and manual automatisms. Preoperative evaluation (magnetic resonance imaging) demonstrated a non-enhancing heterogeneous lesion in the mesial aspect of the right temporal lobe consistent with lowgrade glial neoplasm. A neurologic assessment was performed after extubation and it showed no neurologic deficits. Subsequently the patient was transported to the pediatric intensive care unit where his recovery was satisfactory. Anticonvulsant medications should be continued and administered the day of surgery to prevent intraoperative and postoperative seizures.

Open spine stabilization with polymethylmethacrylate (PMMA) augmentation procedures requires significant attention during anesthetic management due to the complication of PMMA embolization. This chapter presents a case study of a 54-year-old male with a T12 burst fracture presented for a second stage posterior instrumentation of T9-L4. It presents a case of hemodynamic instability due to embolization during surgery as well as its management. Myocardial ischemia, pulmonary embolism (PE) from deep venous thrombosis or PMMA, and anaphylactoid/anaphylaxis reaction were considered. This patient had osteoporosis, a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures. Cardiopulmonary presentation is either immediate or delayed and can be catastrophic. Consider a chest X-ray, echocardiogram, and computed tomography scan as diagnostic tools. If strongly symptomatic, consult cardiothoracic surgery for possible embolectomy.

Abdominal aortic aneurysm (AAA) pain should be considered by the acute care provider as a harbinger of aortic leakage or rupture. Therefore, analgesic selection in AAA is influenced by the high potential for hemodynamic instability. This chapter discusses the role of opioids and NSAIDs in abdominal aortic aneurysm. When treating pain in patients with suspected ruptured AAA, the most important consideration is the effect the analgesic will have on the patient's hemodynamic status. Opioids, in small titrated doses, are the analgesics recommended by experts in AAA pain relief. Most opioids can cause minor reductions in heart rate and blood pressure. Hypotension is much less likely to occur with fentanyl since this agent does not cause histamine release often associated with morphine. In patients with normal renal function, NSAIDs (e.g. ketorolac) have been used perioperatively, without sequelae, in patients undergoing abdominal and retroperitoneal procedures.