Developing expertise in the practice of anesthesia, as with any other highly specialized field, involves memorizing facts and recognizing situations. It has long been recognized by educators and psychologists that memorizing facts is easier when the student or trainee has a cognitive framework into which the facts fit. This is nowhere more true than in the practice of medicine and the subspecialty of anesthesiology. Knowing the principles behind a physiological system will help the anesthesia practitioner not only remember but also understand the individual items that must be recalled. For example, knowing the anatomy of the subclavian vein and the fact that it would be difficult to apply direct pressure to it (or other reasons) will help you remember that coagulopathy is a contraindication to placing a central venous catheter in the subclavian site. Understanding why congestive heart failure (CHF) patients should not lie flat should prevent you from placing them in the Trendelenburg position, even if you do not initially remember that CHF can also be a contraindication for subclavian catheterization.

Recognition of a specific situation can be a powerful tool. Knowing what cues to look for in a situation is a major part of making good decisions. Knowing patient pathology, recognizing unusual circumstances, or even thinking that things that do not “feel” right could and should be hints to the junior anesthesia practitioner to slow down and actively search for reasons that something might be or go wrong. If you feel uncomfortable entering a situation (see Chapter 178), then it might be a good time to think about contingency plans. This feeling can be a signal that you should actively generate a list of contraindications to the procedure or therapy you are considering. Ask yourself what could go wrong, what you can do to prevent a problem, and how you can effectively respond to a problem when it arises. Generating “what could go wrong” scenarios can lead to better decision making and allow you to respond more gracefully to adverse events.

Fortunately, absolute contraindications in anesthetic practice are relatively few. They often involve either a commonly used drug, such as succinylcholine, or a rarely seen medical disease, such as scleroderma or acute intermittent porphyria. When confronted with an absolute contraindication
in a clinical situation, the anesthesia practitioner should not only “know” the specifics of the contraindication but also take steps to “rule out” the contraindication, with the use of a forcing function. Several familiar examples of this involve the use of items on a “latexfree” cart for a patient with a latex allergy or the physical removal of all vials of succinylcholine from the anesthesia cart if there is a strong contraindication. Similarly, when caring for a patient with acute intermittent porphyria, consider writing out a list of medications considered safe or probably safe and then using only those drugs on the list.

Relative contraindications in the practice of anesthesia are much more common than the very strong or absolute contraindications. Usually, they involve the exercise of more judgment, and as such, must always be placed in the context of the appropriate risk-benefit analysis. If you are discussing a proposed anesthetic plan with a senior anesthesia provider and she says something to the effect of “Well, you can do that, but you don’t want to if you don’t have to and you must be very careful,” take the time to discuss the pros, cons, risks, benefits, and factors that will ultimately determine the final decision.