Anaesthesia at a Glance

90 Pages·2014·15.42 MB·English

by  Julian Stone

Anaesthesia
at a Glance
Julian Stone
Consultant Anaesthetist
Great Western Hospital NHS Foundation Trust
Swindon, UK;
Senior Clinical Lecturer
University of Bristol
Bristol, UK
William Fawcett
Consultant Anaesthetist
Royal Surrey County Hospital NHS Foundation Trust;
Senior Fellow
Postgraduate Medical School
University of Surrey
Guildford, UK
This edition first published 2013 © 2013 by Julian Stone and William Fawcett.
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Library of Congress Cataloging-in-Publication Data
Stone, Julian, author.
Anaesthesia at a glance / Julian Stone, William Fawcett.
p. ; cm. – (At a glance)
Includes bibliographical references and index.
ISBN 978-1-4051-8756-5 (pbk. : alk. paper) – ISBN 978-1-118-76533-3 (ePub) – ISBN 978-1-118-
76532-6 – ISBN 978-1-118-76531-9 – ISBN 978-1-118-76530-2 (Mobi) – ISBN 978-1-118-76529-6
I. Fawcett, William, 1962– author. II. Title. III. Series: At a glance series (Oxford, England)
[DNLM: 1. Anesthesia–methods. 2. Anesthesiology–instrumentation. 3. Anesthetics. WO 200]
RD81
617.9′6–dc23
2013018954
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may
not be available in electronic books.
Cover image: © iStockphoto/Beerkoff
Cover design by Meaden Creative
Set in 9 on 11.5 pt Times by Toppan Best-set Premedia Limited
1 2013
Contents
Preface 4 17 Emergency anaesthesia 44
How to use your textbook 5 18 Obstetric anaesthesia 46
About the companion website 8 19 Ophthalmic anaesthesia 48
Abbreviations 9 20 Paediatric anaesthesia 50
21 Cardiac and thoracic anaesthesia 52
 1 History of anaesthesia 10 22 Regional anaesthesia 54
 2 Monitoring 12 23 Anaesthetic emergencies in the operating theatre 56
 3 Equipment 14 24 Anaesthetic emergencies in the wider hospital 59
 4 Airway devices 16 25 Trauma 62
 5 Fluid management 18 26 Orthopaedic anaesthesia 64
 6 Preoperative preparation of the patient for surgery 21 27 Anaesthesia and obesity 67
 7 Temperature regulation 24 28 Anaesthesia and old age 70
 8 The perioperative patient journey 26 29 Anaesthesia and diabetes 72
 9 General anaesthesia – inhalational anaesthetics 28 30 Anaesthesia for vascular surgery 74
10 General anaesthesia – intravenous anaesthetics 30 31 Anaesthesia for ENT and maxillofacial surgery 76
11 Local anaesthetics 32 32 Awareness 78
12 Neuromuscular blocking drugs 34 33 Anaesthesia for ECT, dental surgery and special needs 80
13 Acute pain 36 34 Postoperative management 82
14 Postoperative nausea and vomiting 38 35 Anaesthesia away from the hospital setting 84
15 Chronic pain 40
16 The airway 42 Index 86
Contents  3
Preface
Anaesthesia is often intimidating for students. Within the relatively Each chapter has a self assessment section of both multiple choice
short time allocated to this disciplines on most undergraduate curric- questions and case studies. The answers are not exhaustive, but should
ula, there seems to be a bewildering array of unfamiliar drugs, equip- encourage further reading on the subject.
ment and practical procedures. Yet at the very heart of anaesthesia is Whilst this book is aimed primarily at undergraduate medical stu-
the modern concept of perioperative medicine. The fundamentals of dents, it may also prove of value to Foundation Doctors looking after
anaesthesia, such as assessment and management of the airway, res- patients in the perioperative period, doctors embarking on a career
piration, circulation and analgesia, are applicable to all hospital staff in anaesthesia and theatre staff such as Operating Department
involved in the care of the surgical patient. Practitioners
Both authors are practising clinical anaesthetists and also actively The authors would like to thank Laura Murphy, Helen Harvey,
involved in undergraduate teaching. Moreover, as anaesthetists are the Elizabeth Norton, Simon Jones, Ruth Swan, Kevin Fung and Brenda
largest single group of doctors within hospital medicine it seems Sibbald. They acknowledge and dedicate this book to those who have
appropriate that a contemporary undergraduate textbook is available given encouragement and support throughout. JS would like to thank
as an introduction to the specialty. Edwina, Freddie, Hugo and Lucinda. WF would like to thank Victoria,
The aim of the authors has been to cover the practice of anaesthesia George, Alice and Joseph.
to a level appropriate for a medical student who is about to embark on
the Foundation Programme. Certain specialized subjects that are tra- Julian Stone
ditionally taught, such as physics, have therefore been omitted. William Fawcett
4  Preface
How to use your textbook
Features contained within your textbook
Each topic is presented in a double-page
spread with clear, easy-to-follow dia- 3 Equipment Anaesthetic machine 15 times per hour). The main aim is infection control; it also serves
The anaesthetic machine (Figure 3.1a,b) provides anaesthetic gases in to remove unscavenged gases.
gterxatm.s supported by succinct explanatory F(igau)r eA 3na.1e s Athneateics tmhaetcihci neequipment ( b ) Ganaase csytlhinedteicr sm oanc htihnee b(Nac2kO o lef ftth, eO2 right) (c) Rotameter toHtchoonee m tr thehdme eea o s mrinpor eratgoadianpm s qo geourtatuaeisontr l ntfle(i Otto( i(wes2C,ps. / lGapiTitrOrtho,i ne)pN, go gr2 reOrataais)otc inhl(oeFsi)an,i vgegaeun ttsr th eeaetr h 3sspe a.aa1 ft aecivn )eap,an prpeteo savsrtsihsisazuei enratrie gc b.b rtGmeeofa aaottshchr eheifln irobngewae tcc u iakirrtsn c b uitsnahietrget.. BTothfhe rAceteiosncera r maudtdgeahjlacuithvisentiedanr bge (tl,khe iwe cnp akFirl-erlGf scrssFeouue urf)eirr pcot-lelmsia mos ttriiht cicen.y gTCli hn(GeAdO eFPr GL tOo)F 2 vt ih(asTe lsv aupebpa lieptsi l e3ione.f1dtt.) e f.Tnro hpmerye tshaerene ta .mn Taaehdsies-
Vaporizer has a spring-loaded disk that opens at a pressure limit, which can be
Part of the fresh gas flow (FGF) enters the vaporizer. Full saturation altered by opening or closing a valve, adding more or less tension to
with volatile agent is achieved typically by a series of wicks to create the spring. During assisted ventilation, closure of the valve allows
a large surface area. As volatile anaesthetic is removed, energy is lost greater inspiratory pressure to be generated before the spill valve
due to latent heat of vaporization. Temperature compensation occurs opens.
to maintain output, for example by use of a bimetallic strip which The following are commonly used circuits.
bends as the temperature alters. The Bain circuit (Figure 3.2) is coaxial. An inner tube leads to the
Safety features ptoa ttiheen ta n(daeelsitvheertiincg m FaGchFi)n, ea. sItu risro iunnefdfiincgie notu tdeurr tiunbge s ppoansstaens eeoxuhsa lberde agtahs-
• Non-interchangeable screw threads (NISTs) prevent the incorrect ing as rebreathing of exhaled gas occurs unless the FGF is at least
pipeline gas being connected to the machine inlet. twice the patient’s minute volume. It is efficient for controlled ventila-
• A pin index system is used to prevent incorrect cylinder tion, especially if an expiratory pause occurs, allowing build up of
connection. FGF at the patient end of the circuit that is then the first to be delivered
• Barotrauma to both patient and machine is avoided by using pres- with the next inspiration.
sure reducing valves/regulators and flow restrictors. A circle system (Figure 3.3) allows low FGF during assisted ven-
• The oxygen failure warning alarm is pressure driven and alerts of tilation, and in theory can be only a small amount above the calculated
T a b l e 3 . 1 iCnydleinndteifrie cdo bloyu trh e– c ionl otuhre o Uf Kt,h cey blionddye rasn adr sehoulder Figure 3.2 Bain coaxial circuit i•mTdm ehaApmece chingcnidnuaeiesrnn atgei tsp ne oit dpengier ssaltpi hsnlt eahe yd egoee ardlc is ycv blyefliylrnoi ydnwa:ed .r eb flTroa ohbftwa ibsiii l tnusid sre( ebFla.ai ivsgfieeurx, ereefddo 3rtpc.h1rirnecosg)us uwgthrhieet h tvibhnaoe r biaaba brninolae te ahsomitrghiehefitteecirrce,. Onavmsae2i le nwvcd eoeefsnold,ls r aui anncmsih tAfipiialtlPdillolirLynen gn vtf o)aot. hl ravC eltel hOo ceawi2 nr pc diafus ot aiirtae rbnaietnstss oae(e3relrbfs–v.et o4hWdi mer tibibLtcyha/ ikgunsg.po /ttdmhaaeki enlc i aifmroncerdl .e a n dAaiutr relhot sigtg,w eh6noe– rw8o mnFaesGLh-wF/ok uagitys/,
Gas Cylinder body colour Shoulder colour or pipeline Expired gas flowmeter, that is the pressure difference across the bobbin remains Self-inflating bag mask valve has the advantage of not needing an
FiTa(gsOANEhnueednixirert y tem trgoT oo3aeanu .jnwbo3oslaxre oil t l3 Cxymi.i d1roTo)ceofu l epgn aatstiesyed sni stto eusBBFFmturrllaaleepeccnnptkkcclsihhe t dbbh llbruuoyee upgipheoluinte t thoe ahnoasepsiWBFFttrralhhaeelie.cnnt tPkccei/hhicpw ebbmhdlliuuat eegec/a hqwsiunh aeiistsr et/aF( veFqlresrGuensosatF hcri)lt oageltoaroussrr sfeldow fFlorwes (hF GgaFTFrs)heigpeu larrecese 3edr. 4vbo y i raL b avareygnn tcgialoanst ocbRbroeaepgsee rbvlaoidres tdcElori•v•••ihanno oaifamesgg tHVEIpncatt n. ohsaehimO t<yntMtelnue a2pe r2 ae rtt onir5oborosrinrltt l% oxodg oa flabNtwtibeemcthoea crnobk2Oihwm enOengrici i2n tn) gglyeu eaa s.wbtga r naateolgT es naariirxti ivsth eddvrhflnhy iasecm ee:sgoigdtp an n w htebfseolod h aein to.snrrebehw utii bAsiil rmfiflelcziiOabatv tncu eyrtuyrime2e enrnos l ar odshat s(taensao aar n:cdiftno hmft zdoich w enasehw hrrietvoN an hiiatathieuggceeethn2 eishkshrOsnecsc,lnp ee py r g ap perdcebc.iN,inrcrroa. ovaeeadtis2acneufisvlO etk strlecisagroeb nn o irgbwdugfsdtoluaa,il i onekupsrgropn vgt nsrixarhpteeet oesya ehvrdss bfllegrty e.s h sovw erpnuuO eewenaotrhpipnse xrrx)i b ert. c yttiv ey ahhchgtlsipfwie e seefngca cennobktaasoca t ssoueiatspae s dbsitdetns tie,bhdyoe r a tpieele nthen(ihd rlv.sae heie tsvet vethb mtreuleiieyaorgcbn tcew kthieitkodcf--t,. FbiLLbTlb•ao•ni nelebGfahasaTTt hderepscdrFyi shh oyieni cnMreettn tndheagy oind nMeapg.so te c fhosoOceubeiccelntipsnieCo2 etote ihccpdocgo uptee soobilytsirhoosognle p nat blccadtbaoe,diuerl nlstaesneswrat vdoio dtutshrheo xee sacedaa yetanhis inrdgson e( ad eM1vnh tsp now3e .apo aa an5suIovscnltod siri i tdsuhklintiaenuehore tr ccioagsentnoeoil sr eci ibe;hrlztdi upaes as)e alrt oo iarrynoatnrluethnantare scee tttxgdetihres i.ol lrits eoeaovbrn T narraol vybali h tiyagonendire.sl ht xoe lb wdEet nMae dtceex-g(niuulrpMeiai celrlwvn.mloaib eie n;Ouilrprhr llgen l lelna iarebtrfifncoetn)uslthed raoi trnei (euldtmnFetdhg behcv ,ie ae galaaariute nu linsiitvrd.od rnitg.ee peenp c.I.: r b.lrti a3iw eloTscca.a r4iaedhsilt)nndyheee.
From patientUnidviarelvcetsional VSsoSrpewo nomdittnaecitl achalih,tmn aiteoeonon iuccsha alr vneesgnept ibrilaeatttiwiooennen bc•c•b alaienSSura atucarita ocniaovtndiine r oain.wn ssSg a: dicg yneaaa lgvdssie ve jouicnesfsrrg etedveatdeedibo ln ltigneovtea s entds/rhvee eeaosgd n ma CaaatriiGetetv s 4Oeauth -nsb peuadartta eir mcl> sla sy3ugnu 5savdrt sLee edb-n/sgomet ee eiiasdnsn v ea.tnar ocTiao tlttithaehv bicdeeslo , ea mnsp tuftmauaocsisrtonsit so ia vbpanleelnh aiceousearrs ess eua.ted sh sSec e.wcdotai micvtt.ho-- tc•fd•hr aioefVFnfim iivcibd mauarelle plotefi- r icoobnlupavrtleuertai-n b,col aya mpstrgtiycoiooconvns pgcessoeo moasspun ecerandocsrt pe e t ipeo cauarf to scv tevhthihdeiiednew wegt.ti .iippat h bo lyaafr nytp hnreeeng sdobsoslianctrdogaep ca.i hc Tle ehavvleie eytrwu hob aneov nbeth eaaei n rhsgoca lrnreead eiillnne-
enging tubing has a wider bore (30 mm), preventing accidental roaded over it once the scope is within the trachea.
TAitnoh tc eoaa rbtneshiasoectr taebir noe aonxefsh s asttlohehddaea ttC ilocOimc 2bce.ru eirsa atinhrecin:ogr312 p.c. .o i rHHNrca22autCO2ietOC d+O3 C3+ O+ 22 C N a a ( OO HH H ) 22 C O 3Shs N yo o dadCdr2iaauoCC mxOliOimd 3(3 e5e+ s+ % i s2 o)2 faHa Nc n2maaOdlOi c xpHituoumtrae (s o7sf5i ut%mh)e, (1%) hSanhdorletdStandardPolio McCoy cthoenLanoterwec taigoiarn s e txfloc obhwraesna gtrehe idonucgcc ecu irrescn utvhiitrrsoo.ungmhe nthtael aiimr cpoanctd iatinodn icnogs ts.y Ostepmer a(tei.ngg. •cra aiAnlr obbaeod fueegdlti eoa vsise t rha niet tiwinpth reponad suasc epesro ootvhre alrta crtryaanncg hbeeeaa lpl variisenswgeds )i s ian snteode tnah. etr alacrhyenaxl t(ucbliec kiss
Anaesthesia at a Glance, First Edition. Julian Stone and William Fawcett.
14 © 2013 Julian Stone and William Fawcett. Published 2013 by John Wiley & Sons, Ltd. Equipment 15
7 Temperature regulation Patients lose heat during the perioperative period. Heat loss can start • nasopharyngeal or oesophageal thermistor;
on the ward or during transfer to the theatre suite, especially if wearing • thermistor within the pulmonary artery (e.g. within a pulmonary
only a thin theatre gown. It is more common in children, especially artery catheter);
babies, as they have a larger surface area to body mass ratio. • liquid crystal thermometer – heat sensitive crystals in a plastic strip
Figure 7.1 The four ways heat is lost If aH yppatoitehnetr’sm piar eionp therisa tsievtet integm isp edreafitunreed iass <a 3c6o°rCe t ethmepne aracttuivree <w3a6r.m0°inCg. whAic hth cearmn ibseto ar pips laie sde mtoi cthoen dfourcetohre awdh;ose electrical resistance falls as
RTednriafaefdnerigrsaeyftne iborte nott few4 mee0leep%nce trtarwotomu rbaeogdnieetsi cof CEtadh ionspeenta rvautgeriiyrecb ntietmitdro'amsnn es3sdkf0iiena%r t iwsel iyrll e abpede jagatrceeeadntltye tr oif mtt(iihvoeoTAenat h s fcaafueaennr sbreddeeos snc dc stouoyh ninl onldtdoufi)luosl derttcohm stb eiheoat h ettnieiaeno mt (sn Fatip inniitegs utfre utoacrertuioeduorn .rr 7 dewA .h u1aniycs)yat. psee>o:ds3 tt rh6hfaa°redoClsamii.maa tsutihhoseon. u,Es lckdfoif nebn’revse e dntchett leiraoreymnsep,od oer fnevocsareep speo ltreoaacrres-- WMatemnaarpamienereadsttu/athrhieun meiniiscndriiegfaiae s det( seF;g imagitsu errpese s ep7Ao.r3 na)hdetsau tr arapenidd l dym utoor icsithnuargneg eesx cinh atnegmep efirlatteurr eis.
Evaporation 25% Conduction 5% relAayuetdo nvoima tihc ec opnotsrtoelr ioofr theymppoethraatluarme uiss. mediated by: uwsautaelrl yv ainpcoourrp ofrroatmed eixnhtoa ltehde rbersepaitrhaitnogry c igrcauseits. Tahnids ahbeslposr bws ahremat aanndd
Aevlseli1voan0aan.usgscpppe%r .rsaf rwooe la rgioruwaasocyiorzts ite llpaleioeo ssibrtssms eilt bo oohy e efinsve.nx ci.tbaSpac oT otor aumhrwe srsleiaoeeegs sssllsdi a pctdes taviytdru aeipolan r npise itf entot k oovag hiurhnaf iry laes pah,p a wohrewrtrgaeaea aepatotytetf.iron, TcdpwAwaoramiie ftapnttfhoneati e sursattnihnfincheteettgen re b o tbottoef esepli fynhtm ehwigwernpeia aegliaelntte rlti i nonandv s eigtitaarneu we t epcracoareoot ngbsoon ylc,bield n oej.bouecn.yfcgcr t et.ftd aliaasuoicrs inetdoecf dotr ••(a••••s mysnscapFmohwhloeatuiarneecvpinnr-apteaasotgthrt thirheiiinensinosevrg g ntaceia;i;l nocrd oi )nvunfp;ta lgeratsai sruobt i,hptd uloweahitnlirrehangmortegeamaor ltetg iiao ovcemi a ntnhc s,oeceo cuesoanui.nntstgl rtat,l. or or wieb lsbs;xyshumi itsdvceotuohssor l ti<aoihnntc1 ig clm0 enu–a uerna1ssona5 cniea%lnasee tt s behtotorshefo ns ewhbietaiue.nc atas ta;r odepn:irployod suaec ttsiimossnau;lel haFtFbphsuerola ou mratdic wcdicuetd oaicdviwrvtf mesyaea. r irwetrsmhd awae ers matrn o/mrewi mnxua3gtec r7 drhmm° e CloTeei dftvhh euitofshrsly deiubn s iolp.gdofa sw tg aisaeI fsnw flet> suaa5 irtsd0mo 0 p t woahmisearLs rpii mbnaolttefeio re. ,fln aut a.di sdIo t u isisbsh longeuo-ivlltade ay nse a rieltelf dfs ehbscolhotuieovleddet
• use of surgical skin prep;
• exposed surgical site (e.g. laparotomy); Warmed blankets
Figure 7.2 The three phases of heat loss during anaesthesia •• rpeomoro vnault roitfi obneahla vstiaotuursa/lt hriens ppoantiseenst,s e w.gi.t hc lao tphaeusc eittyc. ;of insulating fat. Simple and effective for short cases.
Ambient temperature In modern operating theatres temperature can
37.0 Ethfef ehcytp ooft haanlaamesuths eissi aal toenre tde msop tehraatt uhreea tc-coonntrsoerl vCinegn mtraela csuornetsro alr we ittrhigin- be accurately controlled and should be at least 21°C.
Core body temp (°C)35.5 Redistribution Linear heat loss Plateau gacPpPtPh aeehhhaurrhaaaneissssipd egeeemh sh ae 132eettr::h: try a a RrP.L b eltlTeioeoeand hwmltpeieiecseahaprt rrueaerh i s rte–bi–eaesa umt s tauht n i oprpeoosefearnl . orton h adw–epeItut murae iocrtnlrp oted ilia tscouoaisiosacnnr snltm od i itorfdn iea hnnu tnpetou rhtieaite denaqtd- o lguhl s fo bahue asloeabnstiatdhsn a theyrege eqe rls hdompauthetisre soosaenlt.rotcsrt e ii esHdagb2ssu uu es(haretlaFiiafostnoitt ugegonalrrou rr s tfyesr3.hres o ie hnr7m ieos1i.t s2 usicgpat)r o:rotsheer.noeads tu etearosrt. SP•••P iolhgroSsveyetehgsonpriipevt-oolereotniahrnraalipee lntra digemavn nesarica paeasae;ashnstcthit vehibe evesebrsi eliaianua ngni t(s pksecelhe.aegltnfasi.; s v/sohapecnaicttnr,us ai reln T sdophguree eces ipteao ildr:leyud ruaiflc eam nroaavedesiamthtieeonsnita h)e.exaatc elorbssa.tes
Consequences of hypothermia poaxiyng. eInt ipnrcorveiassioesn otox yogtehne rc eosnsseunmtiaplt ioorng, awnsh.i cThh icsa nco lueladd rteos uinlta dine qcuearete-
The consequences of hypothermia are: bral ischaemia (can present with confusion) or myocardial ischaemia
0 1 Length of an2aesthesia (h) 3 4 •p roshdiuvcetriionng;, with increased O2 consumption/increased CO2 (e.Ign. annogni-nsah,i vcearridniga ct hfearimluoreg,e dnyessrihs,y uthnmcoiausp)l.ing of oxidative phospho-
Figure 7.3 Methods to maintain temperature in an anaesthetized patient •• iimmppaaiirreedd wphliattee lceet ll ffuunnccttiioonn leleaaddiningg t o top osptoopsteorpateirvaet iivnef ecbtlieoend;ing/ rtryilpahtioosnp hoactceu. rIst wisi tmh tohree pimropdourcttainotn ionf nheeoant aetnaelr ghyea itn pstreoaddu ocfti aodne, naonsdi nies
Hexecahta angned moisture Acomnbtireonlt temperature Wi.va. rfmluiedds h• aaeAlmtlela rttehodem daarbsu;ogv em metaabyo claisumse. delayed recovery from surgery and there- msaetRudroiaauttiteoidnn e v imrae octhnoevit eosrryy,m rEpoCaotGmhe) tmicco annne itrobvreoi unsag f sf(yencsotteenmd-i n (bvβya3 s isrvheeci vebeplrotionorgds ).porre sostuhreer,
rbLecooAa(otwCencnha xtahss gnohiaeoemaodtesprdns hlavuttpas eacfhes h, rlw htlreoeemsi miiitw oa3nteoiishncceeet)f Pa awtaiernmte cda mn alitet orness FoF– f lousv rfeihlcduroe yiwudd sla/ dabhr ilmobror eoewt druea, ss rpuemtrsd ooee drffdu o ocrifp t aelsalrl r aabgtrueieot v ngotsihlvueemnes fPpmMW•for eaoeriartInoemtiaythe ftsdn rnuoi tasetordhi rself eeta i a wm dmyomst ye hpotrewdmyoonai m erinsdpattluiaoarlpgs rennraaci iint nsbhnc gtieag ttc moeior. tng etTemgaehammhv veahiopropbscomiei trdmidrieasov a n oemetrtpeuvo.laa;eyre taet riitews theu irsneni,ae satrtrsws etmsse irhin ootem ihgvpdcde.pee h dlrru eehaumf tefrrtieieaovincat neigtusnli uysgvgaer en ea nadasraeeen usi:sndrnsti hfnaaoreg afesr ratieahaspdn eint ad rwehe aersadeedtrhia mastedetsiiiimonniaangg-. m••••• opoapdDvnenroorettdxuhipmacagionhpdesfsorin oanetltlhmite.nraoe.tn sctearna sbees ,u ese.gd. tpoh ayvsoosidti gomr tirneeat shivering include:
is given;
Anaesthesia at a Glance, First Edition. Julian Stone and William Fawcett.
24 © 2013 Julian Stone and William Fawcett. Published 2013 by John Wiley & Sons, Ltd. Temperature regulation 25
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