Table Of ContentANAESTHESIA FOR THE HIGH RISK PATIENT
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ANAESTHESIA FOR
THE HIGH RISK PATIENT
Edited by
Dr Ian McConachie, Consultant in Anaesthesia & Intensive Care
Blackpool Victoria Hospital
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© 2002
Greenwich Medical Media Limited
137 Euston Road
London NW1 2AA
870 Market Street, Ste 720,
San Francisco, CA 94102
ISBN 1 84110 072 2
First Published 2002
Apart from any fair dealing for the purposes of research or private study, or criticism
or review,as permitted under the UK Copyright Designs and Patents Act 1988,this
publication may not be reproduced, stored, or transmitted, in any form or by any
means, without the prior permission in writing of the publishers, or in the case of
reprographic reproduction only in accordance with the terms of the licences issued
by the appropriate Reproduction Rights Organisations outside the UK. Enquiries
concerning reproduction outside the terms stated here should be sent to the publish-
ers at the London address printed above.
The right of Ian McConachie to be identified as editor of this work has been asserted
by him in accordance with the Copyright Designs and Patents Act 1988.
While the advice and information in this book is believed to be true and accurate,
neither the authors nor the publisher can accept responsibility or liability for any
loss or damage arising from actions or decisions based in this book. The ultimate
responsibility for treatment of patients and the interpretation lies with the medical
practitioner. The opinions expressed are those of the author and the inclusion in
the book of information relating to a particular product,method or technique does
not amount to an endorsement of its value or quality, or of the claims made of it by
its manufacturers. Every effort has been made to check drug dosages; however, it is
still possible that errors have occured. Furthermore,dosage schedules are constantly
being revised and new side effects recognised. For these reasons, the medical prac-
titioners are strongly urged to consult the drug companies’ printed instructions
before administering any of the drugs mentioned in this book.
The publisher makes no representation,express or implied,with regard to the accuracy
of the information contained in this book and cannot accept any legal responsibility
or liability for any errors or omissions that may be made.
A catalogue record for this book is available from the British Library.
Project Manager
Gavin Smith
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CONTENTS
Preface........................................................................................................
vii
Contributors ..............................................................................................
ix
1. Epidemiology and identification of the high-risk surgical patient ..........
1
A. Adams
2. Respiratory risk and complications ......................................................
29
A. Adams
3. Lessons from the National Confidential Enquiry into
Perioperative Deaths ............................................................................
41
K. Paramesh and C. Dunkley
4. Analgesia for the high risk patient ........................................................
51
F. Duncan and D.J. Counsell
5. Local anaesthetic techniques ................................................................
65
B. Lord
6. The critically ill patient in the operating theatre ..................................
77
D. Hume and I. McConachie
7. The elderly patient .............................................................................. 101
S. Vaughan
8. Perioperative optimisation .................................................................. 117
M. Cutts
9. The patient with coronary heart disease .............................................. 127
S. Lakshmanan and M. Hartley
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10. Valvular heart disease and pulmonary hypertension .............................. 141
C. Harle
11. Emergency abdominal aortic surgery.................................................... 153
G. Johnson and M. Chamberlain
12. Gastrointestinal surgery ........................................................................ 165
A. Heard and N. Harper
13. Perioperative renal insufficiency and failure .......................................... 179
I. McConachie
14. The role of the cardiology consult ........................................................ 199
S. Bulugahapitiya and D. Hesketh Roberts
15. The risk of anaemia and blood transfusion............................................ 215
M. Bewsher
16. Admission criteria for HDU and ICU.................................................. 227
V. Prasad and J. Cupitt
17. The meaning of risk ............................................................................ 239
A. Adams
Index .......................................................................................................... 249
CONTENTS
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PREFACE
This text:
•
Is aimed primarily at trainees in Anaesthesia though more experienced
practitioners may find it useful as a refresher in recent concepts and
advances. A basic knowledge of physiology, pharmacology and anaes-
thesia is assumed.
•
May be a useful ‘aide memoire’ for the FRCA and other examinations in
anaesthesia.
•
Aims to provide practical information on the management of high-risk
patients presenting for surgery as well as sufficient background informa-
tion to enable understanding of the principles and rationale behind
their anaesthetic and perioperative management. We hope it will prove
useful but we would emphasise that this, or any other book, is no
substitute for experienced supervision, support and training.
•
Is not a substitute for the major anaesthetic texts but concentrates on
principles of management of the most challenging anaesthetic cases.
•
Aims to provide guidance to help manage these patients in the peri-
operative period in line with modern concepts of critical care ‘outreach’
and the potential role of the anaesthetist as perioperative physician.
•
Emphasises cardiovascular risk, cardiac disease and cardiac management
as these are undoubtedly the most important aspects of perioperative
anaesthetic risk.
•
The choice of topics is, by nature of the size of text intended, selective
but should appeal and be useful to the majority of practitioners. Important
information not readily available in similar texts, e.g. a summary of all
confidential enquiry into perioperative deaths (CEPOD) reports, peri-
operative renal failure,the role of the cardiology consult and indications
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for admission to high dependency unit (HDU) and intensive care unit
(ICU) are included.
•
The format is designed to provide easy access to information presented
in a concise manner. We have tried to eliminate all superfluous mate-
rial. Selected important or controversial references are presented as well
as suggestions for Further reading. The style of the chapters vary. This
is deliberate. Some relate more to basic principles, physiology, pharma-
cology,etc. – bookwork. Others are more practical in nature, discussing
the principles of anaesthetic techniques for certain high-risk situations.
•
The authors are all experienced practitioners working in a large, busy
DGH with a high proportion of sick, elderly patients presenting for
both elective and emergency surgery. The authors are committed to
providing a high level of perioperative care of patients undergoing
anaesthesia. We make no apologies for repetition of important principles
and facts.
I McConachie
Blackpool
2001
PREFACE
viii
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CONTRIBUTORS
Blackpool Victoria Hospital, Whinney Heys Road,
Blackpool FY3 8NR, England
Department of Anaesthesia
Dr A. Adams FRCS FRCA
Dr K. Paramesh FRCA
Dr C. Dunkley FRCA
Dr D.J. Counsell FRCA
Dr B. Lord FRCA
Dr D. Hume FRCA
Dr S. Vaughan MRCP FRCA
Dr M. Cutts MRCP FRCA
Dr S. Lakshmanan FRCA
Dr M. Hartley FRCA
Dr C. Harle FRCA
Dr G. Johnson FRCA
Dr M. Chamberlain FRCA
Dr A. Heard FRCA
Dr N. Harper FRCA
Dr V. Prasad FRCA
Dr J. Cupitt FRCA
Dr M. Bewsher FRCA
Dr I. McConachie FRCA
Department of Cardiology
Dr S. Bulugahapitiya MRCP
Dr D. Hesketh Roberts FRCP
Acute Pain Service
Ms F. Duncan SRN
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