Lectures Notes Clinical Anesthesia

170 Pages·2004·2.46 MB·English

by  Carl L. Gwinnutt

LECTURE NOTES
Clinical
Anaesthesia
CARL GWINNUTT
2ndedition
GCAPR 7/2/04 5:31 PM Page i
Lecture Notes: Clinical Anaesthesia
GCAPR 7/2/04 5:31 PM Page iii
Lecture Notes
Clinical
Anaesthesia
Carl L. Gwinnutt
MB BS MRCS LRCP FRCA
Consultant Anaesthetist
Hope Hospital, Salford
Honorary Clinical Lecturer in Anaesthesia
University of Manchester
Second Edition
GCAPR 7/2/04 5:31 PM Page iv
© 2004 C. Gwinnutt
© 1997 Blackwell Science Ltd
Published by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK
Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
First published 1997
Reprinted 1998, 1999, 2000, 2001, 2002
Second edition 2004
Library of Congress Cataloging-in-Publication Data
Gwinnutt, Carl L.
Lecture notes on clinical anaesthesia / Carl L. Gwinnutt.—2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-4051-1552-1
1. Anesthesiology. 2. Anesthesia.
[DNLM: 1. Anesthesia. 2. Anesthetics—administration & dosage. WO 200 G9945L 2004] I. Title.
RD81.G843 2004
617.9¢6—dc22
2004007261
ISBN 1-4051-1552-1
A catalogue record for this title is available from the British Library
Set in 8/12 Stone Serif by SNP Best-set Typesetter Ltd., Hong Kong
Printed and bound in the United Kingdom by TJ International Ltd, Padstow, Cornwall
Commissioning Editor: Vicki Noyes
Editorial Assistant: Nic Ulyatt
Production Editor: Karen Moore
Production Controller: Kate Charman
For further information on Blackwell Publishing, visit our website:
http://www.blackwellpublishing.com
The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has
been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the
publisher ensures that the text paper and cover board used have met acceptable environmental accreditation
standards.
GCAPR 7/2/04 5:31 PM Page v
Contents
Contributors vi
Preface vii
List of Abbreviations viii
1 Anaesthetic assessment and
preparation for surgery 1
2 Anaesthesia 15
3 Postanaesthesia care 71
4 Management of perioperative
emergencies and cardiac arrest 90
5 Recognition and management of the
critically ill patient 112
6 Anaesthetists and chronic pain 139
Index 151
v
GCAPR 7/2/04 5:31 PM Page vi
Contributors
Tim Johnson Anthony McCluskey
Consultant in Pain Management and Anaesthesia Consultant in Anaesthesia and Intensive Care
Hope Hospital Medicine
Salford Stepping Hill Hospital
Stockport
Richard Morgan
Consultant Anaesthetist Jas Soar
Hope Hospital Consultant in Anaesthesia and Intensive Care
Salford Medicine
Southmead Hospital
Bristol
vi
GCAPR 7/2/04 5:31 PM Page vii
Preface
In the first edition, I asked the question, ‘Should will encounter before deciding on a career in
medical students be taught anaesthesia?’ I firmly anaesthesia. On the other hand, it is also impor-
believed that they should, and in the intervening tant that you are aware of the continuing essential
years nothing has happened to change my view. role that many of my colleagues play in treating
Indeed, with the continuing expansion of the roles and helping patients live with chronic pain prob-
and responsibilities of anaesthetists, it is now more lems and the principles upon which these are
important than ever that as medical students you based.
understand that we do far more than provide the With this edition, I have endeavoured to identi-
conditions under which surgery can be performed fy the skills you will need and the challenges you
safely. I hope that this second edition reflects these will meet in the early years after qualification. The
changes. book remains a skeleton on which to build, not
Anaesthetists are increasingly responsible for the only from within other texts, but also with clinical
development and care of patients preoperatively experience. I remain hopeful that if, after reading
and postoperatively and in the recognition and this book, you feel motivated to learn by desire
management of those who are critically ill. With rather than need I will be a little bit closer to
the help of my colleagues, I have tried to reflect this achieving my aims.
expanding role in the updated text, particularly as
these are areas that as newly qualified doctors, you Carl Gwinnutt
vii
GCAPR 7/2/04 5:31 PM Page viii
List of Abbreviations
AAGBI Association of Anaesthetists of Great GI gastrointestinal
Britain & Ireland GTN glyceryl trinitrate
ADH antidiuretic hormone HAFOE high airflow oxygen enrichment
AED automated external defibrillator HDU high dependency unit
ALS advanced life support HIV human immunodeficiency virus
ALT alanine aminotransferase HR heart rate
APC activated protein C HRT hormone replacement therapy
APPT activated partial thromboplastin time ICP intracranial pressure
ARDS acute respiratory distress syndrome ICU intensive care unit
ASA American Society of Anesthesiologists I:E inspiratory:expiratory
AST aspartate aminotransferase ILM intubating LMA
ATN acute tubular necrosis IM intramuscular
BLS basic life support INR international normalized ratio
BNF British National Formulary IPPV intermittent positive pressure ventilation
CAVH continuous arteriovenous haemofiltration IR immediate release
CBF cerebral blood flow ITU intensive therapy unit
CCU coronary care unit IV intravenous
CL creatinine clearance IVRA intravenous regional anaesthesia
CR
CNS central nervous system JVP jugular venous pressure
COPD chronic obstructive pulmonary disease LMA laryngeal mask airway
COX cyclo-oxygenase enzymes (COX-1, 2) LVEDP left ventricular end-diastolic pressure
CPAP continuous positive airway pressure M6G morphine-6-glucuronide
CPR cardiopulmonary resuscitation MAC minimum alveolar concentration
CSF cerebrospinal fluid MAP mean arterial pressure
CT computerized tomography MET Medical Emergency Team
CVP central venous pressure MH malignant hyperpyrexia (hyperthermia)
CVS cardiovascular system MI myocardial infarction
CVVH venovenous haemofiltration MOFS multiple organ failure syndrome
DIC disseminated intravascular coagulation MR modified release
DNAR do not attempt resuscitation MRI magnetic resonance imaging
ECF extracellular fluid MRSA methicillin-resistant Staphylococcus aureus
EMLA eutectic mixture of local anaesthetics NSAID non-steroidal anti-inflammatory drug
ENT ear, nose and throat NICE National Institute for Clinical Excellence
FEV forced expiratory volume in 1 second NIPPV non-invasive positive pressure ventilation
1
FFP fresh frozen plasma OCP oral contraceptive pill
FRC functional residual capacity PAFC pulmonary artery flotation catheter
FVC forced vital capacity PCA patient-controlled analgesia
GCS Glasgow Coma Scale PCV pressure-controlled ventilation
GFR glomerular filtration rate PEA pulseless electrical activity
GGT gamma glutamyl transferase PEEP positive end expiratory pressure
viii
GCAPR 7/2/04 5:31 PM Page ix
List of Abbreviations
PEFR peak expiratory flow rate TCI target controlled infusion
PHN postherpetic neuralgia TENS transcutaneous electrical nerve stimulation
PMGV piped medical gas and vacuum system TIVA total intravenous anaesthesia
PONV postoperative nausea and vomiting TNF tumour necrosis factor
PT prothrombin time TOE transoesophageal echocardiography
RS respiratory system TOF train-of-four
RSI rapid sequence induction TPN total parenteral nutrition
SIMV synchronized intermittent mandatory VF ventricular fibrillation
ventilation VIE vacuum-insulated evaporator
SIRS systemic inflammatory response syndrome V/Q ventilation/perfusion
SpO2 oxygenation of the peripheral tissues VT ventricular tachycardia
SVR systemic vascular resistance
ix
GCAPR 7/2/04 5:31 PM Page i
Lecture Notes: Clinical Anaesthesia