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Lecture Notes: Clinical Anaesthesia GCAPR 7/2/04 5:31 PM Page Ii GCAPR 7/2/04 5:31 PM Page i Lecture Notes: Clinical Anaesthesia GCAPR 7/2/04 5:31 PM Page ii To Karen, Matthew and Mark. Thank you for the never-ending help, encouragement, humour and always having so much patience. 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 4Management 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 CLCR creatinine clearance IVRA intravenous regional anaesthesia 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 FEV1 forced expiratory volume in 1 second NIPPV non-invasive positive pressure ventilation 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 x GCA1 7/2/04 5:31 PM Page 1 Chapter 1 Anaesthetic assessment and preparation for surgery greater detail are advised to consult the document The process of preoperative produced by the Association of Anaesthetists (see assessment Useful websites). By virtue of their training and experience, anaes- thetists are uniquely qualified to assess the risks in- Stage 1 — Screening herent in administering an anaesthetic. In an ideal world, all patients would be seen by their anaes- Not all patients need to be seen in a preoperative thetist sufficiently ahead of the planned surgery to assessment clinic by an anaesthetist. This stage minimize all risks without interfering with the aims to ‘filter’ patients appropriately. Screening to smooth running of the operating list. Until determine who needs to be seen is achieved by recently, for elective procedures, this took place using either a questionnaire or interview, the con- when the patient was admitted, usually the day be- tent of which has been determined with the agree- fore surgery. This visit also allowed the most suit- ment of the anaesthetic department. The process able anaesthetic technique to be determined, can be carried out in a number of ways: completion along with an explanation and reassurance for the of a questionnaire by the patient,
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