ii Any or all parts of this manual may be reproduced, provided the parts reproduced are free- not for sale. For commercial purposes, no part of this manual may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without permission in writing from the publisher. The intent of this manual is to be freely used, copied, and distributed in Developing Countries for the teaching and promotion of basic anesthesia knowledge/skills. The purpose of this manual is to provide developing countries with a copyright free basic anesthesia manual. This manual can be freely copied and translated into a native language for the promotion of basic anesthesia knowledge/skills. Contributors with credited pictures and illustrations have graciously given permission for their material to be used for this specific purpose. The author and publishers of this manual cannot accept liability from the use of this manual or errors in translation. It is up to each translator to ensure that the translation is correct. Knowledge about the art and science of anesthesia continues to change. It is up to each anesthesia provider to continue to learn and upgrade their knowledge. This manual only contains basic knowledge and is not a replacement for more comprehensive anesthesia information. iii “Every prudent man acts out of knowledge.” Proverbs 13:15 Soli Deo Gloria iv Acknowledgements This project would not have been possible without the help of many. The World Health Organization and Michael B. Dobson MD kindly gave permission to utilize illustrations from the publication Anaesthesia at the District Hospital, WHO, Geneva, 2000 for two earlier editions, published in Afghanistan and Cambodia. Permission to use material from the WHO publication is not an endorsement of this anesthesia manual over other manuals that may be available. The WHO does not endorse any specific company or product. Since the earlier editions, this manual has been configured to provide a copyright free edition to all who would desire it. Professional illustrations were provided by Welti & Rose Advertising, Inc. Photographs provided by the author and William H. Hartland Jr. CRNA, PhD. I am indebted to Dr. Mark Schanbacher who spent many hours with me going over this manual, word by word, and sentence by sentence. Several anesthesia providers/medical professionals gave their time to this worthy task. This group of academic and clinical experts provided valuable insights and thoughtful consideration to the content of this manual. Invaluable guidance was provided by Chuck Biddle CRNA, PhD; William Hartland Jr. CRNA, PhD; Richard A. Henker CRNA, PhD; John Nagelhout CRNA, PhD; Bob Halliburton CRNA, DNSc; Karen Zaglaniczny CRNA, FAAN, PhD; Donald M. Bell CRNA, DNSc, APN; Michael J. Kremer CRNA, FAAN, DNSc; John Aker CRNA, MS; Sandra M. Ouellette, CRNA, M.Ed., FAAN; Suzanne Brown, CRNA; Dennis L. Edwards MD; Deb Hansen Pharm.D; Ken Gross MD; Ken Foster MD; W.C. Petty MD; Asad Fayaz MD; Malte L. von Blumroder MD; Uffe Romer MD; Karen Mindling RN; and Carson F. Frazzini CRNA, MS. Editorial assistance was provided by Dan Fong , Leigh Berthoff, Jenera Turman, and Sandra Rosse. The cover was designed by Steve “Human” Pfauter. Initial layout by Janelle Meyers. Thank you for your contributions! v Introduction This manual is not complete. However, it is an excellent start. Anesthesia is essential for the practice of surgery. It is a great responsibility that we are given as anesthesia providers. Patients undergoing surgery put their lives in our hands. It is our duty to protect the patient, to give the patient our full attention, and to administer the safest anesthetic possible. Vigilance means to be alert to danger or threats. Each of us must be vigilant when giving anesthesia to avoid unnecessary complications. It is my prayer that this manual will help teach the anesthesia provider in training as well as serve as a review for those who are currently practicing the art and science of anesthesia. Every effort was made to ensure that the material and information contained in this manual is correct and up-to-date. The publishers and author cannot accept liability from any potential errors contained in this manual or errors that may occur from the use of this material. If this manual is published, translated, or used for the promotion of basic anesthesia knowledge, the author would appreciate an email. This project continues to evolve and your input is critical to making it useful in the developing world. Please feel free to contact me at [email protected] with comments, questions, recommendations for future editions, and any concerns. Daniel D. Moos vi Resources A number of resources are available for the anesthesia provider in developing countries. Books Anaesthesia at the District Hospital, 2nd Edition. Michael B. Dobson. Published by the World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists. This manual was published to help guide medical officers in small hospitals. It contains a wealth of practical and useful information. This book is available in English. Internet Resources Manuals Safe Anaesthesia. Lucille Bartholomeusz, 3rd edition updated and revised by Jean Lees. This manual is available at http://www.worldanaesthesia.org . This 700+ page manual contains comprehensive information concerning anesthesia. Individual chapters may be downloaded. This manual is available in English. Basic Guide to Resuscitation for Developing Countries. Daniel D. Moos. This manual is available at http://www.worldanaesthesia.org and http://ifna-int.org . This manual can be freely downloaded, copied, and translated for the promotion of basic resuscitation techniques. Additional information concerning basic resuscitation may be obtained at http://erc.edu (European Resuscitation Council) and http://americanheart.org (American Heart Association). Primary Trauma Care is an excellent resource for basic trauma care. It is available at http://www.primarytraumacare.org . This thirty-nine page manual is available in English, Chinese, Spanish, French, Indonesian, Mongolian, Farsi, and Vietnamese. Education World Anaesthesia Online can be accessed at http://www.nda.ox.ac.uk/wfsa/. This web site is dedicated to the promotion of anesthesia knowledge and skills in the developing vii world. Update in Anaesthesia is “An educational journal aimed at providing practical advice for those working in isolated or difficult environments.” The majority of the updates are available online in English. A small number of updates are available online in Russian and French. The print version is available in English, Russian, French, Mandarin, and Spanish. World Anaesthesia can also be accessed at http://www.neda.ox.ac.uk/wfsa/ . World Anaesthesia is a newsletter of the World Federation of Societies of Anaesthesia. The newsletter allows “for the exchange of views & ideas on advancing the specialty of anaesthesia in the developing world.” It is available in English. International Organizations International Federation of Nurse Anesthetists (IFNA) was founded in 1989 and currently has 34 country members. The IFNA is an international organization whose mission is in part dedicated to the advancement of educational standards and practices of anesthesia. The IFNA website is located at http://www.ifna-int.org . Additional resources concerning the IFNA include: Caulk R, Ouellette S M. The International Federation of Nurse Anesthetists A Professional Study and Resource Guide For The CRNA. AANA Publishing 2001; Chapter 19: 381-406. McAuliffe M. Countries where anesthesia is administered by nurses. AANAJ 64 (5), 469-479. Henry B, McAuliffe M. Practice and education of nurse anesthetists. Bulletin of the World Health Organization.The International Journal of Public Health. 77 (3), 267-270. World Federation of Societies of Anesthesiologists (WFSA) was founded in 1955 and currently has 122 country members. The objectives of the WFSA is the improve/disseminate knowledge concerning the standards of anesthesia, pain treatment, trauma management and resuscitation to all countries of the world. The WFSA website can be located at http://anaesthesiologists.org . viii Table of Contents Chapter 1: Medical Math Formula Method 2 Conversion of Ratios and Percent 4 Converting % to mg 5 Converting mg to % 5 IV Fluid Calculations 5 Chapter 2: Documentation Pre-Anesthesia Evaluation 8 Anesthesia Care Documentation 10 Chapter 3: Fluid Management and Fluid Replacement Preoperative Evaluation 19 Calculating Fasting Fluid Deficit 19 Fluid Maintenance Requirements 20 Insensible Fluid Loss 20 Fluid Replacement Based on Surgical Trauma 21 Blood Loss 21 IV Solutions 21 Estimating Blood Volume 24 Chapter 4: Medications used in Anesthesia Malignant Hyperthermia 29 Inhalation Anesthetic Agents 31 Induction Agents 37 Muscle Relaxants/Paralytics 41 Muscle Relaxant Reversal Agents 46 ix Chapter 4: Medications used in Anesthesia continued… Anti-Cholinergics 48 Opioid Analgesics 49 Opioid Agonist-Antagonists 51 Opioid Agonists 53 Non-Opioid Analgesics 54 Anti-Anxiety Agents 55 Benzodiazepine Reversal Agent 56 Anti-Nausea Medications 57 Common Vasopressors 59 Resuscitation Medications 61 Basic Considerations 61 Chapter 5: Preparing for Anesthesia General Equipment Check 70 Patient Related Equipment Check 71 Preoperative Assessment 71 Medical History, Interview, and Physical Exam 72 Review of Systems 75 Laboratory Values 76 Physical