Anaesthesia for f Medical Students Pat Sullivan M.D. 1999 Edition Acknowledgements: ( The author gratefully acknowledges the work of William Sullivan MA., M.D., John c Heng MA., Ola Rosaeg M.D., FRCPC, and medical students Susie Quackenbush and Bing Kong for their general suggestions, proofreading and editing skills during the ( preparation of this manual. Special thanks to Robert Elliot M.D., for his assistance in the design of the cover page. (- ( Canadian Cataloguing in Publication Data Sullivan, Pat Anaesthesia for medical students Includes bibliographical references. ISBN 0-9699801-0-8 1. Anesthesiology. I. Ottawa Civic Hospital. Dept. of Anaesthesia 11. Title. Printed by DocuLink International O Copyright 1995 by Pat Sullivan. Revised 1999. All rights reserved. No part of ( this book may be reproduced, stored in a retrieval system, or transmitted in any form ( or by any means, electronic, mechanical, photocopying, or otherwise without the writ- ten permission of the author. ( ( Published by the Department of Anaesthesia, Ottawa Civic Hospital. Address correspondence to: ( Patrick Sullivan MD, FRCPC ( Department of Anaesthesia c Ottawa Civic Hospital, B310 1053 Carling Avenue Ottawa, Ontario, Canada, K1Y 4E9 ( T:613 - 761 - 4940 F:613 - 761 -5032 ( E: [email protected]~n.ca ( a : Contributing Authors Dr. Gregory Allen Dr. John Kitts - Assistant Professor Associate Professor Anesthesia Pennsylvania State University University of Ottawa MHAUS Hotline Consultant Vice President Medical Affairs - Department of Anesthesia Ottawa Hospital - Hershey, Pennsylvania ' Dr. Anne Lui - Dr. Wayne Barry Assistant Professor - Assistant Professor University of Ottawa University of Ottawa Department of Anesthesia Department of Anesthesia Ottawa Hospital - Civic Campus - Ottawa Hospital - Civic Campus Dr. John Penning Dr. Greg Bryson Assistant Professor - Assistant Professor University of Ottawa - University of Ottawa Director of the Acute Pain Service Department of Anesthesia Department of Anesthesia - Director Preadmission Unit Ottawa Hospital - Civic Campus - Ottawa Hospital - Civic Campus Dr. Gordon Reid Dr. Robert Cirone Assistant Prsfessor - Staff Anesthesiologist University of Ottawa Department of Anesthesia Director Malignant Hyperthermia St. Joseph's Hospital Investigation Unit Toronto Department of Anesthesia Ottawa Hospital - Civic Campus Dr. Robert Elliot Assistant Professor Dr. Linda Robinson University of Ottawa Assistant Professor Department of Anesthesia University of Ottawa Ottawa Hospital - General Campus Department of Anesthesia Ottawa Hospital - Civic Campus Introduction Specialists in the fields of medicine and should know. A11 other material is surgery may ask why medical students ~rovidedfor background reading which should be exposed to the specialty of the student may know. The manual is anesthesia. We believe that there are to be used as a primary reference for basic concepts and technical skills that lectures on monitoring in anesthesia, every physician should possess, and that and on acute and chronic pain manage- these concepts and skills are best taught ment. The problem-based tutorial ques- by our specialty. tion will also be on material covered in this manual. Medical school curricula across North America are repeatedly criticized for The student who completes the anest- lacking the teaching of both acute and hesia rotation should have acquired chronic pain management. In addition, confidence in airway management skills students who pursue a career in surgery, including mask ventilation and tracheal emergency medicine or internal medi- intubation, as well as securing intra- cine are expected to have the skills to venous access. Important concepts for manage a patient's airway. However, the student to attain during their rotation they usually have had no formal teach- include: ing in these basic skills. Finally, medi- cal school curricula in North America 1. Preoperative assessment. are rapidly changing. Students are now 2. Basic principles of managing acute asked to commit themselves to a spe- and chronic pain disorders. cialty during the third year of their 3. The appropriate use of local anaes- medical school training. We believe thetic agents. that this process is unfair. We also 4. Analgesic options for women in recognize that a student with no prior labour. exposure to anesthesia is unlikely to 5. Basic neonatal assessment and re- choose anesthesia as a career. suscitation. 6. Intravenous fluid and blood compo- This manual was written with contribut- nent therapy including the potential ing authors from the Departments of complications of a blood product Anesthesia at the Ottawa Civic and transfusion. General Hospitals for medical students spending two weeks of their clinical rotation in the specialty of anesthesia. Six specific objectives are used to focus Patrick Sullivan MD, FRCPC the students reading. The text is high- Assistant Professor lighted by two asterisks (**) for University of Ottawa, material that is essential and that the Resident Program Director student must know, and one asterisks Department of Anesthesia (*) for material which the student University of Ottawa Preface The first public demonstration of ether macology and resuscitation of acutely was by W.T.G. Morton in the traumatized patients. The importance of Etherdome of the Massachusetts General imparting these skills and knowledge to Hospital in 1846. Ether anaesthesia medical students has been realized by became widely available and would those responsible for medical school soon be followed by chloroform and curricula. Accreditation bodies are nitrous oxide. Surgeons were not demanding that anaesthetists teach med- particular about who poured the ether or ical students. chloroform so long as someone was there to do the job. It was not until the When the new curriculum, founded on early 1920's that physicians began to problem-based learning, was adopted in show interest in anaesthesia as a the Faculty of Medicine at the Univer- specialty. By the end of World War I1 sity of Ottawa, anaesthesia was given the infant specialty was firmly estab- responsibilities in the program. Each lished and university training programs student must spend two weeks in an began. anaesthesia rotation and many anaesthe- tists participate in small group sessions. The emphasis has traditionally been on Dr. Patrick Sullivan found that an an- postgraduate teaching. Why has aesthesia manual, which would meet the undergraduateanaesthesia teachingbeen needs of medical students submerged in neglected or de-emphasized? It was a new curriculum, was not available. because the medical school curriculum The manual he and his co-authors have was controlled by older, traditional written covers all of the important disciplines that were unwilling to material a medical student must and relinquish time for competing spe- should know. It is best taught by an- cialties. This was complicated by the aesthetists because it falls almost fact that anaesthetists originally worked exclusively in their domain. The only in the operating room, and found it organization of the manual makes it difficult to be freed from that responsi- essential reading for students rotating bility to undertake teaching outside the through anaesthesia who want to operating room. Anaesthesia has optimize their brief exposure to anaes- expanded to include other services thesia, which has so much to offer. which include Intensive Care, Acute and Chronic Pain Services, Malignant Hyperthermia Diagnostic Services, and a Pre-admission Unit. Anaesthetists have developed many skills which are J. Earl Wynands, M.D. valuable to physicians, regardless of Professor and Chairman their discipline. They have become Department of Anaesthesia specialists in applied physiology, phar- University of Ottawa Table of Contents 1. Rotational Objectives ............................... 2 . Anaesthesia Overview ............................... 3 . Preoperative Evaluation and Risk Assessment .............. 4 . Premedication ..................................... 5 . Getting Started: A practical approach to the OR ..................... 6 . Intubation and Anatomy of the Airway ................... 7 . Intubation Decisions ................................ 8 . The Laryngeal Mask Airway .......................... 9 . Rapid Sequence Induction ............................ 10. Monitoring in Anaesthesia ............................ 11. General Intravenous Anaesthetic Agents .................. 12. Muscle Relaxants .................................. 13. Inhalational Agents ................................. 14. Narcotic Agonists and Antagonists ...................... 15. Local and Regional Anaesthetics ....................... 16. Acute Pain Mechanisms and Management ................. 17. Chronic Pain ...................................... 18 . Obstetrical Anaesthesia .............................. 19. Basic Neonatal Resuscitation .......................... 20 . Intravenous Fluid and Blood Component Therapy ........... 21 . Common Perioperative Problems ....................... 22. Managing the Circulation ............................. 23 . Oxygen Therapy and Hypoxemia ....................... 24 . Unusual Anaesthetic Complications: Malignant Hyperthermia .......................... Aspiration Syndrome ............................. Allergic Reactions ............................... Appendix: Intravenous Access .............................. Review Questions ....................................... Index ...........................................