1 Acknowledgements Thanks to all the registrars and junior doctors who have worked in my Department over the years for the opportunity they have given me to both teach and learn from them. Thanks to all those people who have said over the years, “You should write a textbook.” Now I can say that I have done so. Thanks to my colleagues for their comments and insightful feedback. Thanks to Barb Lindbergs for permission to use the Anaesthetic Machine check documents and for access to her costing spreadsheets. Lastly I would like to thank my wife who inspires and tolerates me. I welcome any comments, criticism or vitriol and they can be conveyed to me at [email protected] Lachlan Rathie Toowoomba April 2016 Disclaimer Every effort has been made to ensure the information contained within this book is accurate and correct; especially with regard to drug dosages. Despite this, errors may have been made and advances or changes in medical science and practice may render some information incorrect or incomplete. Current drug product information monographs are the most reliable source of prescribing information. 2 TABLE OF CONTENTS Setting the scene A bit about the structure of this book ....................................................................... 7 Why have I written this book? .................................................................................... 9 Common errors made by trainee anaesthetists ....................................................... 12 Curriculums.................................................................................................................. 13 What you should be able to do after a year ............................................................. 15 Resources ..................................................................................................................... 17 How to learn anaesthesia ........................................................................................... 21 Tools of the Trade Monitoring- all those pretty waveforms .................................................................. 25 The Electroencephalogram and Its Application to Anaesthesia .......................... 32 The Anaesthetic Machine .......................................................................................... 45 The White Stuff ........................................................................................................... 53 Thiopentone and Ketamine ...................................................................................... 63 Volatile Agents and Nitrous Oxide .......................................................................... 68 Muscle Relaxants and Reversal ................................................................................. 84 Analgesics, Antiemetics and Local Anaesthetics .................................................... 98 The Main Event Preoperative Assessment ......................................................................................... 108 Planning the Anaesthetic ......................................................................................... 127 The IV and drawing up drugs ................................................................................. 132 Induction of Anaesthesia ......................................................................................... 138 3 Maintenance of Anaesthesia .................................................................................... 144 Emergence ................................................................................................................. 151 How to do a spinal (& an epidural) ........................................................................ 156 Everything you should know about Propofol TCI .............................................. 168 Putting it all together- Example Cases ................................................................... 177 Special Situations Obstetric Anaesthesia ............................................................................................... 185 Paediatric Anaesthesia .............................................................................................. 201 The Obese Patient .................................................................................................... 209 A few words about endoscopy................................................................................ 218 Crises in a Nutshell Difficult Airway 101 ................................................................................................. 222 Hypoxia ...................................................................................................................... 236 Hypotension .............................................................................................................. 240 High Airway Pressure ............................................................................................... 243 Perioperative Medicine Studies you should probably know about ............................................................. 248 Antithrombotic Drug Management ....................................................................... 253 The bleeding patient and transfusion therapy ...................................................... 257 Making a Difference ................................................................................................. 268 Miscellany My Top Twenty Tips ................................................................................................ 276 The Cost of Things ................................................................................................... 277 4 Preparing for the Primary Examination ................................................................ 279 Pre-Questionnaire ..................................................................................................... 283 Initial Assessment of Anaesthetic Competence- example paper ....................... 285 Midyear Checklist for Meeting with Supervisor- JCCA ...................................... 288 My Other Books ....................................................................................................... 290 5 Setting the scene An assortment of textbooks from the author's personal collection 6 A bit about the structure of this book This book is arranged into seven sections. The first section endeavours to explain why I have written this book. It outlines the existing deficits in the textbook literature, the shortcomings in trainee knowledge I have witnessed firsthand and the errors that have resulted. The two curriculums pertaining to anaesthetic training in Australia are briefly described as well as their practical implications. I have listed what skills and attributes that are both likely and necessary to be gained after a year of anaesthetic practice. The best available resources are reviewed to inform practitioners of their value to the learner anaesthetist and perhaps help you decide whether to buy any of them for your personal library. Finally are some thoughts about how to learn anaesthesia. The second section, ‘Tools of the Trade’, gives some detailed core information about the integral tools of our profession- namely our equipment with a focus on the anaesthetic machine and patient monitors and the drugs with a focus on the important anaesthetic drug classes. A common theme in the book is to expressly focus on pragmatic but core knowledge that is required to conduct anaesthesia safely but is lacking or hard to find in conventional learning resources. At the end of some of the chapters in this section and the next four are up to three separate items. The first of these are selected references. These are not exhaustive or definitive but references I feel worthy of reading in their own right by the junior anaesthetist. The second item comprises challenge questions relating to the content in the preceding chapter or chapters. The answers are on the following page. Some of these will even challenge your consultant! The third component that follows some chapters I collectively term ‘light relief’ and contains items of a humorous/ cynical/ sarcastic nature. The third and largest section of this book I have dubbed ‘The Main Event’. This relates to the actual conduct of anaesthesia and is further subdivided into chapters relating to preoperative assessment, planning and giving the anaesthetic. There is a detailed chapter about propofol TCI, a subject whose practical application is a lot better realized than an understanding of its theoretical foundation. Lastly is a section outlining in a stepwise fashion the anaesthetic management of some common cases. To an extent this synthesizes information from earlier chapters and applies it to example cases. The emphasis is very much on giving a practical and common sense foundation to what we do every day in the operating theatre. I believe you should critically appraise and be able to justify your practice and this section attempts to do just that. The next section relates to the two main specialty areas of anaesthetics that all generalist anaesthetists practise in- namely obstetrics and paediatrics. Again common errors and deficits are addressed as well as practical considerations for safe practice. A chapter is devoted to the most significant challenge of our professional lives- obesity. Finally are some thoughts about the commonest procedures performed that require anaesthetic services, namely endoscopy. The fifth section relates to crisis management. There are many good resources