CLINICAL ANAESTHESIA Lecture Notes 4th Edition Review of the previous edition CLINICAL ANAESTHESIA “Lecture Notes Clinical Anesthesia offers a comprehensive review of general anesthesiology principles G and practices in a quick and easy-to-read style. I recommend it as an excellent first-step for students w and other medical professionals who are interested in the field of anesthesiology.” in n Mohanad Shukry, MD, Anesthesiology, June 2009 u Lecture Notes t t L e Perfect for medical students, junior doctors, anaesthetic nurses and allied health professionals, c Lecture Notes Clinical Anaesthesia provides a thorough introduction to the modern principles and t u practices of clinical anaesthesia. r e N Full-colour diagrams, photographs and key fact boxes support easy understanding of the theory of o anaesthetics allowing confident transfer of information into clinical practice. t e s C LN This fourth edition has been fully revised and updated to reflect recent developments within the L Carl Gwinnutt anaesthetics specialty and is fully supported by a wide-range of self-assessments for study and revision I purposes together with a range of ‘tips for anaesthesia attachments’ that start each chapter. N Matthew Gwinnutt I C Whether you need to develop your knowledge for clinical practice, or refresh that knowledge in the run-up A to examinations, Lecture Notes Clinical Anaesthesia will help foster a systematic approach to the clinical L 4th Edition situation for all medical students and hospital doctors. A N For information on all the titles in the Lecture Notes series, please visit: www.lecturenoteseries.com A E S T H For more information on the complete range of All content reviewed by students for students E Wiley-Blackwell medical student and junior doctor S publishing, please visit: Wiley-Blackwell Medical Education books are designed I www.wileymedicaleducation.com exactly for their intended audience. All of our books are A developed in collaboration with students. This means that our To receive automatic updates on Wiley-Blackwell books are always published with you, the student, in mind. books and journals, join our email list. Sign up today at www.wiley.com/email If you would like to be one of our student reviewers, go to 4 www.reviewmedicalbooks.com to find out more. th E d itio n ISBN 978-0-470-65892-5 9 780470 658925 www.wiley.com/go/medicine BASQ 06/27/2012 15:32:7 Page170 FFIRS 06/27/2012 16:31:8 Page1 Clinical Anaesthesia Lecture Notes FFIRS 06/27/2012 16:31:8 Page2 Toawonderfulwifeandmarvellous,uncomplainingmother. FFIRS 06/27/2012 16:31:8 Page3 Clinical Anaesthesia Lecture Notes Carl Gwinnutt MBBSMRCSLRCPFRCA FormerlyConsultantAnaesthetist SalfordRoyalHospitalNHSFoundationTrust HonoraryClinicalLecturerinAnaesthesia UniversityofManchester,UK Matthew Gwinnutt MBChB(Hons) CoreTraineeinAnaesthesia MerseyDeanery Liverpool,UK FourthEdition FFIRS 06/27/2012 16:31:8 Page4 Thiseditionfirstpublished2012#2012byJohnWiley&Sons,Ltd. Wiley-BlackwellisanimprintofJohnWiley&Sons,formedbythemergerofWiley’sglobal Scientific,TechnicalandMedicalbusinesswithBlackwellPublishing. 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Setin8.5/11pt,Utopia-RegularbyThomsonDigital,Noida,India. 1 2012 FTOC 06/27/2012 15:46:47 Page5 Contents Listofcontributors,vi Preface,vii Acknowledgements,viii Listofabbreviations,ix 1 Anaestheticassessmentandpreparationforsurgery,1 2 Anaestheticequipmentandmonitoring,18 3 Drugsandfluidsusedduringanaesthesia,39 4 Thepracticeofgeneralanaesthesia,58 5 Localandregionalanaesthesia,79 6 Specialcircumstances,88 7 Post-anaesthesiacare,100 8 Theacutelyilladultpatientontheward,121 Section1:Recognitionandassessment,121 Section2:Managementofcommonemergencies,131 Answerstoshort-answerquestions,159 Answerstotrue/falsequestions,171 Index,177 FLOC 06/27/2012 15:48:23 Page6 Contributor AnthonyMcCluskey ConsultantinAnaesthesiaandCriticalCare StockportNHSFoundationTrust SteppingHillHospital Stockport,UK FPREF 06/27/2012 15:57:26 Page7 Preface Itisnowover15yearssinceIembarkeduponthe Also included is a small chapter covering some first edition of this book, and with each subse- of the specialist branches of anaesthesia that quent edition I have tried to respond to the students may encounter; it has not been possi- demands of the readers and the changes within ble to cover every one and I hope those whose thespecialtyofanaesthesiaitself.Inrecentyears specialties are not included will understand. theanaesthetist’srolehasexpandeddramatically Trainees from many specialties now work as from simply ‘providing the conditions under part of the ‘Hospital at Night’ team, and one of whichsurgerycanbeperformedsafely’andnow theirrolesistorespondtorequestsforhelpwith involves contact with the majority of patients acutelyillpatientsthattheymaynotbefamiliar admitted to hospital. This includes playing a with.Followingonfromthesuccessofthechap- majorroleinpreoperativeassessmentandpost- terinthepreviouseditionontherecognitionand operativecare,acute and chronic pain manage- management of the acutely ill patient on the ment, as well as the recognition, resuscitation ward,thishasnowbeenexpandedintotwosec- andmanagementofthecriticallyill.Thisedition tions;thefirstonrecognitionandassessmentof seesmanychangestoreflectthis. thesechallengingpatients,followedbyadviceon The first major change to this edition is the howinitiallytomanagecommonlyencountered lossofthechaptergivinganoverviewofcritical problems. care. During my career in anaesthesia I have Butperhapsthegreatestchangeforthisedition been privileged to see this specialty grow from isthatInowwelcomemyson,asheembarksona theeffortsofgroupsof enthusiaststoitsrecent careerinanaesthesia,asco-author.Hehaspro- formalrecognitionandtheformationoftheFac- videdafreshinsightintothespecialtyasseenby ultyofIntensiveCareMedicinewithintheRoyal ananaesthetistintraining,andismoreawareof CollegeofAnaesthestists.Consequently,Iwould whatmedicalstudentsneedtoknow,ratherthan encourage students to turn to the many excel- whatIthinktheyoughttoknow.Hehasworked lenttextsavailableonthisfascinatingandevolv- tirelessly on the manuscript and provided new ingspecialty. photographic illustrations; for that I owe him The next change in this edition is a reorgan- enormously–thankyou! ization of the way anaesthesia is presented. IclosebyreiteratingwhatIsaidattheendof Firstly, information on equipment, monitoring theprefaceofthepreviousedition,butthistime and the drugs and fluids you will see anaesthe- themessagecomesfrombothofus;wehopeyou tists use in their everyday practice. This is enjoythisbook,butevenmorewehopeithelps followed by an overview of ‘giving an anaes- you care for your patients. If it has, tell your thetic’, which describes the processes and pro- friends; if it hasn’t, tell us why and we’ll try to cedures used to ensure the patient’s safety. ensurethatthenexteditionisevenbetter! FACKNOW 06/27/2012 15:50:36 Page8 Acknowledgments IwouldliketothankIntersurgicalforFigures2.3 his help and advice with transversus abdominis and 2.5, Aircraft Medical for Figure 2.7(d), and planeblocksandFigure5.2. Tanya Lachlan, Deltex Medical for Figures 2.18 ThanksareduetotheDifficultAirwaySociety and2.19.Figure2.10isfromMcGuireandYounger, for Figure 6.3 and the National Tracheostomy 2010(seeusefulinformationsectioninChapter2), SafetyProjectforFigures8.1and8.2. with permission of Oxford University Press on I would also like to express my sincere grati- behalfoftheBritishJournalofAnaesthesia. tudetoDrRichardMorgan,ProfessorGarySmith Figures 8.6, 8.7, 8.8 and 8.9 are reproduced andDrJasSoarfortheircontributionstothepre- withkindpermissionfromMichaelScottandthe vious edition, some of which by necessity have ResuscitationCouncil(UK). beenincludedinthisedition. Figure 4.12 is reproduced with permission of Dr.P.RossandIamgratefultoDrJ.Corcoranfor