SAFE ANAESTHESIA SAFE ANAESTHESIA by by Lucille Bartholomeusz Lucille Bartholomeusz 1986 1986 Third edition updated and revised Third edition updated and revised by by Jean Lees Jean Lees 2006 2006 i i Copyright Lucille Bartholomeusz Copyright Lucille Bartholomeusz ISBN 1 86252 876 4 ISBN 1 86252 876 4 This book is copyright. Apart from any fair dealing for the purposes of This book is copyright. Apart from any fair dealing for the purposes of private study, research, criticism or review as permitted under the Copyright private study, research, criticism or review as permitted under the Copyright Act, no part may be reproduced by any process without written permission. Act, no part may be reproduced by any process without written permission. Enquiries to: Enquiries to: Jean Lees e-mail [email protected] Jean Lees e-mail [email protected] First edition 1986 First edition 1986 Second edition 1996 Second edition 1996 Third edition 2006 Third edition 2006 ii ii Preface to the third edition Preface to the third edition In revising this well-respected book I have tried to retain the original In revising this well-respected book I have tried to retain the original structure and, particularly, the ethos of the book in keeping with its origins structure and, particularly, the ethos of the book in keeping with its origins as described in the preface to the 1st edition. as described in the preface to the 1st edition. The whole text has been updated and revised in line with current anaesthetic The whole text has been updated and revised in line with current anaesthetic teaching. I have added new chapters on hypothermia and acute pain relief teaching. I have added new chapters on hypothermia and acute pain relief and have amalgamated and re-arranged some other chapters for easier and have amalgamated and re-arranged some other chapters for easier reference. reference. There have been many people (some unknown to me) involved in the There have been many people (some unknown to me) involved in the revision and I thank them all. Andrew and Kellie Robinson who put the revision and I thank them all. Andrew and Kellie Robinson who put the whole book on disc made an enormous contribution. Others have whole book on disc made an enormous contribution. Others have contributed sections, ideas and illustrations – Ruth Colman, Bill Casey, Ray contributed sections, ideas and illustrations – Ruth Colman, Bill Casey, Ray Towey, Grant Haldane, Alex Bojarska and Roger Eltringham and John Towey, Grant Haldane, Alex Bojarska and Roger Eltringham and John Main. Main. Lois Gibson encouraged me to tackle this enormous task and gave of her Lois Gibson encouraged me to tackle this enormous task and gave of her experience and invaluable help throughout the revision of the text. experience and invaluable help throughout the revision of the text. Iain Wilson has been a great support and encouragement and, along with Iain Wilson has been a great support and encouragement and, along with Isabeau Walker, has scrutinised the whole text, given advice and helpful Isabeau Walker, has scrutinised the whole text, given advice and helpful suggestions throughout. suggestions throughout. I have added a number of illustrations and diagrams and I gratefully I have added a number of illustrations and diagrams and I gratefully acknowledge permission to reproduce these from: acknowledge permission to reproduce these from: • World Health Organisation. • World Health Organisation. Anaesthesia at the District Hospital 2nd ed. Michael Dobson Anaesthesia at the District Hospital 2nd ed. Michael Dobson • WA /WFSA • WA /WFSA Update journals edited by Walters & Wilson. Update journals edited by Walters & Wilson. Thanks also to Lin and Paul for the cover design. Thanks also to Lin and Paul for the cover design. Finally thanks to my husband Norman who has collected and prepared Finally thanks to my husband Norman who has collected and prepared many of the illustrations, assembled the index and encouraged me to many of the illustrations, assembled the index and encouraged me to continue when difficulties arose. Without his help and support this project continue when difficulties arose. Without his help and support this project would not have reached completion. would not have reached completion. I hope this text will continue to assist all anaesthetists in developing I hope this text will continue to assist all anaesthetists in developing countries who, with limited support and training opportunities, are working countries who, with limited support and training opportunities, are working hard to improve conditions for their patients. hard to improve conditions for their patients. Jean Lees Jean Lees MB,ChB. FRCA MB,ChB. FRCA August 2006 August 2006 iii iii Preface to the first edition Preface to the first edition How this book came to be written How this book came to be written I am a Christian. I believe that a life surrendered to Christ is used of Him to I am a Christian. I believe that a life surrendered to Christ is used of Him to His glory and the benefit of others. In doing so the Christian is enriched and His glory and the benefit of others. In doing so the Christian is enriched and blessed a hundred fold. blessed a hundred fold. While pursuing my postgraduate training in anaesthetics I was conscious of While pursuing my postgraduate training in anaesthetics I was conscious of a very strong desire to do this. To let the knowledge and experience I had a very strong desire to do this. To let the knowledge and experience I had gained be available for His use. gained be available for His use. One year after I finished my training as an anaesthetist an article appeared One year after I finished my training as an anaesthetist an article appeared in ‘Africa Now’ (which was then the magazine of the Sudan Interior in ‘Africa Now’ (which was then the magazine of the Sudan Interior Mission). This described the need for an anesthesiologist to start a training Mission). This described the need for an anesthesiologist to start a training program for nurse anaesthetists in order to equip them to carry out program for nurse anaesthetists in order to equip them to carry out anaesthetic duties in Mission hospitals. The surgical workload in these anaesthetic duties in Mission hospitals. The surgical workload in these hospitals was comparable to a small district hospital in Australia. The only hospitals was comparable to a small district hospital in Australia. The only language required for teaching was English. If my desire to serve was language required for teaching was English. If my desire to serve was sincere, then surely this job must have been meant for me. sincere, then surely this job must have been meant for me. Arriving in Nigeria I found three very competent Nigerian nurses ready to Arriving in Nigeria I found three very competent Nigerian nurses ready to commence the training program. commence the training program. At the conclusion of the year, the course completed, the trainees dispersed At the conclusion of the year, the course completed, the trainees dispersed to the various hospitals they came from, and I returned home pledged to go to the various hospitals they came from, and I returned home pledged to go back if I was needed again. back if I was needed again. Five years later it was suggested I organise another such training course. Five years later it was suggested I organise another such training course. Awaiting me this time were four students; two males and two females. We Awaiting me this time were four students; two males and two females. We had a very good year of work and fellowship. had a very good year of work and fellowship. Before my return home I had many requests that the notes used for the Before my return home I had many requests that the notes used for the training program be published. This was suggested for the following training program be published. This was suggested for the following reasons: reasons: • Textbooks written for those anaesthetists with less than the • Textbooks written for those anaesthetists with less than the conventional training were difficult to obtain. conventional training were difficult to obtain. • Library facilities were not available in the smaller hospitals. It is • Library facilities were not available in the smaller hospitals. It is important for every anaesthetist to possess at least one book covering important for every anaesthetist to possess at least one book covering most aspects of anaesthesia. A need was felt for a text which dealt with most aspects of anaesthesia. A need was felt for a text which dealt with basic anaesthetics and which would also be useful as a reference book basic anaesthetics and which would also be useful as a reference book when unusual surgical procedures were performed, unusual medical when unusual surgical procedures were performed, unusual medical problems were met with and when complications set in during and problems were met with and when complications set in during and after the anaesthetic. after the anaesthetic. • Techniques used successfully in Developing Countries, embodying • Techniques used successfully in Developing Countries, embodying safe modern principles of anaesthesia using drugs, equipment and safe modern principles of anaesthesia using drugs, equipment and facilities available, should be documented. facilities available, should be documented. iv iv • The experience gained in setting up an anaesthetic service and • The experience gained in setting up an anaesthetic service and organizing a training program for nurse anaesthetists should be organizing a training program for nurse anaesthetists should be documented for the use of others. documented for the use of others. My first reaction to this was a very definite “no”. I did not feel capable of My first reaction to this was a very definite “no”. I did not feel capable of fulfilling this request. I could think of many other anaesthetists who if they fulfilling this request. I could think of many other anaesthetists who if they applied themselves to the task would do a far better job. It was too big a applied themselves to the task would do a far better job. It was too big a task and too time consuming anyway. A few months after I returned home a task and too time consuming anyway. A few months after I returned home a very dear friend from Sri Lanka, my country of birth, wrote to me with the very dear friend from Sri Lanka, my country of birth, wrote to me with the suggestion that I write a book based on my experiences in Nigeria. This suggestion that I write a book based on my experiences in Nigeria. This made me feel decidedly uneasy. Is this what I should be doing? I then made me feel decidedly uneasy. Is this what I should be doing? I then prayed that if this was part of the work God wanted me to do I would be prayed that if this was part of the work God wanted me to do I would be obedient in doing it. I pledged myself that if one more request was made I obedient in doing it. I pledged myself that if one more request was made I would consider writing a book. would consider writing a book. A few months later, my very dear friend Lois Gibson, who was also one of A few months later, my very dear friend Lois Gibson, who was also one of my trainees, working in Niger, returned home unexpectedly. A phone call my trainees, working in Niger, returned home unexpectedly. A phone call conveyed a special request that a Handbook of Anaesthesia be published. conveyed a special request that a Handbook of Anaesthesia be published. The techniques described in this book are used successfully today in three The techniques described in this book are used successfully today in three hospitals in Nigeria, one hospital in Niger and one hospital in the Peoples hospitals in Nigeria, one hospital in Niger and one hospital in the Peoples Republic of Benin. Republic of Benin. This book could not have been written without the help and encouragement This book could not have been written without the help and encouragement of Lois Gibson and my many medical and Christian friends, both here and of Lois Gibson and my many medical and Christian friends, both here and in Nigeria. A special word of thanks to my husband, John for his quiet in Nigeria. A special word of thanks to my husband, John for his quiet encouragement and help, especially at those times when my enthusiasm was encouragement and help, especially at those times when my enthusiasm was waning. To our dear friend, Harry Reynolds, without whose wisdom, waning. To our dear friend, Harry Reynolds, without whose wisdom, expertise and hard work this book would not have been possible, my very expertise and hard work this book would not have been possible, my very sincere thanks. Acknowledgement is made to the following, for kind sincere thanks. Acknowledgement is made to the following, for kind permission to reproduce the diagrams: permission to reproduce the diagrams: • Blackwell Scientific Publications • Blackwell Scientific Publications Anatomy for Anaesthetists – Ellis and Feldman Anatomy for Anaesthetists – Ellis and Feldman • English University Press • English University Press Anaesthesia and the EMO system – John Farnam Anaesthesia and the EMO system – John Farnam • Churchill Livingstone • Churchill Livingstone Anaesthesia, Resuscitation and Intensive Care – Morris and Anaesthesia, Resuscitation and Intensive Care – Morris and Campbell Campbell • Oxford University Press • Oxford University Press Medical Care in Developing Countries – Maurice King Medical Care in Developing Countries – Maurice King My thanks go to my trainees and patients in Nigeria from whom I learned so My thanks go to my trainees and patients in Nigeria from whom I learned so much. This book goes out to those who labour to give of their best under much. This book goes out to those who labour to give of their best under very difficult circumstances. very difficult circumstances. Lucille Bartholomeusz MB BS, FFARACS December 1986 Lucille Bartholomeusz MB BS, FFARACS December 1986 v v CONTENTS CONTENTS SECTION 1 INTRODUCTION 1–6 SECTION 1 INTRODUCTION 1–6 Chapter 1 Principles and history of anaesthesia 1 Chapter 1 Principles and history of anaesthesia 1 SECTION 2 BASIC SCIENCES IN RELATION 7-80 SECTION 2 BASIC SCIENCES IN RELATION 7-80 TO ANAESTHESIA TO ANAESTHESIA Chapter 2 Anatomy of the respiratory tract in relation 7 Chapter 2 Anatomy of the respiratory tract in relation 7 to anaesthesia to anaesthesia Chapter 3 Respiratory physiology 17 Chapter 3 Respiratory physiology 17 Chapter 4 Cardiovascular physiology 35 Chapter 4 Cardiovascular physiology 35 Chapter 5 The somatic and autonomic nervous systems 49 Chapter 5 The somatic and autonomic nervous systems 49 Chapter 6 Pharmacology in relation to anaesthesia 57 Chapter 6 Pharmacology in relation to anaesthesia 57 SECTION 3 FUNDAMENTAL PRINCIPLES 81–178 SECTION 3 FUNDAMENTAL PRINCIPLES 81–178 OF ANAESTHESIA OF ANAESTHESIA Chapter 7 Preoperative care 81 Chapter 7 Preoperative care 81 Chapter 8 The airway and its maintenance 97 Chapter 8 The airway and its maintenance 97 Chapter 9 LMA and endotracheal intubation 107 Chapter 9 LMA and endotracheal intubation 107 Chapter 10 Artificial ventilation of the lungs 135 Chapter 10 Artificial ventilation of the lungs 135 Chapter 11 Inhalational anaesthetic agents 141 Chapter 11 Inhalational anaesthetic agents 141 Chapter 12 Muscle relaxants and anaesthesia 165 Chapter 12 Muscle relaxants and anaesthesia 165 SECTION 4 LOW COST EQUIPMENT 179–210 SECTION 4 LOW COST EQUIPMENT 179–210 AND LOW COST TECHNIQUES AND LOW COST TECHNIQUES Chapter 13 Low cost equipment 179 Chapter 13 Low cost equipment 179 • The EMO vaporiser 180 • The EMO vaporiser 180 • The Oxford inflating bellows 184 • The Oxford inflating bellows 184 • Other low cost vaporisers. 189 • Other low cost vaporisers. 189 Chapter 14 Low cost techniques: 195 Chapter 14 Low cost techniques: 195 • Using the EMO and controlled ventilation 196 • Using the EMO and controlled ventilation 196 • Using the OMV and controlled ventilation 204 • Using the OMV and controlled ventilation 204 • Ketamine/relaxant anaesthesia and 207 • Ketamine/relaxant anaesthesia and 207 controlled ventilation controlled ventilation • Ketamine as a sole anaesthetic 208 • Ketamine as a sole anaesthetic 208 vi vi SECTION 5 CONVENTIONAL EQUIPMENT 211–238 SECTION 5 CONVENTIONAL EQUIPMENT 211–238 AND TECHNIQUES AND TECHNIQUES Chapter 15 Conventional equipment 211 Chapter 15 Conventional equipment 211 • The anaesthetic machine - Boyle's machine • The anaesthetic machine - Boyle's machine Chapter 16 Conventional techniques 227 Chapter 16 Conventional techniques 227 • Techniques of general anaesthesia using the • Techniques of general anaesthesia using the Boyle's machine Boyle's machine SECTION 6 REGIONAL ANAESTHESIA 239–286 SECTION 6 REGIONAL ANAESTHESIA 239–286 Chapter 17 The pharmacology of local anaesthetic drugs 239 Chapter 17 The pharmacology of local anaesthetic drugs 239 Chapter 18 Selected local anaesthetic techniques 245 Chapter 18 Selected local anaesthetic techniques 245 • Axillary block 249 • Axillary block 249 • Intravenous lignocaine block 252 • Intravenous lignocaine block 252 • Field block for herniorrhaphy 254 • Field block for herniorrhaphy 254 • Penile block 257 • Penile block 257 • Digital nerve block 258 • Digital nerve block 258 • Caudal block 259 • Caudal block 259 Chapter 19 Spinal anaesthesia 263 Chapter 19 Spinal anaesthesia 263 SECTION 7 ANAESTHESIA FOR SPECIAL 287-422 SECTION 7 ANAESTHESIA FOR SPECIAL 287-422 TYPES OF SURGERY TYPES OF SURGERY Chapter 20 Paediatric anaesthesia 287 Chapter 20 Paediatric anaesthesia 287 Chapter 21 Obstetric anaesthesia 313 Chapter 21 Obstetric anaesthesia 313 Chapter 22 Anaesthesia for neurosurgery 343 Chapter 22 Anaesthesia for neurosurgery 343 Chapter 23 Anaesthesia for eye surgery 351 Chapter 23 Anaesthesia for eye surgery 351 Chapter 24 Anaesthesia for ear, nose and throat surgery 365 Chapter 24 Anaesthesia for ear, nose and throat surgery 365 Chapter 25 Anaesthesia for dental surgery 375 Chapter 25 Anaesthesia for dental surgery 375 Chapter 26 Anaesthesia for thyroid surgery 389 Chapter 26 Anaesthesia for thyroid surgery 389 Chapter 27 Anaesthesia for chest surgery 397 Chapter 27 Anaesthesia for chest surgery 397 Chapter 28 Anaesthesia for abdominal surgery 403 Chapter 28 Anaesthesia for abdominal surgery 403 Chapter 29 Anaesthesia for urology 407 Chapter 29 Anaesthesia for urology 407 Chapter 30 Anaesthesia for gynaecology 413 Chapter 30 Anaesthesia for gynaecology 413 Chapter 31 Anaesthesia for orthopaedic surgery 417 Chapter 31 Anaesthesia for orthopaedic surgery 417 vii vii SECTION 8 ANAESTHESIA AND THE 423- 502 SECTION 8 ANAESTHESIA AND THE 423- 502 MEDICAL STATE OF THE PATIENT MEDICAL STATE OF THE PATIENT Chapter 32 Anaesthesia and anaemia 423 Chapter 32 Anaesthesia and anaemia 423 Chapter 33 Anaesthesia and diseases common in developing 427 Chapter 33 Anaesthesia and diseases common in developing 427 countries countries Chapter 34 Anaesthesia and cardiac disease 439 Chapter 34 Anaesthesia and cardiac disease 439 Chapter 35 Anaesthesia and respiratory disease 445 Chapter 35 Anaesthesia and respiratory disease 445 Chapter 36 Anaesthesia and the elderly 451 Chapter 36 Anaesthesia and the elderly 451 Chapter 37 Anaesthesia and renal disease 455 Chapter 37 Anaesthesia and renal disease 455 Chapter 38 Anaesthesia and liver disease 459 Chapter 38 Anaesthesia and liver disease 459 Chapter 39 Anaesthesia and diabetes mellitus 461 Chapter 39 Anaesthesia and diabetes mellitus 461 Chapter 40 Anaesthesia and adrenal insufficiency 467 Chapter 40 Anaesthesia and adrenal insufficiency 467 (including steroid replacement therapy) (including steroid replacement therapy) Chapter 41 Anaesthesia and obesity 471 Chapter 41 Anaesthesia and obesity 471 Chapter 42 Anaesthesia and the burned Patient 475 Chapter 42 Anaesthesia and the burned Patient 475 Chapter 43 Anaesthesia and uncommon diseases 481 Chapter 43 Anaesthesia and uncommon diseases 481 Chapter 44 Anaesthesia and the AIDS patient 493 Chapter 44 Anaesthesia and the AIDS patient 493 Chapter 45 Anaesthesia for surgical emergencies 497 Chapter 45 Anaesthesia for surgical emergencies 497 (including major trauma) (including major trauma) SECTION 9 ANAESTHETIC COMPLICATIONS SECTION 9 ANAESTHETIC COMPLICATIONS AND HOW TO TREAT THEM 503–528 AND HOW TO TREAT THEM 503–528 Chapter 46 Complications and treatment Chapter 46 Complications and treatment • Cardiovascular complications 504 • Cardiovascular complications 504 • Respiratory complications 510 • Respiratory complications 510 • Gastrointestinal complications 519 • Gastrointestinal complications 519 • Urinary complications 524 • Urinary complications 524 • Neurological complications 525 • Neurological complications 525 • Opthalmological complications 526 • Opthalmological complications 526 • Others 526 • Others 526 viii viii SECTION 10 TOPICS OF INTEREST TO THE 529-684 SECTION 10 TOPICS OF INTEREST TO THE 529-684 ANAESTHETIST ANAESTHETIST Chapter 47 Venepuncture and its technique 529 Chapter 47 Venepuncture and its technique 529 Chapter 48 Intravenous fluid therapy 535 Chapter 48 Intravenous fluid therapy 535 Chapter 49 Blood transfusion/autotransfusion 547 Chapter 49 Blood transfusion/autotransfusion 547 Chapter 50 Monitoring during anaesthesia 573 Chapter 50 Monitoring during anaesthesia 573 Chapter 51 Hypothermia 585 Chapter 51 Hypothermia 585 Chapter 52 Shock 591 Chapter 52 Shock 591 Chapter 53 The recovery room 601 Chapter 53 The recovery room 601 Chapter 54 Oxygen therapy 605 Chapter 54 Oxygen therapy 605 Chapter 55 Acute pain relief 611 Chapter 55 Acute pain relief 611 Chapter 56 Chest physiotherapy 629 Chapter 56 Chest physiotherapy 629 Chapter 57 Respiratory failure 633 Chapter 57 Respiratory failure 633 Chapter 58 Cardio pulmonary resuscitation 637 Chapter 58 Cardio pulmonary resuscitation 637 Chapter 59 Acid-base balance 647 Chapter 59 Acid-base balance 647 Chapter 60 Cleaning and sterilization 655 Chapter 60 Cleaning and sterilization 655 Chapter 61 Hazards in the operating theatre 661 Chapter 61 Hazards in the operating theatre 661 Chapter 62 Do’s and don’ts and some common problems 669 Chapter 62 Do’s and don’ts and some common problems 669 ix ix x x