Smith and Aitkenhead’s Textbook of Anaesthesia 7th Edition

Front Cover
Inside Front Cover
Half Title
Smith and Aitkenhead's Textbook of Anaesthesia
Copyright Page
Contents
List of Contributors
Acknowledgements
Preface
Section 1 Basic sciences
1 General principles of pharmacology
Basic principles
Chemical structure
Isomerism
Ketamine
Bupivacaine
Transport of drugs
Ionisation and equilibria
How do drugs act?
Receptor-mediated effects
G protein–coupled receptors
Second messenger systems
What influences the response of a receptor?
Drug actions on enzymes
Enzyme kinetics
Physicochemical properties
How does the body process drugs (pharmacokinetics)?
Absorption
Distribution
Protein binding
Metabolism
Elimination
Pharmacokinetic principles
Compartment models
Volume of distribution
Elimination
Clearance
Metabolism
Enzyme induction and inhibition
Routes of administration
Oral
Gastric emptying
Bioavailability
Lingual, buccal and nasal
Intramuscular and subcutaneous
Intravenous
Bolus
Infusions
Fixed-rate infusions
Total intravenous anaesthesia and target controlled infusions
Context-sensitive half-time
Rectal
Transdermal
Inhalation
Epidural
Spinal/Intrathecal (subarachnoid)
Pharmacological variability
The effect of age on pharmacokinetics
The effects of obesity on pharmacokinetics
Pharmacogenetics
Drug interactions and adverse drug effects
Pharmaceutical
Pharmacokinetic
Pharmacodynamic
Adverse drug reactions
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
2 Data, statistics and clinical trials
Types of data
Summarising data
Sampling
Probability
Data distributions
Uniform distributions
Non-uniform distributions
Chi-squared distribution
Inferring information from a sample
Bias
Selection bias
Topic selection
Population selection
Inclusion/exclusion bias
Methodological bias
Outcome bias
Detection bias
Missing outcomes
Reporting bias
Testing
Chi-squared test
Rank tests
t-Tests
Multiple testing
Relationship testing
Comparison of techniques
Predictive testing and scoring systems
Test accuracy
Risk scoring
Survival analysis
Types of error
Other categories of error
Confidence intervals
Bayesian statistics
Clinical trials
Observational studies
Cohort studies
Case control studies
Cross-sectional studies
Interventional studies
Evidence
Population
Intervention
Comparison
Outcome
Timeliness
Regulatory approvals
Ethical review
Sponsorship
Local approvals
National approvals
Trial registration
Specific aspects of trial conduct
Informed consent
Randomisation
Blinding/concealment
Completeness of follow-up
Stages of drug trials
Publication
Publication checklists
Presentation of results
Evidence-based medicine
Systematic review and meta-analysis
Audit, research and service evaluation
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
3 Inhalational anaesthetic agents and medical gases
Kinetics of inhaled anaesthetic agents
Mechanism of action
Lipid theory (Meyer–Overton relationship)
Protein site of action theory
Minimum alveolar concentration
Pharmacokinetics of inhaled anaesthetic agents
The second gas effect
Individual anaesthetic agents
Isoflurane
Uses
Physical properties
Systemic effects
Pharmacology
Desflurane
Uses
Physical properties
Systemic effects
Pharmacology
Sevoflurane
Uses
Physical properties
Systemic effects
Sevoflurane and carbon dioxide absorbers
Pharmacology
Halothane
Uses
Physical properties
Systemic effects
Pharmacology
Halothane-associated hepatic dysfunction
Comparison of isoflurane, desflurane, sevoflurane and halothane (Table 3.2)
Systemic effects
Pharmacology
Nitrous oxide
Uses
Presentation and storage
Manufacture
Physical properties
Mechanism of action
Systemic effects
Diffusion hypoxia
Pharmacokinetics
Effects on closed gas spaces
Effects on blood and the nervous system
Environment
Other agents
Xenon
Physical properties
Systemic effects
Enflurane
Diethyl ether
Medical gases
Oxygen
Uses
Presentation and storage
Manufacture
Adverse pulmonary effects
Adverse systemic effects
Cardiovascular depression
Central nervous system oxygen toxicity
Retrolental fibroplasia
Depressed haemopoiesis
Medical air
Uses
Entonox
Uses
Helium
Uses
Presentation and storage
Properties
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Patient factors
Surgical factors
Question 3
Answer 3
4 Intravenous anaesthetic agents and sedatives
Intravenous anaesthetic drugs
Mechanism of action
Pharmacokinetics
Speed of injection
Blood flow to the brain
Protein binding
Extracellular pH and pKa of the drug
The relative solubility of the drug in lipid and water
Offset of hypnotic effect
Precautions when using i.v. anaesthetics
Pharmacology of individual intravenous anaesthetic drugs
Propofol
Chemical structure
Physical properties and presentation
Pharmacology
Central nervous system
Cardiovascular system
Respiratory system
Skeletal muscle
Gastrointestinal system
Uterus and placenta
Hepatic/renal
Endocrine
Pharmacokinetics
Adverse effects
Pain on injection
Sedation in ICU
Awareness during induction of anaesthesia
Other adverse effects
Precautions
Ketamine hydrochloride
Chemical structure
Physical characteristics and presentation
Pharmacology
Central nervous system
Cardiovascular system
Respiratory system
Skeletal muscle
Gastrointestinal system
Uterus and placenta
Eye
Pharmacokinetics
Adverse effects
Specific indications
The high-risk patient
Paediatric anaesthesia
Difficult locations and developing countries
Analgesia and sedation
Absolute contraindication
Precautions
Etomidate
Chemical structure
Physical characteristics and presentation
Pharmacology
Pharmacokinetics
Adverse effects
Specific indications
Outpatient anaesthesia
Compromised cardiovascular status
Precautions
Thiopental sodium
Chemical structure
Physical characteristics and presentation
Pharmacology
Central nervous system
Cardiovascular system
Respiratory system
Skeletal muscle
Uterus and placenta
Eye
Hepatic/renal function
Pharmacokinetics
Adverse effects
Indications
Absolute contraindication
Precautions
Obstetrics
Maintenance of anaesthesia using i.v. agents
Practical techniques for i.v. maintenance of anaesthesia
Intermittent injection
Manually controlled infusion
Target-controlled infusion
Closed-loop systems
Future developments in i.v. anaesthetic drugs
Sedative and anxiolytic drugs
Indications for the use of sedative drugs
Drugs used as sedatives
Benzodiazepines
Pharmacology
Physical properties of benzodiazepines
Systemic effects
CNS effects
Muscle relaxation
Respiratory effects
Cardiovascular effects
Pharmacokinetics
Midazolam
Flumazenil
Non-benzodiazepine hypnotics (Z-drugs)
α2-Adrenoceptor agonists
Pharmacology
Dexmedetomidine
CNS effects
CVS effects
Respiratory
Endocrine
Metabolism
Pharmacokinetics
Dosage
Clonidine
CNS effects
CVS effects
Respiratory effects
Pharmacokinetics
Dosage
Opioids
Antipsychotics
Pharmacology
Haloperidol
Dosage
Droperidol
Dosage
Olanzapine
Dosage
Miscellaneous
Melatonin
Dosage
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answers 4
Question 5
Answers 5
References/Further reading
5 Local anaesthetic agents
Mechanism of action of local anaesthetics
Mechanism of local anaesthetic inhibition of the voltage-activated Na+ channel
The voltage-activated Na+ channel
Pain fibres
Local anaesthetic structure
Pharmacological properties of local anaesthetics
Differential sensory and motor blockade
Pharmacokinetics
Absorption
Distribution
Metabolism
Clearance
Placental transfer
Clinical preparation of local anaesthetics
Enantiomer pharmacology
Pharmacology of individual local anaesthetics
Lidocaine
Bupivacaine
Levobupivacaine
Ropivacaine
Prilocaine
Other local anaesthetic drugs
Local anaesthetic toxicity
Mechanisms of systemic toxicity
Systemic toxicity
Prevention of severe local anaesthetic toxicity
Management of severe local anaesthetic toxicity
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
6 Physiology and pharmacology of pain
Mechanisms of pain
Inflammation
Neuropathic pain
Visceral pain
Pharmacology of analgesic drugs
Opioids
Mechanism of action
Analgesic action
Central nervous system
Opioid structure
Pharmacokinetics and physicochemical properties
Routes of administration
MOP agonists
Morphine
Codeine
Diamorphine
Oxycodone
Hydromorphone
Meperidine (pethidine)
Fentanyl
Alfentanil
Sufentanil
Remifentanil
Methadone
Dihydrocodeine
Tramadol
Tapentadol
Mixed agonist–antagonist opioids
Partial agonists
Buprenorphine
Opioid antagonists
New developments in opioid pharmacology
Paracetamol
Mechanism of action
Pharmacokinetics
Pharmacodynamics
Overdose and hepatic toxicity
Non-steroidal anti-inflammatory drugs (NSAIDs)
Mechanism of action
Pharmacokinetics
Pharmacodynamics
Analgesia
Gastrointestinal system
Cardiovascular
Platelet function
Renal function
Aspirin-induced asthma
Contraindications
COX-2–specific inhibitors
Mechanism of action
Pharmacodynamics
Analgesia
Gastrointestinal
Haematological
Renal
Conclusion
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
References/Further reading
7 Postoperative nausea and vomiting
Definitions
Mechanisms of nausea and vomiting
Vomiting centre
Chemoreceptor trigger zone
Stimulation of the vomiting centre
Gastrointestinal tract
Vestibular system
Cardiovascular system
Cortical inputs
Gag reflex
Neural and muscular coordination during nausea and vomiting
Adverse effects of PONV
Identifying patients at risk
Patient factors
Anaesthetic factors
Surgical factors
Postdischarge nausea and vomiting
Pharmacology
Dopamine (D2) receptor antagonists
Butyrophenones
Phenothiazines
Benzamides
Histamine (H1) receptor antagonists
Cholinergic (M1) receptor antagonists
Serotonin (5-HT3) receptor antagonists
Corticosteroids
Substance P (NK1) antagonists
Cannabinoids
Alternative pharmacological approaches
Management
Prevention
Treatment
Other techniques
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
8 Muscle function and neuromuscular blockade
Physiology of neuromuscular transmission
Pharmacology of neuromuscular transmission
Depolarising neuromuscular blocking agents
Suxamethonium (succinylcholine chloride)
Inherited factors
Acquired factors
Adverse effects of suxamethonium
Muscle pains
Increased intraocular pressure
Increased intragastric pressure
Hyperkalaemia
Cardiovascular effects
Allergic anaphylaxis
Characteristics of depolarising neuromuscular block
Non-depolarising neuromuscular blocking agents
Benzylisoquinolinium compounds
Atracurium besilate
Cisatracurium
Doxacurium chloride
Mivacurium chloride
Aminosteroid compounds
Pancuronium bromide
Vecuronium bromide
Pipecuronium bromide
Rocuronium bromide
Rapacuronium bromide
Factors affecting duration of non-depolarising neuromuscular block
Characteristics of non-depolarising neuromuscular block
Reversal agents
Anticholinesterases
Neostigmine
Edrophonium
Pyridostigmine
Physostigmine
Organophosphorus compounds
Cyclodextrins
Sugammadex
Dose
Neuromuscular monitoring
Mechanomyography
Electromyography
Accelerography
Modes of stimulation
Twitch
Train-of-four twitch response
Tetanic stimulation
Post-tetanic potentiation or facilitation
Double-burst stimulation (DBS)
Indications for neuromuscular monitoring
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
9 Cardiovascular system
The autonomic nervous system
Sympathetic nervous system
Neurotransmitters of the sympathetic nervous system
Receptor pharmacology of the sympathetic nervous system
Parasympathetic nervous system
Neurotransmitters of the parasympathetic nervous system
Receptor pharmacology of the parasympathetic nervous system
Cardiovascular physiology
Cardiovascular electrophysiology
The normal cardiac impulse and its conduction
Generation of the pacemaker action potential
Cardiac myocyte action potential
Control of heart rate
Cardiac muscle contraction
The cardiac cycle
1. Inflow phase
2. Isovolumetric contraction
3. Ejection phase
4. Isovolumetric relaxation and rapid ventricular filling
Control of cardiac output
Stroke volume and cardiac output
Control of cardiac output
Preload
Contractility
Afterload
Control of blood pressure
Structure of vascular smooth muscle
Vascular smooth muscle contraction
Control of vascular tone
Ion channels and the maintenance of basal tone
Intrinsic control of vascular tone
Myogenic autoregulation
Endothelial regulation
Vasoactive factors
Autacoids
Extrinsic control
Sympathetic nervous system
Systemic hormonal control
Cardiovascular reflexes
Valsalva manoeuvre
Phase 1
Phase 2
Phase 3
Phase 4
Myocardial oxygen delivery
Cardiovascular pharmacology
Drugs acting on the sympathetic nervous system
Sympathomimetic agents
Inotropy
Catecholamines
Endogenous catecholamines
Adrenaline
Noradrenaline
Dopamine
Synthetic catecholamines
Dobutamine
Dopexamine
Isoprenaline
Non-catecholamine sympathomimetics
Non-catecholamines: acting via adrenergic receptors
Ephedrine
Phenylephrine
Metaraminol
Non-catecholamines: acting via non-adrenergic mechanisms
Phosphodiesterase inhibitors
Vasopressin
Glucagon
Levosimendan
Selective β-agonists
Salbutamol
Sympatholytic agents
Centrally acting sympatholytic drugs
Clonidine
Dexmedetomidine
Methyldopa
Peripherally acting sympatholytic drugs
Adrenergic neuron blocking drugs
Ganglion blocking drugs
Adrenergic receptor antagonists
α-Receptor antagonists (α-blockers)
Non-selective α-blockers
Selective α-blockers
β-Receptor antagonists (β-blockers)
Labetalol
Drugs acting on the parasympathetic nervous system
Parasympathetic antagonists
Atropine
Glycopyrronium bromide
Parasympathetic agonists
Anticholinesterase drugs
Vasodilators
Nitrates/nitric oxide donors
Potassium channel activators
Calcium channel blockers
Antiarrhythmic drugs
Mechanisms of action of antiarrhythmic drugs
Class I
Class II
Class III
Amiodarone
Class IV
Other antiarrhythmics
Digoxin
Adenosine
Magnesium sulphate
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
10 Respiratory system
Control of breathing
Respiratory centre
Central pattern generator
CNS connections to the CPG
Physiological factors affecting breathing control
Peripheral reflexes
Carbon dioxide
Oxygen
Respiratory stimulants
Respiratory muscles
Work of breathing
Respiratory system mechanics
Elastic recoil
Surfactant
Time dependence of respiratory system elasticity
Compliance
Static lung volumes
Respiratory system resistance
Passive control of airway size
Airway collapse
Active control of airway size
Bronchodilator drugs
Pulmonary circulation
Pulmonary vascular resistance
Active control of pulmonary resistance
Hypoxic pulmonary vasoconstriction
Pulmonary vasodilators
Processing of endogenous compounds by the pulmonary circulation
Regional ventilation and perfusion
Ventilation
Perfusion
Effect of alveolar pressure on lung perfusion
V̇/Q̇ relationships
Alveolar air equation
Shunt
Dead space
Oxygen and carbon dioxide transport
Diffusion
O2 carriage in blood
Haemoglobin
Cellular hypoxia
Oxygen therapy
CO2 carriage in blood
Respiratory effects of general anaesthesia
Control of breathing
Effects of general anaesthesia on FRC and gas exchange
Positive pressure ventilation
Effects of IPPV on the lungs
Respiratory effects
Ventilator-induced lung injury
Respiratory physiology at high altitude
Respiratory effects of altitude
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
11 Renal physiology
Renal anatomy
Glomerular anatomy, filtration and tubular feedback
Renin–angiotensin–aldosterone system and vasopressin
Vasopressin
Tubular function and urine formation
Proximal convoluted tubule
Loop of Henle
Thin descending limb of the loop of Henle
Thin ascending limb of the loop of Henle
Thick ascending limb of the loop of Henle
Distal convoluted tubule
Collecting tubule
Pharmacology of drugs acting on the kidney
Diuretics
Site of action: whole nephron
Osmotic diuretics
Mannitol
Site of action: proximal convoluted tubule
Carbonic anhydrase inhibitors
Acetazolamide
Site of action: loop of Henle
Loop diuretics
Furosemide
Bumetanide
Site of action: distal convoluted tubule
Thiazide diuretics
Site of action: distal convoluted tubule
Potassium-sparing diuretics
Amiloride and triamterene
Spironolactone and eplerenone
Desmopressin
Assessment of renal function
Acute kidney injury and contrast nephropathy
Intrinsic renal injury
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
12 Fluid, electrolyte and acid–base balance
Physiology of electrolytes and water balance
Basic definitions
Compartmental distribution of total body water
Solute composition of body fluid compartments
Extracellular fluid
Intracellular fluid
Water homeostasis
Practical fluid balance
Rule 1
Rule 2
Dehydration
Assessment of dehydration
Laboratory assessment
Perioperative fluid therapy, optimisation and enhanced recovery
Crystalloids or colloids
Sodium, potassium, chloride, phosphate and magnesium
Sodium balance
Disorders of sodium and water balance
Hypernatraemia
Consequences of hypernatraemia
Treatment of hypernatraemia
Hyponatraemia
Consequences of hyponatraemia.
Treatment of hyponatraemia.
Potassium balance
Hypokalaemia
Hyperkalaemia
Chloride balance
Hyperchloraemia.
Hypochloraemia.
Phosphate balance
Hyperphosphataemia.
Hypophosphataemia.
Magnesium balance
Hypermagnesaemia.
Hypomagnesaemia.
Acid–base balance
Basic definitions
Acid–base disorders
Metabolic acidosis
Clinical effects and treatment
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Stewart’s physicochemical theory of acid–base balance
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
13 Metabolism, the stress response to surgery and perioperative thermoregulation
Metabolism
Cellular respiration pathway
Anaerobic glycolysis
The pentose phosphate pathway
Gluconeogenesis
Carbohydrates
Proteins
Lipids
Cholesterol
Ketones
Measuring metabolic rate
Basic nutritional requirements
Starvation
The effects of chronic malnutrition on anaesthesia
The stress response to surgery
Carbohydrate mobilisation
Protein catabolism
Fat Metabolism
Cardiovascular effects
Gastrointestinal effects
Renal effects
Immunological system effects
Local factors and the immunological (cytokine) response
Effect of anaesthesia on the stress response
Thermoregulation and anaesthesia
Physiology
Heat balance
Thermogenesis
Heat loss
Thermoregulation
Thermoreceptors
Central control
Effector mechanisms
Measurement of temperature
Effect of general anaesthesia on thermoregulation
Widening of the interthreshold range
Stages of hypothermia
Phase 1 (redistribution stage)
Phase 2 (heat loss > heat production)
Phase 3 (plateau phase)
Effect of regional anaesthesia on thermoregulation
Consequences of perioperative hypothermia
Physical, active and passive strategies for avoiding perioperative hypothermia
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
14 Blood, coagulation and transfusion
The physiology of blood
Blood cells and plasma
Blood coagulation
Coagulopathies and their impact on anaesthesia and surgery
Monitoring of coagulation
Diseases affecting coagulation
Thrombocytopenia
Acquired coagulopathies
Trauma-induced coagulopathy
Disseminated intravascular coagulation
Drug-induced coagulopathies
Interventional procedures and regional anaesthesia in coagulopathic patients
Thrombosis and acute ischaemic events
Blood products and blood transfusion
Red cell storage lesion
Major haemorrhage and massive transfusion protocols
Blood management for elective surgery
Jehovah’s Witnesses
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Section 2 Physics and apparatus
15 Basic physics for the anaesthetist
Basic definitions
Basic mathematical functions
Fluids
Behaviour of gases
Filling ratio
Entonox
Pressure
Gas regulators
Pressure relief valves
Pressure-reducing valves (pressure regulators)
Pressure demand regulators
Flow of fluids
Turbulence and flow resistance in physiology and anaesthetic practice
The Venturi, the injector and Bernoulli
The Coanda effect
Heat
Temperature and its measurement
Vaporisation
Humidity and humidification
Absolute and relative humidity
Humidification of the respiratory tract
Solubility of gases
Solubility coefficients
Diffusion
Osmosis
Electricity
Basic elements and circuits
Biological electrical signals
Electrical safety
Isolation circuits
Microshock
Safety testing
The defibrillator
Diathermy
Radiation
X-rays
Radiation safety
Magnetic resonance imaging
Physical principles of MRI
Ultrasound
Lasers
Physical principles of lasers
Optical fibres
Fires and explosions
Fuels
Support of combustion
Sources of ignition
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
16 Anaesthetic apparatus
Gas supplies
Bulk supply of anaesthetic gases
Bulk store
Oxygen
Oxygen concentrators
Nitrous oxide
Medical compressed air
Piped medical vacuum
Terminal outlets
Gas supplies
Cylinders
The anaesthetic machine
Supply of gases
Pressure gauges
Pressure regulators
Flow restrictors
Pressure relief valves on regulators
Flowmeters
Problems with flowmeters
Quantiflex
Hypoxic guard
Vaporisers
Safety features of modern anaesthetic machines
Breathing systems
Adjustable pressure-limiting valve
Classification of breathing systems
Mapleson A systems
Mapleson B and C systems
Mapleson D system
Mapleson E and F systems
Mapleson ADE system
Drawover systems
Rebreathing systems
Soda lime
Baralyme
Circle system
Manual resuscitation breathing systems
Ventilators
Inspiration
Constant pressure generator
Constant flow generator
Change from inspiration to expiration
Expiration
Change from expiration to inspiration
Delivery of anaesthetic gas
Monitoring of ventilator function
Humidification and bacterial filters
Portable ventilators
High-frequency ventilation
Venturi injector device
Scavenging
Scavenging apparatus
Active systems
Semi-active systems
Passive systems
Reservoir bags
Protecting the breathing system in anaesthesia
Suction apparatus
Infusion pumps
Volumetric pumps
Syringe drivers
Patient-controlled analgesia pump
Target-controlled infusion pumps
Perioperative warming devices
Intravenous fluid warming devices
Body warming devices
Decontamination of anaesthetic equipment
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
References/Further reading
17 Clinical measurement and monitoring
Process of clinical measurement
Stages of clinical measurement
Essential requirements for clinical measurement
The importance of repeated measurements
Measurement of continuous signals over time
Analogue and digital measurement
Digital signal processing
Analogue-to-digital conversion
Data display
Biological electrical signals
Amplification and gain stability
Input impedance and common mode rejection
Frequency response
Noise and interference
Noise originating from the patient
Noise originating from the patient–electrode interface
Noise originating outside the patient
Electrical interference.
The importance of low electrode impedance.
Biological mechanical signals
Electromechanical transducers
The cardiovascular system
Electrocardiography
Arterial pressure
Indirect methods
Oscillometric measurement of arterial pressure
Other techniques
Direct measurement
Resonant frequency and damping
Determination of the resonant frequency and damping
Optimal damping
Accuracy of arterial pressure measurements
Central venous pressure
Pulmonary artery pressure
Cardiac output
The Fick principle
Indicator dilution
Chemical indicator dilution
Thermal indicator dilution
Pulse contour analysis
Doppler ultrasonography
Generation and detection of ultrasound
Properties of ultrasound
Detection of motion by the Doppler effect: cardiac output
Transoesophageal echocardiography
Thoracic electrical bioimpedance
The respiratory system
Clinical
Respiratory rate
Oesophageal stethoscope
Airway pressure
Measurement of gas flow and volume
Measuring volume
Spirometers
Gas meters
The Dräger volumeter
The Wright respirometer
Integration of the flow signal
Indirect methods of measuring tidal volume
Measuring gas flow
Volume–time methods
Variable orifice (constant pressure change) flowmeters
Rotameter
The peak flowmeter
Variable pressure change (fixed orifice) flowmeters
Bourdon gauge flowmeter
Pneumotachograph
Other devices for measuring gas flow
Hot-wire flowmeters
Ultrasonic flowmeters
Gas and vapour analysis
Chemical methods
Physical methods
Non-specific methods
Thermal conductivity
Refractive index: interference refractometers
Specific methods
Oxygen
Carbon dioxide and anaesthetic gases
Absorption of radiation
Mass spectrometry
Gas–liquid chromatography
Raman scattering
Blood gas analysis
The glass pH electrode
The CO2 electrode (Severinghaus electrode)
Oxygenation
Oxygen tension
Oxygen electrode: the polarographic method
Galvanic or fuel cell
Transcutaneous electrodes
Oxygen content
Oximetry: measurement of oxygen saturation
In vitro oximetry
Pulse oximetry
Respiratory quotient
The nervous system
Depth of anaesthesia
The isolated forearm technique
The electroencephalogram and evoked potentials
Auditory evoked potentials
Other techniques
Intracranial pressure
Brain oxygenation
Neuromuscular junction
Temperature
Liquid expansion thermometers
Chemical thermometers
Infrared thermometers
Remote reading instruments
Resistance-wire thermometers
Thermistor thermometers
Thermocouple thermometers
Dial thermometers
Bimetallic strip thermometers
Blood loss and transfusion
Red cell loss
Blood clotting
Near-patient testing
Monitoring standards
Alarms
Oxygen supply
Breathing systems
Vapour analyser
Cardiovascular
Infusion devices
General guidelines for monitoring during anaesthesia
Additional monitoring
Monitoring during transfer
Anaesthetic recordkeeping
Automated records
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Section 3 Fundamentals of anaesthesia & perioperative medicine
18 Quality and safety in anaesthesia
Culture of quality and safety
Understanding generation of errors: systems approach
Safety behaviour and non-technical skills
Communication and teamwork
Situational awareness
Anticipation and preparedness
Decision-making
Measuring safety and quality
Safety culture
Measuring quality
Clinical outcomes: real or surrogate
Selecting a good quality indicator
Quality improvement tools
Requirements for quality improvement
Checklists
WHO checklist
Designing problems out of the system
Safety by design
Organisational design
Making it easy to do the right thing
Understanding workarounds
Learning from incidents
Acknowledging and recording that they happen
Appropriate analysis of incidents
Feedback to relevant staff
Organisational memory
Models for implementing quality improvement programmes
Plan-Do-Study-Act
Lean production system
Root cause analysis
Failure modes and effects analysis
Safety II
Infection prevention and control
Reducing transmission
Handwashing
Gloves
Aprons
Disposal of contaminated equipment
Equipment sterility
Sterile precautions
Cross-infection
Antimicrobial agents
Mechanism of action
Pharmacokinetics
Tolerability
Resistance
Safe use of antibiotics
Immunisation
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
References/Further reading
19 Preoperative assessment and premedication
The process of preoperative assessment
Who, when and where?
History
Presenting condition
Functional capacity
Concurrent medical history
Obstructive sleep apnoea
Frailty
Anaesthetic history
Family history
Drug history
History of allergy
Smoking history
Alcohol history
Social circumstances
Physical examination
Investigations
Cardiorespiratory investigations
Plasma biomarkers
ECG
Resting transthoracic echocardiography
Dobutamine stress echocardiography
Pulmonary function tests
Tests of functional capacity
Six-minute walk test
Incremental shuttle walk test
Cardiopulmonary exercise testing
Ventilatory efficiency.
Identification of myocardial dysfunction.
Risk assessment and optimisation
Prediction of non-specific adverse outcome
American Society of Anesthesiologists (ASA) physical status classification
Surgical Outcome Risk Tool
Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity
American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator
Prediction of specific adverse perioperative events
Major adverse cardiac events
Postoperative pulmonary complications
The difficult airway
Venous thromboembolism
Optimisation
Preparation for elective surgery
Providing information to the patient and obtaining consent
Generic preparation of the patient
Specific preparation of the patient
Communication of anticipated perioperative care needs
Premedication and other prophylactic measures
Relief from anxiety
Reduction in secretions
Reduction in gastric volume and elevation of gastric pH
PONV prophylaxis
Pre-emptive analgesia
Other prophylactic measures
Steroid supplementation
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
20 Intercurrent disease and anaesthesia
Cardiovascular disease
Ischaemic heart disease
Preoperative assessment
Clinical features
Functional capacity
Extent of surgery
Cardiac risk stratification
Management
Investigations
Management of pre-existing cardiovascular disease
Ischaemic heart disease.
Previous coronary bypass graft surgery.
Previous percutaneous coronary intervention.
Hypertension
Heart failure
Pulmonary hypertension
Cerebrovascular disease
Treatment and additional interventions
β-blockers.
Arrhythmias.
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor antagonists.
Antiplatelet agents.
Anticoagulants.
Statins.
General anaesthetic principles in patients with cardiovascular disease
Anaesthetic agents
Cardiac implantable electronic devices
Specific issues in anaesthetic management
Valvular heart disease
General principles
Aortic stenosis
Mitral stenosis
Aortic regurgitation
Mitral regurgitation
Mitral valve prolapse
Infective endocarditis
Hypertrophic cardiomyopathy
Respiratory disease
Assessment
History
Examination
Investigations
Effects of anaesthesia and surgery
Obstructive pulmonary disease
Chronic obstructive pulmonary disease
Asthma
Preoperative management
Treatment of airways obstruction
Treatment of active infection
Treatment of cardiac failure
Weight reduction
Smoking
Anaesthesia
An approach with minimal intervention
Elective mechanical ventilation
Regional anaesthesia
Anaesthetic agents
Postoperative care
Analgesia
Obstructive sleep apnoea
Bronchiectasis
Restrictive lung disease
Bronchial carcinoma
Tuberculosis
Haematological disorders
Anaemia
Haemoglobinopathies
Sickle-cell disease
Thalassaemia
Neutropenia
Gastrointestinal disease
Malnutrition
Fluid and electrolyte depletion
Gastrointestinal reflux
Liver disease
Preoperative assessment
Cardiovascular function
Respiratory function
Acid–base and fluid balance
Hepatorenal syndrome
Bleeding problems
Infection
Drug metabolism
Hepatic failure
Conduct of anaesthesia
Renal disease
Preoperative assessment
Fluid balance
Sodium
Potassium
Calcium
Cardiovascular effects
Neurological effects
Haematological effects
Other
Drug treatment
Anaesthesia
Perioperative acute kidney injury
Diabetes mellitus
Complications of diabetes mellitus
Cardiovascular
Renal disease
Ocular problems
Infection
Neuropathy
Autonomic neuropathy
Measuring glycaemic control
Treatment regimens
Non-insulin glucose-lowering drugs
Insulins
Perioperative management
Concurrent drug therapy
Emergency surgery and diabetic ketoacidosis
Other endocrine disorders
Pituitary disease
Acromegaly
Cushing’s disease
Hypopituitarism
Diabetes insipidus
Thyroid disease
Goitre
Thyrotoxicosis
Hypothyroidism
Disease of the adrenal cortex
Phaeochromocytoma
Hypersecretion of cortisol
Primary hypersecretion of aldosterone (Conn’s syndrome)
Adrenocortical insufficiency
Steroid cover for anaesthesia and surgery
Neurological disease
General considerations
Assessment
Respiratory impairment
Altered innervation of muscle and hyperkalaemia
Autonomic disturbances
Raised intracranial pressure
Epilepsy
Status epilepticus
Parkinson’s disease
Respiratory
Cardiovascular
Gastrointestinal
Medications
Anaesthetic management
Multiple sclerosis
Peripheral neuropathies
Motor neuron disease
Spinal cord lesions with paraplegia
Myasthenia gravis
Dystrophia myotonica
Psychiatric disease
Drug interactions in psychiatric disorders
Antidepressants
Antipsychotics
Mood stabilisers
Connective tissue disorders
Rheumatoid arthritis
Airway
Respiratory system
Cardiovascular system
Anaemia
Renal function
Drug therapy
Conduct of anaesthesia
Other connective tissue diseases
Human immunodeficiency virus
Myeloma
Porphyria
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
21 Consent and information for patients
Capacity
Voluntariness
Types of consent
Information
Methods and timing of information provision
Communicating risk
The Mental Capacity Act and incapacity
Best interests
Decisions by proxy
Restraint and deprivation of liberty
The Deprivation of Liberty Safeguards and intensive care
Consent in special circumstances
Emergency
Children
Obstetrics
Epidural analgesia
Caesarean delivery
Teaching and learning
Summary
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
22 The practical conduct of anaesthesia
Preparation for anaesthesia
Equipment checks
Alternative means of ventilation
Perform manufacturer’s machine check
Power supply
Gas supplies and suction
Suction
Medical gas supplies
Breathing system and vaporisers
Manual leak test of vaporiser
Carbon dioxide absorber
Alternative breathing systems
Correct gas outlet
Breathing systems
Ventilator
Scavenging
Airway equipment
Single-use devices
Ancillary and resuscitation equipment
Machine failure
‘Shared responsibility’ equipment
Monitoring the patient during anaesthesia
Recording and audit
Patient safety checklists
Trained ancillary staff
Physicians’ assistants (anaesthesia)
Induction of anaesthesia
Inhalational induction
Complications and difficulties
Signs of anaesthesia
Intravenous induction
Complications and difficulties
Maintenance of anaesthesia
Inhalational anaesthesia with spontaneous ventilation
Indications
Conduct
Inhalational technique for tracheal intubation
Anaesthesia using neuromuscular blocking agents
Indications
Conduct
Adequacy of anaesthesia
Adequacy of neuromuscular blockade
Reversal of neuromuscular blockade
Total intravenous anaesthesia
Practical aspects of TIVA
Patient positioning for surgery
Emergence and recovery
Conduct of tracheal extubation/ SAD removal
Recovery
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
23 Airway management
Section 1
Anaesthetic airway equipment
Face-masks
Oropharyngeal and nasopharyngeal airways
Connectors and catheter mounts
Supraglottic airway devices
First-generation SADs
Classic LMA
Flexible LMA
Second-generation SADs
ProSeal LMA
LMA Supreme and LMA Protector
i-gel
Baska mask
Intubating LMA
Laryngeal tubes
Laryngoscopes
Macintosh laryngoscope
Specialised blades
Straight blade
McCoy (levering) laryngoscope
Videolaryngoscopes
Flexible intubating laryngoscope and bronchoscope
Tracheal tubes
Tracheal tube size
Plain and cuffed tracheal tubes
Cuff design, volume and pressure
Tube shape
Specialised tracheal tubes
Cricothyroidotomy devices
Other apparatus
Bougie
Stylet
Aintree intubating catheter
Airway exchange catheters
Section 2
Routine airway management
Preoxygenation
Use of the face-mask
Use of a SAD
Indications
Contraindications
Conduct of SAD insertion
Tracheal intubation
Indications (many are relative)
Contraindications
Preparation
Anaesthesia for tracheal intubation
Laryngoscopy
Nasal intubation
Difficult tracheal intubation
Aetiology
Airway assessment
Defining difficulty
History
Examination
Predictors of difficult face-mask ventilation
Predictors of difficult SAD insertion or failure
Specific tests to predict risk of difficult laryngoscopy
Mouth opening – interincisor gap
Mallampati test
Flexion/extension of the upper cervical spine
Thyromental distance (Patil test)
Sternomental distance (Savva test)
Protrusion of the mandible (prognathism)
Combined tests
Advanced testing
Predicting difficulty with FONA
Predicting difficulty securing the airway awake
Assessing risk of regurgitation and aspiration
Conduct of anaesthesia
Preparation
General anaesthesia
Awake tracheal intubation and induction of anaesthesia while maintaining spontaneous ventilation
Complications of airway management
Airway removal at the end of surgery
Supraglottic airway device removal
Tracheal tube removal (extubation)
Complications of tracheal extubation
Laryngeal spasm (laryngospasm), bronchospasm or coughing
Airway obstruction
Regurgitation/aspiration
Airway management during emergency anaesthesia
Anaesthesia for the patient at increased risk of regurgitation/aspiration
Preparation
Induction
Preparation
Cricoid force
Induction
Failed intubation during RSI
Maintenance
Reversal and emergence
Management of the difficult airway
Before managing the difficult airway
Preparedness
Organisational preparedness
Guidelines
Equipment
Communication and training
Personal preparedness
Assessment and planning a strategy
Management of the unanticipated difficult airway
The ASA and DAS guidelines and the Vortex approach
Difficult face-mask ventilation
Difficult SAD insertion and ventilation
Management of unanticipated difficult tracheal intubation
Plan A: Primary tracheal intubation attempt
Plan B: Maintaining oxygenation and SAD insertion
Tracheal intubation via a SAD
Tracheal intubation via an ILMA
Plan C: Final attempt at face-mask ventilation
Management of unanticipated difficult intubation during RSI
Plan D: Management of ‘cannot intubate, cannot oxygenate’ (CICO)
CICO and obesity
Emergency front of neck airway
Scalpel cricothyroidotomy
Narrow-bore cannula with high-pressure source ventilation
Wide-bore cannula (≥ 4-mm ID)
Ventilation and expiration via cricothyroidotomy devices
Wide-bore cannula and scalpel cricothyroidotomy
Narrow-bore cannula
The Vortex approach
Management of the predicted difficult airway
Training, teamwork and human factors
Before approaching the difficult airway
Securing the airway awake
Administration of NMBAs in the patient with a difficult airway
Selecting an appropriate size of tracheal tube
Oxygenation for predicted difficult airways
Planning a strategy and ‘place of safety’ planning
Fibreoptic intubation
Topicalisation of the airway
Fibreoptic endoscopy
Railroading the tracheal tube
Conventional laryngoscopy or videolaryngoscopy
Awake SAD placement
Awake FONA
Tubeless techniques
Induction of anaesthesia while maintaining spontaneous ventilation
Inhalational technique
Intravenous technique
Management of the obstructed airway
Upper airway obstruction
Mid-tracheal obstruction
Lower tracheal or bronchial obstruction
Tracheal extubation and recovery
Guidelines on the management of tracheal extubation
The difficult airway in other locations
After difficult airway management
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
24 Pain
Acute pain
Organisation and objectives of the acute pain service
Pain measurement tools
Analgesic ladder
Analgesic strategy
Opioids
Patient-controlled analgesia
Subcutaneous
Intramuscular
Transdermal
Oral
Non-opioid adjuncts
Non-steroidal anti-inflammatory drugs
NMDA receptor antagonists
α2-Agonists
Lidocaine
Gabapentinoids
Inhalational analgesics
Rescue analgesia
Acute preoperative pain
Paediatric pain
Pain in pregnancy
Sickle-cell crisis
Patients with burns
Acute to chronic pain
Chronic pain
Epidemiology
Assessment of chronic pain
Pain history
Physical examination
Investigations
Explanation
Chronic pain syndromes
Classification of pain
Nociceptive pain
Somatic pain
Visceral pain
Neuropathic pain
Complex regional pain syndrome
Management of chronic pain
Physical therapies
Psychological therapies
Pain management programme
Pharmacological therapies
Cancer pain
Non-cancer pain
Paracetamol.
NSAIDs.
Opioid analgesics.
Adjuvant analgesics.
Anticonvulsants.
Tricyclic and SNRI antidepressants.
Antiarrhythmic drugs.
Ketamine.
Capsaicin.
Cannabinoids.
Interventional pain therapies.
Local anaesthetics.
Botulinum toxin.
Neurolytic techniques.
Radiofrequency lesioning.
Corticosteroids.
Medial branch block of the dorsal ramus (lumbar and cervical facet nerve blocks).
Sympathetic nerve blocks.
Transcutaneous electrical nerve stimulation.
Spinal cord stimulation.
Acupuncture.
Costs of pain management services
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
25 Regional anaesthetic techniques
Features of regional anaesthesia
Complications of regional anaesthetic techniques
Patient assessment and selection
Selection of technique
Premedication
Timing
Regional block equipment
Needles
Catheters
Non-Luer connection systems for regional anaesthesia
Nerve stimulators
Ultrasound
Monitoring
Asepsis
Inadvertent wrong-sided block
Supplementary techniques
Aftercare
Continuous perineural infusion of local anaesthetics
Block failure
Intravenous regional anaesthesia
Indications
Method
Tourniquet pain
Choice of drug
Lower limb
Central nerve blocks
Contraindications to central nerve blocks
Anatomy of the epidural and subarachnoid space
Spinal anaesthesia
Indications
Types of surgery
Performance of spinal anaesthesia
Preparation
Technique of spinal blockade in the lateral position
Factors affecting spread
Factors affecting duration
Agents
Continuous spinal anaesthesia
Physiological effects of spinal blockade
CNS
RS
CVS
GI
GU
Epidural block
Indications
Performance of epidural block
Equipment
Preparation
Technique
Single-dose technique
Catheter insertion
Factors affecting spread
Factors affecting onset
Factors affecting duration
Agents
Combined spinal-epidural anaesthesia
Caudal anaesthesia
Indications
Method
Physiological effects of epidural block
Complications of central nerve blocks
Immediate
Late
Peripheral blocks
Head and neck blocks
Stellate ganglion block
Cervical plexus blocks
Upper limb blocks
Anatomy of the brachial plexus
Interscalene block
Supraclavicular block
Infraclavicular block
Axillary block
Median, radial and ulnar nerve blocks
Radial
Median
Ulnar
Truncal blocks
Thoracic paravertebral block
Pectoral blocks (PECS I and PECS II) and serratus plane block
Ilioinguinal and iliohypogastric block
Transversus abdominis plane block
Rectus sheath block
Lower limb blocks
Sciatic nerve block
Anatomy
Method
Femoral nerve block and fascia iliaca block
Anatomy
Method
Adductor canal block
Ankle block
Anatomy
Method
Continuous peripheral nerve block
Periarticular techniques
Special situations
Paediatric regional anaesthesia
Topical anaesthesia
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
26 Complications arising from anaesthesia
Causes of complications
Human error
Communication failure
Equipment failure
Coexisting disease
Inevitable complications
Avoidance of complications
Experience
Redundant systems
Monitoring
Management of complications
Generic management
The evolving problem
Record keeping
Medicolegal aspects of complications
Common complications
Pulmonary complications
Atelectasis
Pneumonia
Pulmonary venous thromboembolism
Cardiovascular complications
Hypotension
Myocardial ischaemia and infarction
Arrhythmias
Bradyarrhythmias
Tachyarrhythmias
Neurological complications
Accidental awareness during general anaesthesia
Stroke
Nerve injury
Injury to the spinal cord or nerve roots
Spinal cord ischaemia and infarction.
Spinal cord injury after neuraxial anaesthesia.
Direct needle trauma.
Vertebral canal haematoma.
Infection.
Chemical damage.
Injury to peripheral nerves
Nerve injury related to patient position.
Nerve injury after peripheral nerve blockade.
Method of nerve and needle localisation.
Block timing in relation to general anaesthesia.
Needle design.
Injection pressure.
Drug complications
Adverse drug reactions
Type A reactions
Type B reactions
Immunological drug reactions.
Anaphylactic reaction.
Intravenous drugs
Local anaesthetics
Latex
Others
Anaphylactoid reaction.
Non-immunological histamine release.
Anaesthesia in patients with known significant allergy.
Idiosyncratic drug reactions.
Acute intermittent porphyria.
Physical complications
Cutaneous and muscular injury
Injury during airway management
Ophthalmic injury
Thermal and electrical injury
Vascular injury and tourniquets
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
27 Management of critical incidents
References/Further reading
28 Resuscitation
Science and guidelines
Epidemiology
Prevention
Guidelines for the prevention of in-hospital cardiac arrest (Resuscitation Council (UK))
Cardiopulmonary resuscitation
Diagnosis of cardiac arrest
High-quality CPR
Starting CPR in hospital
Advanced life support
Shockable rhythms (VF/pulseless VT)
Sequence of actions
Precordial thump
Witnessed and monitored VF/pulseless VT in the cardiac arrest
Non-shockable rhythms (PEA and asystole)
Sequence of actions for PEA and asystole
During CPR
Optimising the quality of cardiopulmonary resuscitation
Potentially reversible causes
Use of ultrasound imaging during ALS
Resuscitation in the operating room
Cardiac arrest in the prone position
Cardiac arrest caused by local anaesthetic
Airway management and ventilation
Circulation
Intravascular access
Drugs
Adrenaline
Atropine
Antiarrhythmic drugs
Bicarbonate
Calcium
Mechanical CPR
Extracorporeal cardiopulmonary resuscitation
Periarrest arrhythmias
Tachycardia
Bradycardia
Post-resuscitation care
Post–cardiac arrest syndrome
Airway and breathing
Circulation
Disability (optimising neurological recovery)
Seizure control
Targeted temperature management
Treatment of hyperpyrexia
Cooling techniques.
Prognostication
Clinical examination
Biochemical markers
Neurophysiological studies
Imaging studies
Organ donation
Decisions relating to cardiopulmonary resuscitation
DNACPR decisions in the perioperative period
Recommended Summary Plan for Emergency Care and Treatment
National Cardiac Arrest Audit
Acknowledgement
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
29 Postoperative and recovery room care
Staff
Facilities
Monitoring
Handover
Postoperative planning
Discharge from PACU
Levels of postoperative care
Common early postoperative complications
Central nervous system
Pathophysiology
Investigation
Drugs
Pain
Cerebral pathological conditions
Paediatric emergence delirium
Postoperative delirium
Postoperative cognitive dysfunction
Respiratory system
Airway obstruction
Laryngeal spasm
Laryngeal oedema
Bronchospasm
Hypoventilation
Drugs
Postoperative residual neuromuscular block
Others
Hypoxaemia
Ventilation-perfusion abnormalities
Shunt
Diffusion defects
Diffusion hypoxia
Reduced venous oxygen content
Pulmonary changes after abdominal surgery
Atelectasis
Pneumonia
Oxygen therapy
Oxygen therapy devices
Fixed-performance devices.
Variable-performance devices.
Controlled oxygen therapy
Cardiovascular system
Hypotension
Decreased preload – hypovolaemia
Reduced myocardial contractility – acute coronary syndrome
Reduced myocardial contractility – ventricular failure
Arrhythmias
Decreased SVR – drugs
Decreased SVR – sepsis
Hypertension
Renal system
Acute kidney injury
Effects of anaesthesia
Gastrointestinal system
Postoperative hepatic dysfunction
Postoperative nausea and vomiting
Other complications
Pain management
Headache
Sore throat
Hoarseness
Laryngeal granulomata
Shivering
Surgical considerations
Quality assurance
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Section 4 Clinical anaesthesia
30 Managing the high-risk surgical patient
What makes an operation high risk?
What makes a patient high risk?
General risk prediction scoring systems
Further investigations for risk assessment
Routine and special investigations
Reducing risk before surgery
Alternatives to major surgery
Preoperative interventions to reduce risk
Beta-blockade
Statin therapy
Coronary revascularisation
Smoking cessation
Respiratory therapy
Correction and management of anaemia
Identifying patients in need of post-operative critical care
Level 1 care
Perioperative management of the high-risk patient
Choice of anaesthetic and analgesic technique
Haemodynamic monitoring and fluid therapy
Preload responsiveness to guide fluid therapy
Fluid restriction regimens
Postoperative management
Passive leg raise to assess fluid responsiveness
Monitoring on the general ward
Monitoring in the critical care unit
Vasoactive drugs in the high-risk surgical patient
Enhanced recovery after surgery
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Patient factors
Surgical factors
Question 2
Answer 2
31 Surgery under anaesthesia for the older surgical patient
Ageing: physiological decline
Cardiovascular
Respiratory
Neurological
Renal
Haematological
Ageing: multimorbidity
Ageing: geriatric syndromes
Frailty
Delirium
Using Comprehensive Geriatric Assessment in the preoperative setting
Intraoperative considerations
Postoperative care in older surgical patients
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
32 Anaesthesia for the obese patient
Measuring obesity
Obesity and the metabolic syndrome
The adipose organ
Obesity pathophysiology, comorbidity and anaesthetic management
Airway
Airway adjuncts
Respiratory system
Anatomy
Pathophysiology
Obstructive sleep apnoea
Anaesthetic management points
Cardiovascular system
Pathophysiology
Vascular disease
Gastrointestinal
Pharmacology
Intravenous anaesthetic agents
Target-controlled infusions
Inhalational anaesthetic agents
Neuromuscular blocking agents
Suxamethonium
Non-depolarising neuromuscular blocking agents
Sugammadex
Approach to anaesthesia for obese patients
Perioperative risk in obesity
Bariatric operations
Gastric banding
Sleeve gastrectomy
Malabsorptive procedures
Postoperative care of the bariatric surgery patient
Management of patients presenting post–bariatric surgery
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
33 Paediatric anaesthesia
Anatomy and physiology
Respiratory system
Anatomy
Physiology
Cardiovascular system
Fetal circulation and cardiorespiratory changes at birth
In utero
At birth
Neonatal and infant circulation
Central nervous system
Liver function and drug metabolism
Renal function
Temperature regulation
Conduct of anaesthesia
Preoperative assessment
Investigations
Preoperative fasting
Premedication
Induction of anaesthesia
Airway and ventilation management
Intraoperative management
Monitoring and temperature control
Maintenance
Fluid management
Emergence, recovery and postoperative care
Regional anaesthesia/analgesia
Airway emergencies
Epiglottitis
Croup
Inhaled foreign body
Neonatal emergency surgery
Laparotomy for necrotising enterocolitis
Inguinal hernia repair
Pyloromyotomy
Oesophageal atresia/ tracheo-oesophageal fistula repair
Abdominal wall defects (exomphalos and gastroschisis)
Diaphragmatic hernia repair
Child protection and safeguarding
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
34 Anaesthesia for day surgery
Introduction
Preoperative assessment
Patient suitability for day surgery
Social factors
Medical factors
Surgical factors
Anaesthetic techniques
General anaesthesia
Inhalational anaesthetic agents
Intravenous anaesthetic agents
Analgesia
Simple analgesics
Opioids
Local anaesthetics
Analgesia after discharge
Adjuncts
Postoperative nausea and vomiting
Airway management
Regional anaesthesia
Spinal anaesthesia
Plexus or nerve blockade
Sedation
Recovery in day surgery
Stage 1 recovery
Stage 2 recovery
Management and organisation of the day surgery unit
Audit
Education and training
Controversies in day surgery
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
35 Anaesthesia for general, gynaecological and genitourinary surgery
Anaesthetic considerations
Patient positioning
Head-down
Lloyd-Davies and lithotomy
Lateral and prone positioning
Surgical techniques
Laparoscopic surgery
Robotic surgery
Other endoscopic surgery
Patient factors
Obese and bariatric patients
Elderly and frail patients
Cancer and chemotherapy
Anaesthetic techniques
Regional anaesthesia
Epidural analgesia
Spinal anaesthesia
Other regional and local anaesthetic techniques
Conduct of anaesthesia
Anaesthetic agents
Day-case and enhanced recovery surgery (see Chapter 34)
Nausea, vomiting and postoperative feeding
Heat loss
Perioperative antimicrobial and venous thromboembolic prophylaxis
Blood transfusion and conservation
Critical care
Anaesthetic implications of specific operations
Emergency abdominal surgery
Elective abdominal and pelvic surgery
Prostate surgery
TUR syndrome (a.k.a. TURP syndrome)
Nephrectomy and renal surgery
Intrauterine and transurethral bladder surgery
Breast, hernia, perineal, penile and testicular surgery
Continence surgery
Surgery for renal tract stones
Early pregnancy
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
36 Anaesthesia for orthopaedic surgery
The patient population
Techniques of anaesthesia
General anaesthesia
Regional anaesthesia
Postoperative analgesia
Oral and intravenous agents
Central neuraxial drugs
Peripheral nerve blocks
Surgical considerations
Positioning
Prophylaxis against infection
Prophylaxis against hypothermia
Prophylaxis against thromboembolism
Limb tourniquets
Blood conservation
Avoidance of red cell loss
Cell salvage
Pharmacological control of fibrinolysis
Modified transfusion triggers
Hypotensive anaesthesia
Specific surgical procedures
Primary hip arthroplasty
Hip resurfacing arthroplasty
Dislocation of a prosthetic hip
Hip fracture
Primary knee arthroplasty
Revision of hip/knee arthroplasty
Shoulder replacement
Arthroscopic shoulder surgery
Spinal surgery
Peripheral surgery
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
37 Anaesthesia for ENT, maxillofacial and dental surgery
Airway management for shared airway surgery
ENT surgery
Tonsillectomy
Adenoidectomy
Rigid endoscopy and microlaryngoscopy
Thyroid and parathyroid surgery
Tracheostomy
Nasal and sinus surgery
Ear surgery
ENT emergencies
Bleeding tonsil
Epistaxis
Epiglottitis and stridor
Oral and maxillofacial surgery
Oral surgery
Orthognathic surgery
Facial trauma and fractures
Anaesthesia for head and neck cancer surgery
Laryngectomy
Excision of salivary glands
Neck dissection
Surgery for oral, nasal and oropharyngeal cancer
Dental anaesthesia
General anaesthesia
Sedation
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
38 Ophthalmic anaesthesia
Anatomy and physiology of the eye
Control of intraocular pressure
Ocular blood flow
Oculocardiac reflex
Cornea
Conditions for intraocular surgery
Expulsive haemorrhage
Drugs
Choice of anaesthesia
General anaesthesia
Assessment and preparation
Ophthalmic drugs relevant to the anaesthetist
Induction of anaesthesia
Airway management
Maintenance of anaesthesia
Local anaesthesia for ophthalmic surgery
Relevant anatomy for ophthalmic regional techniques
Nomenclature of blocks
Patient selection
Ophthalmic regional blocks
Modern retrobulbar block
Inferotemporal peribulbar block (see Fig. 38.5)
Medial peribulbar block (Fig. 38.7)
Sub-Tenon’s block (Fig. 38.8)
Ultrasound-guided ophthalmic blocks
Local anaesthetic agents and adjuncts
Complications of ophthalmic regional blocks
Orbital haemorrhage
Prevention of haemorrhage
Central spread of local anaesthetic agent
Mechanism
Signs and symptoms
Treatment
Prevention
Damage to the globe
Optic nerve damage
Extraocular muscle malfunction
Sneezing
Ophthalmic procedures requiring general anaesthesia
Penetrating eye injury
Cataract surgery
Vitreoretinal surgery
Corneal transplant surgery
Strabismus surgery
Glaucoma surgery
Dacryocystorhinostomy
Other oculoplastic procedures
Paediatric procedures
Sedation and ophthalmic blocks
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
39 Anaesthesia for vascular, endocrine and plastic surgery
Major vascular surgery
General considerations
Preoperative medical therapy in vascular surgical patients
Abdominal aortic aneurysm
Elective open AAA repair
The postoperative period
Emergency open repair
Endovascular aortic aneurysm repair
Thoracic endovascular aortic repair
Branched grafts and hybrid procedures
Surgery for occlusive peripheral vascular disease
Bypass of aortoiliac occlusion
Peripheral arterial reconstruction
Carotid artery surgery
Cardioversion
Preanaesthetic assessment
Anaesthesia
Surgery for tumours of the endocrine system
Carcinoid tumour
Medical management
Anaesthesia
Phaeochromocytoma
Diagnosis
Preoperative preparation
Anaesthesia
Surgery for adrenal cortical disorders
Thyroid and parathyroid surgery
Plastic surgery
General considerations
Head and neck
Anaesthesia for pedicled and free flap surgery
Limbs
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
40 Neurosurgical anaesthesia
Applied anatomy and physiology
Anatomy
Brain
Spinal cord
Cerebrospinal fluid
Meninges
Vascular supply
Autonomic nervous system
Physiology
Intracranial pressure
Cerebral blood flow
Cerebral metabolism
Effects of oxygen and carbon dioxide on cerebral blood flow
General principles of neurosurgical anaesthesia
Monitoring during neurosurgical anaesthesia
Induction of anaesthesia
Positioning
Maintenance of anaesthesia
Blood pressure management
Fluid replacement therapy
Supplementary drug therapy
Antibiotics
Heat loss
Venous thromboembolism
Techniques for reducing intracranial pressure
Recovery from anaesthesia
Postoperative care
Anaesthesia for intracranial surgery
Intracranial tumours
Pituitary surgery (hypophysectomy)
CSF shunt insertion
Awake craniotomy
Treatment of trigeminal neuralgia
Posterior fossa craniotomy
Sitting position
Detection and treatment of air embolism
Anaesthesia for interventional neuroradiology
Anaesthesia for surgery of the spine and spinal cord
Anaesthesia for cervical spine surgery
Anterior cervical decompression
Posterior cervical laminectomy
Anaesthesia for thoracic and lumbar spine surgery
Chronic pain procedures
Anaesthesia for emergency intracranial surgery
Cerebrovascular lesions
Open aneurysm surgery
Traumatic lesions
Chronic subdural haematoma
Management of the brain-injured patient
Key management points
Intensive care management of head-injured patients
General care
Sedation
Lung ventilation
Fluid therapy and nutrition
Neurological care
Assessment
ICP monitoring
Anaesthesia for CT and MRI scanning
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
41 Anaesthesia for thoracic surgery
Anatomy
Radiographic surface markings
Preoperative assessment
Lobectomy or pneumonectomy
Staging of lung cancer
General anaesthetic considerations
Predicted postoperative lung function
Exercise testing
Prediction of mortality
Lung volume reduction
Intraoperative considerations
Positioning
Rigid bronchoscopy
Cervical mediastinoscopy
Unilateral lung procedures and lung isolation
Double-lumen endobronchial tubes
Step 1
Step 2
Step 3
Endobronchial blockers
Lung-volume reduction
Tracheal surgery
Oesophageal surgery
Hypoxaemia during one-lung ventilation
Postoperative analgesia
Epidural
Paravertebral
Intrathecal morphine
Postoperative considerations
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
42 Anaesthesia for cardiac surgery
Ischaemic heart disease
Valvular disease
Arrhythmias
Implantable rhythm management devices
Congenital heart disease
Cardiopulmonary bypass
Venous reservoir
Pumps
Oxygenator
Connecting tubes, filters, manometer, suction
Fluid prime
Preoperative assessment
Exercise electrocardiography
Cardiac catheterisation
Echocardiography
Radionuclide imaging
CT/MRI
Additional investigations
Preoperative drug therapy
Investigations
Risk assessment
Monitoring
Electrocardiography
Systemic arterial pressure
Central venous pressure
Cardiac output
Echocardiography
Cerebral monitoring
Temperature
Biochemistry and haematology
Pathophysiology
Anaesthetic technique
Premedication
Induction of anaesthesia
Anaesthesia before cardiopulmonary bypass
Cardiopulmonary bypass
Myocardial preservation
Perfusion on bypass
Cell salvage
Coagulation control
Oxygen delivery
Acid–base balance
Serum potassium concentration
Weaning from cardiopulmonary bypass
Low cardiac output state
Intra-aortic balloon pump
Extracorporeal mechanical support
Bleeding
Haemodynamics after cardiopulmonary bypass
Other aspects
Temperature
Biochemical monitoring
Cardiac rhythm
Heart block
Supraventricular arrhythmias
Ventricular arrhythmias
Postoperative care
Bleeding
Analgesia
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
43 Obstetric anaesthesia and analgesia
Anatomy and physiology of pregnancy
Progesterone
Haemodynamic changes (Table 43.1)
Aortocaval compression
Regional blood flow
Respiratory changes (Table 43.2)
Renal changes
Gastrointestinal changes
Haematological changes (Table 43.5)
Coagulation
The epidural and subarachnoid spaces
The epidural space in pregnancy
Pain pathways in labour and caesarean section
The placenta
Functions of the placenta
Transport of respiratory gases
Hormone production
Immunological
Placental transfer of drugs
Factors determining placental transfer
Materno–fetal concentration gradient
Molecular weight and lipid solubility
Protein binding
Degree of ionisation
Maternal and fetal pH
Placental factors and uteroplacental blood flow
Effects of drugs on the fetus
Effects of drugs on the neonate
Lactation and drugs in obstetric anaesthesia
Pharmacology of relevant drugs
Uterotonic drugs
Syntocinon (oxytocin)
Carbetocin
Ergometrine
Syntometrine
Prostaglandins
Carboprost
Misoprostol
Dinoprostone
Mifepristone (RU486)
Tocolytic drugs
β2-adrenergic receptor agonists (terbutaline, salbutamol, ritodrine)
Oxytocin antagonists (atosiban)
Glyceryl trinitrate
Indomethacin
Basic obstetrics
Labour
The first stage of labour
The second stage of labour
The third stage of labour
Fetal monitoring
Urgency of caesarean section
Umbilical cord blood analysis
Feeding and antacid prophylaxis in labour
Pain and pain relief in labour
The effect of pain and analgesia on the mother and fetus
The ideal analgesic
Analgesia during labour
Non-pharmacological analgesia
Birth preparation classes
Environment and the management of labour
Transcutaneous electrical nerve stimulation
Complementary therapies
Parenteral (systemic) analgesia
Inhalational analgesia
Regional analgesia for labour
Epidural and subarachnoid analgesia
Technique of regional analgesia
Consent
Combined spinal-epidural for labour and the ‘walking’ epidural
Management of the labouring woman with epidural analgesia
Posture
Mobility
Monitoring of mother and baby
Maintenance of analgesia
Repeated bolus administration
Continuous infusion by syringe pump
Patient-controlled epidural analgesia
Programmed intermittent epidural bolus
Problems maintaining epidural analgesia
Regional anaesthesia for the parturient
Elective caesarean section
Spinal anaesthesia
Epidural anaesthesia
Combined spinal-epidural anaesthesia
Emergency caesarean section
Topping up an existing epidural
Spinal anaesthesia for an emergency
Forceps and ventouse delivery
Retained placenta
Repair of trauma to the birth canal
Failed neuroaxial anaesthesia
Postdelivery analgesia
Vaginal deliveries
Caesarean section
Complications of regional anaesthesia and analgesia in obstetrics
Shearing of the epidural catheter
Post–dural puncture headache
Management of dural puncture and PDPH
Backache
Bloody tap
Hypotension
Neurological deficit
Effect on labour and mode of delivery
General anaesthesia for the parturient
Technique of general anaesthesia in obstetric practice
Assessment of the pregnant woman presenting for anaesthesia and analgesia
Emergencies in obstetric anaesthesia
Haemorrhage
Antepartum haemorrhage
Postpartum haemorrhage
Anaesthetic management of haemorrhage
Preoperative assessment
Intraoperative management
Failed intubation
Pre-eclampsia and eclampsia
Aetiology of eclampsia and pre-eclampsia
Clinical presentation of pre-eclampsia
Cardiovascular system
Central nervous system
Renal system
Haematological system
Respiratory system
Management of pre-eclampsia
The role of epidural analgesia and anaesthesia in pre-eclampsia
Eclampsia
Thromboembolic disease
Amniotic fluid embolism
Sepsis
Maternal and neonatal resuscitation
Neonatal resuscitation
Anaesthesia for interventions other than delivery or extraction of retained products of conception
Cervical cerclage
The pregnant patient with a surgical (non-obstetric) emergency
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
44 Emergency and trauma anaesthesia
Preoperative assessment
Cardiovascular system
Respiratory system
Airway
Assessment of circulating volume
Intravascular volume deficit
Extracellular volume deficit
The full stomach
Lower oesophageal sphincter
Gastric emptying
Anaesthetic techniques
Preinduction
Induction
Inhalational induction
Awake fibreoptic intubation
Regional anaesthesia
Maintenance of anaesthesia
Fluid management
Emergency laparotomy in the older patient
National Emergency Laparotomy Audit
Major trauma
Scoring systems
Abbreviated Injury Scale
Injury Severity Score
Revised Trauma Score
Trauma management
The trauma team
Primary survey/damage control resuscitation
Airway/breathing
Circulation
Permissive hypotension
Haemostatic resuscitation
Cardiac ‘pump failure’
Damage control surgery
Trauma anaesthesia
Vascular access
Analgesic considerations in trauma patients
Intranasal
Oral transmucosal
Inhalational
Intravenous
Anaesthetic considerations in the prehospital environment
Mechanisms of injury
Scene safety
Teamwork
Working at the scene
Logistical considerations
Extrication
Clinical considerations
Prehospital emergency anaesthesia
Cervical spine control
Transfer to hospital
Management of major incidents
Treatment at a major incident
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
45 Anaesthesia in resource-poor areas
Background
Challenges to the provision of anaesthesia
Population and procedures
Anaesthesia without electricity or pressurised gas supplies
Conduct of anaesthesia
Monitoring
Ketamine intravenous anaesthesia
Dose
Inhalational anaesthesia using draw-over vaporisers
Draw-over equipment pitfalls
Ether (diethyl ether)
Physical properties
Systemic effects
RS
CVS
GI
Other
Pharmacology
Halothane
Regional anaesthesia
Perioperative blood loss
Intensive care
Education and training
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
46 Anaesthesia outside the operating theatre
Anaesthesia in remote locations within the hospital
General considerations and principles
Anaesthesia in the radiology department
Computed tomography
General principles
Anaesthetic management
Magnetic resonance imaging
General principles
Anaesthetic management
Staff safety.
Patient safety.
Equipment.
Monitoring.
Conduct of anaesthesia.
Diagnostic and interventional angiography
General principles
Anaesthetic management
Complications of angiography
Local
General
Interventional neuroradiology
Anaesthetic considerations
Mechanical thrombectomy
Cardiac catheterisation
Transcatheter aortic valve implantation
Pacemaker and implantable cardioverter defibrillator insertion
Endovascular aortic aneurysm repair
Vertebroplasty
Transjugular intrahepatic portosystemic shunt procedures
Anaesthesia for radiotherapy
Anaesthetic considerations
Anaesthesia for electroconvulsive therapy
Indications
Contraindications
Anaesthetic considerations
Anaesthesia in the Emergency Department
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
47 Anaesthesia and organ transplantation
General considerations in organ transplantation
Epidemiology
Transplant recipient listing/organ allocation
Organ procurement
Anaesthetic management: general principles
Organ donation procedure
Deceased donor donation
Live-related organ donation
Organ transplantation procedure
Preoperative assessment of transplant recipients
Intraoperative management
Postoperative management
Transplant recipients undergoing non-transplant procedures
Preoperative considerations
Transplanted organ status
Function of other organ systems
Immunosuppression
Presence of infection
Intraoperative considerations
Avoidance of surgical stress
Reducing injury to transplanted organ
Infection
Postoperative considerations
Anaesthesia for organ transplantation and transplant recipients: organ-specific considerations
Renal transplantation
Preoperative assessment
Intraoperative
Postoperative
Anaesthesia for renal transplant recipients
Surgical presentation
Anaesthetic considerations
Liver transplantation
Preoperative assessment
Intraoperative
Intraoperative monitoring
Blood conservation
Postoperative
Anaesthesia for liver transplant recipients
Surgical presentation
Preoperative status
Intraoperative management
Cardiac transplantation
Preoperative
Intraoperative
Postoperative
Anaesthesia for cardiac transplant recipients
Surgical presentation
Preoperative status
Anaesthetic considerations
Pulmonary transplantation
Preoperative
Intraoperative
Postoperative
Anaesthesia for pulmonary transplant recipients
Preoperative status
Surgical presentation
Anaesthetic considerations
Pancreas transplantation
Preoperative
Intraoperative
Postoperative
Anaesthesia for pancreas transplant recipients
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
48 The intensive care unit
Staffing an intensive care unit
ICU consultants
ICU residents
ICU nursing staff
Physiotherapists
Pharmacists
Dieticians
Microbiologist
Outreach teams
ICU admission and ethical decision-making
Assessment of patients
History
Examination
Airway
Breathing
Circulation
Disability (central nervous system)
Gastrointestinal tract
Renal system
Limbs/skin and wounds
Catheters and infection
Investigations/interventions
Management plans
Transfers
Monitoring in ICU
Arterial pressure
Echocardiography
Ultrasound
Neurological monitoring
Institution of intensive care
Respiratory system
Type 1 respiratory failure – PaO2 < 8 kPa with normal/low PaCO2
Type 2 respiratory failure – PaO2 < 8 kPa and PaCO2 > 8 kPa
Assessment of the patient with respiratory failure
Management of respiratory failure
Continuous positive airway pressure
Non-invasive ventilation
Invasive mechanical ventilation
Tracheal intubation
Sedation and analgesia.
Tracheostomy
Overview of modes of ventilation
Volume-controlled ventilation
Pressure-controlled ventilation
Synchronised intermittent mandatory ventilation
Pressure support ventilation/assisted spontaneous breathing
Inverse ratio ventilation
Airway pressure release ventilation
Positive end-expiratory pressure
‘Open-lung’ ventilation techniques
Problems associated with mechanical ventilation
Problem solving in ventilated patients
Ventilation strategies
High-frequency oscillation ventilation
Prone positioning
Extracorporeal membrane oxygenation
Weaning from mechanical ventilation
Cardiovascular system
Shock
Applied cardiovascular physiology
Optimisation of the cardiovascular system
Gastrointestinal system
Manifestations of gastrointestinal tract failure
Nutrition
Enteral feeding
Parenteral feeding
Refeeding syndrome
Stress ulcer prophylaxis
Blood glucose
Fluid balance
Renal dysfunction
Renal replacement therapy
Continuous venovenous haemofiltration
Continuous venovenous haemodialysis
Continuous venovenous haemodiafiltration
Vascular access for RRT
Neurological system
Other aspects of intensive care
Venous thromboembolism prophylaxis
ICU-acquired muscle weakness
Healthcare-associated infection
Catheter-related bloodstream infection
Antibiotic therapy
Ventilator-associated pneumonia
Psychological problems
Delirium
Care bundles
Outcome after intensive care
Death in intensive care
Futility and withdrawal
Neurological death
Organ donation
Discharge from intensive care
Follow-up clinics
References/Further reading
Self-assessment questions and answers
Question 1
Answer 1
Question 2
Answer 2
Question 3
Answer 3
Question 4
Answer 4
Question 5
Answer 5
Index
Inside Back Cover