Anaesthesia: Illustrated Clinical Cases PDF
Preview Anaesthesia: Illustrated Clinical Cases
illustrated clinical cases Anaesthesia MAGNUS A GARRIOCH MB ChB (Birm), FRCA, FRCP (Glas), FFICM Consultant (Attending) in Anaesthesiology and Critical Care Manchester Royal Infirmary Central Manchester University Hospitals NHS Trust Manchester, UK W BOSSEAU MURRAY MB ChB (Pretoria), FRCA (Lon), MD (Stellenbosch) Professor of Anesthesiology Department of Anesthesia Pennsylvania State University Hershey, USA K21815 Garrioch final.indd 1 15/10/14 11:36 AM CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2015 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20140917 International Standard Book Number-13: 978-1-4822-3904-1 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publish- ers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copy- right.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com CONTENTS Preface iv Contributors v Foreword vii List of Abbreviations viii Clinical Cases 1 Appendix 310 Index 312 K21815 Garrioch final.indd 3 15/10/14 11:36 AM PREFACE The learning principles of this Illustrated Clinical Cases series of books lend themselves perfectly to the subject of anaesthesia. This book stimulates thought and enhances knowledge for both the novice and the experienced anaesthetist/anaesthesiologist alike. The reader becomes an active learning participant by considering questions based on the visual images presented and then immediately gaining access to the relevant answer on the following page. The two authors, with their comprehensive trans-Atlantic clinical and teaching experience, have provided a wide breadth of subject matter that is directly related to the knowledge required to excel in anaesthesia. Many years of practical, hands-on teaching experience and of using actual patient cases to instruct trainees and colleagues have equipped them to produce this book. Their experience was particularly useful when thinking about how to phrase this collection of questions and answers. Subjects are presented in a random fashion, in a similar way to which a practicing clinician encounters real clinical issues with patients, physicochemical concepts and anaesthesia equipment. By completion of the book, the reader will have gained much insight into most aspects of anaesthesia practice. Case reports are an integral part of learning, and by having to recall the facts related to a specific case, the reader will be able to recognise areas where more in-depth reading would be advisable. A strong emphasis is also placed on the knowledge and comprehension required by both the Royal College of Anaesthetists and the North American examining boards to promote a deeper understanding of complex concepts, rather than just a simple list of facts. Readers will hopefully also be tempted to use some of the questions for their personal revision or the teaching of others. This book can be used again and again. What is not intended is to provide a rigorous and detailed diagnosis and treatment of each disease as found in standard textbooks. The questions provided build upon one another to cover a broad scope of anaesthesia subjects presented in such a way as to be both varied and interesting. Written with the needs of trainee doctors in anaesthesia in mind, we intend that the book might also be useful for experienced anaesthetists/anaesthesiologists with limited diversity of practice or for those who have become very specialised. These practitioners may not encounter such cases on a regular basis, but they might occasionally be required to deal with them. The book should also be useful for operating department practitioners and anaesthesia nurses in the UK and advanced Certified Registered Nurse Anesthetist (CRNA) students and experienced CRNA practitioners in North America. Finally, we wish to acknowledge the numerous high-quality contributions from Dr David Fehr in the USA and Dr Alan McLean in the UK. We also wish to thank our partners, James Allen and Janette Murray, for their love, patience and support, without which this book would not have come to fruition. We sincerely hope you find this book both a useful and enjoyable read. Magnus Garrioch Bosseau Murray iv K21815 Garrioch final.indd 4 15/10/14 11:36 AM CONTRIBUTORS Keith Anderson FRCA Stephen Kimatian MD, FAAP Consultant Anaesthetist Professor of Anesthesiology and Pediatrics Glasgow Royal Infirmary Cleveland Clinic Glasgow, UK Cleveland, Ohio, USA Dougal Atkinson FRCA, FFICM David Kissinger MD, FACS Consultant in Anaesthesia and Critical Chief of Surgery Care South Sacramento Kaiser Permanente Manchester Royal Infirmary Medical Center Manchester, UK Sacramento, California, USA Mark A Boustred MD Donald Martin MD Assistant Professor of Plastic and Professor of Anesthesiology Reconstructive Surgery Pennsylvania State University College of Pennsylvania State University College of Medicine Medicine Hershey, Pennsylvania, USA Hershey, Pennsylvania, USA Gavin McCalum FRCA Colin Campbell FRCR Consultant in Anaesthetics and Chronic Consultant Radiologist Pain Southern General Hospital Southern General Hospital Glasgow, UK Glasgow, UK David Fehr MD John McGowan MSc, DIMC, RCSEd Associate Professor of Anesthesiology RN Resuscitation Officer Pennsylvania State University College of Southern General Hospital Medicine Glasgow, UK Hershey, Pennsylvania, USA Alan McLean FRCP Kevin Holliday FRCA Consultant in Spinal Injuries Consultant in Anaesthetics and Intensive Southern General Hospital Care Glasgow, UK Raigmore Hospital Inverness, Scotland, UK Regina O’Connor FFARCSI Consultant Anaesthetist Riyad Karmy-Jones MD, FRCSC, Southern General Hospital FRCSC(CT), FACS, FCCP, FAHA Glasgow, UK Clinical Director of Trauma Legacy Emanuel Medical Center Portland, Oregon, USA v K21815 Garrioch final.indd 5 15/10/14 11:36 AM Charles Palmer MD Kathleen R Rosen MD Professor of Neonatal and Perinatal Professor of Anesthesiology Medicine Case Western Reserve University Pennsylvania State University College of Cleveland, Ohio, USA Medicine Hershey, Pennsylvania, USA Douglas Russell FRCA Consultant Anaesthetist Robert Prempeh FRCS(Ed), Southern General Hospital FRCS(Glas) Glasgow, UK Consultant in Neurological Rehabilitation Forth Valley, UK John E Tetzlaff MD Professor of Anesthesiology Lester T Proctor MD Cleveland Clinic Professor of Anesthesiology Cleveland, Ohio, USA University of Wisconsin Medical School Madison, Wisconsin, USA Lars Williams FRCA Consultant in Anaesthetics and Chronic Artur Pryn FRCA Pain Consultant in Anaesthetics Southern General Hospital Inverclyde Royal Hospital Glasgow, UK Greenock, UK Liz Wilson FRCA, FFICM Puneet Ranote FRCA Consultant in Anaesthesia and Intensive Consultant in Anaesthetics Care St George’s Healthcare NHS Trust Royal Infirmary of Edinburgh London, UK Edinburgh, UK Urmila Ratnasabapathy FRCA Margaret M Wojnar MD Consultant in Neuroanaesthetics Professor of Pulmonary and Intensive Care Southern General Hospital Medicine Glasgow, UK Pennsylvania State University College of Medicine Kevin Rooney FRCA Hershey, Pennsylvania, USA Consultant in Anaesthesia and Intensive Care Medicine Royal Alexandra Hospital Paisley, UK vi K21815 Garrioch final.indd 6 15/10/14 11:36 AM FOREWORD The author Henry David Thoreau once said that “a truly good book teaches me better than to read it. I must soon lay it down, and commence to living on its hint”. This is such a book. I doubt that anyone who reads it will not find an educational ‘hint’ on virtually every page. As such it is a tome that brings you up to date, stimulates your mind and encourages diagnostic and strategic thinking. The specialty of anaesthesia is not simply a technical service. It is increasingly the case that the anaesthesiologist/anaesthetist is recognised as an overarching term for those with further skills in perioperative medicine and as physicians in intensive care and pain medicine. The scope of this book is enormous and it covers all the specialty areas that anaesthesiologists/anaesthetists should recognise as their area of practice. It will stimulate you. Some readers will enjoy the revision in the fields of physics and clinical measurement. Others will be pressed by the physiology and pharmacology cases and others by the anatomical and statistical questions. However, all should enjoy the unique way that the scope of medical practice of relevance to anaesthesia is introduced within these pages. Learn from the proposed management given for the clinical scenarios; that is the future of our specialty, and this book will be an excellent read for all trainee anaesthesiologists/ anaesthetists and more senior colleagues who aspire to that role. Peter Nightingale MBBS, FRCA, FRCP, FFICM Consultant in Anaesthesia and Intensive Care Medicine University Hospital of South Manchester Manchester, UK . vii K21815 Garrioch final.indd 7 15/10/14 11:36 AM LIST OF ABBREVIATIONS ACE angiotensin-converting enzyme INR international normalised ratio AF atrial fibrillation IV intravenous APTT activated partial thromboplastin LA local anaesthesia time MAC minimum alveolar ATLS advanced trauma life support concentration AV atrioventricular NSAID non-steroidal anti-inflammatory BP blood pressure drug bpm beats per minute O oxygen 2 BSA body surface area PaO partial pressure of oxygen 2 CBC complete blood count dissolved in arterial blood CNS central nervous system P O partial pressure of alveolar A 2 CO carbon dioxide oxygen 2 COPD chronic obstructive pulmonary PEEP positive end-expiratory pressure disease PO partial pressure of oxygen 2 CPET cardiopulmonary exercise PT prothrombin time testing SIRS systemic inflammatory response CPR cardiopulmonary resuscitation syndrome CSF cerebrospinal fluid SLE systemic lupus erythematosus CT computed tomography TEG thromboelastogram CTPA computed tomography TOE transoesophageal pulmonary angiogram echocardiogram/ CVP central venous pressure echocardiography CXR chest X-ray U+E urea and electrolytes D&C dilatation and curettage V/Q ventilation/perfusion (ratio) D&E dilatation and evacuation ECG electrocardiogram ECMO extra-corporeal membrane oxygenation EEG electroencephalogram EMG electromyogram ESR erythrocyte sedimentation rate ET endotracheal (tube) FBC full blood count FIO fraction of inspired oxygen 2 GA general anaesthesia GCS Glasgow Coma Score/Scale GI gastrointestinal Hb haemoglobin HCG human chorionic gonadotropin Hct haematocrit I:E inspiratory:expiratory (ratio) ICP intracranial pressure ICU intensive care unit viii K21815 Garrioch final.indd 8 15/10/14 11:36 AM QUESTION 1 1 This 32-year-old lady presented with a diffuse swelling on the left side of her neck (1a). Over the past 3–4 months she had become slightly hoarse. The patient is scheduled for a partial thyroidectomy. A radiograph of her chest is shown (1b). 1a 1b i. What is this diffuse swelling likely to be? ii. What other symptoms and signs may she mention or exhibit? iii. What are the indications for partial thyroidectomy? iv. Why should a CXR be done as a routine in this type of patient, and what does this radiograph show? v. How would you manage this case at anaesthetic induction and at extubation? 1 K21815 Garrioch final.indd 1 15/10/14 11:36 AM
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