Appendices to Basic Guide to Anesthesia for Developing Countries

242 Pages·2008·6.14 MB·English

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Any or all parts of this manual may be reproduced, provided the parts reproduced are
free- not for sale. For commercial purposes, no part of this manual may be reproduced
or utilized in any form or by any means, electronic or mechanical, including photocopying
and recording, or by any information storage and retrieval system, without permission in
writing from the publisher.
The intent of this manual is to be freely used, copied, and distributed
in Developing Countries for the teaching and promotion of basic
anesthesia knowledge/skills.
The purpose of this manual is to provide developing countries with a copyright
free basic anesthesia manual. This manual can be freely copied and translated
into a native language for the promotion of basic anesthesia knowledge/skills.
Contributors with credited pictures and illustrations have graciously given
permission for their material to be used for this specific purpose. The author
and publishers of this manual cannot accept liability from the use of this
manual or errors in translation. It is up to each translator to ensure that the
translation is correct. Knowledge about the art and science of anesthesia
continues to change. It is up to each anesthesia provider to continue to learn
and upgrade their knowledge. This manual only contains basic knowledge and
is not a replacement for more comprehensive anesthesia information.
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“Every prudent man acts out of knowledge.”
Proverbs 13:15
Soli Deo Gloria
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Acknowledgements

This project would not have been possible without the help of many. The World Health
Organization and Michael B. Dobson MD kindly gave permission to utilize illustrations
from the publication Anaesthesia at the District Hospital, WHO, Geneva, 2000 for two
earlier editions, published in Afghanistan and Cambodia. Permission to use material from
the WHO publication is not an endorsement of this anesthesia manual over other manuals
that may be available. The WHO does not endorse any specific company or product. Since
the earlier editions, this manual has been configured to provide a copyright free edition to all
who would desire it.

Professional illustrations were provided by Welti & Rose Advertising, Inc. Photographs
provided by the author and William H. Hartland Jr. CRNA, PhD.

I am indebted to Dr. Mark Schanbacher who spent many hours with me going over this
manual, word by word, and sentence by sentence. Several anesthesia providers/medical
professionals gave their time to this worthy task. This group of academic and clinical
experts provided valuable insights and thoughtful consideration to the content of this
manual. Invaluable guidance was provided by Chuck Biddle CRNA, PhD; William Hartland
Jr. CRNA, PhD; Richard A. Henker CRNA, PhD; John Nagelhout CRNA, PhD; Bob
Halliburton CRNA, DNSc; Karen Zaglaniczny CRNA, FAAN, PhD; Donald M. Bell
CRNA, DNSc, APN; Michael J. Kremer CRNA, FAAN, DNSc; John Aker CRNA, MS;
Sandra M. Ouellette, CRNA, M.Ed., FAAN; Suzanne Brown, CRNA; Dennis L. Edwards
MD; Deb Hansen Pharm.D; Ken Gross MD; Ken Foster MD; W.C. Petty MD; Asad Fayaz
MD; Malte L. von Blumroder MD; Uffe Romer MD; Karen Mindling RN; and Carson F.
Frazzini CRNA, MS. Editorial assistance was provided by Dan Fong , Leigh Berthoff,
Jenera Turman, and Sandra Rosse. The cover was designed by Steve “Human” Pfauter.
Initial layout by Janelle Meyers.

Thank you for your contributions!
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Introduction
This manual is not complete. However, it is an excellent start. Anesthesia is essential for the
practice of surgery. It is a great responsibility that we are given as anesthesia providers.
Patients undergoing surgery put their lives in our hands. It is our duty to protect the patient,
to give the patient our full attention, and to administer the safest anesthetic possible.

Vigilance means to be alert to danger or threats. Each of us must be vigilant when giving
anesthesia to avoid unnecessary complications.

It is my prayer that this manual will help teach the anesthesia provider in training as well as
serve as a review for those who are currently practicing the art and science of anesthesia.

Every effort was made to ensure that the material and information contained in this manual
is correct and up-to-date. The publishers and author cannot accept liability from any
potential errors contained in this manual or errors that may occur from the use of this
material.

If this manual is published, translated, or used for the promotion of basic anesthesia
knowledge, the author would appreciate an email. This project continues to evolve and your
input is critical to making it useful in the developing world. Please feel free to contact me at
[email protected] with comments, questions, recommendations for future editions, and
any concerns.

Daniel D. Moos
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Resources

A number of resources are available for the anesthesia provider in developing countries.

Books

Anaesthesia at the District Hospital, 2nd Edition. Michael B. Dobson. Published by the
World Health Organization in collaboration with the World Federation of Societies of
Anesthesiologists. This manual was published to help guide medical officers in small
hospitals. It contains a wealth of practical and useful information. This book is available in
English.

Internet Resources
Manuals

Safe Anaesthesia. Lucille Bartholomeusz, 3rd edition updated and revised by Jean Lees.
This manual is available at http://www.worldanaesthesia.org . This 700+ page manual
contains comprehensive information concerning anesthesia. Individual chapters may be
downloaded. This manual is available in English.

Basic Guide to Resuscitation for Developing Countries. Daniel D. Moos.
This manual is available at http://www.worldanaesthesia.org and http://ifna-int.org . This
manual can be freely downloaded, copied, and translated for the promotion of basic
resuscitation techniques. Additional information concerning basic resuscitation may be
obtained at http://erc.edu (European Resuscitation Council) and http://americanheart.org
(American Heart Association).

Primary Trauma Care is an excellent resource for basic trauma care. It is available at
http://www.primarytraumacare.org . This thirty-nine page manual is available in
English, Chinese, Spanish, French, Indonesian, Mongolian, Farsi, and Vietnamese.

Education

World Anaesthesia Online can be accessed at http://www.nda.ox.ac.uk/wfsa/. This web
site is dedicated to the promotion of anesthesia knowledge and skills in the developing
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world. Update in Anaesthesia is “An educational journal aimed at providing practical advice
for those working in isolated or difficult environments.” The majority of the updates are
available online in English. A small number of updates are available online in Russian and
French. The print version is available in English, Russian, French, Mandarin, and Spanish.

World Anaesthesia can also be accessed at http://www.neda.ox.ac.uk/wfsa/ . World
Anaesthesia is a newsletter of the World Federation of Societies of Anaesthesia. The
newsletter allows “for the exchange of views & ideas on advancing the specialty of
anaesthesia in the developing world.” It is available in English.

International Organizations

International Federation of Nurse Anesthetists (IFNA) was founded in 1989 and
currently has 34 country members. The IFNA is an international organization whose
mission is in part dedicated to the advancement of educational standards and practices of
anesthesia. The IFNA website is located at http://www.ifna-int.org .

Additional resources concerning the IFNA include:

Caulk R, Ouellette S M. The International Federation of Nurse Anesthetists A Professional
Study and Resource Guide For The CRNA. AANA Publishing 2001; Chapter 19: 381-406.

McAuliffe M. Countries where anesthesia is administered by nurses. AANAJ 64 (5), 469-479.

Henry B, McAuliffe M. Practice and education of nurse anesthetists. Bulletin of the World
Health Organization.The International Journal of Public Health. 77 (3), 267-270.

World Federation of Societies of Anesthesiologists (WFSA) was founded in 1955 and
currently has 122 country members. The objectives of the WFSA is the
improve/disseminate knowledge concerning the standards of anesthesia, pain treatment,
trauma management and resuscitation to all countries of the world. The WFSA website can
be located at http://anaesthesiologists.org .
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Table of Contents

Chapter 1: Medical Math
Formula Method 2
Conversion of Ratios and Percent 4
Converting % to mg 5
Converting mg to % 5
IV Fluid Calculations 5

Chapter 2: Documentation
Pre-Anesthesia Evaluation 8
Anesthesia Care Documentation 10

Chapter 3: Fluid Management and Fluid Replacement
Preoperative Evaluation 19
Calculating Fasting Fluid Deficit 19
Fluid Maintenance Requirements 20
Insensible Fluid Loss 20
Fluid Replacement Based on Surgical Trauma 21
Blood Loss 21
IV Solutions 21
Estimating Blood Volume 24

Chapter 4: Medications used in Anesthesia
Malignant Hyperthermia 29
Inhalation Anesthetic Agents 31
Induction Agents 37
Muscle Relaxants/Paralytics 41
Muscle Relaxant Reversal Agents 46
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Chapter 4: Medications used in Anesthesia continued…
Anti-Cholinergics 48
Opioid Analgesics 49
Opioid Agonist-Antagonists 51
Opioid Agonists 53
Non-Opioid Analgesics 54
Anti-Anxiety Agents 55
Benzodiazepine Reversal Agent 56
Anti-Nausea Medications 57
Common Vasopressors 59
Resuscitation Medications 61
Basic Considerations 61

Chapter 5: Preparing for Anesthesia
General Equipment Check 70
Patient Related Equipment Check 71
Preoperative Assessment 71
Medical History, Interview, and Physical Exam 72
Review of Systems 75
Laboratory Values 76
Physical Exam 76
Premedication 78
ASA Classification 78

Chapter 6: Positioning and Monitoring
Preventing Injury to the Patient 81
Monitoring Guedel’s Signs/Stages of Anesthesia 85
Monitoring Neuromuscular Blockade 87
Monitoring Vital Signs 90
Pulse Oximetry 91
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Chapter 6: Positioning and Monitoring continued…
Capnography 92
Precordial/Esophageal Stethoscope 93

Chapter 7: Airway Management
Preoperative Assessment 97
Features of Potential Difficult Intubation 98
Airway Management 99
Artificial Airways 101
Tracheal Intubation 103
Pediatric versus Adult Airway 104
Pediatric Endotracheal Tube Recommendations 104
Pediatric/Adult Endotracheal Tube Size and Depth 105
Magill’s Forceps 107
Stylet 107
Preparation 108
Positioning 108
Steps of Intubation 109
Confirming Endotracheal Tube Placement 113
Mainstem Bronchus Intubation 115
Esophageal Intubation 115
Failed Intubation 115
Failed Ventilation 116
Endotracheal Tube Obstruction 117
Additional Complications 117
Upper Respiratory Infection 119
Aspiration Prophylaxis 119
Cricoid Pressure and Rapid Sequence Induction 120
Laryngeal Mask Airway 122
Minimum Anesthetic Airway Equipment 124