Basic Physiology for Anaesthetists PDF
Preview Basic Physiology for Anaesthetists
Basic Physiology for Anaesthetists SecondEdition David Chambers SalfordRoyalNHSFoundationTrust Christopher Huang UniversityofCambridge Gareth Matthews UniversityofCambridge UniversityPrintingHouse,CambridgeCB28BS,UnitedKingdom OneLibertyPlaza,20thFloor,NewYork,NY10006,USA 477WilliamstownRoad,PortMelbourne,VIC3207,Australia 314–321,3rdFloor,Plot3,SplendorForum,JasolaDistrictCentre, NewDelhi–110025,India 79AnsonRoad,#06–04/06,Singapore079906 CambridgeUniversityPressispartoftheUniversityofCambridge. ItfurtherstheUniversity’smissionbydisseminatingknowledgeinthepursuitof education,learning,andresearchatthehighestinternationallevelsofexcellence. www.cambridge.org Informationonthistitle:www.cambridge.org/9781108463997 DOI:10.1017/9781108565011 ©CambridgeUniversityPress2019 Thispublicationisincopyright.Subjecttostatutoryexceptionandtothe provisionsofrelevantcollectivelicensingagreements,noreproductionofanypart maytakeplacewithoutthewrittenpermissionofCambridgeUniversityPress. Firstpublished2015 Secondedition2019 PrintedintheUnitedKingdombyTJInternationalLtd.PadstowCornwall. AcataloguerecordforthispublicationisavailablefromtheBritishLibrary. LibraryofCongressCataloging-in-PublicationData Names:Chambers,David,1979-author.|Huang,Christopher,1951-author.| Matthews,Gareth,1987-author. Title:Basicphysiologyforanaesthetists/DavidChambers,Christopher Huang,GarethMatthews. Description:Secondedition.|Cambridge,UnitedKingdom;NewYork,NY: CambridgeUniversityPress,2019.|Includesbibliographicalreferences andindex. Identifiers:LCCN2019009280|ISBN9781108463997(pbk.:alk.paper) Subjects:|MESH:PhysiologicalPhenomena|Anesthesiology–methods Classification:LCCRD82|NLMQT104|DDC617.9/6–dc23 LCrecordavailableathttps://lccn.loc.gov/2019009280 ISBN978-1-108-46399-7Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceor accuracyofURLsforexternalorthird-partyinternetwebsitesreferredtoin thispublicationanddoesnotguaranteethatanycontentonsuchwebsitesis, orwillremain,accurateorappropriate. .......................................................................................................................................... Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateand up-to-dateinformationthatisinaccordwithacceptedstandardsandpractice atthetimeofpublication.Althoughcasehistoriesaredrawnfromactual cases,everyefforthasbeenmadetodisguisetheidentitiesoftheindividuals involved.Nevertheless,theauthors,editors,andpublisherscanmakeno warrantiesthattheinformationcontainedhereinistotallyfreefromerror, notleastbecauseclinicalstandardsareconstantlychangingthroughresearch andregulation.Theauthors,editors,andpublishersthereforedisclaimall liabilityfordirectorconsequentialdamagesresultingfromtheuseof materialcontainedinthisbook.Readersarestronglyadvisedtopaycareful attentiontoinformationprovidedbythemanufacturerofanydrugsor equipmentthattheyplantouse. DC: To Sally, for not vetoing this second edition. CH: To friends and teachers: Charles Michel, Morrin Acheson, Richard Adrian, Sir David Weatherall and John Ledingham. In memoriam absen- tium, in salutem praesentium. GM: To my wife, Claire, and our beautiful baby daughter, Eleanor. I also remainindebtedtoProfessorChristopherHuangforfosteringmyoriginal interestin physiology, as well as supportingme throughout my career. Contents Foreword ix Russell Perkins Preface to theSecond Edition xi Preface to theFirstEdition xiii List of Abbreviations xiv Section 1 The Basics 22 Controlof Ventilation 93 1 GeneralOrganisationof the Body 1 23 Pulmonary Circulation 97 2 Cell Components and Function 6 24 Oxygen Toxicity 102 3 Genetics 9 25 Ventilatory Failure 104 4 The Cell Membrane 13 26 Anaesthesia andthe Lung 107 5 Enzymes 18 Section 3 Cardiovascular Physiology Section 2 Respiratory Physiology 27 Cardiac AnatomyandFunction 111 6 The UpperAirways 21 28 Cardiac Cycle 117 7 The Lower Airways 24 29 Cardiac Output and ItsMeasurement 121 8 Oxygen Transport 30 30 Starling’sLaw and Cardiac Dysfunction 131 9 Carbon Dioxide Transport 37 31 Cardiac Pressure–Volume Loops 136 10 AlveolarDiffusion 40 32 Cardiac Ischaemia 141 11 Ventilationand Dead Space 45 33 Systemic Circulation 145 12 Static Lung Volumes 50 34 Arterial System 148 13 Spirometry 56 35 Arterial Pressure Waveforms 155 14 Hypoxia and Shunts 63 36 Capillaries and Endothelium 158 15 Ventilation–PerfusionRelationships 68 37 VenousSystem 163 16 Ventilation–PerfusionZonesin the Lung 71 38 VenousPressure Waveforms 166 17 Oxygen Delivery andDemand 74 39 Lymphatics 168 18 AlveolarGas Equation 77 40 Cardiovascular Reflexes 170 19 Oxygen Cascade 80 41 Valsalva Manoeuvre 175 20 Lung Compliance 82 42 ExercisePhysiology 178 21 Work of Breathing 88 43 ExerciseTesting 185 vii Contents Section 4 Neurophysiology 70 Acid–Base Physiology 329 44 Neuronal Structure and Function 189 71 Micturition 338 45 The Brain 192 Section 7 Blood and Immune System 46 Cerebrospinal Fluid 198 47 Blood–BrainBarrier 200 72 Haemostasis 341 48 Cerebral Blood Flow 202 73 Transfusion 350 49 IntracranialPressure andHeadInjury 206 74 Anaemia andPolycythaemia 356 50 The SpinalCord 211 75 Immune System 360 51 Resting Membrane Potential 221 76 Plasma Constituents 371 52 Nerve Action Potential andPropagation 225 Section 8 Energy Balance 53 SynapsesandtheNeuromuscularJunction 231 77 Metabolism 373 54 Skeletal Muscle 239 78 Starvation 384 55 MuscleSpindlesandGolgiTendonOrgans 246 79 Stress Response 387 56 Smooth Muscle 249 57 Cardiac Muscle 252 Section 9 Endocrine Physiology 58 The Electrocardiogram 262 80 Hypothalamus and Pituitary 391 59 AutonomicNervous System 267 81 Thyroid,Parathyroid and Adrenal 396 60 Pain Physiology 272 61 The Eyeand Intraocular Pressure 276 Section 10 Developmental Physiology Section 5 Gastrointestinal Tract 82 Maternal Physiology duringPregnancy 405 83 Foetal Physiology 411 62 Saliva, Oesophagus andSwallowing 279 84 Paediatric Physiology 418 63 Stomach and Vomiting 283 85 Physiology of Ageing 422 64 Gastrointestinal Digestion and Absorption 289 86 Physiology of Obesity 427 65 Liver: Anatomy and Blood Supply 295 Section 11 Environmental Physiology 66 Liver Function 299 87 Altitude 431 Section 6 Kidney and Body Fluids 88 Diving 434 67 Renal Function, Anatomy and 89 Temperature Regulation 436 Blood Flow 307 68 Renal Filtration andReabsorption 313 69 Renal Regulation of Waterand Electrolyte Index 439 Balance 318 viii Foreword This second edition of Basic Physiology for Anaesthe- in the exam setting. Not only should this book be tists has carried forward the style, depth and content essential reading for those new to the speciality or that made the first edition such a great success. It those preparing for exams, but established specialists coversallaspectsofhumanphysiologythatareessen- and consultants should have access to a copy to give tialfortheartandsciencethatismodernanaesthesia. structure to their teaching, as well as to rekindle Patients need to be reassured that their anaesthetists fading knowledge. Those sitting anaesthesia exams arewellinformedoftheworkingsofthehumanbody can be confident that many of those responsible for in health as well as disease. testing their knowledge will themselves have con- The authors are both expert physiology scientists sulted this book! andclinicians–thiscombinationisclearlyseeninthe book’sstructure.Eachchapterexplainsthephysiology Dr RussellPerkinsFRCA andisfollowedbytheclinicalapplicationsrelevantto ConsultantAnaesthetist,RoyalManchester the speciality. The illustrations are simple line draw- Children’sHospital ings that are easy to follow and, importantly for Member of Council and Final FRCA Examiner, traineeanaesthetists, easy to recall orevenreproduce RoyalCollege ofAnaesthetists ix Preface to the Second Edition ‘Why are you writing a second edition? Surely noth- To that end, in addition to thoroughly revising ing in classical physiology ever changes?’ One of us and updating each chapter, we have added six new (DC) has been asked these questions several times. It chapters,includingthoseonthephysiologyoftheeye is true that many of the fundamental physiological and upper airway and on exercise testing. We have concepts described in this second edition of Basic alsosoughttoincludemorepathophysiology,suchas Physiology for Anaesthetists remain the same. What cardiac ischaemia and physiological changes in does change, however, is how we apply that physio- obesity.Wehavetriedtoremaintruetotheprinciples logicalknowledgeclinically.Inthefouryearssincewe with which we wrote the first edition, keeping the wrote the first edition of this book, high-flow nasal conceptsassimpleaspossiblewhilstremainingtruth- oxygen therapy has revolutionised airway manage- fulandillustratingeachchapterwithpointsofclinical ment, cancer surgery has become the predominant relevance and easily reproducible line diagrams. In indication for total intravenous anaesthesia and new response to positive feedback, the question-and- classes of oral anticoagulants have emerged, to name answer style remains to best help readers prepare for but afewdevelopments.Allof these changes in daily postgraduate oral examinations. anaesthetic practice are underpinned by a thorough understanding of basic physiology. xi Abbreviations ACA anteriorcerebralartery DNA deoxyribonucleicacid ACE angiotensin-convertingenzyme DOAC direct-actingoralanticoagulant ACh acetylcholine DRG Dorsalrespiratorygroup AChE acetylcholinesterase ECF extracellularfluid ACI anteriorcirculationinfarct ECG electrocardiogram AChR acetylcholinereceptor EDPVR end-diastolicpressure-volumerelationship ACom anteriorcommunicatingartery EDV end-diastolicvolume ADH antidiuretichormone EEG electroencephalogram ADP adenosinediphosphate EF ejectionfraction AF atrialfibrillation EPO erythropoietin AGE alveolargasequation ER endoplasmicreticulum AMP adenosinemonophosphate ESPVR end-systolicpressure-volumerelationship ANP atrialnatriureticpeptide ESV end-systolicvolume ANS autonomicnervoussystem ETT endotrachealtube APTT activatedpartialthromboplastintime FAD flavinadeninedinucleotide ARDS acuterespiratorydistresssyndrome FEV forcedexpiratoryvolumein1s 1 ARP absoluterefractoryperiod FO fractionofinspiredoxygen i 2 ATP adenosinetriphosphate FRC functionalresidualcapacity AV atrioventricular FTc flowtimecorrected BBB blood–brainbarrier FVC forcedvitalcapacity BMR basalmetabolicrate GABA γ-aminobutyricacid BNP brainnatriureticpeptide GBS Guillain–Barrésyndrome BSA bodysurfacearea GCS Glasgowcomascale CA carbonicanhydrase GFR glomerularfiltrationrate C O arterialoxygencontent GI gastrointestinal a 2 CBF cerebralbloodflow Hb haemoglobin CC closingcapacity HbA adulthaemoglobin CCK cholecystokinin HbF foetalhaemoglobin CI cardiacindex HCN hyperpolarisation-activatedcyclicnucleotide CMR cerebralmetabolicrate gated CNS centralnervoussystem HFNO High-flownasaloxygen CO cardiacoutput HPV hypoxicpulmonaryvasoconstriction CoA coenzymeA HR heartrate COHb carboxyhaemoglobin ICA internalcarotidartery COPD chronicobstructivepulmonarydisease ICF intracellularfluid CPET cardiopulmonaryexercisetest ICP intracranialpressure CPP cerebralperfusionpressure IRI ischaemicreperfusioninjury CRPS complexregionalpainsyndrome IVC inferiorvenacava CSF cerebrospinalfluid LA leftatrium C O venousoxygencontent LBBB leftbundlebranchblock v 2 CVP centralvenouspressure LMA laryngealmaskairway CVR cerebralvascularresistance LOH loopofHenle DASI Dukeactivitystatusindex LOS loweroesophagealsphincter DBP diastolicbloodpressure LV leftventricle DCML dorsalcolumn-mediallemniscal LVEDP leftventricularend-diastolicpressure DCT distalconvolutedtubule LVEDV leftventricularend-diastolicvolume DHPR dihydropyridinereceptor LVESV leftventricularend-systolicvolume xiv ListofAbbreviations LVF leftventricularfailure RAP rightatrialpressure MAC minimumalveolarconcentration RBC redbloodcell MAO monoamineoxidase RBF renalbloodflow MAP meanarterialpressure RMP restingmembranepotential MCA middlecerebralartery RNA ribonucleicacid MET metabolicequivalentofatask ROS reactiveoxygenspecies MetHb methaemoglobin RR respiratoryrate MG myastheniagravis RRP relativerefractoryperiod MI myocardialinfarction RSI rapidsequenceinduction MPAP meanpulmonaryarterypressure RV rightventricle MW molecularweight RVEDV rightventricularend-diastolicvolume N O nitrousoxide RVF rightventricularfailure 2 NSTEMI non-STelevationmyocardialinfarction RyR ryanodinereceptor NAD+ nicotinamideadeninedinucleotide SA sinoatrial NMDA N-methyl-D-aspartate S O arterialhaemoglobinoxygensaturation a 2 NMJ neuromuscularjunction SBP systolicbloodpressure OER oxygenextractionratio SD strokedistance OSA obstructivesleepapnoea SR sarcoplasmicreticulum PAC pulmonaryarterycatheter SSEP somatosensoryevokedpotential P CO arterialtensionofcarbondioxide STEMI STelevationmyocardialinfarction a 2 P O arterialtensionofoxygen SV strokevolume a 2 P barometricpressure SVC superiorvenacava B PCI percutaneouscoronaryintervention SVI strokevolumeindex PCT proximalconvolutedtubule SVR systemicvascularresistance PCA posteriorcerebralartery SVT supraventriculartachycardia PCom posteriorcommunicatingartery SVV strokevolumevariation PCWP pulmonarycapillarywedgepressure TF tissuefactor PE pulmonaryembolism TIMI thrombolysisinmyocardialinfarction PEEP positiveend-expiratorypressure TLC totallungcapacity PEEP extrinsicpositiveend-expiratorypressure TOE trans-oesophagealechocardiography PEEPe intrinsicpositiveend-expiratorypressure V̇/Q̇ ventilation–perfusion i ̇ PEFR peakexpiratoryflowrate V alveolarventilation A PNS peripheralnervoussystem V alveolarvolume A PPP pentosephosphatepathway VC vitalcapacity PRV polycythaemiarubravera V deadspacevolume ̇D PV peakvelocity V minuteventilation E PVA pressure-volumearea V tidalvolume T PT prothrombintime VF ventricularfibrillation PTH parathyroidhormone VRG ventralrespiratorygroup PVR pulmonaryvascularresistance VT ventriculartachycardia RA rightatrium VTI velocity-timeintegral RAA renin–angiotensin–aldosterone vWF vonWillebrandfactor xv
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