DEVELOPING ANAESTHESIA - Medbox

206 Pages·2007·5.01 MB·English

by  David Pescod

DEVELOPING ANAESTHESIA
TEXTBOOK

Dr. David Pescod
MBBS FANZCA
Version 1.6 2007
Pescod, David, 1959-.
Developing anaesthesia: guidelines for anaesthesia in
Developing countres.

Includes index.
ISBN 0 9586452 5 6.

1. Anaesthesia – Developing countries – Handbooks, manuals,
Etc. I. Title.

617.96091724

For the latest version and associated resources please access
www.developinganaesthesia.org

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Developing Nations 2.0
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2
www.developinganaesthesia.org

Welcome to www.developinganaesthesia.org. This website has been created to promote the
advancement of anaesthetic practice and to empower anaesthetists in countries with limited
resources. The site also hopes to foster the growth of an online community of anaesthetists
thoughout the world.

A web-based resource has significant advantages. The information provided can remain
current and be tailored to the requirements of the community. Hard copy texts may be
expensive, difficult to access and inappropriate to the delivering of anaesthesia outside of
tertiary institutions. The majority of journals have similar limitations.

developinganaesthesia.org is a free, up to date resource, specifically designed to address these
problems.

The authors envisage the website will have five principle functions, though the dynamic nature
of web publishing will allow the evolution of the site as directed by the anaesthesia
community.

1. Continuing Education
developinganaesthesia.org will provide an anaesthetic educational resource for anaesthetists.
The site contains a textbook, articles, case studies and links. With time the site will contain
power point and video presentations.

2. Anaesthetic Training
developinganaesthesia.org will provide an anaesthetic educational resource for anaesthetic
trainees. The site will contain lecture notes for physiology, pharmacology, equipment,
monitoring and statistics.

3. Teach the Teacher
developinganaesthesia.org will provide a resource to aid anaesthetists in educational methods.

4. Peer-reviewed Publication
developinganaesthesia.org will provide a venue for peer-reviewed publication online at no cost
to authors or readers. All submitted material (case studies, articles, audits etc) is welcomed and
encouraged.

5. Discussion Forums
developinganaesthesia.org has an open forum for discussion, exchange of ideas/experience and
seeking advice. A panel of anaesthetists with experience in delivering anaesthesia and teaching
in developing countries will moderate the forum but colleges in similar countries may provide
the most relevant advice.

Success and the growth of www.developinganaesthesia.org will depend on feedback from the
anaesthetic community it serves. Please have a look at the site and register as a user, there is
no cost. Registration allows you to participate in forum discussions, submit your own articles
and comments and in doing so help foster community growth.
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CONTENTS

CHAPTER ONE: PREOPERATIVE MANAGEMENT

1. PREOPERATIVE ASSESSMENT 9

2. PREOPERATIVE INVESTIGATIONS 13

3. PREMEDICATION 14

4. PREOPERATIVE FASTING 15

5. AIRWAY ASSESSMENT 17

6. CARDIOVASCULAR DISEASE 19
 Ischaemic heart disease
 Valvular heart disease
 Hypertension

7. PERIOPERATIVE BETA BLOCKADE 23

8. RESPIRATORY DISEASE 25
 Respiratory infections
 Asthma
 Chonic obstructive airway disease

9. SMOKING 27

10. STEROID SUPPLEMENTATION 28

11. RENAL DISEASE 29
 Acute renal failure
 Chonic renal failure

12. LIVER DISEASE 32

13. DIABETES 34

14. EMERGENCY SURGERY 36

CHAPTER TWO: GENERAL ANAESTHESIA

15. CHECKING THE EQUIPMENT 38

16. BREATHING SYSTEMS 43
 Circle system
 Mapleson breathing systems

17. DRAWOVER ANAESTHESIA 47
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18. INDUCTION OF ANAESTHESIA 51
 Intravenous induction
 Inhalation induction
 Patient positioning

19. AIRWAY MANAGEMENT 55

20. RAPID SEQUENCE INDUCTION 72

21. INHALATION ANAESTHETIC AGENTS 75
 Diethyl ether
 Halothane
 Trichloroethylene
 Enflurane
 Sevoflurane
 Methoxyflurane
 Cyclopropane
 Nitrous oxide

22. INTRAVENOUS INDUCTION AGENTS 81
 Thiopentone
 Propofol
 Ketamine

23. BENZODIAZEPINES 86

24. NEUROMUSCULAR BLOCKADE 87
Non-depolarisning
• Tubocurarine Gallamine
• Alcuronium Atracurium
• Pancuronium Vecuronium
• Cisatracurium Rocuronium
• Mivacurium Pipecuronium
• Fazidinium Metocurine

Depolarising
• Suxamethonium

CHAPTER THEE: PAEDIATRIC ANAESTHESIA

25. PAEDIATRIC ANATOMY,
PHYSIOLOGY & PHARMACOLOGY 93

26. ANAESTHESIA FOR INFANTS AND CHILDREN 97
 Preoperative assessment
 Premedication
 Parents in induction room
 Induction of anaesthesia

27. PAEDIATRIC ANAESTHETIC EQUIPMENT 101

28. CAUDAL EPIDURAL ANAESTHESIA 103
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CHAPTER FOUR: OBSTETRICS AND GYNAECOLOGY

29. LABOUR ANALGESIA 106
 Epidural anaesthesia for labour

30. CAESAREAN SECTION 111
 General anaesthesia

31. SPINAL ANAESTHESIA FOR OBSTETRIC PATIENTS 113

32. RESUSCITATION OF THE NEWBORN INFANT 116

33. OBSTETRIC HAEMORRHAGE 120
 Placenta praevia
 Placental abruption
 Uterine rupture
 Retained placenta
 Uterine atony
 Ectopic pregnancy

34. PRE-ECLAMPSIA 122

CHAPTER FIVE: REGIONAL ANAESTHESIA

35. SPINAL ANAESTHESIA 125

36. COMPLICATIONS OF SPINAL ANAESTHESIA 132

37. INTRAVENOUS REGIONAL ANAESTHESIA 136

38. LOCAL ANAESTHETIC TOXICITY 138

CHAPTER SIX: POST ANAESTHETIC CARE UNIT (RECOVERY)

39. POST ANAESTHETIC CARE UNIT (RECOVERY) 141

40. COMPLICATIONS 143
 Cardiovascular complications
 Respiratory complications
 Central nervous system complications

41. PAIN MAMAGEMENT 148

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CHAPTER SEVEN: CRITICAL INCIDENT MANAGEMENT

42. CRISIS IN ANAESTHESIA 154

43. HAEMORRHAGE 156

44. BLOOD TRANSFUSION 160

45. HYPOTENSION 166

46. HYPERTENSION 168

47. CARDIAC ARRHYTHMIAS 169

48. SINUS BRADYCARDIA 170

49. TACHYARRHYTHMIAS 171

50. PERIOPERATIVE MYOCARDIAL ISCHAEMIA 173

51. ACUTE CORONARY SYNDROME 175

52. CARDIAC ARREST 177

53. PAEDIATRIC ARREST 180

54. HYPOXAEMIA 182

55. HIGH AIRWAY PRESSURE 184

56. LARYNGOSPASM 187

57. ANAPHYLAXIS 188

58. MALIGNANT HYPERTHERMIA 190

59. HYPERNATRAEMIA 192

60. HYPONATRAEMIA 193

61. HYPERKALAEMIA 194

62. HYPOKALAEMIA 196

CHAPTER EIGHT: QUALITY ASSURANCE AND IMPROVEMENT

63. QUALITY ASSURANCE 197

INDEX 199

CREATIVE COMMONS LICENSE 207
7
The word anaesthesia is derived from the Greek language, meaning “without sensation”.
Modern anaesthesia is safe. In countries that have extensive anaesthetic resources, the risk of
dying is one in 100,000 to 500,000. The risk of death has decreased to one-tenth of what it was
thirty years ago. Safety has improved with better knowledge of pharmacology and physiology,
and advances in drugs, investigations, monitoring and education. The complexity and expense
of providing anaesthesia has escalated.

When resources (personnel, equipment, drugs and funding) are limited, an anaesthetist with
good clinical skills and a thorough knowledge of physiology, pharmacology, equipment and
how disease will affect the patient, can provide safe and effective anaesthesia.

All anaesthetists must pay careful attention to detail. There must be thorough preoperative
assessment and planning for anaesthesia. The anaesthetist should anticipate problems and have
a secondary anaesthetic plan to deal with these problems. They must also be well trained in
treating unanticipated emergencies.

Good clinical skills of history taking and examination can approximate the accuracy of
complex investigations. There are simple “bedside tests” of respiratory and cardiovascular
function that can predict intra-operative problems and postoperative recovery.

All appropriate anaesthetic monitoring should be used when available. Increasing complexity
of monitoring can improve patient safety but continuous close observation of the patient and
basic monitoring will provide a safe anaesthetic and detect adverse events.

With advances in drugs and equipment the intricacy of delivering anaesthesia has increased,
but when resources are limited an anaesthetist who is thoroughly familiar with an appropriate
anaesthetic technique can provide a safe and effective anaesthetic service.

This text aims to provide clinical guidance for anaesthetic trainees and anaesthetists who are
providing anaesthesia with limited resources.

Acknowledgements
The author wishes to thank the Australian Society of Anaesthetists and the World Federation
of Societies of Anaesthesiologists who have funded several teaching programmes in Mongolia,
which inspired the creation of a textbook for developing countries, the anaesthetic staff of the
Northern Hospital Melbourne Victoria Australia and Jeanette Thirlwell, Emeritus Consultant
Children’s Hospital Westmead (Sydney), who have provided constructive criticism and proof
reading, and DAN Asia-Pacific who have given advice and invaluable assistance with
publication.

The views expressed in this publication are those of the author alone.

Every effort has been made to trace and acknowledge copyright. However should any
infringement have occurred, the authors tender their apologies and invite copyright owners to
contact them.

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1. PREOPERATIVE ASSESSMENT

Every patient should be seen by the anaesthetist before surgery. The anaesthetist must
determine if the patient is ill, if the illness increases the chance that the surgery/anaesthesia
may adversely affect the patient’s health and if the illness can be improved before surgery.

The anaesthetist should also ask about the past medical history, past anaesthetic history, family
history, examine the patient and assess the patient’s airway. With this knowledge the
anaesthetist can decide if the patient needs medical treatment before the surgery, when the
surgery can be done, what sort of anaesthetic to give and how to look after the patient after
surgery.

Medical History

The anaesthetist must take a medical history. This history includes why the patient is
having the surgery and also any serious illness, in particular heart disease (including
ischaemic heart disease, cardiac failure and valvular disease), respiratory disease
(including asthma and smoking), diabetes, kidney disease and reflux oesophagitis. The
anaesthetist should also ask about medications, allergies and determine the patient’s
exercise tolerance.
The patient’s exercise tolerance gives a good indication of the chance that the patient’s
health will be poorly affected by surgery/anaesthesia. If the patient is unable to climb a
flight of stairs then they are at increased risk.

Medications

Drugs of special significance to anaesthesia include anticoagulants, steroids and diabetic
treatment. As a general rule, with the exception of these drugs, it is best not to stop any
drugs before surgery.

Allergy and Drug Reactions

The anaesthetist must ask the patient about unusual, unexpected or unpleasant reactions
to drugs. True allergic reactions are uncommon but any drug that has caused a skin
reaction, facial or oral swelling, shortness of breath, choking, wheezing or hypotension
should be considered to have caused an allergic response and must be avoided.

Anaesthetic History

The anaesthetist should read any old anaesthetic notes. Good anaesthetic notes will
include responses to drugs, ease of mask ventilation and endotracheal intubation and any
anaesthetic complications. Patients should be asked about their prior anaesthetics.

Family History

The anaesthetist should ask if anyone in the family has had a bad reaction to anaesthesia.

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Smoking and Alcohol

Patients should be encouraged to stop smoking and alcohol before surgery.

Physical Examination

The anaesthetist must perform a physical examination. This examination must pay
special attention to the patient’s airway, cardiovascular and respiratory systems.

Every patient’s airway must be assessed to determine how difficult it will be to mask
ventilate and intubate. This assessment includes measuring mouth opening, neck flexion
and extension and the distance from the mandible to the thyroid cartilage and looking in
the mouth.

Cardiovascular examination is particularly concerned with determining the hydration
status of the patient (heart rate, blood pressure, postural drop, any signs of dehydration),
signs of cardiac failure and cardiac valve abnormalities. Patients who have a low blood
pressure and tachycardia must have intravenous fluid resuscitation before commencing
surgery/anaesthesia.

Respiratory examination should look for signs of upper airway obstruction,
bronchospasm or infection.

At this stage the anaesthetist may have diagnosed several problems that require further
investigation and treatment before surgery.

Documentation

The preoperative assessment should be documented, ideally on a preoperative
assessment form.

ASA classification

It is useful to assign an ASA (American Society of Anesthiologists) classification.

ASA 1: a normal healthy person
ASA 2: a patient with mild systemic disease
ASA 3: a patient with severe systemic disease limiting activity but not incapacitating
ASA 4: a patient with incapacitating systemic disease that is a constant theat to life
ASA 5: an extremely ill patient who is not expected to live 24 hours with or without an
operation

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