The Anaesthesia Science Viva Book, 2nd Edition

443 Pages·2008·5.22 MB·English

by  Simon Bricker

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The Anaesthesia Science Viva Book
Second Edition

The Anaesthesia
Science Viva Book
SECOND EDITION
Clinical science as applied to anaesthesia,
intensive therapy and chronic pain
A guide to the oral questions
SIMON BRICKER MA, MB ChB, FRCA
ExaminerintheFinalFRCA
ConsultantAnaesthetist
TheCountessofChesterHospital
Chester,UK
Medical illustrations by
CELYN BRICKER
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521726443
©S. Bricker 2009
This publication is in copyright. Subject to statutory exception and to the
provision of relevant collective licensing agreements, no reproduction of any part
may take place without the written permission of Cambridge University Press.
First published in print format 2008
ISBN-13 978-0-511-45569-8 eBook(EBL)
ISBN-13 978-0-521-72644-3 paperback
Cambridge University Press has no responsibility for the persistence or accuracy
of urls for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
Every effort has been made in preparing this publication to provide accurate and
up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in this
publication. Readers are strongly advised to pay careful attention to information
provided by the manufacturer of any drugs or equipment that they plan to use.
Contents
Preface to the Second Edition page ix
Preface to the First Edition xi
1 Advice on answering clinical science viva questions 1
2 Anatomy and its applications 13
The cerebral circulation 13
The internal jugular vein 15
Ocular anatomy 19
The autonomic nervous system 21
The trigeminal nerve 24
The nose 26
Sensory nerve supply to the face 29
Cervical plexus 31
The larynx 33
Innervation of the larynx 36
The anatomy of the trachea and bronchi 38
Surface anatomy of the neck (percutaneous tracheostomy
and cricothyroidotomy) 42
The stellate ganglion 44
Myocardial blood supply 46
Myocardial innervation 49
Intercostal nerves 51
The diaphragm 53
The liver 56
The coeliac plexus 59
Blood supply to the spinal cord 61
The lumbar sympathetic chain 63
Innervation of the inguinal region 65
The brachial plexus 67
The ulnar nerve 71
The radial nerve 73
The median nerve 74
The antecubital fossa 76
Arterial supply of the hand 78
Anatomy relevant to subarachnoid (spinal) anaesthesia 80
The extradural (epidural) space 83
The sacrum 86
The femoral triangle 89
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Contents
The femoral nerve 91
The sciatic nerve 93
Sensory innervation of the foot 95
Cross-sectional areas of interest: eye, neck and lumbar region 97
3 Physiology 101
Pneumothorax 101
Central venous pressure and cannulation 104
Fluid therapy 107
Compensatory responses to blood loss 110
Control of breathing 112
Apnoea and hypoventilation 116
Compliance 118
The failing lung 120
Bronchomotor tone (asthma) 123
Preoperative assessment of cardiac function 125
Oxygen delivery 127
Oxygen–haemoglobin dissociation curve 129
Hyperbaric oxygen 132
Oxygen toxicity 134
One-lung anaesthesia 136
Pulmonary oedema 138
Pulmonary hypertension (hypoxic pulmonary vasoconstriction) 141
Intracranial pressure 143
Cerebral blood flow 147
Intraocular pressure 150
The neuromuscular junction 153
Physiological changes of late pregnancy relevant to general anaesthesia 156
Non-obstetric surgery in the pregnant patient 159
Circulatory changes at birth (congenital heart disease) 161
Physiology and clinical anatomy of the infant and neonate 164
Postoperative nausea and vomiting 168
Obesity 170
Physiology of ageing 172
The ‘stress response’ to surgery 174
The glucocorticoid response to surgery 176
Adrenaline (epinephrine) 178
5-Hydroxytryptamine (serotonin) 180
Nitric oxide 183
Plasma proteins 185
Thyroid function 186
Nutrition 189
4 Pharmacology 193
Chirality 193
Propofol 195
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Contents
Ketamine 197
Thiopental and etomidate 199
Inhalational agents: comparison with the ideal 202
Nitrous oxide 205
Neuromuscular blocking drugs 209
Suxamethonium 211
Opiates/opioids 213
Local anaesthetics: actions 216
Local anaesthetics: toxicity 220
Local anaesthetics: alkalinization 223
Bupivacaine, ropivacaine, lidocaine and prilocaine 225
Spinal adjuncts to local anaesthetics 228
Induced hypotension 230
Clonidine 233
Anti-arrhythmic drugs 235
ß-adrenoceptor blockers 238
Anti-hypertensive drugs and anaesthesia 241
Hypotension and its management 243
Inotropes 246
Drugs used in the treatment of nausea and vomiting 249
Drug overdose: prescribed and therapeutic drugs 251
Recreational drugs and drugs of abuse 253
Drugs affecting mood 256
Drugs affecting coagulation 258
Cyclo-oxygenase (COX) enzymes 262
Magnesium sulphate 265
Tocolytics (drugs which relax the uterus) 266
Drugs which stimulate the uterus 268
Target-controlled infusion (TCI) 270
Conscious sedation 273
Drugs used to treat diabetes mellitus 275
Bioavailability 277
Design of a clinical trial for a new analgesic drug 280
5 Physics, clinical measurement, equipment and statistics 283
Depth of anaesthesia 283
Evoked potentials 287
Pulse oximetry 288
Measurement of CO 290
2
The fuel cell (oxygen measurement) 293
Supply of medical gases 294
The anaesthetic machine 296
Flowmeters 298
Laminar and turbulent flow 300
Vaporizers 301
Anaesthetic breathing systems 304
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Contents
Soda lime 309
Scavenging 311
The gas laws 312
Gases and vapours 315
Pressure 317
Intra-arterial blood pressure measurement 319
Measurement of organ blood flow 322
Measurement of cardiac output 323
Jugular venous bulb oxygen saturation (SjVO ) 326
2
Temperature and its measurement 327
Heat loss 329
Humidification (of inspired gases) 332
Lasers 334
Magnetic resonance imaging 335
Ultrasound 337
Peripheral nerve location using a stimulator 340
Electrical safety 342
Defibrillation 345
Surgical diathermy 347
Biological potentials 349
Osmosis 351
Parametric and non-parametric data 353
Clinical trials: errors in interpretation of data 356
6 Miscellaneous science and medicine 359
Mechanisms of action of general anaesthetics 359
Jaundice 361
Latex allergy 363
Brain stem death testing 365
Haemofiltration 367
Blood groups 369
Complications of blood transfusion 371
Cytochrome P450 373
Mitral valve disease 375
Aortic valve disease 378
Electroconvulsive therapy 380
Postpartum haemorrhage 382
Pre-eclampsia 383
The complex regional pain syndrome 385
Diabetic ketoacidosis 388
Pain pathways 391
Spinal cord injury 393
Immunology (and drug reactions) 395
Sepsis 398
The arterial tourniquet 400
Index 405
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