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 9586452 Anaesthesia – Developing countries – Handbooks, manuals, Etc I Title 617.96091724 For the latest version and associated resources please access www.developinganaesthesia.org Creative Commons Developing Nations 2.0 You are free to copy, distribute, display, and perform the work and to make derivative works Under the following conditions: Developing Nations You may exercise the above freedoms in developing nations only Attribution You must give the original author credit • For any reuse or distribution, you must make clear to others the license terms of this work • Any of these conditions can be waived if you get permission from the copyright holder Your fair use and other rights are in no way affected by the above This is a human-readable summary of the Legal Code (the full license) Disclaimer http://creativecommons.org/licenses/disclaimer-popup?lang=en 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 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 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 Teach the Teacher developinganaesthesia.org will provide a resource to aid anaesthetists in educational methods 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 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 CONTENTS CHAPTER ONE: PREOPERATIVE MANAGEMENT PREOPERATIVE ASSESSMENT PREOPERATIVE INVESTIGATIONS 13 PREMEDICATION 14 PREOPERATIVE FASTING 15 AIRWAY ASSESSMENT 17 CARDIOVASCULAR DISEASE  Ischaemic heart disease  Valvular heart disease  Hypertension 19 PERIOPERATIVE BETA BLOCKADE 23 RESPIRATORY DISEASE  Respiratory infections  Asthma  Chonic obstructive airway disease 25 SMOKING 27 10 STEROID SUPPLEMENTATION 28 11 RENAL DISEASE  Acute renal failure  Chonic renal failure 29 12 LIVER DISEASE 32 13 DIABETES 34 14 EMERGENCY SURGERY 36 CHAPTER TWO: GENERAL ANAESTHESIA 15 CHECKING THE EQUIPMENT 38 16 BREATHING SYSTEMS  Circle system  Mapleson breathing systems 43 17 DRAWOVER ANAESTHESIA 47 18 INDUCTION OF ANAESTHESIA  Intravenous induction  Inhalation induction  Patient positioning 51 19 AIRWAY MANAGEMENT 55 20 RAPID SEQUENCE INDUCTION 72 21 INHALATION ANAESTHETIC AGENTS  Diethyl ether  Halothane  Trichloroethylene  Enflurane  Sevoflurane  Methoxyflurane  Cyclopropane  Nitrous oxide 75 22 INTRAVENOUS INDUCTION AGENTS  Thiopentone  Propofol  Ketamine 81 23 BENZODIAZEPINES 86 24 NEUROMUSCULAR BLOCKADE Non-depolarisning • Tubocurarine • Alcuronium • Pancuronium • Cisatracurium • Mivacurium • Fazidinium 87 Gallamine Atracurium Vecuronium Rocuronium Pipecuronium Metocurine Depolarising • Suxamethonium CHAPTER THEE: PAEDIATRIC ANAESTHESIA 25 PAEDIATRIC ANATOMY, PHYSIOLOGY & PHARMACOLOGY 93 26 ANAESTHESIA FOR INFANTS AND CHILDREN  Preoperative assessment  Premedication  Parents in induction room  Induction of anaesthesia 97 27 PAEDIATRIC ANAESTHETIC EQUIPMENT 101 28 CAUDAL EPIDURAL ANAESTHESIA 103 CHAPTER FOUR: OBSTETRICS AND GYNAECOLOGY 29 LABOUR ANALGESIA  Epidural anaesthesia for labour 106 30 CAESAREAN SECTION  General anaesthesia 111 31 SPINAL ANAESTHESIA FOR OBSTETRIC PATIENTS 113 32 RESUSCITATION OF THE NEWBORN INFANT 116 33 OBSTETRIC HAEMORRHAGE  Placenta praevia  Placental abruption  Uterine rupture  Retained placenta  Uterine atony  Ectopic pregnancy 120 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  Cardiovascular complications  Respiratory complications  Central nervous system complications 143 41 PAIN MAMAGEMENT 148 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 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 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 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 10 ...Pescod, David, 1959- Developing anaesthesia: guidelines for anaesthesia in Developing countres Includes index ISBN 9586452 Anaesthesia – Developing countries – Handbooks, manuals,... Disclaimer http://creativecommons.org/licenses/disclaimer-popup?lang=en www.developinganaesthesia.org Welcome to www.developinganaesthesia.org This website has been created to promote the advancement... as directed by the anaesthesia community Continuing Education developinganaesthesia.org will provide an anaesthetic educational resource for anaesthetists The site contains a textbook, articles,