Key Clinical Topics in Anaesthesia Roger Langford, David Ashton-Cleary
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1Key Clinical Topics in Anaesthesia
2
3Key Clinical Topics in Anaesthesia
Roger Langford BMBS BMedSci(Hons) FRCA Consultant in Anaesthesia, Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK David Ashton-Cleary MBChB(Hons) FRCA FHEA DICM Locum Consultant in Critical Care & Anaesthesia, Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
4© 2014 JP Medical Ltd.
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9781907816772
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5Preface
The apparent simplicity of an uneventful surgical intervention with minimal side-effects belies the evolving complexity of the anaesthetic techniques required. New surgical techniques, a shift towards day-case operating and, in particular, an increasingly elderly and co-morbid population make the anaesthetist's task ever more challenging. In the emergency setting, patients are now undergoing procedures where previously there would have been no surgical option. This demands an increasing awareness of peri-operative and intensive care medicine from the anaesthetist. To maintain this knowledge base, a focussed distillation of current literature is required.
Key Topics in Anaesthesia is a succinct reference for the practicing anaesthetist and anaesthetic assistant as well as a structured resource for those preparing for post-graduate examinations in anaesthesia and intensive care medicine. Subject matter has been picked from topical literature, recent examination topics and ‘old chestnuts’ to cover the breadth of present practice.
A range of authors with specialist interests have been selected to develop the content. This draws on latest standards in clinical best practice, current evidence and guidelines and information on practical considerations. Each alphabetically ordered chapter provides a carefully structured commentary on the topic, suggestions for further reading as well as links to other relevant chapters and, in many cases, online resources.
Roger Langford
David Ashton-Cleary
June 2014
6
7Acknowledgements
Particular thanks must go to Dr Paul Upton and Dr Tim Craft for producing the original concept of this book, ‘Key Topics in Anaesthesia’, which was an examination ‘revision-favourite’ for many years. We are grateful for their permission to use and adapt their original structure and content.
The editors would like to thank the following clinicians for their expertise in assisting with the following topics. Dr Pete Stoddart and Ian Jenkins, Bristol Children's Hospital for assistance in the paediatric topics; Dr David Knight, Birmingham Children's Hospital for help with topic 9 (Burns); Dr Cathy Ralph, Royal Cornwall Hospital, for her support with topic 8 (Blood transfusion and salvage) Dr Will Fox, Royal Cornwall Hospital, for his assistance with topics 46 and 47 on obesity.
Finally, we are extremely grateful to our wives, Polly and Gemma, for their patience during the writing and editing of this book.
Roger Langford
David Ashton-Cleary
13Abbreviations 2,3-DPG
2,3-diphosphoglycerate
5HT
5-hydroxytryptamine (serotonin)
AAA
abdominal aortic aneurysm
AAGBI
Association of Anaesthetists of Great Britain and Ireland
ABG
arterial blood gas
ACC/AHA
American College of Cardiology and American Heart Association
ACE
angiotensin converting enzyme
Ach
acetylcholine
ACS
acute coronary syndrome
ACT
activated clotting time
ACTH
adrenocorticotropic hormone
ADH
antidiuretic hormone
ADP
adenosine diphosphate
AF
atrial fibrillation
AHI
apneoa hypopnoea index
AIDS
acquired immunodeficiency syndrome
AKI
acute kidney injury
ALI
acute lung injury
ALS
advanced life support
APLS
advanced paediatric life support
APTT
activated partial thromboplastin time
AR
aortic regurgitation
ARDS
acute respiratory distress syndrome
AS
aortic stenosis
ASA
American Society of Anesthesiologists grading system
ASD
atrial septal defect
ATN
acute tubular necrosis
ATP
adenosine triphosphate
AVR
aortic valve replacement
BiPAP
bilevel positive airway pressure
BLS
basic life support
BMI
body mass index
BP
blood pressure
CABG
coronary artery bypass grafting
CBF
cerebral blood flow
CBW
corrected body weight
CCF
congestive cardiac failure
CICV
‘cannot intubate, cannot ventilate’ scenario
CKD
chronic kidney disease
CNB
central neuraxial block
14CNS
central nervous system
CO
cardiac output (or carbon monoxide)
COPD
chronic obstructive pulmonary disease
CPAP
continuous positive airway pressure
CPB
cardiopulmonary bypass
CPD-A
citrate, phosphate, dextrose, adenine
CPET
cardiopulmonary exercise testing
CPP
cerebral perfusion pressure
CQC
Care Quality Commission
CRBSI
catheter-related bloodstream infections
CSE
combined spinal epidural
CSF
cerebrospinal fluid
CT
computed tomography
CTZ
chemoreceptor trigger zone
CVE
cerebrovascular event
CVP
central venous pressure
CVS
cardiovascular system
CXR
chest X-ray
DAS
Difficult Airway Society
DBD
donation after brain death
DCD
donation after cardiac death
DCI
delayed cerebral ischaemia
DHCA
deep hypothermic circulatory arrest
DIC
disseminated intravascular coagulopathy
DLT
double lumen tube
DMD
Duchenne muscular dystrophy
DNA
deoxyribose nucleic acid
DPP
dipeptidyl peptidase
DVT
deep vein thrombosis
ECMO
extracorporeal membrane oxygenation
ECG
electrocardiogram
ECT
electroconvulsive therapy
ECTAS
electroconvulsive therapy accreditation service
EEG
electroencephalogram
ELISA
enzyme-linked immunosorbent assay
EMG
electromyogram
EMI
electromagnetic interference
EPO
erythropoietin
ENT
ear nose and throat
ERAS
enhanced recovery after surgery
ERPC
evacuation of retained products of conception
ETCO2
end-tidal carbon dioxide
ETT
endotracheal tube
15EVAR
endovascular abdominal aortic aneurysm repair
EVD
external ventricular drain
FB
foreign body
FBC
full blood count
FEV
forced expiratory volume
FFP
fresh-frozen plasma
FiO2
fractional inspired oxygen concentration
FRC
functional residual capacity
FVC
forced vital capacity
GA
general anaesthesia
GABA
gamma-aminobutyric acid
GCS
Glasgow Coma Score (Scale)
GFR
glomerular filtration rate
GI
gastrointestinal
GMC
General Medical Council
GP
general practitioner
GTN
glyceryl trinitrate
GUCH
grown-up congenital heart disease
HbA1C
glycosylated haemoglobin
HCAI
healthcare-acquired infection
HDU
high dependency unit
HELLP
haemolysis elevated liver-enzymes low platelets
HEMS
helicopter emergency medical services
HFJV
high-frequency jet ventilation
HFOV
high-frequency oscillatory ventilation
HIV
human immunodeficiency virus
HPA
hypothalamo-pituitary adrenal axis
HPV
human papilloma virus
HTLV
human T-cell lymphotropic virus
IAP
intra-abdominal pressure
IBW
ideal body weight
ICD
implanted cardioverter defibrillator
ICNARC
Intensive Care National Audit and Research Centre
ICP
intracranial pressure
ICS
Intensive Care Society
ICU
intensive care unit (critical care)
IHD
ischaemic heart disease
IHPS
infantile hypertrophic pyloric stenosis
IE
infective endocarditis
IgE
immunoglobulin E
IL-1
interleukin 1
ILMA
intubating laryngeal mask airway
ILS
immediate life support
16IMV
intermittent mandatory ventilation
INR
international normalised ratio
IOP
intraocular pressure
IPC
infection prevention and control
IPPV
intermittent positive pressure ventilation
IR
interventional radiology
IRV
inverse ratio ventilation
IUCD
intrauterine contraceptive device
IV
intravenous
IVC
inferior vena cava
LA
local anaesthesis
LDH
lactate dehydrogenase
LASER
Light Amplification by Stimulated Emission of Radiation
LMA
laryngeal mask airway
LMWH
low molecular weight heparin
LSCS
lower segment caesarean section
LVEDP
left ventricular end-diastolic pressure
LVEF
left ventricular ejection fraction
LVH
left ventricular hypertrophy
MAC
minimum alveolar concentration
MAP
mean arterial pressure
MCA
Mental Capacity Act
MCT
mast cell tryptase
MDMA
methylene-dioxy-meth-amphetamine
MET
metabolic equivalent
MG
myaesthenia gravis
MH
malignant hyperpyrexia
MI
myocardial infarction
MILS
manual in-line stabilization
MLT
microlaryngeal tube
MODS
multiple organ dysfunction syndrome
MR
mitral regurgitation
MRI
magnetic resonance imaging
MRSA
methicillin-resistant Staphylococcus aureus
MS
mitral stenosis (or muscular sclerosis)
MV
mitral valve
NAP
Royal College of Anaesthetists National Audit Project
NCEPOD
National Confidential Enquiry into Perioperative Deaths
NEC
necrotising enterocolitis
NIBP
noninvasive blood pressure
NICE
National Institute for Health and Care Excellence
NMDA
N-methyl-D-aspartic acid
NMS
neuroleptic malignant syndrome
17NNT
number needed to treat
NO
nitric oxide
NPSA
National Patient Safety Agency
NSAID
nonsteroidal anti-inflammatory drug
NSTEMI
non-ST-elevation myocardial infarction
NTS
nucleus tractus solitarius
OCR
oculocardiac reflex
ODP
operating department practitioner
OLV
one lung ventilation
OSA
obstructive sleep apnoea
PaCO2
arterial partial pressure of carbon dioxide
PaO2
arterial partial pressure of oxygen
PAP
pulmonary artery pressure
PAV
proportional assist ventilation
PCA
patient-controlled analgesia
PCEA
patient-controlled epidural anaesthesia
PCP
Phencyclidine (1-(1-phenylcyclohexyl)-piperidine)
PCV
pressure-controlled ventilation
PDA
patent ductus arteriosus
PE
pulmonary embolism
PEEP
positive end-expiratory pressure
PEFR
peak expiratory flow rate
PEP
post-exposure prophylaxis
PET
positron emission tomography
PFO
patent foramen ovale
PICU
paediatric intensive care unit
PONV
postoperative nausea and vomiting
P-POSSUM
Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity
PPE
personal protective equipment
PRST
blood Pressure, heart Rate, Sweating and Tears
PV
pulmonary valve
PVR
pulmonary vascular resistance
RA
regional anaesthesia
RAE
Ring Adair and Elwyn endotracheal tube
RBC
red blood cell
RCT
randomised-controlled trial
REM
rapid eye movement
RF
radio frequency
RhA
rheumatoid arthritis
RRT
renal replacement therapy
RSI
rapid sequence induction
SACD
sudden adult cardiac death
18SAG-M
saline, adenine, glucose, mannitol
SAH
subarachnoid haemorrhage
SAPS
simplified acute physiology score
SBP
systolic blood pressure
SCI
spinal cord injury
SHOT
serious hazards of transfusion
SIMV
synchronised intermittent mandatory ventilation
SIRS
systemic inflammatory response syndrome
SLE
systemic lupus erythematosus
SpO2
pulse-oximetry oxygen saturation
SR
sarcoplasmic reticulum
SSEP
somatosensory evoked potential
SSRI
selected serotonin reuptake inhibitor
STEMI
ST-elevation myocardial infarction
STOP
surgical termination of pregnancy
SV
spontaneous ventilation
SVR
systemic vascular resistance
TACO
transfusion-associated circulatory overload
TARN
Trauma Audit and Research Network
TB
tuberculosis
TBI
traumatic brain injury
TBSA
total body surface area
TBW
total body weight
TCI
target-controlled infusion
TEG
thromboelastography
TIVA
total intravenous anaesthesia
TMJ
temporomandibular joint
TNFα
tumour necrosis factor α
TOE
transoesophageal echocardiography
TRALI
transfusion-related acute lung injury
TURP
transurethral resection of prostate
TV
tricuspid valve
V/Q
ventilation/perfusion
VAP
ventilator-associated pneumonia
VALI
ventilator-associated lung injury
vCJD
variant Creutzfeldt–Jakob disease
VCV
volume-controlled ventilation
VF
ventricular fibrillation
VSD
ventricular septal defect
VT
ventricular tachycardia
VTE
venous thrombo-embolism
WHO
World Health Organization
19Contributors