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Understanding Anaesthesiology
S Ahanatha Pillai
CHAPTER 1:
Introduction
CHAPTER 2:
History of Anaesthesia
A WORLD WITHOUT ANAESTHESIA
THE ORIGIN OF THE PRESENT DAY ANAESTHESIA
THE STORY OF “THE LAUGHING GAS”
THE STORY OF FIRST PUBLIC DEMONSTRATION OF SURGICAL ANAESTHESIA
THE STORY ABOUT “PAINLESS CHILD BIRTH”
THE STORY OF THIOPENTONE SODIUM
ANAESTHESIA IN INDIA
Brief History of Anaesthesia in India
The Two World Wars and Anaesthesia in India
Important Events in the History of Anaesthesia in the World
HISTORY IN A NUTSHELL
CHAPTER 3:
Anaesthesiologist
LEARNING ANAESTHESIOLOGY
FUNCTIONS OF THE ANAESTHESIOLOGIST
Good
Efficient (Skillful)
Well Informed (Knowledgeable)
Safe
Discipline
Devotion
Dedication
SURGEON-ANAESTHETIST RELATIONS
Appraisal
Operating Theatre Suite and Theatre Discipline
Surgical Hand Disinfection (Scrub Up)
OPERATING DEPARTMENT MANAGER
CHAPTER 4:
Surgical Team
JOB DESCRIPTIONS
Surgeon and his Assistant
Anaesthetist
Assisting Nurse (With the Adjectives – Well Trained, Skillful and Dedicated)
Anaesthetic Technician (Theatre Assistant or Theatre Technician)
Nursing Assistant
Unskilled Personnel Working Inside the Operating Room
Stretcher Bearers
Luscar (General Worker)
Sanitary Worker
THE CO-ORDINATOR OF THE TEAM
The Responsibilities of the Co-ordinator
Planning the Operation List
Planning the Team for Different Procedures
Planning the Postoperative Care
Maintenance of Theatre Asepsis
Points for Theatre Asepsis
CHAPTER 5:
Safe Practice of Anaesthesia
A. OPERATION THEATRES - MINIMUM REQUIREMENTS
B. ANAESTHESIA CARE – PRINCIPLE
C. STAFFING
D. ANAESTHESIA RECORD AND MACHINE
E. BASIC EQUIPMENTS
F. INTRAOPERATIVE MONITORING
G. THE RECOVERY AREA
SAFETY DURING ANAESTHESIA
ACCIDENTS DURING ANAESTHESIA
The Anaesthetists
Equipments and Drugs
Monitoring
The Patient
ANAESTHETIC RECORDS
MONITORING DURING ANAESTHESIA
MINIMUM MONITORING STANDARDS
Disadvantages of Monitors
The Summary of the Recommendations Proposed by the Various Societies. Revised in 1994
This Care During Anaesthesia may be Divided into Four Heads
Clinical Monitoring of the Patient
BASIC MONITORING WITH INSTRUMENTS
Monitoring the Anaesthetic Machine
Monitoring of the Patient
The Cardiovascular System
ECG
Monitoring the Circulation
Arterial Pressure
Peripheral Pulse
Pulse Plethysmography
Arterial Oxygen Saturation: Pulse Oximetry (Fig. 5.2)
Peripheral Perfusion
Urine Output
Limitations of Monitors
CHAPTER 6:
Mechanics of Respiration
CHAPTER 7:
Oxygen and Anaesthesia
OXYGEN
Commercial Preparation
Presentation
Physiological Facts about Oxygen
Work of Breathing
Hypoxia during Anaesthesia
Transport of Oxygen in Blood
Simple Solution of Oxygen in the Plasma
Oxyhaemoglobin
Oxygen Dissociation Curve
Carbon Dioxide Tension
The pH of the Blood
Stored Blood
Temperature
The Clinical Significance of Oxygen Dissociation Curve
Discussion
Hypoxia or Oxygen Lack
Classification of the Causes of Hypoxia
Hypoxic Hypoxia
Anaemic Hypoxia
Stagnant Hypoxia
Histotoxic Hypoxia
Cyanosis
Effects of Hypoxia
Cardiovascular System
Respiratory System
Metabolism
Organ Failure
Postoperative Hypoxia
Ventilation Perfusion Mismatch
Reduced Cardiac Output
Hypoventilation
Drugs
Obstruction
Pain
Intraoperative Hyperventilation
Methods of Oxygen Therapy
Devices
Oxygen Masks
Nasal Catheters or Prongs
Oxygen Tent
PULSE OXIMETER “WHAT HAS TO BE KNOWN”
The Pulse Oximeter and Its Use in Clinical Anaesthesia
Interpretation of Waveform and Perfusion Indicator
Depth of Anaesthesia
Volume Status of the Patient
Analyzing the Waveform for Interpretation
Working Principle
Other Uses
Arterial Pressure
Peripheral Perfusion
Urine Output
Limitations of Monitors
CHAPTER 8:
Operating Department
ACCESS ZONES
Red Line
Patient Transport
Supplies
Disposal
Administration and Teaching
Catering
Cleaning
Design
Types of Operating Departments
Construction
Walls and Ceiling
Floors
Lighting
General Lighting
Operation (task) Area Illumination
The Terminology
Types of Operating Luminaires
Pendant Services
Ventilation
Plenum Turbulent Air Flow System
Ultra Clean Ventilation System
Storage
CHAPTER 9:
Anaesthesia Machine
COMPRESSED GAS CYLINDERS USED IN ANAESTHESIA (MEDICAL GAS SUPPLY)
Cylinders
Oxygen Cylinders
Advantages of Central Pipe Line Supply of Gases
Nitrous Oxide Cylinders
Central Vacuum Unit
METHODS OF ADMINISTRATION OF GENERAL ANAESTHESIA
Open Method (Open Drop Method)
Semi-Open Method
Semi-Closed Technique (System)
Closed Technique (System)
THE ESSENTIAL ITEMS TO BE KEPT ON THE WORK TOP OF AN ANAESTHETIC MACHINE
THE ESSENTIAL TERMS TO BE KEPT ON THE WORK TIP OF AN ANAESTHESIA MACHINE
CHAPTER 10:
Operating Table and Positions Used for Surgeries
POSITIONS FOR SURGERY
Supine or Dorsal Recumbent Position
Trendelenberg Position
Gallbladder and Liver Position
Lateral Position of Extension (Kidney Position)
Lithotomy Position
Position for Abdominoperineal Resection of Rectum
CHAPTER 11:
Basic Skills
INTUBATION TECHNIQUE
ENDOTRACHEAL TUBES
SPECIAL TYPES OF ENDOTRACHEAL TUBES
INTUBATION
The Purpose of Intubation
Human Assistance
LARYNGEAL MASK AIRWAY (LMA)
Design and Discription of Standard Laryngeal Mask Airway
METHOD OF USING LARYNGEAL MASK AIRWAY (As advised by the Manufacturer)
Directions for Removal
Indication and Usage
Contraindications
Precautions
Adverse Effects
MODIFIED VERSIONS OF LMA
LMA Unique
Flexible LMA
Short Tube LMA
Intubating LMA
LMA Pro-seal
Accuracy Equipments for Intubating Magill's Intubating Forceps: (3 Sizes)
Laryngeal Spray: (Macintosh)
Forrester Spray (Fig. 11.35)
10% Xylocaine Spray
INTRAVENOUS CANNULATION
Facts to be Remembered
THE STEPS FOR IV CANNULATION
CHAPTER 12:
Clinical Anaesthesia
GUEDEL's CLASSIFICATION OF STAGES AND PLANES OF ANAESTHESIA
Good Surgical Anaesthesia
Definition
Triad of Anaesthesia
BALANCED ANAESTHESIA
Definition
CLASSIFICATION OF ANAESTHESIA
CHAPTER 13:
Preanaesthetic Assessment
GUIDELINES FOR PREANAESTHETIC VISIT
Definition
History of Allergy
Physical Examination
Cardiovascular System
Respiratory System
Central Nervous System
BASIC LABORATORY INVESTIGATIONS
Haemoglobin
Urine Albumin
Urine Sugar
ECG
X-ray Chest
Grading of Risk
Fit for Anaesthetic
INFORMED CONSENT FOR ANAESTHESIA AND SURGERY
Consent for Anaesthesia, Surgery and Other Necessary Procedures
Jehovah's Witnesses
PREOPERATIVE STARVATION
CANCELING CASES
CHOICE OF ANAESTHESIA
Physical Status
Type of Surgery
The skill and the requirement of the surgeon
The skill and preference of the anaesthesiologist
The patient's wishes
Teaching purpose
CHAPTER 14:
Preanaesthetic Medications
EFFECTS OF PRE- MEDICATION
Graph I (Fig. 14.1)
Graph II (Fig. 14.2)
CHAPTER 15:
Balanced Anaesthesia (In Modern Practice)
RECOVERY FROM ANAESTHESIA
Definition
The Five Recovery Criteria:
Is it a good sign? Be careful!
CHAPTER 16:
Anaesthesia and Vital Organs
ANAESTHESIA AND LIVER
Anatomy
Physiology
Functions of the Liver
General Metabolism
Storage
Synthesis
Detoxication of Drugs
Modifications in Liver Blood Flow
Flow in the Conscious State
Flow in Anaesthetised Patient
Flow during Hypotension due to Autonomic Blockade
Flow during Hypotension Associated with Vasoconstriction
Flow during Hypothermia
Flow with Vasoconstrictor Drugs
Anaesthesia and Hepatic Cells
ANAESTHESIA AND KIDNEY
Anatomy
Vascular System
Urinary System
Nerve Supply
Physiology
Applied Physiology of Glomerular Filtration
Tubular Reabsorption
Renal Blood Flow in Conscious Patient
Renal Blood Flow in Anaesthetised Patient
Effects of Haemorrhage on Renal Blood Flow under Anaesthesia
Effects of Vasopressor Drugs
Renal Damage in Relation to Anaesthesia and Surgery
ANAESTHESIA AND BRAIN
Cerebral Metabolism
Blood Supply to Brain
Anatomy of Circulation
Venous Drainage
Factors Affecting the Cerebral Blood Flow
Arterial PCO2
Arterial PO2
Cerebral Perfusion Pressure
Venous and Intracranial Pressures
Autonomic System
Temperature
Blood Viscosity
Age
Drugs
Failure of Autoregulation
Intracranial Pressure
Definition
Munro Kellie's Doctrine
Causes of Increased Intracranial Pressure
Causes of Reduced Intracranial Pressure
Cerebrospinal Fluid
ANAESTHESIA AND HEART
Anatomy of Coronary Arteries
Coronary Artery Blood Flow
Coronary Artery Dilators
The Heart Rate
Vascular Reflexes
Cardiac Output
Venous Return
Effects of Anaesthetic Agents on Cardiac Output
Vascular System
Arterial System
The Capillaries
The Venous System
MYOCARDIAL OXYGEN CONSUMPTION UNDER ANAESTHESIA
Tachycardia
Bradycardia
Common Drugs used in Cardiovascular Diseases
Antianginal Drugs
Nitrates
Beta Blockers
Calcium Channel Blockers
Drugs for Treatment of Cardiac Failure
Diuretics
Nitrates
Digoxin
Angiotensin Converting Enzyme (ACE) Inhibitors
Prazosin
Anti-Arrhythmic Drugs
Arrhythmias of Sinus Origin
Ectopic Rhythms
Conduction Block
Preexcitation Syndromes
Adenosine
Antihypertensive Drugs
Diuretics
Vasodilators
Beta-blockers
CHAPTER 17:
Guidelines for Emergency Abdominal Surgeries
CHAPTER 18:
Perioperative Anaesthetic Complications
CHAPTER 19:
Maintenance of Airway in an Unconscious Patient
CHAPTER 20:
Recovery Room Guidelines
POSTANAESTHESIA CARE UNIT (PACU) (RECOVERY ROOM)
History
Recovery Room
The Transport to Recovery Room
Intensive Therapy Unit (ITU)
High Dependency Unit (HDU)
The Purpose of Recovery Room
SYSTEMS MAINLY AFFECTED DURING RECOVERY
Central Nervous System
Cardiovascular System
Respiratory System
Some Facts to be Remembered during the Observation of Postanaesthetic Patients
Recovery Criteria
Clinical Assessment of Adequacy of Reversal of NMB
Subjective
Objective
Unreliable
Reliable
The Six Tests are
Common Postoperative Problems
Guidelines for Postanaesthetic Care
Expectations
Formulating Guidelines
Infrastructure
Location
Space Allocation
Other Essential Provisions
Equipments
Resuscitation Equipments
Staffing (Personnel)
Procedure Protocol
Central Nervous System Recovery
Ensure
Respiratory System
Ensure
Cardiovascular Stability
Ensure
Surgical Wound
Observe for
Conclusion
CHAPTER 21:
Postoperative Nausea and Vomiting (PONV)
CHAPTER 22:
General Anaesthesia
CHAPTER 23:
Assessment of Blood Loss during Surgery and Volume Replacement
CHAPTER 24:
Regional Anaesthesia
XYLOCAINE (LIDOCAINE OR LIGNOCAINE)
BUPIVACAINE
Toxic Reactions of Local Anaesthetics
Raised Blood Levels May be Caused by Two Reasons
Manifestations
Central Nervous System
Manifestations
Cardiovascular System
Techniques of Regional Anaesthesia
CHAPTER 25:
Central Neural Block
SPINAL ANAESTHESIA
Other Names
Anatomy
Clinically Significant Anatomical Points
Lumbar Puncture
The Drugs
PHYSIOLOGY OF SPINAL ANAESTHESIA AND RELATED PROBLEMS
Some Facts to be Remembered
Positioning the Patient
Care During the Technique
Nerve Fibres and their Conduction Capabilities
A fibres
B fibres
C fibres
Order of Blockade
Recovery
When Can a Patient Walk After Spinal Anaesthesia?
SPINAL HYPOTENSION
Control of Arterial Pressure
Organ Perfusion
Cerebral Circulation
Coronary Circulation
Renal Perfusion
Circulatory Effects of Central Neural Block
The Type of Block and the Degree of Hypotension
The Obstetric Patient and Spinal Hypotension
MANAGEMENT OF SPINAL HYPOTENSION
Vasopressors
Ephedrine
Mephentermine
The Other Drugs
An Example
EPIDURAL ANAESTHESIA
Total Spinal
Cardinal Signs
COMBINED SPINAL-EPIDURAL ANAESTHESIA (CSEA)
CHAPTER 26:
Theatre Asepsis and Sterilization of Equipments
OPERATING THEATRE ENVIRONMENT AND ASEPSIS
Infections
Definitions
Antiseptics
Disinfectants
Germicide
Detergent Antiseptics
Theatre Sterilization Schedule
Daily
Carbolising
Micro Nebulisers: (OTI CARE)
Boiling
Potassium Permanganate and Formalin
Ultraviolet Light
Ultraviolet Air Cleaners
STERILIZATION OF EQUIPMENTS
Types of Equipments
Low Risk Equipments
Intermediate Equipments
High Risk Equipments
Cleaning and Sterilization
Decontamination (Cleaning infected material)
Manual
Automatic Washing Machine
Ultrasonic Washer
Disinfection
Methods of Disinfection
Sterilization
Cold Chemical Methods
DISINFECTION AND STERILIZATION OF EQUIPMENTS
General Classification
Physical Methods of Sterilization (Heat Sterilization)
Moist Heat
Boiling
Pasteurisation
Autoclave: (steam under pressure)
Ideal Packing
Advantages of Autoclaving
Testing for Adequacy of Sterilization
Dry Heat
Chemical Sterilization Methods
Advantages
Disadvantages
Vapour (Formaldehyde)
Gases (Ethylene Oxide or Propylene Oxide)
Liquids
Phenol
Iodine
Ethyl Alcohol
Hexa Chlorophene
Chlorhexidene Gluconate
Glutaraldehyde (Cidex)
Nu Cidex
Iodophores
Chlorine Compounds
Detergents
Gamma Rays
Ultraviolet Rays
Filtration (Bacterial filters)
STERILIZATION OF EACH GROUP OF ANAESTHETIC EQUIPMENTS
Direct Contact with the Respiratory Tract
Nearer to the Respiratory Tract
Remote Ones
The Method of Sterilization
Special Concern about Contamination with Tuberculosis Infection
Hepatitis B (Australian antigen)
Central Sterilization Department
Points to be Remembered
CHAPTER 27:
Day Care Anaesthesia
CHAPTER 28:
Some Commonly Used Procedures, Equipments and Drugs
CHAPTER 29:
Cardiopulmonary Cerebral Resuscitation (CPCR)
TERMINOLOGY
HISTORY
MODERN RESUSCITATION
CARDIAC ARREST
Three forms of Cardiac Arrest
SUDDEN CARDIAC ARREST
Common Causes of Cardio-respiratory Arrest
EFFECT OF CARDIAC ARREST (CIRCULATORY ARREST)
TREATMENT (RESUSCITATION)
Aim
Mouth to Airway Breathing
Bag and Mask Ventilation
Bag and Endotracheal Tube Ventilation
Inotropic drugs;
Sodium Bicarbonate
ABCD of Resuscitation
Atmosphere Air Ventilation
Method
Caution
The Clinical Effect of Effective Cardiac Compression
Adrenaline
Intracardiac Adrenaline Should not be used because
In Ventricular Fibrillation
In Asystole
In EMD
OTHER DRUGS
Calcium Chloride
Glucagon
Atropine Sulphate
Vasoactive Drugs
Isoprenaline Sulphate
Dopamine
Dobutamine
Hydrocortisone
Sodium Bicarbonate
Cerebral Prophylaxis
The Drugs Used for Cerebral Prophylaxis Are
Steroids
Diuretics
Diuretics
Frusemide
Mannitol 20%
Corticosteroids
Renal Prophylaxis
Treatment of “Asystole”
Treatment of “Ventricular Fibrillation”
Defibrillation
What is defibrillation?
The Principle of Defibrillation
DC Defibrillation
Pharmacological Defibrillation
Brain Salvage
Management
Key points
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