Professional Documents
Culture Documents
Clinical
Anaesthesia
CARL GWINNUTT
2nd edition
Lecture Notes: Clinical Anaesthesia
Lecture Notes
Clinical
Anaesthesia
Carl L. Gwinnutt
MB BS MRCS LRCP FRCA
Consultant Anaesthetist
Hope Hospital, Salford
Second Edition
© 2004 C. Gwinnutt
© 1997 Blackwell Science Ltd
Published by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
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Contents
Contributors vi
Preface vii
List of Abbreviations viii
Index 151
v
Contributors
vi
Preface
In the first edition, I asked the question, ‘Should will encounter before deciding on a career in
medical students be taught anaesthesia?’ I firmly anaesthesia. On the other hand, it is also impor-
believed that they should, and in the intervening tant that you are aware of the continuing essential
years nothing has happened to change my view. role that many of my colleagues play in treating
Indeed, with the continuing expansion of the roles and helping patients live with chronic pain prob-
and responsibilities of anaesthetists, it is now more lems and the principles upon which these are
important than ever that as medical students you based.
understand that we do far more than provide the With this edition, I have endeavoured to identi-
conditions under which surgery can be performed fy the skills you will need and the challenges you
safely. I hope that this second edition reflects these will meet in the early years after qualification. The
changes. book remains a skeleton on which to build, not
Anaesthetists are increasingly responsible for the only from within other texts, but also with clinical
development and care of patients preoperatively experience. I remain hopeful that if, after reading
and postoperatively and in the recognition and this book, you feel motivated to learn by desire
management of those who are critically ill. With rather than need I will be a little bit closer to
the help of my colleagues, I have tried to reflect this achieving my aims.
expanding role in the updated text, particularly as
these are areas that as newly qualified doctors, you Carl Gwinnutt
vii
List of Abbreviations
viii
List of Abbreviations
ix
Lecture Notes: Clinical Anaesthesia
Chapter 1
Anaesthetic assessment and
preparation for surgery
1
Chapter 1 Anaesthetic assessment and preparation for surgery
The most obvious type of patient who fits into Nurses who have been specifically trained are par-
this class are those scheduled for day case (ambula- ticipating increasingly in the preparation of these
tory) surgery. These patients should be seen at the patients, by taking a history, performing an exami-
time of admission by the anaesthetist, who will: nation and ordering appropriate investigations
• confirm the findings of the screening; (see below). Alternatively it may be a member of
• check the results of any baseline investigations; the surgical team.
• explain the type of anaesthetic appropriate for The patients, who will need to be seen by the
the procedure; anaesthetist, are those identified for whatever rea-
• have the ultimate responsibility for deciding it is son as having actual or potential anaesthetic prob-
safe to proceed. lems. This is often symptomatic concurrent disease
despite optimal treatment, or previous or potential
anaesthetic problems. Patients may also have been
Stage 2 — The preoperative
deferred initially for review by a medical specialist,
assessment clinic
for example cardiologist, to optimize medical
The patients seen here are those who have been treatment. This allows the anaesthetist to:
identified by the screening process as having • make a full assessment of the patient’s medical
coexisting medical problems that: condition;
• are well controlled with medical treatment; • review any previous anaesthetics administered;
• are previously undiagnosed, for example dia- • evaluate the results of any investigations;
betes, hypertension; • request any additional investigations;
• are less than optimally managed, for example • explain and document:
hypertension, angina; • the anaesthetic options available and the po-
• have abnormal baseline investigations; tential side-effects;
• show a need for further investigations, for exam- • the risks associated with anaesthesia;
ple pulmonary function tests, echocardiography; • discuss plans for postoperative care.
• indicate previous anaesthetic difficulties, for The ultimate aim is to ensure that when the patient
example difficult intubation; is admitted for surgery, the chances of being can-
• suggest potential anaesthetic difficulties, for celled as a result of ‘unfit for anaesthesia’ are mini-
example obesity, previous or family history of mized. Clearly the time between the patient being
prolonged apnoea after anaesthesia; seen in the assessment clinic and the date admitted
• are to undergo complex surgery with or without for surgery cannot be excessive, and is generally
planned admission to the intensive therapy unit between 4 and 6 weeks.
(ITU) postoperatively.
Once again, not all these patients will need to be
The anaesthetic assessment
seen by an anaesthetist in the clinic, although it is
essential that anaesthetic advice from a senior Whoever is responsible for the anaesthetic assess-
anaesthetist is readily available. Those who may not ment must take a full history, examine each pa-
need to be seen by an anaesthetist include: tient and ensure that appropriate investigations
• Patients with well-controlled concurrent are carried out. When performed by non-anaes-
medical conditions, for example hypertension, thetic staff, a protocol is often used to ensure all the
asthma. They may need additional investigations relevant areas are covered. This section concen-
that can be ordered according to an agreed proto- trates on features of particular relevance to the
col and then re-assessed. anaesthetist.
• Patients with previously undiagnosed or less
than optimally managed medical problems. They
can be referred to the appropriate specialist at this
stage and then re-assessed.
2
Anaesthetic assessment and preparation for surgery Chapter 1
Table 1.1 New York Heart Association classification of cardiac function compared to Specific Activity Scale
Class I: Cardiac disease without limitation of physical Can perform activities requiring ≥7 mets
activity Jog/walk at 5 mph, ski, play squash or basketball,
No fatigue, palpitations, dyspnoea or angina shovel soil
Class II: Cardiac disease resulting in slight limitation of Can perform activities requiring ≥5 but <7 mets
physical activity Walk at 4 mph on level ground, garden, rake,
Asymptomatic at rest, ordinary physical activity weed, have sexual intercourse without stopping
causes fatigue, palpitations, dyspnoea or
angina
Class III: Cardiac disease causing marked limitation of Can perform activities requiring ≥2 but <5 mets
physical activity Perform most household chores, play golf, push
Asymptomatic at rest, less than ordinary activity the lawnmower, shower
causes fatigue, palpitations, dyspnoea or angina
Class IV: Cardiac disease limiting any physical activity Patients cannot perform activities requiring ≥2 mets
Symptoms of heart failure or angina at rest, Cannot dress without stopping because of
increased with any physical activity symptoms; cannot perform any class III activities
3
Chapter 1 Anaesthetic assessment and preparation for surgery
4
Anaesthetic assessment and preparation for surgery Chapter 1
patients may have been issued with a ‘Medic Alert’ riage is reduced by carboxyhaemoglobin, and nico-
type bracelet or similar device giving details or a tine stimulates the sympathetic nervous system,
contact number. Although halothane is now less causing tachycardia, hypertension and coronary
popular for maintenance of anaesthesia, the ap- artery narrowing. Apart from the risks of chronic
proximate date of previous anaesthetics should be lung disease and carcinoma, smokers have a signifi-
identified if possible to avoid the risk of repeat expo- cantly increased risk of postoperative chest infec-
sure (see page 33). Details of previous surgery may tions. Stopping smoking for 8 weeks improves
reveal potential anaesthetic problems, for example the airways; for 2 weeks reduces their irritability;
cardiac, pulmonary or cervical spine surgery. and for as little as 24 h before anaesthesia decreases
carboxyhaemoglobin levels. Help and advice
should be available at the preoperative assessment
Family history
clinic.
All patients should be asked whether there are any • Alcohol This is measured as units consumed per
known inherited conditions in the family (e.g. week; >50 units/week causes induction of liver en-
sickle-cell disease, porphyria). Have any family zymes and tolerance to anaesthetic drugs. The risk
members experienced problems with anaesthesia; of alcohol withdrawal syndrome postoperatively
a history of prolonged apnoea suggests pseudo- must be considered.
cholinesterase deficiency (see page 34), and an un- • Drugs Ask specifically about the use of drugs for
explained death malignant hyperpyrexia (see page recreational purposes, including type, frequency
98). Elective surgery should be postponed if any and route of administration. This group of patients
conditions are identified, and the patient investi- is at risk of infection with hepatitis B and human
gated appropriately. In the emergency situation, immunodeficiency virus (HIV). There can be diffi-
anaesthesia must be adjusted accordingly, for culty with venous access following IV drug abuse
example by avoidance of triggering drugs in a due to widespread thrombosis of veins. With-
patient with a family history of malignant drawal syndromes can occur postoperatively.
hyperpyrexia. • Pregnancy The date of the last menstrual period
should be noted in all women of childbearing age.
The anaesthetist may be the only person in theatre
Drug history and allergies
able to give this information if X-rays are required.
Identify all medications, both prescribed and self- Anaesthesia increases the risk of inducing a spon-
administered, including herbal preparations. Pa- taneous abortion in early pregnancy. There is an
tients will often forget about the oral contraceptive increased risk of regurgitation and aspiration in
pill (OCP) and hormone replacement therapy late pregnancy. Elective surgery is best postponed
(HRT) unless specifically asked. The incidence of until after delivery.
use of medications rises with age and many of
these drugs have important interactions with
The examination
anaesthetics. A current British National Formulary
(BNF), or the BNF website, should be consulted As with the history, this concentrates on the car-
for lists of the more common and important ones. diovascular and respiratory systems; the remaining
Allergies to drugs, topical preparations (e.g. io- systems are examined if problems relevant to
dine), adhesive dressings and foodstuffs should be anaesthesia have been identified in the history. At
noted. the end of the examination, the patient’s airway is
assessed to try and identify any potential prob-
lems. If a regional anaesthetic is planned, the ap-
Social history
propriate anatomy (e.g. lumbar spine for central
• Smoking Ascertain the number of cigarettes or the neural block) is examined.
amount of tobacco smoked per day. Oxygen car-
5
Chapter 1 Anaesthetic assessment and preparation for surgery
6
Anaesthetic assessment and preparation for surgery Chapter 1
Grade I Grade II
7
Chapter 1 Anaesthetic assessment and preparation for surgery
malignancy, where thoracic surgery is planned, or (COPD) or asthma. Measure peak expiratory flow
in those from areas of endemic tuberculosis who rate (PEFR), forced expiratory volume in 1 s (FEV1)
have not had a chest X-ray in the last year. and FVC. Patients who are dyspnoeic or cyanosed
• Pulmonary function tests: dyspnoea on mild exer- at rest, found to have an FEV1 <60% predicted, or
tion, chronic obstructive pulmonary disease are to have thoracic surgery, should also have arte-
rial blood gas analysed while breathing air.
• Coagulation screen: anticoagulation, a history of a
bleeding diatheses or a history of liver disease or
jaundice.
• Sickle-cell screen (Sickledex): a family history of
sickle-cell disease or where ethnicity increases the
risk of sickle-cell disease. If positive, electrophore-
sis for definitive diagnosis.
• Cervical spine X-ray: rheumatoid arthritis, a
history of major trauma or surgery to the neck or
when difficult intubation is predicted.
Echocardiography
This is becoming increasingly recognized as a use-
ful tool to assess left ventricular function in pa-
tients with ischaemic or valvular heart disease, but
whose exercise ability is limited, for example by se-
vere osteoarthritis. The ejection fraction and cont-
ractility can be calculated and any ventricular wall
motion abnormalities identified. Similarly, ven-
tricular function post-myocardial infarction can be
assessed. In patients with valvular lesions, the de-
gree of dysfunction can be assessed. In aortic
stenosis an estimate of the pressure gradient across
the valve is a good indication of the severity of the
Figure 1.2 The thyromental distance. disease. As an echocardiogram is performed in
Table 1.2 Baseline investigations in patients with no evidence of concurrent disease (ASA 1)
Age of patient Minor surgery Intermediate surgery Major surgery Major ‘plus’ surgery
FBC: full blood count; RFT: renal function tests, to include sodium, potassium, urea and creatinine; ECG:
electrocardiogram; BS: random blood glucose; CXR: chest X-ray. Clotting to include prothrombin time (PT), activated
partial thromboplastin time (APTT), international normalized ratio (INR). Courtesy of National Institute for Clinical Excellence.
8
Anaesthetic assessment and preparation for surgery Chapter 1
patients at rest, it does not give any indication of • Cushing’s or Addison’s disease.
what happens under stress. A stress echocardio- • Hypopituitarism.
gram can be performed during which drugs are
given to increase heart rate and myocardial work, Renal disease
simulating the conditions the patient may en- • Chronic renal failure.
counter, while monitoring changes in myocard- • Patients undergoing renal replacement therapy.
ial performance. For example the inotrope
dobutamine acts as a substitute for exercise whilst Haematological disorders
monitoring the ECG for ischaemic changes (dobu- • Bleeding diatheses, for example haemophilia,
tamine stress echocardiography). thrombocytopenia.
• Therapeutic anticoagulation.
• Haemoglobinopathies.
Medical referral
• Polycythaemia.
Patients with coexisting medical (or surgical) con- • Haemolytic anaemias.
ditions that require advice from other specialists • Leukaemias.
should have been identified in the preoperative
assessment clinic, not on the day of admission.
Risk associated with anaesthesia
Clearly a wide spectrum of conditions exist; the
and surgery
following are examples of some of the more com-
monly encountered. At the end of the day the question that patients ask
is ‘Doctor, what are the risks of having an anaesthetic?’
Cardiovascular disease These can be divided into two main groups.
• Untreated or poorly controlled hypertension or
heart failure.
Minor
• Symptomatic ischaemic heart disease, despite
treatment (unstable angina). These are not life threatening and can occur even
• Arrhythmias: uncontrolled atrial fibrillation, when anaesthesia has apparently been uneventful.
paroxysmal supraventricular tachycardia, and Although classed as minor, the patient may not
second and third degree heart block. share this view. They include:
• Symptomatic or newly diagnosed valvular heart • failed IV access;
disease, or congenital heart disease. • cut lip, damage to teeth, caps, crowns;
• sore throat;
Respiratory disease • headache;
• Chronic obstructive pulmonary disease, particu- • postoperative nausea and vomiting;
larly if dyspnoeic at rest. • retention of urine.
• Bronchiectasis.
• Asthmatics who are unstable, taking oral steroids
Major
or have a FEV1 <60% predicted.
These may be life-threatening events. They
Endocrine disorders include:
• Insulin and non-insulin dependent diabetics • aspiration of gastric contents;
who have ketonuria, glycated Hb (HbA1c) >10% or • hypoxic brain injury;
a random blood sugar >12 mmol/L. Local policy • myocardial infarction;
will dictate referral of stable diabetics for peri- • cerebrovascular accident;
operative management. • nerve injury;
• Hypo- or hyperthyroidism symptomatic on cur- • chest infection.
rent treatment. In the United Kingdom, the Confidential Enquiry
9
Chapter 1 Anaesthetic assessment and preparation for surgery
Absolute
Class Physical status mortality (%)
I A healthy patient with no organic or psychological disease process. The pathological process 0.1
for which the operation is being performed is localized and causes no systemic upset
II A patient with a mild to moderate systemic disease process, caused by the condition to 0.2
be treated surgically or another pathological process, that does not limit the patient’s
activities in any way; e.g. treated hypertensive, stable diabetic. Patients aged >80 years
are automatically placed in class II
III A patient with severe systemic disease from any cause that imposes a definite functional 1.8
limitation on activity; e.g. ischaemic heart disease, chronic obstructive lung disease
IV A patient with a severe systemic disease that is a constant threat to life, e.g. unstable angina 7.8
V A moribund patient unlikely to survive 24 h with or without surgery 9.4
into Perioperative Deaths (CEPOD 1987) revealed gery being undertaken, which leads to a degree of
an overall perioperative mortality of 0.7% in ap- inter-rater variability. However, patients placed in
proximately 500 000 operations. Anaesthesia was higher categories are at increased overall risk of
considered to have been a contributing factor in perioperative mortality (Table 1.3).
410 deaths (0.08%), but was judged completely re-
sponsible in only three cases — a primary mortality
Multifactorial risk indicators
rate of 1:185 000 operations. When the deaths
where anaesthesia contributed were analysed, the The leading cause of death after surgery is
predominant factor was human error. myocardial infarction, and there is significant
Clearly, anaesthesia itself is very safe, particu- morbidity from non-fatal infarction, particularly
larly in those patients who are otherwise well. in those patients with pre-existing heart disease.
Apart from human error, the most likely risk is Not surprisingly, attempts have been made to iden-
from an adverse drug reaction or drug interaction. tify factors that will predict those at risk. One sys-
However, anaesthesia rarely occurs in isolation and tem is the Goldman Cardiac Risk Index, used in
when the risks of the surgical procedure and those patients with pre-existing cardiac disease undergo-
due to pre-existing disease are combined, the risks ing non-cardiac surgery. Using their history,
of morbidity and mortality are increased. Not sur- examination, ECG findings, general status and
prisingly a number of methods have been de- type of surgery, points are awarded in each
scribed to try and quantify these risks. category (Table 1.4).
The points total is used to assign the patient to
one of four classes; the risks of a perioperative car-
Risk indicators
diac event, including myocardial infarction, pul-
The most widely used scale for estimating risk is monary oedema, significant arrhythmia and death
the American Society of Anesthesiologists (ASA) are:
classification of the patient’s physical status. The • class I (0–5 points) 1%
patient is assigned to one of five categories de- • class II (6–12 points) 5%
pending on any physical disturbance caused by • class III (13–25 points) 16%
either pre-existing disease or the process for which • class IV (=26 points) 56%
surgery is being performed. It is relatively subjec- This has been shown to be a more accurate predic-
tive and does not take into account the type of sur- tor than the ASA classification.
10
Anaesthetic assessment and preparation for surgery Chapter 1
Points
History
Age >70 years 5
Myocardial infarction within 6 months 10
Examination
Third heart sound (gallop rhythm), raised JVP 11
Significant aortic stenosis 3
ECG
Rhythm other than sinus, or presence of premature atrial complexes 7
>5 ventricular ectopics per minute 7
General condition
PaO2 <8 kPa or PaCO2 >7.5 kPa on air
K+ <3.0 mmol/L; HCO3- <20 mmol/L
Urea >8.5 mmol/L; creatinine >200 mmol/L
Chronic liver disease
Bedridden from non-cardiac cause
For each criterion 3
Operation
Intraperitoneal, intrathoracic, aortic 3
Emergency surgery 4
Table 1.5 Overall approximate risk (%) of major cardiac complication based on type of surgery and patient’s cardiac risk index
Apart from any risk as a result of pre-existing car- Table 1.5. Major cardiac complication includes
diac disease, the type of surgery the patient is un- myocardial infarction, cardiogenic pulmonary
dergoing will also have its own inherent risks; oedema, ventricular tachycardia or cardiac death.
carpal tunnel decompression will carry less risk Assessing a patient as ‘low risk’ is no more of a
than a hip replacement, which in turn will be less guarantee that complications will not occur than
risky than aortic aneurysm surgery. In other words, ‘high risk’ means they will occur; it is only a guide-
the sicker the patient and the bigger the operation, line and indicator of probability. For the patient
the greater the risk. This is clearly demonstrated in who suffers a complication the rate is 100%!
11
Chapter 1 Anaesthetic assessment and preparation for surgery
Ultimately it is the risk/benefit ratio that must be to establish the patient’s medical history, drugs
considered for each patient; for a given risk, it is taken regularly and allergies. In the trauma patient
more sensible to proceed with surgery that offers enquire about the mechanism of injury. All emer-
the greatest benefit. gency patients should be assumed to have a full
Further reductions in the perioperative mortality stomach. Details may only be available from rela-
of patients have been shown to result from im- tives and/or the ambulance crew.
proving preoperative preparation by optimizing
the patient’s physical status, adequately resuscitat-
ing those who require emergency surgery, moni- Informing the patient and consent
toring appropriately intraoperatively, and by
providing suitable postoperative care in a high de- What is consent?
pendency unit (HDU) or intensive care unit (ICU).
It is an agreement by the patient to undergo a spe-
cific procedure. Only the patient can make the de-
Classification of operation cision to undergo the procedure, even though the
Traditionally, surgery was classified as being either doctor will advise on what is required. Although
elective or emergency. Recognizing that this was the need for consent is usually thought of in terms
too imprecise, the National Confidential Enquiry of surgery, in fact it is required for any breach of a
into Perioperative Deaths (NCEPOD) devised four patient’s personal integrity, including examina-
categories: tion, performing investigations and administering
• Elective: operation at a time to suit both patient an anaesthetic. A patient can refuse treatment or
and surgeon; for example hip replacement, vari- choose a less than optimal option from a range of-
cose veins. fered (providing an appropriate explanation has
• Scheduled: an early operation but not imme- been given — see below), but he or she cannot insist
diately life saving; operation usually within 3 on treatment that is not on offer.
weeks; for example surgery for malignancy.
• Urgent: operation as soon as possible after resus-
What about an unconscious patient?
citation and within 24 h; for example intestinal ob-
struction, major fractures. This usually arises in the emergency situation, for
• Emergency: immediate life-saving operation, re- example a patient with a severe head injury. Asking
suscitation simultaneous with surgical treatment; a relative or other individual to sign a consent form
operation usually within 1 h; for example major for surgery on the patient’s behalf is not appropri-
trauma with uncontrolled haemorrhage, extra- ate, as no one can give consent on behalf of
dural haematoma. another adult. Under these circumstances medical
All elective and the majority of scheduled cases can staff are required to act ‘in the patient’s best inter-
be assessed as described above. However, with ur- ests’. This will mean taking into account not only
gent cases this will not always be possible; as much the benefits of the proposed treatment, but also
information as possible should be obtained about any views previously expressed by the patient (e.g.
any concurrent medical problems and their treat- refusal of blood transfusion by a Jehovah’s
ment, and allergies and previous anaesthetics. The Witness). This will often require discussion with
cardiovascular and respiratory systems should be the relatives, and this opportunity should be used
examined and an assessment made of any poten- to inform them of the proposed treatment and the
tial difficulty with intubation. Investigations rationale for it. All decisions and discussions must
should only be ordered if they would directly affect be clearly documented in the patient’s notes.
the conduct of anaesthesia. With true emergency Where treatment decisions are complex or not
cases there will be even less or no time for assess- clear cut, it is advisable to obtain and document
ment. Where possible an attempt should be made independent medical advice.
12
Anaesthetic assessment and preparation for surgery Chapter 1
13
Chapter 1 Anaesthetic assessment and preparation for surgery
14
Chapter 2
Anaesthesia
15
Chapter 2 Anaesthesia
Table 2.2 Commonly used anti-emetic drugs, dose and route of administration
16
Anaesthesia Chapter 2
17
Chapter 2 Anaesthesia
Oropharyngeal airway
• Curved plastic tubes, flattened in cross-section
and flanged at the oral end. They lie over the
tongue, preventing it from falling back into the
pharynx.
• Available in a variety of sizes suitable for all pa-
tients, from neonates to large adults. The com-
monest sizes are 2–4, for small to large adults,
respectively.
• An estimate of the size required is given by com-
paring the airway length with the vertical distance
between the patient’s incisor teeth and the angle of
the jaw.
• Initially inserted ‘upside down’ as far as the back
of the hard palate (Fig. 2.2a), rotated 180° (Fig.
2.2b) and fully inserted until the flange lies in front
of the teeth, or gums in an edentulous patient (Fig.
2.2c,d).
Figure 2.1 Mask being held on a patient’s face.
Nasopharyngeal airway
• Round, malleable plastic tubes, bevelled at the
Facemasks
pharyngeal end and flanged at the nasal end.
• A commonly used type in adults is the BOC • Sized on their internal diameter in millimetres,
anatomical facemask (Fig. 2.1), designed to fit the length increasing with diameter. The common
contours of the face with the minimum of sizes in adults are 6–8 mm, for small to large adults,
pressure. respectively.
• Leakage of anaesthetic gases is minimized by an • A guide to the correct size is made by comparing
air-filled cuff around the edge. the diameter to the external nares.
• Masks are made in a variety of sizes, and the • Prior to insertion, the patency of the nostril
smallest one that provides a good seal should be (usually the right) should be checked and the air-
used. way lubricated.
• Some masks have a transparent body allowing • The airway is inserted along the floor of the nose,
identification of vomit, making them popular for with the bevel facing medially to avoid catching
resuscitation. the turbinates (Fig. 2.3).
• All masks must be disinfected between each • A safety pin may be inserted through the flange
patient use. Alternatively single use masks are to prevent inhalation of the airway.
available. • If obstruction is encountered, force should not
be used as severe bleeding may be provoked.
Instead, the other nostril can be tried.
Simple adjuncts
The oropharyngeal (Guedel) airway, and to a lesser
Problems with airways
extent the nasopharyngeal airway, are used in con-
junction with the techniques described above to Snoring, indrawing of the supraclavicular,
help maintain the airway after the induction of suprasternal and intercostal spaces, use of the ac-
anaesthesia. cessory muscles or paradoxical respiratory move-
18
Anaesthesia Chapter 2
(a) (b)
19
Chapter 2 Anaesthesia
20
Anaesthesia Chapter 2
Tracheal intubation
This is the best method of providing and securing a
clear airway in patients during anaesthesia and re-
(b)
suscitation, but success requires abolition of the la-
ryngeal reflexes. During anaesthesia, this is usually
achieved by the administration of a muscle
relaxant (see below). Deep inhalational anaesthe-
sia or local anaesthesia of the larynx can also be
used, but these are usually reserved for patients
where difficulty with intubation is anticipated, for
example in the presence of airway tumours or im-
(c) mobility of the cervical spine.
21
Chapter 2 Anaesthesia
(a)
(b) (c)
22
Anaesthesia Chapter 2
23
Chapter 2 Anaesthesia
Tip of
Tongue laryngoscope
pushed in vallecula
to left
False cords —
aryepiglottic
folds
True cords
Laryngeal
opening
(tracheal rings
just to left)
Positioning Intubation
The patient’s head is placed on a small pillow with The tracheal tube is introduced into the right side
the neck flexed and the head extended at the of the mouth, advanced and seen to pass through the
atlanto-occipital joint, the ‘sniffing the morning cords until the cuff lies just below the cords. The
air’ position. The patient’s mouth is fully opened tube is then held firmly and the laryngoscope is
using the index finger and thumb of the right hand carefully removed, and the cuff is inflated suffi-
in a scissor action. ciently to prevent any leak during ventilation.
Finally the position of the tube is confirmed and
secured in place.
Laryngoscopy
For nasotracheal intubation a well-lubricated
The laryngoscope is held in the left hand and the tube is introduced, usually via the right nostril
blade introduced into the mouth along the right- along the floor of the nose with the bevel pointing
hand side of the tongue, displacing it to the left. medially to avoid damage to the turbinates. It is ad-
The blade is advanced until the tip lies in the gap vanced into the oropharynx, where it is usually
between the base of the tongue and the epiglottis, visualized using a laryngoscope in the manner de-
the vallecula. Force is then applied in the direction in scribed above. It can then either be advanced di-
which the handle of the laryngoscope is pointing. The rectly into the larynx by pushing on the proximal
effort comes from the upper arm not the wrist, to end, or the tip picked up with Magill’s forceps
lift the tongue and epiglottis to expose the larynx, (which are designed not to impair the view of the
seen as a triangular opening with the apex anteri- larynx) and directed into the larynx. The proce-
orly and the whitish coloured true cords laterally dure then continues as for oral intubation.
(Fig. 2.7).
24
Anaesthesia Chapter 2
25
Chapter 2 Anaesthesia
26
Anaesthesia Chapter 2
27
Chapter 2 Anaesthesia
Cricothyroid
membrane
(a)
28
Anaesthesia Chapter 2
Trachea
29
Table 2.3 Intravenous drugs used for the induction of anaesthesia and their effects
30
Speed of Duration
Induction induction of action Effects on
Drug dose (mg/kg) (s) (mins) CVS Effects on RS Effects on CNS Other side-effects Comments
Propofol 1.5–2.5 30–45 4–7 Hypotension, Apnoea up to Decreases CBF Pain on injection, Non-cumulative,
worse if 60 s, depression and ICP involuntary repeated injections
hypovolaemic or of ventilation movement, or infusion used to
cardiac disease hiccoughs maintain anaesthesia
Chapter 2 Anaesthesia
(see TIVA)
Etomidate 0.2–0.3 30–40 3–6 Relatively less Depression of Decreases CBF Pain on injection, Emulsion available,
cardiovascular ventilation and ICP, involuntary less painful.
depression anticonvulsant movement, No histamine release,
hiccoughs non-cumulative, but
suppresses steroid
synthesis
Thiopentone 2–6 20–30 9–10 Dose dependent Apnoea, Decreases CBF Rare but severe Patients may ‘taste’
hypotension, depression of and ICP, adverse garlic or onions!
worse if ventilation anticonvulsant reactions Cumulative, delayed
hypovolaemic or recovery after repeat
cardiac disease doses
Ketamine 1–2 50–70 10–12 Minimal in fit Minimal CBF Vivid Subanaesthetic
patients, better depression of maintained, hallucinations doses cause
tolerated if ventilation, profound analgesia. Can be
cardiovascular laryngeal analgesia used as sole
compromise reflexes better anaesthetic drug in
preserved, adverse
bronchodilation circumstances, e.g.
prehospital
Midazolam 0.1–0.3 40–70 10–15 Dose dependent Depression of Mildly Causes amnesia
hypotension, ventilation, anticonvulsant
worse if worse in elderly
hypovolaemic or
cardiac disease
CVS: cardiovascular system; RS: respiratory system; CNS: central nervous system; CBF; cerebral blood flow; ICP: intracranial pressure; TIVA: total intravenous anaesthesia.
Table 2.4 Inhalational anaesthetic drugs and their effects
Sevoflurane Low; 6–7% for Low; rapid changes Ø BP, vasodilatation Depresses ventilation Minimal effect on Popular for inhalation
induction, 2–3% for of depth CBF at clinical induction
maintenance concentration
Desflurane Low; 6–9% for Low; rapid changes Ø BP, ≠ HR Depresses ventilation Minimal effect on Pungent, boils at 23°C
maintenance of depth CBF at clinical
concentration
Isoflurane Medium; 5% for Medium Ø BP, ≠ HR, Depresses ventilation Slight ≠ CBF and ICP Pungency limits use
induction, 1–1.5% for vasodilatation for induction
maintenance
Halothane High; 3–4% for High Ø BP, vasodilatation, Depresses ventilation ≠≠ CBF, ≠ ICP May cause hepatitis on
induction, 0.5–1% for myocardial depression, repeat exposure
maintenance arrhythmias common
Enflurane Medium; 1.5–2% for Medium Ø BP Depresses ventilation ≠ CBF, ≠ EEG activity Pungency limits use
maintenance for induction
CVS: cardiovascular system; RS: respiratory system; CNS: central nervous system; BP: blood pressure; HR: heart rate; CBF: cerebral blood flow; ICP: intracranial pressure;
ECG: electroencephalograph.
31
Anaesthesia Chapter 2
Chapter 2 Anaesthesia
movement in 50% of subjects following a surgical ples in reverse. Only a small amount of an insolu-
stimulus. At 1 MAC, or multiples thereof, the ble drug will have to be excreted to allow brain par-
anaesthetic effect will be the same and a compari- tial pressure to fall. With a more soluble drug, a
son of the side-effects can be made. Compounds larger amount will need to be excreted, which will
with a low potency (e.g. desflurane) will have a take proportionately longer.
high MAC, those with a high potency (e.g. Other factors that determine the speed at which
halothane) will have a low MAC. the alveolar concentration rises include:
The effects of inhalational anaesthetics are addi- • A high inspired concentration: limited clinically by
tive, therefore two values for MAC are often quoted — the degree of irritation caused.
the value in oxygen and the value when given with a • Alveolar ventilation: this is most pronounced for
stated percentage of nitrous oxide (which has its own drugs with a high solubility. As large amounts are
MAC), which will clearly be less (Table 2.5). removed from the alveoli, increasing ventilation
The value of MAC is reduced in the elderly, in ensures more rapid replacement.
those with hypotension, hypothermia, and hy- • Cardiac output: if high, results in a greater pul-
pothyroidism, and with concurrent use of opioids; monary blood flow, increasing uptake thereby
it is increased in infants, patients with a pyrexia, lowering the alveolar partial pressure. If low, the
and in those who are chronic drug abusers. converse occurs and the alveolar concentration
rises more rapidly.
Solubility
Inhalational anaesthetics exert their effect on the
Nitrous oxide
central nervous system. It is the partial pressure in
the brain that is responsible for the anaesthetic ef- Nitrous oxide (N2O) is a colourless, sweet-smelling,
fect and this follows closely the partial pressure in non-irritant gas with moderate analgesic proper-
the alveoli. The rate at which the alveolar partial ties but low anaesthetic potency (MAC 105%). As
pressure can be changed determines the rate of the maximum safe concentration that can be ad-
change in brain partial pressure, and hence speed ministered without the risk of hypoxia is approxi-
of induction, change in depth of, and recovery mately 70%, unconsciousness or anaesthesia
from anaesthesia. sufficient to allow surgery is rarely achieved. Con-
One of the main determinants of alveolar partial sequently, it is usually given in conjunction with
pressure is how soluble the inhalational anaesthe- one of the other vapours. Nitrous oxide is pre-
tic is in blood. Relatively insoluble anaesthetics (e.g. mixed with oxygen as a 50 : 50 mixture called
sevoflurane, desflurane) are removed slowly from ‘Entonox’ which is used as an analgesic in obstet-
the alveoli by the pulmonary blood. The alveolar rics and by the emergency services.
(and brain) partial pressures rise quickly and anaes-
thesia is induced rapidly. In contrast, a soluble Systemic effects
anaesthetic (e.g. halothane) is removed rapidly • Cardiovascular depression, exacerbated in pa-
from the alveoli into the pulmonary blood, limit- tients with pre-existing cardiac disease.
ing the rate of rise of alveolar and brain partial pres- • Slight increase in the respiratory rate and a de-
sure. Consequently, induction will be slower. crease in the tidal volume. Decreases the ventila-
Recovery from anaesthesia follows similar princi- tory response to carbon dioxide and hypoxia.
32
Anaesthesia Chapter 2
33
Chapter 2 Anaesthesia
• The problems associated with nitrous oxide can • A massive rise in serum potassium may provoke
be avoided. dysrhythmias in certain patients with:
• A better quality of recovery is claimed. • burns, maximal 3 weeks to 3 months after the
• It may be beneficial in certain types of surgery, burn;
for example neurosurgery. • denervation injury, for example spinal cord
• Pollution is reduced. trauma, maximal after 1 week;
• muscle dystrophies, for example Duchenne’s;
• crush injury.
Disadvantages of total intravenous
Administration of suxamethonium is associated
anaesthesia
with a number of important side-effects:
• Secure, reliable intravenous access is required. • malignant hyperpyrexia in susceptible patients
• Risk of awareness if intravenous infusion fails. (see page 98);
• Cost of electronic infusion pumps. • increased intraocular pressure which may cause
• May cause profound hypotension. loss of vitreous in penetrating eye injuries;
• muscular pain around the limb girdles, most
common 24 h after administration in young
Neuromuscular blocking drugs
adults;
These work by interfering with the normal action • histamine release: usually localized but may
of acetylcholine at the motor end plate, blocking cause an anaphylactoid reaction;
the receptors on the postsynaptic muscle mem- • prolonged apnoea in patients with pseudo-
brane (and possibly other sites). Muscle relaxants cholinesterase deficiency.
are divided into two groups, the names of which
are thought to reflect their mode of action. Pseudocholinesterase deficiency
A variety of genes have been identified which are
involved in pseudocholinesterase production. The
Depolarizing neuromuscular most significant genotypes are:
blocking drugs • normal homozygotes: sufficient enzyme to hy-
drolyse suxamethonium in 4–6 mins (950 per 1000
Suxamethonium population);
This is the only drug of this type in regular clinical use. • atypical heterozygotes: slightly reduced enzyme
It comes ready-prepared (50 mg/mL, 2 mL ampoules). levels; suxamethonium lasts 10–20 mins (50 per
The dose in adults is 1.5 mg/kg IV. After injection, 1000);
there is a short period of muscle fasciculation due to • atypical homozygotes: marked deficiency of en-
depolarization of the muscle membrane, followed by zyme; members of this group are apnoeic for up to
muscular paralysis in 40–60 s. Recovery occurs as a re- 2 h after suxamethonium (1 per 1000).
sult of hydrolysis by plasma (pseudo-) cholinesterase, Treatment of the third group consists of ventila-
with restoration of normal neuromuscular transmis- tory support with maintenance of anaesthesia or
sion after 4–6 mins. This rapid onset makes it the drug sedation until recovery occurs. The patient should
of choice to facilitate tracheal intubation in patients subsequently be warned and given a card that car-
likely to regurgitate and aspirate. ries details and, because of its inherited nature, the
remainder of the family should be investigated.
Systemic effects
• No direct effect on the cardiovascular, respira-
Non-depolarizing neuromuscular
tory or central nervous systems. Bradycardia sec-
blocking drugs
ondary to vagal stimulation is common after very
large or repeated doses, necessitating pretreatment These drugs compete with acetylcholine and block
with atropine. its access to the postsynaptic receptor sites on the
34
Anaesthesia Chapter 2
muscle but do not cause depolarization. (They may • Its maximal effect is seen after approximately
also block prejunctional receptors responsible for 5 mins and lasts for 20–30 mins.
facilitating the release of acetylcholine.) They are • It is given concurrently with either atropine
sometimes referred to as competitive neuromuscu- 1.2 mg or glycopyrrolate 0.5 mg.
lar blockers. The time to maximum effect, that is
when relaxation is adequate to allow tracheal intu-
Assessment of neuromuscular blockade
bation, is relatively slow compared with
suxamethonium, generally 1.5–3 mins. A synopsis This can be achieved either clinically or by using a
of the drugs used is given in Table 2.6. peripheral nerve stimulator.
They are used in two ways:
• following suxamethonium to maintain muscle
Clinical assessment
relaxation during surgery;
• to facilitate tracheal intubation in non-urgent This requires a conscious, co-operative patient
situations. to perform a sustained activity and is therefore
Although recovery of normal neuromuscular limited in its application. Tests commonly used
function eventually occurs spontaneously after include:
the use of these drugs, it is often accelerated by the • lifting the head off the pillow for 5 s;
administration of an anticholinesterase (see below). • a hand grip for 5 s;
• the ability to produce a vital capacity breath,
>10 mL/kg.
Anticholinesterases
Inability to perform these activities and/or the
The action of all the neuromuscular blocking presence of ‘see-sawing’ or paradoxical respiration
drugs wears off spontaneously with time, but this is suggests a degree of residual neuromuscular block.
not always clinically appropriate. In patients who A further dose of neostigmine and an anticholiner-
require reversal of neuromuscular blocking drugs, gic may be required.
an anticholinesterase is given. This inhibits the ac-
tion of the enzyme acetylcholinesterase, resulting
Peripheral nerve stimulation
in an increase in the concentration of acetyl-
choline at the neuromuscular junction (nicotinic This is used in anaesthetized patients, the details
effect). The speed of recovery will depend upon the of which are outside the remit of this book.
intensity of block when reversal is attempted — the The following is intended as no more than a brief
more intense the block the slower the reversal. outline.
Anticholinesterases cannot be used to reverse very A peripheral nerve supplying a discrete muscle
intense block, for example if given soon after the group is stimulated transcutaneously with a cur-
administration of a relaxant (no response to a rent of 50 mA. The resulting contractions are
‘train-of-four’ sequence — see below). observed or measured. One arrangement is to stim-
Anticholinesterases also function at parasympa- ulate the ulnar nerve at the wrist whilst monitor-
thetic nerve endings (muscarinic effect), causing ing the contractions (twitch) of the adductor
bradycardia, spasm of the bowel, bladder and pollicis. Although most often done by looking at or
bronchi, increased bronchial secretions, etc. There- feeling the response, measuring either the force of
fore they are always administered with a suitable contraction or the compound action potential is
dose of atropine or glycopyrrolate to block the un- more objective.
wanted muscarinic effects. Sequences of stimulation used include:
The most commonly used anticholinesterase is • four stimuli each of 0.2 s duration, at 2 Hz for 2 s,
neostigmine: referred to as a ‘train-of-four’ (TOF);
• A fixed dose of 2.5 mg intravenously is used in • One stimulus at 50 Hz of 5 s duration, that is, a
adults. tetanic stimulus;
35
36
Table 2.6 Non-depolarizing neuromuscular blocking drugs
Chapter 2 Anaesthesia
Atracurium 0.5–0.6 mg/kg 0.15–0.2 mg/kg; 30–50 mg/h 90–120 s 20–25 mins Cutaneous histamine Spontaneous
infusion release, degradation in plasma.
Ø BP Cisatracurium a single
isomer, more potent
Rocuronium 0.6–0.7 mg/kg 0.15–0.2 mg/kg; 30–50 mg/h 90–100 s; after 1 mg/kg, 20–30 mins Minimal Alternative to
infusion 60 s suxamethonium for
RSI
Vecuronium 0.1 mg/kg 0.02–0.03 mg/kg; 6–10 mg/h 90–120 s 15–20 mins Minimal, no histamine White powder,
infusion release dissolved before use
Mivacurium 0.15–0.2 mg/kg 0.1 mg/kg 100–120 s 10–15 mins Histamine released if Metabolized by
large dose injected plasma cholinesterase.
rapidly Rapid recovery,
reversal often
unnecessary
Pancuronium 0.1 mg/kg 0.015 mg/kg 120–150 s 35–45 mins ≠ BP, ≠ HR Long-acting
BP: blood pressure; HR: heart rate; RSI: rapid sequence induction.
Anaesthesia Chapter 2
• two groups of three tetanic bursts at 50 Hz, thetic compounds. The term ‘opiate’ is reserved for
750 ms apart. naturally occurring substances, for example mor-
During non-depolarizing neuromuscular block- phine. There are several opioid receptors, each
ade, there is a progressive decremental response to identified by a letter of the Greek alphabet, at
all the sequences, termed ‘fade’. In the TOF, the which this group of drugs can have either agonist or
ratio of the amplitude of the fourth twitch (T4) to antagonist actions. Two of the most important re-
the first twitch (T1) is used as an index of the de- ceptors are m (mu) and k (kappa), and stimulation
gree of neuromuscular blockade. During depolariz- (agonist actions) of these by a pure agonist pro-
ing blockade, the response to all sequences of duces the classical effects of opioids: analgesia (m,
stimulation is reduced but consistent, that is, there k), euphoria (m), sedation (k), depression of ventila-
is no fade. tion (m, k) and physical dependence (m). The sys-
temic effects of opioids due to both central and
peripheral actions are summarized in Table 2.7.
When is it useful to assess the degree of
A synopsis of the pure agonists used in anaesthe-
neuromuscular block?
sia is given in Table 2.8. Because of the potential for
• During long surgical procedures to control the physical dependence, there are strict rules govern-
timing of increments or adjust the rate of an infu- ing the issue and use of most opioid drugs under
sion of relaxants to prevent coughing or sudden the Misuse of Drugs Act 1971 (see below).
movement. This is particularly important during Opioid analgesics can also be partial agonists or
surgery in which a microscope is used, for example partial agonists/antagonists. There are also drugs
neurosurgery. that are pure antagonist, have no analgesic action
• At the end of surgery, to plan reversal of residual and reverse all the central actions of a pure agonist.
neuromuscular block to ensure adequate respira- It is in this role that they are used clinically.
tory muscle function.
• To differentiate between apnoea due to pro-
The partial agonists and mixed
longed action of suxamethonium, suggesting
agonists/antagonists
pseudocholinesterase deficiency, and residual non-
depolarizing block, when both have been given. These drugs were introduced in the hope that, with
• In recovery, to help distinguish between residual only partial agonist activity at m receptors or mixed
neuromuscular block and opioids overdose as a agonist/antagonist actions at m and k receptors,
cause of inadequate ventilation postoperatively. analgesia would be achieved without the problem
The former will show reduced or absent response of depression of ventilation. Such an ideal has not
to stimulation, the latter a normal response. yet been achieved.
37
Chapter 2 Anaesthesia
Urinary tract
Increased sphincter tone and urinary retention
Duration of
Drug Route given Dose Speed of onset action (mins) Comments
38
Anaesthesia Chapter 2
agonist at m receptors, inhibits noradrenaline are classified into five schedules, each with a differ-
uptake and release of 5-hydroxytryptamine (5-HT). ent level of control.
When given intravenously, it is approximately one Schedule 1 Hallucinogenic drugs, including
tenth as potent as morphine and roughly equiva- cannabis and LSD, which currently have no
lent to pethidine, that is, the dose being 1–2 mg/kg. recognized therapeutic use.
It is claimed to cause less respiratory depression Schedule 2 This includes opioids, major stimulants
than equivalent doses of morphine, but if this does (amphetamines and cocaine) and quinal-
occur it is readily reversed by naloxone. A further barbitone.
advantage is that it is not a controlled drug, and is Schedule 3 Drugs thought not as likely to be
therefore more easily available. misused as those in schedule 2, and includes
barbiturates, minor stimulants, buprenorphine
(Temgesic) and temazepam.
The pure antagonist
Schedule 4 This is split into two parts:
The only one in common clinical use is naloxone. • benzodiazepines, which are recognized as
having the potential for abuse;
• androgenic steroids, clenbuterol and growth
Naloxone (Narcan)
hormones.
This has antagonist actions at all the opioid recep- Schedule 5 Preparations which contain very low
tors, reversing all the centrally mediated effects of concentrations of codeine or morphine,
pure opioid agonists. for example cough mixtures.
• The initial IV dose in adults is 0.1–0.4 mg, effec-
tive in less than 60 s and lasting 30–45 mins.
Supply and custody of schedule 2
• It has a limited effect against opioids, with par-
drugs
tial or mixed actions, and complete reversal may
require very high (10 mg) doses. In the theatre complex, these drugs are supplied by
• Following a severe overdose, either accidental or the pharmacy, usually at the written request of a
deliberate, several doses or an infusion of naloxone senior member of the nursing staff, specifying the
may be required, as its duration of action is less drug and total quantity required, and signed.
than most opioids. These drugs must be stored in a locked safe, cabinet
• Naloxone will also reverse the analgesia pro- or room, constructed and maintained to prevent
duced by acupuncture, suggesting that this is prob- unauthorized access. A record must be kept of their
ably mediated in part by the release of endogenous use in the ‘Controlled Drugs Register’ and must
opioids. comply with the following points:
• Separate parts of the register can be used for differ-
ent drugs or strengths of drugs within a single class.
The regulation of opioid drugs
• The class of drug must be recorded at the head of
Some drugs have the potential for abuse and con- each page.
sequent physical dependence, and their use in • Entries must be in chronological sequence.
medicine is carefully regulated. The Misuse of • Entries must be made on the day of the transac-
Drugs Act 1971 controls ‘dangerous or otherwise tion or the next day.
harmful drugs’, which are designated ‘Controlled • Entries must be in ink or otherwise indelible.
Drugs’ and include the opioids. The Act imposes a • No cancellation, alteration or obliteration may
total prohibition on the manufacture, possession be made.
and supply of these substances, in an attempt to • Corrections must be accompanied by a footnote
prevent their misuse. The Misuse of Drugs Regula- that must be dated.
tions 2001 permits the use of Controlled Drugs in • The register must not be used for any other
medicine. The drugs covered by these regulations purpose.
39
Chapter 2 Anaesthesia
40
Anaesthesia Chapter 2
Figure 2.11 Wall-mounted outlets and gas-specific probes for (left to right) oxygen, nitrous oxide, air.
Table 2.9 Medical gas cylinder colours 12 000 kPa (120 bar, 1980 psi) and this falls in direct
Colour proportion to the cylinder contents.
Medical air
Oxygen
This is supplied either by a compressor or in cylin-
Piped oxygen is supplied from a liquid oxygen re- ders. A compressor delivers air to a central reser-
serve, where it is stored under pressure (10–12 bar, voir, where it is dried and filtered to achieve the
1200 kPa) at approximately -180°C in a vacuum- desired quality before distribution. Air is supplied
insulated evaporator (VIE), effectively a thermos to the operating theatre for anaesthetic use at 400
flask. Gaseous oxygen is removed from above the kPa, and at 700 kPa to power medical tools.
liquid, or at times of increased demand, by
vaporizing liquid oxygen using heat from the
Vacuum
environment. The gas is warmed to ambient air
temperature en route from the VIE to the pipeline The final part of the PMGV system is medical
system. A reserve bank of cylinders of compressed vacuum. Two pumps are connected to a system
oxygen is kept adjacent in case of failure of that must be capable of generating a vacuum of at
the main system. A smaller cylinder is attached least 400 mmHg below atmospheric pressure. This
directly to the anaesthetic machine as an emer- is delivered to the anaesthetic rooms, operating
gency reserve. The pressure in a full cylinder is theatre and other appropriate sites. At several
41
Chapter 2 Anaesthesia
Safety features
• The oxygen and nitrous oxide controls are
linked such that less than 25% oxygen cannot be
delivered.
• If carbon dioxide is fitted, flow is limited to
500 mL/min.
• An emergency oxygen ‘flush’ device can be used
to deliver pure oxygen into the breathing system.
• An audible alarm to warn of oxygen failure. This
discontinues the nitrous oxide supply and if the
patient is breathing spontaneously air can be
entrained.
Figure 2.12 Oxygen, air and nitrous oxide flowmeters on • A non-return valve to minimize the effects of
an anaesthetic machine.
back-pressure on the function of flowmeters and
vaporizers.
stages between the outlets and the pumps there are • Pressure relief valves are fitted primarily to pro-
drains and bacterial filters to prevent contamina- tect the equipment, not the patient!
tion by aspirated fluids.
42
Anaesthesia Chapter 2
anaesthetic machine. From this point, specialized the patient’s peak inspiratory demands (30–
breathing systems are used to transfer the gases 40 L/min) to be met with a lower constant flow
and vapours to the patient. from the anaesthetic machine. Its excursion gives
an indication of ventilation and allows manual
ventilation of the patient. It also acts as a further
Checking the anaesthetic machine
safety device, being easily distended at low pres-
It is the responsibility of each anaesthetist to check sure if obstruction occurs.
that the apparatus used will function in the man- • An adjustable expiratory valve To vent expired
ner expected at the beginning of each operating gas, helping to eliminate carbon dioxide. During
session. The main danger is that the anaesthetic spontaneous ventilation, resistance to opening is
machine appears to perform normally, but in fact is minimal so as not to impede expiration. Closing
delivering a hypoxic mixture to the patient. In the valve allows manual ventilation by squeezing
order to minimize the risk of this, the Association the reservoir bag.
of Anaesthetists of Great Britain and Ireland An example of a commonly used system is shown
(AAGBI) has published a Checklist for Anaesthetic in Fig. 2.13.
Machines. Its main aim is to ensure that oxygen
flows through the oxygen delivery system and is
The circle system
unaffected by the use of any additional gas or
vapour. Most modern anaesthetic machines now The traditional breathing systems relied on the po-
have built-in oxygen analysers that monitor the in- sitioning of the components and the gas flow from
spired oxygen concentration to minimize this risk. the anaesthetic machine to eliminate carbon diox-
ide in expired gas, thereby preventing rebreathing
and hypercapnia. Even the most efficient system is
Anaesthetic breathing systems
still wasteful; a gas flow of 4–6 L/min is required
The mixture of anaesthetic gas and vapour travels and the expired gas contains oxygen and anaes-
from the anaesthetic machine to the patient via an thetic vapour in addition to carbon dioxide.
anaesthetic circuit, or more correctly an anaesthetic The circle system (Fig. 2.14) overcomes these
breathing system. Delivery to the patient is via a inefficiencies:
facemask, laryngeal mask or tracheal tube (see pages • The expired gases, instead of being vented to the
18–25). There are a number of different breathing atmosphere, are passed through a container of
systems (referred to as ‘Mapleson A’, B, C, D or E) soda lime (the absorber), a mixture of calcium,
plus a circle system. The details of these systems are sodium and potassium hydroxide, to chemically
beyond the scope of this book, but they all have a remove carbon dioxide.
number of common features, described below. As • Supplementary oxygen and anaesthetic vapour
several patients in succession may breathe through are added to maintain the desired concentrations,
the same system, a low-resistance, disposable bacte- and the mixture rebreathed by the patient. Gas
rial filter is placed at the patient end of the system, flows from the anaesthetic machine to achieve this
and changed between each patient to reduce the can be as low as 0.5 L/min. The circle system is
risk of cross-infection. Alternatively, disposable sys- therefore the only true ‘anaesthetic circuit’.
tems are used, and changed for each patient. • The gases are warmed and humidified as they
pass through the absorber (by-products of the reac-
tion removing carbon dioxide).
Components of a breathing system
There are several points to note when using a circle
All systems consist of the following: system.
• A connection for fresh gas input Usually the com- • As the inspired gas is a mixture of expired and
mon gas outlet on the anaesthetic machine. fresh gas, the concentration of oxygen within the
• A reservoir bag Usually of 2 L capacity to allow circle is not known accurately. The inspired oxygen
43
Chapter 2 Anaesthesia
Connection
to scavenging
system
Adjustable expiratory
valve
Fresh
gas input
Reservoir
bag
44
Anaesthesia Chapter 2
Fresh gas
I input
Soda
E lime
Expiratory
valve
Reservoir
bag
recoil of the chest, and flow occurs into the lungs. curs by passive recoil of the lungs and chest wall. In
This technique is usually referred to as intermittent order to generate a positive pressure, the ventilator
positive pressure ventilation (IPPV). In both sponta- requires a source of energy: gravity, gas pressure or
neous and mechanical ventilation, expiration oc- electricity.
45
Chapter 2 Anaesthesia
46
Anaesthesia Chapter 2
of the breathing system or ventilator to remove ers of ozone, thereby adding to the greenhouse
gases to the outside environment. The patient is effect.
protected against excessive negative pressure being
applied to the lungs by valves with very low open-
Measurement and monitoring
ing pressures. The use of such systems does not
eliminate the problem of pollution; it merely shifts Measurement and monitoring are closely linked
it from one site to another. Inhalational anaesthet- but are not synonymous. A measuring instrument
ics, particularly nitrous oxide, are potent destroy- becomes a monitor when it is capable of delivering
47
Chapter 2 Anaesthesia
A B
a warning when the variable being measured falls • type of operation and operative technique;
outside preset limits. During anaesthesia, both the • anaesthetic technique used;
patient and the equipment being used are moni- • present and previous health of the patient;
tored, the complexity of which depends upon a va- • equipment available and the anaesthetist’s
riety of factors including: ability to use it;
48
Anaesthesia Chapter 2
49
Chapter 2 Anaesthesia
monitors now use five electrodes placed on the an- reaching the photodetector is converted to an elec-
terior chest to allow all the standard leads and V5 trical signal. The absorption due to the tissues and
to be displayed. The ECG alone gives no informa- venous blood is static. This is then subtracted from
tion on the adequacy of the cardiac output and it the beat-to-beat variation due to arterial blood, to
must be remembered that it is possible to have a display the peripheral arterial oxygen saturation
virtually normal ECG in the absence of any cardiac (SpO2), both as a waveform and digital reading (see
output. Fig. 2.18). Pulse oximeters are accurate to ±2%. The
waveform can also be interpreted to give a reading
of heart rate. Alarms are provided for levels of satu-
Non-invasive blood pressure
ration and heart rate. The pulse oximeter therefore
This is the most common method of obtaining the gives information about both the circulatory and
patient’s blood pressure during anaesthesia and respiratory systems and has the advantages of:
surgery. A pneumatic cuff with a width that is 40% • providing continuous monitoring of oxygena-
of the arm circumference must be used and the inter- tion at tissue level;
nal inflatable bladder should encircle at least half • being unaffected by skin pigmentation;
the arm. If the cuff is too small, the blood pressure • portability (mains or battery powered);
will be overestimated, and if it is too large it will be • being non-invasive.
underestimated. Auscultation of the Korotkoff Despite this, there a number of important limita-
sounds is difficult in the operating theatre and au- tions of this device:
tomated devices (Fig. 2.18) are widely used. An • There is failure to realize the severity of hypoxia;
electrical pump inflates the cuff, which then un-
dergoes controlled deflation. A microprocessor-
controlled pressure transducer detects variations in
cuff pressure resulting from transmitted arterial
pulsations. Initial pulsations represent systolic
blood pressure and peak amplitude of the pulsa-
tions equates to mean arterial pressure. Diastolic is
calculated using an algorithm. Heart rate is also de-
termined and displayed. The frequency at which
blood pressure is estimated can be set along with
values for blood pressure, outside which an alarm
sounds. Such devices cannot measure pressure
continually and become increasingly inaccurate
at extremes of pressure and in patients with an
arrhythmia.
Pulse oximeter
A probe, containing a light-emitting diode (LED)
and a photodetector, is applied across the tip of a
digit or earlobe. The LED alternately emits red light
at two different wavelengths in the visible and
infrared regions of the electromagnetic spectrum.
Figure 2.18 Integrated monitoring system displaying ECG
These are transmitted through the tissues and and heart rate (beats/min), non-invasive blood pressure
absorbed to different degrees by oxyhaemoglobin (mmHg), capnograph and end tidal carbon dioxide (kPa),
and deoxyhaemoglobin. The intensity of light pulse oximeter waveform and saturation (%).
50
Anaesthesia Chapter 2
a saturation of 90% equates to a PaO2 of 8 kPa Table 2.10 Uses of end-tidal CO2 measurement
(60 mmHg) because of the shape of the haemoglo-
• An indicator of the degree of alveolar ventilation:
bin dissociation curve. • to ensure normocapnia during mechanical
• It is unreliable when there is severe vasoconstric- ventilation
tion due to the reduced pulsatile component of the • control the level of hypocapnia in neurosurgery
signal. • avoidance of hypocapnia where the cerebral
• It is unreliable with certain haemoglobins: circulation is impaired, e.g. the elderly
• when carboxyhaemoglobin is present, it over- • As a disconnection indicator (the reading suddenly
estimates SaO2; falls to zero)
• when methaemoglobin is present, at an SaO2 > • To indicate that the tracheal tube is in the trachea
(CO2 in expired gas)
85%, it underestimates the saturation.
• As an indicator of the degree of rebreathing
• It progressively under-reads the saturation as the
(presence of CO2 in inspired gas)
haemoglobin falls (but it is not affected by
• As an indicator of cardiac output. If cardiac output
polycythaemia). falls and ventilation is maintained, then end-tidal CO2
• It is affected by extraneous light. falls as CO2 is not delivered to the lungs, e.g.:
• It is unreliable when there is excessive move- • hypovolaemia
ment of the patient. • cardiac arrest, where it can also be used to indicate
effectiveness of external cardiac compression
• massive pulmonary embolus
• It may be the first clue of the development of
The pulse oximeter is not an indicator of the adequacy of
malignant hyperpyrexia (see page 98)
alveolar ventilation.
Hypoventilation can be compensated for by increasing
the inspired oxygen concentration to maintain oxygen
saturation.
51
Chapter 2 Anaesthesia
52
Anaesthesia Chapter 2
53
Chapter 2 Anaesthesia
54
Anaesthesia Chapter 2
median nerve and branches of the medial and chamber’, which fills with blood once the needle
lateral cutaneous nerves of the arm are in close bevel lies within the vein (Fig. 2.21A). Some de-
proximity and easily damaged by needles or vices have flanges or ‘wings’ to facilitate attach-
extravasated drugs. ment to the skin (Fig. 2.21B). All cannulae have a
standard Luer-lock fitting for attaching a giving set
and some have a valved injection port through
Equipment
which drugs can be given (Fig. 2.21C).
Devices of different lengths and diameters are • Seldinger type This is used predominantly to
used; the term ‘cannula’ is used for those 7 cm or achieve cannulation of the central veins (see
less in length, and ‘catheter’ for those longer than below), but peripheral devices are available, de-
7 cm. The external diameter of these devices is signed mainly for use in resuscitation, for example
quoted either in terms of its ‘gauge’ (diameter the Arrow EID cannula (Fig. 2.21D).
increases with decreasing gauge) or millimetres.
The main types of cannulae used are:
Technique for cannulation of a
• Cannula over needle The most popular device,
peripheral vein
available in a variety of sizes, most commonly 14
gauge (2.1 mm) to 22 gauge (0.8 mm). A plastic The superficial veins are situated immediately
(PTFE or similar material) cannula is mounted on a under the skin in the superficial fascia, along with
smaller diameter metal needle, the bevel of which a variable amount of subcutaneous fat. They are
protrudes from the cannula. The other end of the relatively mobile and capable of considerable vari-
needle is attached to a transparent ‘flashback ation in their diameters. The size of cannula used
55
Chapter 2 Anaesthesia
(a) (b)
(c) (d)
Figure 2.22 (a-d) Peripheral intravenous cannulation. Courtesy of Greaves I, Hodgetts T, Porter K. Emergency Care — A
Textbook for Paramedics. London: Harcourt Brace, 1997.
will depend upon its purpose: large-diameter can- avoided as drugs or fluids may leak from the frac-
nulas are required for giving fluid rapidly, smaller ture site.
ones are adequate for giving drugs and mainte- • Encourage the vein to dilate by applying a
nance fluids. tourniquet proximally and gently tapping the skin
over the vein. Warming a cold hand will also help.
• Clean the skin over the vein using either an
As with any procedure where there is a risk of contact alcohol- or iodine-based solution (ensure there is
with body fluids, gloves should be worn by the operator. no risk of allergy if iodine is used).
• A small amount of local anaesthetic (0.2 mL
lignocaine 1%) should be infiltrated into the skin
• Choose a vein capable of accommodating the at the site chosen for venepuncture using a 25
size of cannula needed, preferably one that is both gauge (0.5 mm) needle, particularly if a large (>18
visible and palpable. gauge, 1.2 mm) cannula is used. This reduces pain,
• The junction of two veins is often a good site and makes the patient less likely to move and less
as the ‘target’ is relatively larger. resistant to further attempts.
• Avoid veins over joints as the cannula may • Immobilize the vein to prevent it being dis-
kink if the joint is flexed, with loss of function. placed by the cannula, by pulling the overlying
• Veins distal to fractures should also be skin tight, using your spare hand (Fig. 2.22a).
56
Anaesthesia Chapter 2
• Advance the cannula through the skin at an with inadequate pressure applied over the punc-
angle of 10–15° and then into the vein. Often a ture site to prevent bleeding, and made worse by
slight loss of resistance is felt as the vein is entered forgetting to remove the tourniquet!
and this should be accompanied by the appearance • Extravasation of fluid or drugs Failing to recognize
of blood in the flashback chamber of the cannula that the cannula is not within the vein before use.
(Fig. 2.22b). This indicates that the tip of the The degree of damage to the overlying tissues
needle is within the vein. will depend primarily upon the nature of the
• Reduce the angle of the cannula slightly and ad- extravasated fluid.
vance it a further 2–3 mm into the vein, keeping • Damage to local structures Secondary to poor
the skin taut. This ensures that the first part of technique and lack of knowledge of the local
the plastic cannula lies within the vein. Take care anatomy.
not to push the needle out of the far side of the • Air embolus The peripheral veins normally col-
vein! lapse when empty. However, a cannula may pre-
• Withdraw the needle 5–10 mm into the cannula vent this and allow air to enter the circulation.
so that the bevel no longer protrudes from the end. Most likely following cannulation of a central vein
As this is done, blood may be seen to flow between (see below).
the needle body and the cannula, confirming that • Shearing of the cannula Usually a result of trying
the tip of the cannula is within the vein (Fig. to reintroduce the needle after it has been with-
2.22c). drawn. The safest action is to withdraw the whole
• The cannula and needle should now be ad- cannula and re-attempt at another site.
vanced together along the vein. The needle is re- • Thrombophlebitis Related to the length of time
tained within the cannula to provide support and the vein is in use and irritation caused by the sub-
prevent kinking at the point of skin puncture (Fig. stances flowing through it. High concentrations of
2.22d). drugs and fluids with extremes of pH or high
• Once the cannula is fully inserted the tourniquet osmolality are the main causes, for example anti-
should be released, and the needle removed and biotics, calcium chloride, sodium bicarbonate.
disposed of safely. Once a vein shows signs of thrombophlebitis (i.e.
• Confirm that the cannula lies within the vein by tender, red and deteriorating flow) the cannula
attaching an IV infusion and ensuring it runs must be removed to prevent subsequent infection
freely. Alternatively, inject a small volume of or thrombosis.
saline. Immediate, localized swelling or pain indi-
cates that the cannula is incorrectly positioned. Do
Central venous cannulation
not persist; remove it and try at another site.
• Finally, secure the cannula in an appropriate This may be used for a variety of reasons during
manner with adhesive tape, or a commercial anaesthesia: to monitor the cardiovascular system;
dressing. because of inadequate peripheral venous access;
and to give certain drugs (e.g. inotropes). There
are many different types of equipment and ap-
Complications
proaches to the central veins, and the following is
Most are relatively minor but this must not be used intended as an outline. The use of an ultrasound
as an excuse for carelessness and poor technique. scanner may improve the detection and needle
• Failure Usually a result of pushing the needle localization of central veins.
completely through the vein. It is always best to
attempt cannulation distally in a limb and work
proximally. If multiple attempts are required, fluid
or drugs will not leak from previous puncture sites.
• Haematoma Usually secondary to the above
57
Chapter 2 Anaesthesia
Table 2.12 Complications of central venous obstruction due to haematoma formation in the
cannulation neck or bilateral pneumothoraces.
• Arterial puncture and bleeding causing haematoma
or haemothorax
Whenever a CVP catheter is inserted, a chest X-ray must
• Air embolus
be taken to ensure that the catheter is correctly posi-
• Venous thrombosis
tioned and a pneumothorax has not been caused.
• Pneumothorax
• Thoracic duct injury (left side) and chylothorax
• Hydrothorax if the catheter is intrapleural and fluid
given Equipment for central venous
• Bacteraemia catheterization
• Septicaemia
Three types of catheter are commonly used for per-
• Soft tissue infection at puncture site
cutaneous cannulation of the central veins:
• Injury to nerves:
• brachial plexus
• Catheter over needle Similar to a peripheral IV
• recurrent laryngeal cannula, the main difference is that it is longer to
• phrenic ensure that the tip lies in the correct position with-
in a central vein.
• Seldinger technique The vein is initially punc-
tured percutaneously using a small-diameter
needle. A flexible guidewire is then passed down
Access to the central veins the needle into the vein and the needle carefully
withdrawn, leaving the wire behind. The catheter
The antecubital fossa is now passed over the wire into the vein, some-
This route has a relatively low success rate, but times preceded by a dilator. The advantage of this
fewer complications, the most important of which method is that the initial use of a small needle in-
is thrombophlebitis after prolonged use (>48 h). creases the chance of successful venepuncture and
The basilic vein is preferable, as a catheter passed reduces the risk of damage to the vein.
via this vein is most likely to reach beyond the • Catheter through needle A large-diameter needle
clavipectoral fascia. is introduced into the vein, the catheter is
threaded down the lumen and the needle is with-
The internal jugular vein drawn, leaving the catheter in place.
This approach is associated with the highest inci-
dence of success (95%), and a low rate of complica-
Fluid flow through a cannula
tions (Table 2.12). The right internal jugular offers
certain advantages: there is a ‘straight line’ to the This determined by four factors:
heart, the apical pleura does not rise as high on this • Internal diameter Theoretically, flow is propor-
side, and the main thoracic duct is on the left. tional to the fourth power of the radius. Doubling
the diameter should result in flow increasing
Subclavian vein 16-fold (24). This is rarely achieved in practice, but
This can be approached by both the supra- and in- an increase of four- to fivefold will be seen.
fraclavicular routes. Both are technically more dif- • Length Flow is inversely proportional to the
ficult than the internal jugular route and there is a length of the cannula — doubling the length will
significant incidence of causing a pneumothorax halve the flow.
(2%). The main advantage of this route is com- • Viscosity Flow is inversely proportional to the
fort for the patient during long-term use. viscosity of the fluid — increasing viscosity reduces
Bilateral attempts at central venous cannulation flow. Colloids and blood flow more slowly than a
must not be made because of the risk of airway crystalloid, particularly when they are cold.
58
Anaesthesia Chapter 2
• Pressure Increasing the pressure across the can- concentrations to plasma are rapidly distributed
nula will increase the flow. This is usually achieved throughout the extracellular fluid space (i.e.
by either raising the height of the drip above the intravascular and interstitial volumes). Ultimately,
patient or using external pressure. only 25–30% of the volume administered remains
intravascular. If such fluids are used to restore the
circulating volume, three to four times the deficit
Always use a large-diameter, short cannula during
will need to be given. If crystalloids containing a
resuscitation as the rate of flow is determined primarily
lower concentration of sodium than plasma (e.g.
by the diameter.
4% glucose plus 0.18% saline) are given, then once
the glucose is metabolized the remaining fluid is
distributed throughout the entire body water (i.e.
Intravenous fluids
extracellular and intracellular volumes), and as
During anaesthesia fluids are given intravenously little as 10% will remain intravascular. Crystalloids
to replace losses due to surgery and provide the are used primarily either as an emergency resusci-
patient’s normal daily requirements. Three types tation fluid or to provide a patient’s daily require-
are used: crystalloids, colloids, and blood and its ments of water and sodium.
components.
Colloids
Crystalloids
These are suspensions of high molecular weight
These are solutions of crystalline solids in water. A particles. The most commonly used are derived
wide variety is available and a summary of the from gelatin (Haemaccel, Gelofusine), protein (al-
composition of the most commonly used is shown bumin) or starch (Hespan, HAES-steril). A sum-
in Table 2.13. Those containing sodium in similar mary of their composition is shown in Table 2.14.
Average
molecular
weight Na+ K+ Ca++ Cl- HCO3- Osmolality
Colloid (kDa) (mmol/L) (mmol/L) (mmol/L) (mmol/L) (mmol/L) pH (mosmol/L)
59
Chapter 2 Anaesthesia
Colloids primarily expand the intravascular supplied as a pooled donation from six packs of FFP
volume and can initially be given in a volume sim- in one unit and must be used as soon as possible
ilar to the deficit to maintain the circulating vol- after thawing.
ume. However, they have a finite life in the plasma
and will eventually be either metabolized or ex-
Risks of intravenous blood and
creted and therefore need replacing.
blood products
All blood donations are routinely tested for hepati-
Blood and blood components
tis B surface antigen, hepatitis C, syphilis and anti-
There are several forms of blood and its compo- bodies to the HIV. However, a period exists
nents available. In the intraoperative period the between exposure and the development of anti-
most commonly used are red cell products, platelet bodies. The resultant infected red cells would not
concentrates and clotting factors. be detected by current screening techniques. The
• Whole blood Despite its name, this is basically risk is very small, and has been estimated for hepa-
red cells, plasma proteins and clotting factors titis B at 1 : 105 and for HIV at 1 : 106 units trans-
(levels of V and VIII are low). There are no platelets. fused. In order to try and eliminate these risks,
Each unit contains approximately 510 mL with a techniques now exist for using the patient’s own
haematocrit of 35–45%. Not widely available. blood in the perioperative period.
• Red cell concentrate This is the by-product of the • Predepositing blood Over a period of 4 weeks
removal of plasma from whole blood. Each unit prior to surgery, the patient builds up a bank
contains 250 mL with a haematocrit of 60–75%, of two to four units of blood for retransfusion
and is hence very viscous with a poor flow rate. perioperatively.
• Red cells in optimal additive solution (SAG-M) A • Preoperative haemodilution Following induction
red cell concentrate to which a mixture of saline, of anaesthesia 0.5–1.5 L of blood is removed and re-
adenine and glucose and mannitol has been placed with colloid. This can then be transfused at
added. This improves both red cell survival and the end of surgery.
flow characteristics. Each unit contains 300 mL • Cell savers These devices collect blood lost dur-
with a haematocrit of 50–70%. White cells are ing surgery via a suction system; the red cells are
routinely removed in the UK to prevent the risk of separated, washed and resuspended, ready for re-
prion transmission. transfusion to the patient.
• Platelet concentrates Supplied either as ‘units’
containing 50–60 mL (55 ¥ 109 platelets) or as bags
Intraoperative fluid administration
equivalent to four units. Four units or one bag will
raise the platelet count by 30–40 000 mm3. Given The type and volume of fluid administered during
via a standard giving set without the use of a surgery varies for each and every patient, but must
microaggregate filter, as this will result in the loss take into account:
of significant numbers of platelets. • any deficit the patient has accrued;
• Fresh frozen plasma (FFP) This consists of the • maintenance requirements during the
plasma separated from a single donation and procedure;
frozen within 6 h. Each pack contains 200–250 mL, • losses due to surgery;
with normal levels of clotting factors (except factor • any vasodilatation secondary to the use of a
VIII, 70% normal). It should be infused as soon as regional anaesthetic technique (see page 67).
it has thawed.
• Cryoprecipitate This is produced as a precipitate
The accrued deficit
formed on the controlled thawing of FFP, which is
collected and suspended in plasma. It contains This may be due to preoperative fasting, or losses as
large amounts of factor VIII and fibrinogen. It is a result of vomiting, haemorrhage or pyrexia. Any
60
Anaesthesia Chapter 2
deficit due to fasting is predominantly water from Fluid losses from the first two causes are difficult to
the total body water volume. The volume required measure and are extremely variable. If evaporative
is calculated at the normal daily maintenance rate losses are considered excessive, then 4% glucose
of 1.5 mL/kg/h (from the point at which fasting plus 0.18% saline can be used. Third space losses
began). Although this deficit can be replaced with should be replaced with a solution similar in com-
a fluid such as 4% glucose plus 0.18% saline, position to extracellular fluid, and Hartmann’s is
Hartmann’s solution is widely used intraoperative- commonly used. The rate of administration and
ly. The other main cause of a preoperative deficit is volume required is proportional to surgical trauma
losses either from or into the gastrointestinal tract. and may be as much as 10 mL/kg/h. Blood pres-
This fluid usually contains electrolytes and effec- sure, pulse, peripheral perfusion and urine output
tively depletes the extracellular volume. It is best will give an indication as to the adequacy of re-
replaced with a crystalloid of similar composition, placement, but in complex cases where there are
particularly in respect of the sodium concentra- other causes of fluid loss, particularly bleeding, the
tion; for example 0.9% sodium chloride or trend of the CVP is very useful (see page 52).
Hartmann’s solution. Blood loss is slightly more obvious and easier to
Acute blood loss preoperatively can be replaced measure. Most previously well patients will toler-
with either an appropriate volume of crystalloid ate the anaemia that results from the loss of 20% of
(remembering that only 30% remains intravascu- their blood volume, providing that the circulating
lar) or colloid. If more than 20% of the estimated volume is adequately maintained by the use of
blood volume has been lost (approximately crystalloids or colloids. Beyond this, red cell prepa-
1000 mL), blood should be used, particularly if rations are used in order to maintain the oxygen-
bleeding is ongoing. carrying capacity of the blood. A haemoglobin
level between 8 and 10 g/dL is a safe level even for
those patients with serious cardiorespiratory
Intraoperative requirements
disease. In most cases, the equivalent of the pa-
Maintenance fluids alone are usually only given tient’s estimated blood volume can be replaced
when surgery is prolonged (>1–2 h), or if there is with red cell concentrates, crystalloid and colloid
the possibility of a delay in the patient resuming in the appropriate volumes. Occasionally, blood
oral fluid intake. Most patients will compensate for loss is such that the haemostatic mechanisms are
a preoperative deficit by increasing their oral in- affected. This may be seen as continuous oozing
take postoperatively. When maintenance fluid is from the surgical wound or around IV cannulation
used it should be given at 1.5 mL/kg/h, and sites. If this is suspected, the patient’s coagulation
increased if the patient is pyrexial by 10% for each status must be confirmed (platelet count, PT, APTT,
degree centigrade above normal. fibrinogen levels). Platelets may not be required
Losses during surgery are due to: until losses exceed 1.5 times the estimated blood
• Evaporation This can occur during body cavity volume. Treatment is usually reserved for those
surgery or when large areas of tissue are exposed, cases in which the INR reaches 1.7–2.0, fibrinogen
depleting the total body water. levels fall below 0.5 g/L or the platelet count falls
• Trauma The formation of tissue oedema, the below 50 ¥ 109/L.
volume of which is dependent upon the extent
of tissue damage; it is similar in composition
Local and regional anaesthesia
to extracellular fluid. This fluid is often referred
to as ‘third space loss’ and creates a deficit in When referring to local and regional techniques
the circulating volume that can no longer be and the drugs used, the terms ‘analgesia’ and
accessed. ‘anaesthesia’ are used loosely and interchangeably.
• Blood loss This will depend upon the type and For clarity and consistency the following terms will
site of surgery. be used:
61
Chapter 2 Anaesthesia
Lignocaine 3 mg/kg (plain), Rapid 60–180 mins, depending Used: topically, infiltration,
max. 200 mg on the technique used nerve blocks, IVRA,
6 mg/kg (with epidurally, intrathecally
epinephrine),
max. 500 mg
Bupivacaine 2 mg/kg, max. Nerve block: up Up to 24 h Mainly used for nerve blocks,
150 mg to 40 mins epidurally and intrathecally.
(± epinephrine) Epidurally: 3–4 h, dose dependent Relatively cardiotoxic
in any 4 h 15–20 mins
period Intrathecal: 30 s 2–3 h, dose dependent
Levo bupivacaine An isomer of bupivacaine; most properties very similar, but less cardiotoxic. This allows slightly
higher doses to be given
62
Anaesthesia Chapter 2
gers, toes, penis), as the vasoconstriction can cause ness, slurred speech, twitching, restlessness, mild
fatal tissue ischaemia. hypotension and bradycardia.
• Severe or late: grand mal convulsions followed by
1:80000 = 1g in 80000mL = 1mg in 80mL
coma, respiratory depression and, eventually,
= 0.0125mg/mL or 12.5 mg/mL
apnoea, cardiovascular collapse with profound
1:200000 = 1g in 200000mL = 1mg in 200mL
hypotension and bradycardia, and ultimately, car-
= 0.005mg/mL or 5 mg/mL
diac arrest.
The maximum safe dose in an adult is 250 mg, that
is, 20 mL of 1 : 80 000 or 50 mL of 1 : 200 000. This
Management of toxicity
should be reduced by 50% in patients with is-
chaemic heart disease. If a patient complains of any of the above symp-
toms or exhibits signs, stop giving the local anaes-
thetic immediately! The next steps consist of:
Calculation of doses
• Airway Maintain using basic techniques.
For any drug it is essential that the correct dose is Tracheal intubation will be needed if the protective
given and the maximum safe dose never exceeded. reflexes are absent to protect against aspiration.
This can be confusing with local anaesthetic drugs • Breathing Give oxygen (100%) with support of
as the volume containing the required dose will ventilation if inadequate.
vary depending upon the concentration (expressed • Circulation Raise the patient’s legs to encourage
in per cent), and a range of concentrations exists venous return and start an IV infusion of crystal-
for each drug. The relationship between concentra- loid or colloid. Treat a bradycardia with IV at-
tion, volume and dose is given by the formula: ropine. If no major pulse is palpable, start external
Concentration (% ) ¥ Volume (mL) ¥ 10 = dose (mg ) cardiac compression. If inotropes and vasopressors
are required, invasive monitoring will be needed
and this should be performed on the intensive care
Local anaesthetic toxicity
unit.
This is usually the result of one of the following: • Convulsions These must be treated early.
• Rapid absorption of a normally safe dose Use of an Diazepam 5–10 mg intravenously can be used
excessively concentrated solution or injection into initially but this may cause significant respiratory
a vascular area results in rapid absorption. It can depression. If the convulsions do not respond or
also occur during intravenous regional anaesthesia they recur, then seek assistance.
(IVRA — see below) if the tourniquet is released too Because of the risk of an inadvertent overdose of a
soon or accidentally. local anaesthetic drug, they should only be given
• Inadvertent IV injection Failure to aspirate prior to where full facilities for monitoring and resuscita-
injection via virtually any route. tion are immediately available. In this way the pa-
• Administration of an overdose Failure or error in tient will recover without any permanent sequelae.
either calculating the maximum safe dose or taking
into account any pre-existing cardiac or hepatic
The role of local and regional
disease.
anaesthesia
Signs and symptoms of toxicity are due to effects
on the central nervous system and the cardiovas- Regional anaesthesia is not just an answer to the
cular system. These are dependent on the plasma problem of anaesthesia in patients regarded as not
concentration and initially may represent either a well enough for general anaesthesia. The decision
mild toxicity or, more significantly, the early stages to use any of these techniques should be based on
of a more severe reaction. the advantages offered to both the patient and sur-
• Mild or early: circumoral paraesthesia, numbness geon. The following are some of the considerations
of the tongue, visual disturbances, lightheaded- taken into account.
63
Chapter 2 Anaesthesia
64
Anaesthesia Chapter 2
65
Chapter 2 Anaesthesia
Dura
Dura — not punctured
Epidural space
Ligamentum flavum
Spinous process
Tuohy needle
(a)
Spinous process
resistance disappears dramatically and air or saline Varying concentrations of local anaesthetics are
is injected easily. used depending on what effect is required. For ex-
A plastic catheter is then inserted into the ample, bupivacaine 0.5–0.75% will be needed for
epidural space via the needle. The catheter is surgical anaesthesia with muscle relaxation, but
marked at 5 cm intervals to 20 cm and at 1 cm only 0.1–0.2% for postoperative analgesia. Local
intervals between 5 and 15 cm. If the depth of the anaesthetic will spread from the level of injection
epidural space is noted, this allows the length of both up and down the epidural space. The extent
catheter in the space to be determined. of anaesthesia is determined by:
66
Anaesthesia Chapter 2
Spinal anaesthesia
• Positioning of the patient either during or after
Spinal (intrathecal) anaesthesia results from the in- the injection. Maintenance of the sitting position
jection of a local anaesthetic drug directly into the after injection results in a block of the low lumbar
cerebrospinal fluid (CSF), within the subarachnoid and sacral nerves. In the supine position, the block
space (Fig. 2.24b). The spinal needle can only be in- will extend to the thoracic nerves around T5–6, the
serted below the second lumbar and above the first point of maximum backwards curve (kyphosis) of
sacral vertebrae; the upper limit is determined by the thoracic spine. Further extension can be ob-
the termination of the spinal cord, and the lower tained with a head-down tilt.
limit by the fact that the sacral vertebrae are fused • Increasing the dose (volume and/or concentra-
and access becomes virtually impossible. A single tion) of local anaesthetic drug.
injection of local anaesthetic is usually used, there- • The higher the placement of the spinal anaes-
by limiting the duration of the technique. thetic in the lumbar region, the higher the level of
A fine, 22–29 gauge needle with a ‘pencil point’ block obtained.
or tapered point (for example Whitacre or Sprotte Small doses of an opioid, for example morphine
needle) is used (Fig. 2.25). The small diameter and 0.1–0.25 mg, may be injected with the local anaes-
shape are an attempt to reduce the incidence of thetic. This extends the duration of analgesia for
postdural puncture headache (see below). To aid up to 24 h postoperatively.
passage of this needle through the skin and inter-
spinous ligament, a short, wide-bore needle is in-
Monitoring during local and regional
troduced initially and the spinal needle passed
anaesthesia
through its lumen.
Factors influencing the spread of the local anaes- During epidural and spinal anaesthesia, the guide-
thetic drug within the CSF, and hence the extent of lines on monitoring (see page 49) should be fol-
anaesthesia, include: lowed. A conscious patient is not an excuse for
• Use of hyperbaric solutions (i.e. its specific inadequate monitoring! Particular attention must
gravity is greater than that of CSF), for example be paid to the cardiovascular system as a result of
‘heavy’ bupivacaine (0.5%). This is achieved by the the profound effects these techniques can have.
addition of 8% dextrose. Posture is then used to Maintenance of verbal contact with the patient is
control spread. useful as it gives an indication of cerebral perfu-
67
Chapter 2 Anaesthesia
68
Anaesthesia Chapter 2
69
Chapter 2 Anaesthesia
http://www.rcoa.ac.uk/ http://www.jr2.ox.ac.uk/bandolier/booth/
[The Royal College of Anaesthetists.] painpag/
These two sites are a must if you want to have [The Oxford Pain site. Good for the latest
the latest national UK guidance on anaesthetic evidence-based reviews in pain.]
practice. http://www.mhra.gov.uk/
www.theairwaysite.com [Medicines and Healthcare products Regulatory
[This site is aimed at emergency physicians and Agency. This agency ensures that medicines,
orientated to American practice. It does, healthcare products and medical equipment
however, contain some useful information.] meet appropriate standards of safety, quality,
www.lmaco.com/ performance and effectiveness, and are used
[The laryngeal mask airway company website, safely. Site contains latest drug and device
which has instruction manuals for all the hazards.]
variations in current use.] http://www.aagbi.org/pdf/blood_tran.pdf
http://gasnet.med.yale.edu/ [Association of anaesthetists guidelines on
[The best anaesthesia site on the Web, with free blood transfusion, 2001.]
sign-on, and a virtual textbook of anaesthesia http://www.shotuk.org/
that includes a good section on airway [Serious Hazards of Transfusion (SHOT).
management.] Contains latest UK data.]
http://www.capnography.com/index.html http://www.nysora.com/
[This is an excellent site if you want to know [The best regional anaesthesia site.]
more about capnography. Very detailed, so be
warned.]
70
Chapter 3
Postanaesthesia care
71
Chapter 3 Postanaesthesia care
Table 3.1 Minimum criteria for discharge from recovery of the airways that plays no part in gas exchange.
area No oxygen reaches the alveoli irrespective of the
• Fully conscious and able to maintain own airway inspired oxygen concentration and profound hy-
(although patient may still be ‘sleepy’) poxaemia will follow. Hypoventilation is always
• Adequate breathing accompanied by hypercapnia, as there is an in-
• Stable cardiovascular system, with minimal bleeding verse relationship between arterial carbon dioxide
from the surgical site (PacO2) and alveolar ventilation. Common causes
• Adequate pain relief of hypoventilation include:
• Warm • Obstruction of the airway Most often due to the
tongue. Consider vomit, blood or swelling (e.g.
post-thyroid surgery). Partial obstruction causes
noisy breathing; in complete obstruction there is
Complications and their little noise despite vigorous efforts. There may be a
management characteristic ‘see-saw’ or paradoxical pattern of
ventilation. A tracheal tug may be seen. It is pre-
vented by recovering patients in the lateral posi-
Hypoxaemia
tion, particularly those recovering from surgery
This is the most important respiratory complica- where there is a risk of bleeding into the airway
tion after anaesthesia and surgery. It may start at (e.g. ear, nose and throat (ENT) surgery), or regur-
recovery and in some patients persist for 3 days or gitation (bowel obstruction or a history of reflux).
more after surgery. The presence of cyanosis is very If it is not possible to turn the patient (e.g. after a
insensitive and when detectable the arterial PO2 hip replacement), perform a chin lift or jaw thrust
will be <8 kPa (55 mmHg), a saturation of 85%. The (see page 100). An oropharyngeal or nasopharyn-
advent of pulse oximetry has had a major impact geal airway may be required to help maintain the
on the prevention of hypoxaemia and should be airway (see page 18).
used routinely in all patients. If hypoxaemia is se-
vere, persistent or when there is any doubt, arterial
blood gas analysis should be performed. Hypox- No patient should be handed to the care of the recovery
aemia can be caused by a number of factors, either nurse with noisy respiration of unknown cause.
alone or in combination:
• alveolar hypoventilation;
• ventilation and perfusion mismatch within the • Central respiratory depression The residual effects
lungs; of anaesthetic drugs decrease the ventilatory re-
• diffusion hypoxia; sponse to hypoxia and hypercarbia and also reduce
• pulmonary diffusion defects; the level of consciousness. Support ventilation
• a reduced inspired oxygen concentration. until effects have worn off or reversed. Opioid
analgesics (in excess) cause respiratory depression
and reduce the level of consciousness. If severe, the
Alveolar hypoventilation
administration of the specific antagonist naloxone
This is the commonest cause of hypoxaemia and may be required (see page 39).
results in insufficient influx of oxygen into the • Hypothermia Reduces ventilation but, in the
alveoli to replace that taken up by the blood. As a absence of any contributing factors, it is usually
result, alveolar PO2 (PAO2) and arterial PO2 (PaO2) adequate for the body’s needs.
fall. In most patients, increasing their inspired oxy- • Cerebral haemorrhage or ischaemia May cause
gen concentration will restore alveolar and arterial direct damage to the respiratory centre or, more
PO2. Eventually a point is reached where there is commonly, a deeply unconscious patient unable
only ventilation of ‘dead space’, that is, the volume to maintain a patent airway.
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Postanaesthesia care Chapter 3
• Impaired mechanics of ventilation Pain, particu- venous, with an oxygen content of 15 mL/100 mL
larly after upper abdominal or thoracic surgery, of blood.
prevents coughing, leading to sputum retention • The final oxygen content of blood leaving the
and atelectasis. Provide adequate analgesia (con- lungs will be dependent on the relative propor-
sider central neural block). Residual neuromuscu- tions of shunted blood and non-shunted blood.
lar blockade is suggested by unsustained, jerky
movements with rapid, shallow breathing in a hy-
pertensive, tachycardic patient. For test to confirm For an equivalent blood flow, areas of V/Q < 1 decrease
the diagnosis see page 35. The patient should be oxygen content more than increasing the oxygen con-
given oxygen, reassured, sat upright to improve centration in areas of V/Q > 1 increases content.
73
Chapter 3 Postanaesthesia care
74
Postanaesthesia care Chapter 3
Fig. 3.2 Hudson mask with reservoir and high airflow oxy-
gen enrichment (HAFOE; Venturi) mask.
Fig. 3.1 Hudson mask (top left), MC mask (top right) and
nasal catheters (bottom).
Fixed-performance devices
Examples of this type of device are Hudson and MC These are used when it is important to deliver a
masks (Fig. 3.1). As a guide, they increase the in- precise concentration of oxygen, unaffected by the
spired oxygen concentration to 25–60% with oxy- patient’s ventilatory pattern. These masks work on
gen flows of 2–12 L/min. the principle of high airflow oxygen enrichment
Patients unable to tolerate a facemask who can (HAFOE). Oxygen is fed into a Venturi that en-
nose breathe may find either a single foam-tipped trains a much greater but constant flow of air.
catheter or double catheters, placed just inside the The total flow into the mask may be as high as
vestibule of the nose, more comfortable (see Fig. 45 L/min. The high gas flow has two effects: it
3.1). Lower flows of oxygen are used, 2–4 L/min meets the patient’s peak inspiratory flow, reducing
increasing the inspired oxygen concentration to entrainment of air, and flushes expiratory gas, re-
25–40%. ducing rebreathing. Masks deliver either a fixed
If higher inspired oxygen concentrations are concentration or have interchangeable Venturis to
needed in a spontaneously breathing patient, a vary the oxygen concentration (Fig. 3.2).
Hudson mask with a reservoir can be used (see Fig.
The above systems all deliver dry gas to the
3.2). A one-way valve diverts the oxygen flow into
patient that may cause crusting or thickening
the reservoir during expiration. During inspira-
of secretions and difficulty with clearance. For pro-
tion, the contents of the reservoir, along with
longed use, a HAFOE system should be used with a
the high flow of oxygen (12–15 L/min), result in
humidifier.
minimal entrainment of air, raising the inspired
concentration to 85%. An inspired oxygen con-
Hypotension
centration of 100% can only be achieved by using
either an anaesthetic system with a close-fitting This can be due to a variety of factors, alone or
facemask or a self-inflating bag with reservoir and in combination, that reduce the cardiac output,
non-rebreathing valve and an oxygen flow of the systemic vascular resistance or both (see also
12–15 L/min. page 96):
• hypovolaemia;
• reduced myocardial contractility;
75
Chapter 3 Postanaesthesia care
Management
The commonest cause of oliguria is hypovolaemia;
anuria is usually due to a blocked catheter. • Sit the patient upright.
• Give 100% oxygen.
• Monitor the ECG, blood pressure and peripheral
The extent to which these changes occur will de- oxygen saturation.
pend primarily upon the degree of hypovolaemia. If the diagnosis is unclear, a fluid challenge (maxi-
A tachycardia may not be seen in the patient taking mum 5 mL/kg) can be given and the response ob-
beta blockers and up to 15% of the blood volume served; an improvement in the circulatory status
may be lost without detectable signs in a fit, young suggests hypovolaemia. Where there is no doubt
patient. An arterial blood sample should be about the diagnosis, fluids can be restricted ini-
analysed; a metabolic acidosis is usually found tially and a diuretic (e.g. frusemide 20–40 mg)
after a period of poor tissue perfusion. given intravenously. Trends in the CVP can be
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Postanaesthesia care Chapter 3
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Chapter 3 Postanaesthesia care
78
Postanaesthesia care Chapter 3
chemoreceptor trigger zone and increases gastric sue trauma), most patients start drinking within
motility. An alternative is domperidone (Motili- 1–2 h of surgery and IV fluid is not required. If a
um) 10 mg orally. patient has failed to drink within 4–6 h (usually
• Phenothiazine derivatives Prochlorperazine (Stem- as a result of nausea and vomiting), consideration
etil). Adults 12.5 mg intramuscularly 6 hourly should be given to commencing IV fluids. Provid-
or 15–30 mg orally, daily in divided doses. May ing that the volume of vomit is not excessive, only
cause hypotension due to alpha-blockade. Some maintenance fluids are required. These are calcu-
have antihistamine activity and may cause dystonic lated at 1.5 mL/kg/h, but must take into account
muscle movements. the accrued deficit.
• Anticholinergic drugs Atropine and hyoscine; the For example, a 70 kg patient starved from 0800
latter is available as a transdermal patch. Severe to 1400, who is still unable to take fluids by mouth
side-effects, particularly dry mouth and blurred at 1800 will require:
vision.
• Steroids Dexamethasone 8 mg IV may be useful 1.5mL/kg/h to make up the deficit from
in resistant cases. 0800 until 1800
= 1.5 ¥ 70 (kg) ¥ 10 (h ) ª 1000mL;
1.5mL/kg/h from 1800 until 0800 the
Postoperative intravenous
next morning:
fluid therapy
= 1.5 ¥ 70 (kg) ¥ 14 (h ) ª 1400mL.
Oral intake should be encouraged as not all pa- The total IV fluid requirement = 2400ml
tients require routine IV fluids after anaesthesia in the next 14h.
and surgery. For those that do, the volume and
type of fluid will be determined by a variety of An appropriate rate for the IV fluid would be:
factors, including: • 1000 mL over the first 4 h;
• the site of surgery; • 1000 mL over the following 6 h;
• the extent of tissue damage; • 500 mL over the last 4 h.
• blood loss during and after surgery; This should contain the daily requirement of
• any delay in starting to drink; Na++ 1–1.5 mmol/kg and could be given either
• continuing losses from the gastrointestinal tract. as:
A wide range of fluids are available (see page 59), 2 ¥ 1000 mL 5% glucose and 500 mL 0.9%
and for each patient the type and volume will (normal) saline; or
be dependent upon the calculated maintenance 2 ¥ 1000 mL 4% glucose/0.18% saline, and
requirements of water and electrolytes plus the 500 mL 4% glucose/0.18% saline.
replacement of any abnormal losses. This is The patient should be reviewed at 0800 with
complemented by clinical evaluation of the pa- regard to further management.
tient to ensure that they are adequately hydrated,
as assessed by degree of thirst, moisture of mucous
Major surgery
membranes, blood pressure, pulse, peripheral cir-
culation and an adequate urine output. In complex Following major surgery, postoperative fluid bal-
cases, monitoring the trend of the CVP may also ance is more complex. Assuming that appropriate
prove useful. volumes of water, electrolytes and blood have been
given during the operation, then postoperatively
the fluid and electrolyte requirements will depend
Minor surgery
upon:
Following minor surgical procedures (i.e. taking • the volume needed for ongoing maintenance,
less than 30 mins, with minimal blood loss and tis- which will be increased if the patient is pyrexial;
79
Chapter 3 Postanaesthesia care
• replacement of continuing losses from the measure and usually become evident as a result of
gastrointestinal tract, for example via a nasogastric the above regimen failing to keep the patient ade-
tube; quately hydrated. This is usually seen as thirst, a
• any continued bleeding; dry mouth, cool peripheries with empty superficial
• rewarming of cold peripheries causing veins, hypotension, tachycardia and a decrease
vasodilatation. in the urine output to less than 0.5 mL/kg/h. An
The patient who has undergone major surgery will additional 1L of Hartmann’s solution per 24 h may
require close monitoring to ensure that sufficient need to be added to the above regimen to account
volumes of the correct fluid are administered. A for such losses and adjusted according to the pa-
standard postoperative regimen for the first 24 h tient’s response. These losses may continue for up
postoperatively might therefore consist of: to 48 h after surgery and sufficient extra volumes of
• 1.5 mL/kg/h water, increased by 10% for each °C fluid should be administered to maintain hydra-
if the patient is pyrexial; tion and an adequate circulating volume. Where
• sodium, 1 mmol/kg; large volumes of fluid are required and/or there is
• replacement of measured gastrointestinal losses underlying heart disease, then the CVP should be
with an equal volume of Hartmann’s solution; measured and the trend noted (see page 52) and
• replacement of blood loss of <500 mL with serum electrolytes monitored twice daily.
either:
• Hartmann’s solution (three times the volume
The stress response
of blood lost will be needed as it is distributed
throughout the extracellular fluid (ECF)); or Following major surgery and trauma, various
• colloid, the same volume as the blood loss; neuroendocrine responses result in an increased
• blood loss >1000 mL will require transfusion secretion of a variety of hormones. Antidiuretic
with stored blood. hormone (ADH) secretion is maximal during sur-
It is essential that the patient is reviewed at the end gery and may remain elevated for several days. The
of the day as described above to ensure that the effect of this is to increase water absorption by the
volumes and type of fluid prescribed are adequate kidneys and reduce urine output. Aldosterone se-
for the patient’s needs. cretion is raised secondary to increased cortisol lev-
On the second and subsequent days, the same els and activation of the renin–angiotensin system.
basic principles are used. In addition: This results in sodium retention and increased uri-
• The fluid balance of the previous 24 h must be nary excretion of potassium. Despite this retention
checked. of water and sodium, it is important that fluid
• Ensure that all sources of fluid loss are recorded. input is not restricted in these patients, as the con-
• The patient’s serum electrolytes must be checked tinued losses identified above more than offset the
to ensure adequate replacement. volume retained.
• The urine output for the previous 6 and 24 h After 2–3 days, hormone levels return to normal
should be noted; if decreasing, consider other and this is followed by an increase in the volume of
causes of fluid loss, for example increasing pyrexia, urine passed, which may be augmented by loss of
development of an ileus. fluid as tissue oedema resolves.
• Potassium will be required (in addition to sodi-
um) at the rate of 1 mmol/kg per 24 h.
Postoperative analgesia
If surgery is associated with significant tissue trau-
ma (e.g. total hip replacement, major gastrointesti- After injury, acute pain limits activity until healing
nal surgery), then there will be continued losses has taken place. Modern surgical treatment re-
into the tissues, which have the same effect as any stores function more rapidly, a process facilitated
other form of fluid loss and are often referred to as by the elimination of postoperative pain. A good
‘third space losses’. Such volumes are difficult to example is the internal fixation of fractures, fol-
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Postanaesthesia care Chapter 3
lowed by potent analgesia allowing early mobiliza- what to expect postoperatively, what types of anal-
tion. Ineffective treatment of postoperative pain gesia are available and also by allowing patients to
not only delays this process, but also has other im- explore their concerns.
portant consequences: • Patients who have a pre-existing chronic pain
• Physical immobility: problem are vulnerable to suffering with addition-
• reduced cough, sputum retention and al acute pain. Their nervous systems can be consid-
pneumonia; ered to be sensitized to pain and will react more
• muscle wasting, skin breakdown and cardio- strongly to noxious stimuli. Bad previous pain ex-
vascular deconditioning; periences in hospital or anticipation of severe pain
• thromboembolic disease — deep venous for another reason suggest that extra effort will be
thrombosis and pulmonary embolus; required to control the pain.
• delayed bone and soft tissue healing. • Older patients tend to require lower doses of
• Psychological reaction: analgesics as a result of changes in drug distribu-
• reluctance to undergo further, necessary surgi- tion, metabolism, excretion and coexisting dis-
cal procedures. ease. Prescribing should take these factors into
• Economic costs: account rather than using them as an excuse for in-
• prolonged hospital stay, increased medical adequate analgesia. There is no difference between
complications; the pains suffered by the different sexes having the
• increased time away from normal same operation.
occupations. • Upper abdominal and thoracic surgery cause the
• Development of chronic pain syndromes. most severe pain of the longest duration, control of
Sometimes pain is a useful aid to diagnosis and which is important because of the detrimental ef-
must be recognized and acted upon, for example: fects on ventilation. Pain following surgery on the
• pain due to ischaemia from tissue swelling, body wall or periphery of limbs is less severe and
haematoma formation restricting the circulation for a shorter duration.
causing a compartment syndrome or by dressings
becoming too tight;
Management of postoperative pain
• pain of infection from cellulitis, peritonitis or
pneumonia; This can be divided into a number of steps:
• referred visceral pain in myocardial infarction • assessment of pain;
(arm or neck) or pancreatitis (to the back). • analgesic drugs used;
• techniques of administration;
Any patient who complains of pain that unexpectedly in- • difficult pain problems.
creases in severity, changes in nature or site, or is of new
onset should be examined to identify the cause rather
than simply be prescribed analgesia.
Assessment of acute pain
Regular measurement of pain means that it is more
difficult to ignore and the efficacy of interventions
Factors affecting the experience of pain
can be assessed. There are a variety of methods of
Pain and the patient’s response to it are very assessing pain; Table 3.3 shows a simple, practical
variable and should be understood against the system that is easily administered and understood
background of the individual’s previous personal by patients. The numeric score is to facilitate
experiences and expectations rather than com- recording and allows trends to be identified. Pain
pared with the norm. must be assessed with appropriate activity for the
• Anxiety heightens the experience of pain. The stage of recovery; for example, 5 days after a hip
preoperative visit by the anaesthetist plays a joint replacement a patient would not be expected
significant role in allaying anxiety by explaining to have pain while lying in bed, but adequate
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Chapter 3 Postanaesthesia care
Pain Staff
score view Patient’s view Action
analgesia should allow mobilization with only • pharmacokinetics: how the body distributes,
mild to insignificant pain. metabolizes and eliminates the drug;
• the nature of the stimulus;
• the psychological reaction to the situation.
Analgesic drugs used postoperatively
The biggest step forward in the treatment of acute
(Fig. 3.3)
pain with opioids has been the recognition that
The most commonly used drugs are opioids and individual requirements are very variable and the
NSAIDs. dose needs to be titrated for each patient:
• There is no minimum or maximum dose.
Opioids • Even with best practice some pain will remain.
The pharmacology of opioid drugs and their side- • Minimum levels of monitoring and intervention
effects are covered on page 37. In the UK, mor- are necessary for safe, effective use.
phine is most commonly used to control severe • Additional methods of analgesia should be con-
postoperative pain on surgical units, and dia- sidered if opioid requirements are high.
morphine (heroin) on medical wards, for example
coronary care units, mainly for historical reasons. Overdose
There are few pharmacological differences be- Profound respiratory depression and coma due to
tween these two drugs. Morphine can be given by opioids must be treated using the ABC principles
several routes (Table 3.4). One of the principal described elsewhere (page 99). Having created a
metabolites, morphine-6-glucuronide (M6G), has patent airway and supported ventilation using a
potent opioid effects and may accumulate and bag-valve-mask with supplementary oxygen, the
cause toxicity in patients with renal failure, effects of the opioid can be pharmacologically
particularly the elderly. Fentanyl and oxycodone reversed (antagonized) using naloxone. 0.4 mg is
have less active metabolites than morphine and so diluted to 5 mL with 0.9% saline and given in
may be more suitable for these patients. incremental doses of 1 mL IV (adult dosing). Anal-
For most painful clinical conditions there will be gesia will also be reversed, and careful thought
a blood level of opioid that provides useful analge- must be given to continuing analgesia. HDU care is
sia, that is, a reduction in pain level. The dose usually advisable in this situation.
required to achieve this may vary enormously
between patients as a result of differences in: Long-term complications of opioids
• pharmacodynamics: the effect of the drug on the Adequate treatment of acute pain with opioids is
body (via the receptors); not associated with dependency.
82
Postanaesthesia care Chapter 3
Brain
Spinal
cord
B Oral
Dura L i.m. OPIOIDS
B O i.v.
Oral O sub cut.
L
NSAIDs i.m. D transdermal
O
i.v. transcutaneous
O
p.r.
D
Intrathecal
Anticonvulsants
Epidural
Peripheral
nerve
Local
CSF anaesthetics
83
Chapter 3 Postanaesthesia care
Intravenous Morphine 10 or 20 mg diluted to 1 mg/mL with 0.9% sodium chloride can be given:
• In increments initially of 1–3 mg at 3 min intervals; effective dose may range from 1 to 50 mg or
more (the latter in opioid-tolerant patients)
• Via patient controlled analgesia device (see below)
• As a continuous infusion. Useful where patient cooperation is limited, e.g. in elderly patients or
intensive care units. Problems occur in predicting the correct infusion rate, given the variability of
dose requirement between patients
Very close supervision is required to avoid underinfusion (pain) or overinfusion (toxicity)
This method can be used to replace high doses of oral opioids during the perioperative period
The intravenous dose of morphine is about one-third of the oral dose
Intramuscular • A predetermined dose (e.g. morphine 10 mg) at fixed minimum intervals, e.g. hourly
• Delayed and variable rate of effect
• Precise titration is difficult with repeated cycles of pain and relief
• Does not require complex equipment or a co-operative patient
• Widely available
• Intermittent injections through an indwelling cannula may be more acceptable to staff and
patients
analgesics but patients may need reassurance that • Activation is by the patient depressing a switch
regular dosing of 1 g every 6 h is not associated with that is designed to prevent accidental triggering
hepatic toxicity. A summary of the use of these (hence ‘patient-controlled’).
drugs is given in Table 3.5. • There may be a background, low-dose, continu-
ous infusion.
Analgesic techniques used To prevent the administration of an overdose:
postoperatively • The dose and any background infusion is preset
(usually by a doctor).
• After successful administration of a dose, a sub-
Patient-controlled analgesia (PCA)
sequent dose cannot be administered for a preset
• A microprocessor-controlled syringe pump capa- period, the ‘lockout period’.
ble of being programmed is used to deliver a pre- • The total quantity of drug given over a predeter-
determined dose of a drug intravenously. mined period can be limited.
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Postanaesthesia care Chapter 3
Effects
Anti-inflammatory Yes Yes No
Analgesic (central) Yes Yes Yes
Side-effects
Reduced renal blood flow Yes Probably No
Gastric ulceration Yes Unlikely No
Anti-platelet Yes Unlikely No
Delay bone healing Possible Unlikely No
• Typical settings for an adult using morphine de- Table 3.6 Management of overdose with patient-
livered by a PCA device might be: controlled analgesia (PCA)
• bolus dose: 1 mg; • Stop the PCA
• lockout interval: 5 mins. • Give oxygen via a mask
• Call for assistance
Effective PCA requires: • Consider giving naloxone (as described on page 82)
• That the patient be briefed by the anaesthetist • If the patient is apnoeic, commence ventilation using
and/or nursing staff preoperatively and, if possible, a self-inflating bag-valve-mask device
be shown the device to be used.
• A loading dose of analgesic, usually intraven-
ously before starting. Failure to do this will result in
the patient being unable to get sufficient analgesia • Intravenous administration with greater cer-
from the PCA device and the system will fail. tainty of adequate plasma levels.
• A dedicated IV cannula or non-return valve on
an IV infusion to prevent accumulation of the drug Disadvantages
and failure of analgesia. • Equipment is expensive to purchase and
Observation and recording of the patient’s maintain.
pain score, sedation score and respiratory rate • Requires patient comprehension of the system.
to ensure success. Any patient whose respiratory • Patient must be physically able to trigger the
rate is less than 8 breaths/min and sedation score device.
is 2 or 3 should be treated as described in Table • The elderly are often reluctant to use a PCA
3.6. device.
• The potential for overdose if the device is
Advantages of PCA incorrectly programmed.
• Greater flexibility; analgesia matched to the pa- As pain subsides the PCA can be discontinued, and
tient’s perception of the pain. oral analgesics can be used. The first dose should be
• Reduced workload for the nursing staff. given 1 h prior to discontinuing PCA, to ensure
• Elimination of painful IM injections. continuity of analgesia.
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Chapter 3 Postanaesthesia care
Supra-orbital:
scalp surgery
Sural, saphenous,
deep and superficial
peroneal, post. tibial:
foot surgery
86
Postanaesthesia care Chapter 3
Different combinations of local anaesthetic and example haemorrhage, are particularly vulnerable
opioid infusion have been used successfully. to severe hypotension. Check the extent of the
Ideally, the concentration of local anaesthetic block; if extensive, reduce the rate of infusion.
should block sensory nerves, leaving motor nerves • Respiratory depression Caused by opioid reaching
relatively spared. The choice and dose of opioid the respiratory centre in the medulla. Highly lipid
should be such that the drug passes through the soluble opioids (diamorphine, fentanyl) are rapid-
dura into the CSF in sufficient quantities to block ly taken up by the spinal cord, limiting their spread
the opioid receptors in the spinal cord but not and systemic absorption, and respiratory depres-
spread cranially to cause respiratory depression. sion tends to occur early; less soluble opioids
For example: (morphine) are taken up slowly, and respiratory de-
• bupivacaine 0.167% plus diamorphine pression tends to occur later. A high infusion rate
0.1 mg/mL; of either drug may also lead to respiratory depres-
• bupivacaine 0.125% plus fentanyl 4 mg/mL. sion. Prevented by regular assessment and record-
Epidural infusions can be used to maintain an- ing of vital signs. Treat by supporting ventilation if
algesia for several days. Opioid side-effects are less necessary; stop the epidural infusion; give nalox-
common and less severe than when given systemi- one according to the severity; seek expert help.
cally as the dose is much less. • Sedation Due to opioid reaching the brain either
directly via the CSF or after absorption into the sys-
Points to note temic circulation via the epidural veins. May be
• The infusion rate and the site of the catheter secondary to hypotension and cerebral hypox-
determine the spread of the solution. In the thor- aemia. Prevent by regular assessment and record-
acic epidural space a starting infusion rate might be ing of vital signs. Treat by stopping the infusion; if
4 mL/h; in the lumbar space commence at unresponsive or the level of sedation progresses,
8 mL/h. give naloxone in 0.1 mg increments intravenously;
• The efficacy of the infusion must be monitored seek expert help.
in a similar manner as for PCA. • Pruritus Can be severe and frequently localized
• If analgesia is inadequate, a ‘top-up’ of 3–4 mL of to the nose; may respond to antihistamines, at-
solution may be necessary. ropine or naloxone.
• Observations of the patient’s vital signs should • Retention of urine May be due to the effect of the
then be made on a regular basis according to local opioid on bladder sphincter control or the local
protocol. anaesthetic removing the sensation of a full blad-
• In patients over the age of 60 years, the concen- der. More common in males, particularly if there
tration of opioid is often halved. are already symptoms of prostatism. Prevented
by routine monitoring of urine output in all
Management of complications during postoperative patients. May require short-term
postoperative epidural analgesia catheterization.
This will depend upon whether local anaesthetics • Numbness and weakness of the legs Usually due to
alone or in combination with opioids have been excessive rates of infusion or a too-high concentra-
used. The complications arising as a result of the tion of local anaesthetic. May lead to pressure ul-
use of local anaesthetics intraoperatively are cov- cers on the patient’s heels or sacrum due to lack of
ered on page 63. movement, or falls whilst mobilizing. Prevented
• Hypotension Sympathetic block causes vasodi- by regular observation of effects of epidural and
latation and increased venous pooling. Treat correct adjustment of infusion rate.
acutely with IV fluid and vasopressors (e.g. • Vertebral canal haematoma Can occur as a result
ephedrine according to local policy). Prevented by of trauma by the needle or catheter insertion.
ensuring the patient has an adequate fluid regimen Greater risk in patients on warfarin, heparin,
prescribed. Patients with additional fluid losses, for NSAIDs and other antiplatelet drugs, those with a
87
Chapter 3 Postanaesthesia care
coagulopathy or when severely haemodiluted. • oral morphine immediate release (IR) tablets and
Rare, but consider if profound motor and sensory paracetamol prescribed to be given as a spinal
block far greater than anticipated. wears off.
• Infection Introduced via the catheter. May cause
the formation of an epidural abscess and compro-
Difficult pain problems
mise of the spinal cord. Patients complain typical-
ly of increasing back pain but this may be delayed Patients in whom there is evidence of regular opi-
for several weeks so that the connection to the sur- oid use preoperatively, for example drug addicts,
gery and epidural may be missed. cancer and chronic pain patients and those pa-
If there is any doubt about spinal cord function tients with a previous bad pain experience, will
the epidural infusion should be stopped and a pose a particular problem postoperatively. They are
magnetic resonance imaging (MRI) scan con- best managed using a team approach that will
sidered. Damage to nerves or the spinal cord include:
during insertion of the needle and systemic toxi- • Liaison with the Acute Pain Team to inform it of
city of the local anaesthetic are both unusual the patient’s admission.
complications. • Discussion with the anaesthetist, and surgical
and nursing staff to plan perioperative care,
to:
Intrathecal (spinal) analgesia
• ensure any current opioid medication is con-
(see page 66)
tinued on admission to prevent withdrawal;
Spinal anaesthesia is of insufficient duration to • understand that much larger doses of opioids
provide postoperative pain relief. However, if a than normal may be required;
small dose of opioid, for example morphine • explain that toxicity from high doses of opioid
0.1–0.25 mg, is injected along with the local anaes- is very unlikely;
thetic, this may provide up to 24 h of analgesia. • reassure that addiction is not a concern.
Complications are the same as those due to opioids • Discussion with the patient to explain:
given epidurally, and managed in the same way. • types and effectiveness of analgesic regimes
available postoperatively;
• that analgesia may not be 100% effective;
Other techniques
• that long-term continuation may be
Entonox is a mixture of nitrous oxide (50%) and necessary;
oxygen (50%). It is a weak analgesic with sedative • potential side-effects, especially if regional
properties. Useful for short-term analgesia for analgesia planned.
painful procedures, for example change of dress- • Plan regular reviews during postoperative
ings. It should be avoided in patients with a pneu- period.
mothorax because the nitrous oxide may diffuse • Coordination of care.
into the gas-filled space, increasing the volume.
Further reading
Combining analgesic techniques
Bay I, Nunn JF, Prys Roberts C. Factors affecting
Examples of good practice are: arterial PO2 during recovery from general
• bupivacaine and fentanyl in an epidural anaesthesia. British Journal of Anaesthesia 1968;
infusion; 40: 398–407.
• intravenous PCA morphine and intravenous Gan TJ, Meyer T, Apfel CC et al., and Department
paracoxib in the early postoperative period when of Anesthesiology, Duke University Medical
nil by mouth; Center. Consensus guidelines for managing
88
Postanaesthesia care Chapter 3
89
Chapter 4
Management of perioperative
emergencies and cardiac arrest
Anaesthesia is extremely safe and uneventful, but Cardiovascular collapse is the most common and
occasionally problems occur in the perioperative severe feature. Asthmatics often develop bron-
period that may be incidental or secondary to the chospasm that is resistant to treatment, and any
anaesthetic and potentially life-threatening to the circumstance reducing the patient’s catecholamine
patient. Whatever their nature, most difficulties response (e.g. beta blockers, spinal anaesthesia)
can be dealt with initially using the ABC principles will increase the severity.
of resuscitation: maintain and secure the airway, These events are caused by one of two things:
ensure adequate breathing or ventilation and sup- • An anaphylactic reaction This involves the libera-
port the circulation. Assistance will be required fre- tion of histamine, 5-hydroxytryptamine (5-HT)
quently and should always be sought early. and associated vasoactive substances from mast
cells and basophils, following exposure to a foreign
substance (the drug) to which the individual has
Acute severe drug reactions
become sensitized. It is usually an IgE-mediated
Most drug reactions in anaesthesia are mild and reaction.
transient, consisting mainly of localized urticaria • An anaphylactoid reaction This is clinically indis-
as a result of cutaneous histamine release. The inci- tinguishable from the above, but the release of his-
dence of severe reactions to anaesthetic drugs is ap- tamine, etc. from mast cells is triggered by non-IgE
proximately 1 : 10 000 drug administrations, and is mechanisms.
more common in females. Of those reported to the
Medicines Control Agency, 10% involved a fatality
Causes of allergic reactions
compared to 3.7% for drugs overall. This probably
reflects the frequency with which anaesthetic • Anaesthetic drugs:
drugs are given intravenously. Clinical features in- • muscle relaxants (>50%): rocuronium, suxa-
clude (in order of frequency): methonium, atracurium, vecuronium;
• severe hypotension; • induction agents (5%): thiopentone, propofol.
• severe bronchospasm; • Antibiotics (8%):
• widespread flushing; • penicillin (2% of patients may cross-react to
• hypoxaemia; modern cephalosporins).
• urticaria; • Intravenous fluids:
• angioedema, which may involve the airway; • colloids (3%); haemaccel, gelofusin.
• pruritus, nausea and vomiting. • Latex (17%)
90
Management of perioperative emergencies and cardiac arrest Chapter 4
91
Chapter 4 Management of perioperative emergencies and cardiac arrest
• sympathetic stimulation, pain and anxiety; • After allowing the patient to recover, continue
• a full stomach: using either a regional technique or a rapid-
• an inadequate period of starvation; sequence induction and intubation.
• distension with mask ventilation; • After intubation, aspirate the tracheobronchial
• a history of gastro-oesophageal reflux or a hiatus tree and consider bronchoscopy.
hernia; • Treat bronchospasm as above.
• obesity; • Postoperatively, arrange for a chest X-ray and
• head-down position; physiotherapy.
• presence of a bulbar palsy; • Recover in the ICU or HDU with oxygen therapy.
• oesophageal pouch or stricture. • Postoperative ventilation may be required.
Signs suggesting aspiration include: (iii) Neuromuscular blocking drugs given:
• coughing during induction or recovery from • Intubate with a cuffed tracheal tube to secure the
anaesthesia; airway.
• the presence of gastric contents in the pharynx • Aspirate the tracheobronchial tree before start-
at laryngoscopy or around the edge of the ing positive pressure ventilation.
facemask; • Consider bronchopulmonary lavage with
• progressive hypoxia; saline.
• bronchospasm; • Treat bronchospasm as above.
• respiratory obstruction, if severe; • Pass a nasogastric tube and empty the stomach.
• occasionally, aspiration may go completely un- • If the patient is stable (i.e. not hypoxic or
noticed during anaesthesia, with the development hypotensive), surgery can be continued with post-
of hypoxia, hypotension and respiratory failure operative care as described above.
postoperatively. If aspiration is suspected in a patient postopera-
tively, treat as for (i) above.
There is no place for routine administration of
Management
large-dose steroids. Antibiotics should be given
• Maintain the airway and place the patient head- according to local protocols.
down and on his or her side, preferably the left; in- In those cases where bronchospasm is resistant
tubation is relatively easier on this side. to treatment or there is persistent hypoxia or hy-
• Aspirate any material from the pharynx, prefer- potension, unless surgery is life-saving the patient
ably under direct vision (use a laryngoscope). should be transferred to the ICU for ventilation
(i) Neuromuscular blocking drugs not given; surgery where, in addition, invasive cardiorespiratory
not urgent: monitoring will also be needed.
• Give 100% oxygen via a facemask.
• Allow the patient to recover, give oxygen to
Prevention of aspiration
maintain a satisfactory SpO2.
• Treat bronchospasm with salbutamol or amino- A variety of methods are used, alone or in
phylline as described on page 91. combination:
• Take a chest X-ray and organize regular physio- 1 Reduction of residual gastric volume
therapy. • An adequate period of starvation.
• Consider monitoring on the ICU or HDU, de- • Avoid drugs that delay gastric emptying.
pending on degree of aspiration. • Insertion of a nasogastric tube.
(ii) Neuromuscular blocking drugs not given; surgery • Use of gastrokinetic drugs, for example
essential: metoclopramide.
• Get help, empty the stomach with a nasogastric 2 Increase pH of gastric contents
tube and instill 30 mL sodium citrate. • Sodium citrate to neutralize gastric acid.
92
Management of perioperative emergencies and cardiac arrest Chapter 4
• H2 antagonists, for example ranitidine. via a nasogastric tube, use awake fibreoptic intuba-
• Proton pump inhibitors, for example omepra- tion under local anaesthesia.
zole, rebeprazole. Intubation not essential for surgery:
3 Use of cricoid pressure • Use a LMA, Proseal LMA or Combitube.
See page 26. • Consider using a regional anaesthetic technique.
93
Chapter 4 Management of perioperative emergencies and cardiac arrest
94
Management of perioperative emergencies and cardiac arrest Chapter 4
Subsequent management
Acute severe asthma
If the patient is improving:
This is characterized by any one of: • continue oxygen therapy;
• Severe breathlessness: • give IV hydrocortisone 100 mg 6 hourly or 40–
• an inability to complete a sentence in one 50 mg orally daily;
breath; • give nebulized salbutamol and ipratropium 4–6
• a silent chest; hourly.
• cyanosis. If the patient is not improving:
• Tachypnoea: respiratory rate >25 breaths/min. • continue oxygen therapy;
• Tachycardia: heart rate >110 beats/min. • give nebulized salbutamol 5 mg more frequently,
• Peak expiratory flow (PEF) 33–50% of best or every 15–30 mins or 10 mg continuously hourly;
predicted. • continue ipratropium 0.5 mg 4–6 hourly;
Acute severe asthma is considered life threatening • give magnesium sulphate 1.2–2.0 g IV as slow
in a patient with any one of the following: infusion over 20 mins;
• feeble respiratory effort; • consider IV beta-2 agonist or aminophylline;
• PEF <33% of best or predicted; • consider need for tracheal intubation and
• SpO2 <92%; mechanical ventilation.
• PaO2 <8 kPa; Discuss with Critical Care team if there is:
• normal PaCO2 (4.6–6.0 kPa); • need for tracheal intubation and ventilatory
• cyanosis; support;
• bradycardia, arrhythmias, hypotension; • continuing failure to respond to treatment;
• exhaustion, confusion, coma. • a deteriorating PEF;
• persistent or worsening hypoxia;
95
Chapter 4 Management of perioperative emergencies and cardiac arrest
96
Management of perioperative emergencies and cardiac arrest Chapter 4
be defined as a systolic pressure 40% less than the usually the result of a combination of the above
preoperative value. factors; for example, vasodilatation caused by the
anaesthetic drugs in a hypovolaemic patient.
Additional measures
Sepsis:
• Vasopressors: for example ephedrine to counter-
• Toxins released can cause failure of the precapil- act vasodilatation.
lary sphincters, leading to widespread vasodilata- • Inotropes: for example dopamine or dobutamine
tion of the vascular bed. to increase myocardial contractility.
Spinal cord injury: • Antiarrhythmics.
• Injury to the cervical or upper thoracic cord • A change in position or relief of a tension pneumo-
causes loss of sympathetic tone to blood vessels thorax: to allow venous return.
and vasodilatation. • Needle pericardiocentesis: in the very rare circum-
• If above T5, loss of cardiac sympathetic supply stances of cardiac tamponade.
will result in a bradycardia. • Monitoring of CVP or pulmonary artery pressure: to
Miscellaneous: guide therapy in complex cases.
• Hypercarbia and a pyrexia will both cause
vasodilatation.
Severe hypotension requiring intervention is
97
Chapter 4 Management of perioperative emergencies and cardiac arrest
98
Management of perioperative emergencies and cardiac arrest Chapter 4
Patient evaluation Figure 4.1 Saggital section of the airway, showing how the
This is achieved by placing one hand on the pa- tongue contributes to obstruction.
99
Chapter 4 Management of perioperative emergencies and cardiac arrest
Breathing
Checking for evidence of breathing. Maintain an
airway using one of the above techniques, then
(Fig. 4.4):
• Look: down the line of the chest to see if it is
rising and falling.
• Listen: at the mouth and nose for breath sound,
gurgling or snoring sounds.
• Feel: for expired air at the victim’s mouth and
nose with the side of one’s cheek.
If there is no evidence of spontaneous ventilation,
expired-air ventilation will be required.
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Management of perioperative emergencies and cardiac arrest Chapter 4
Mouth-to-nose ventilation
This technique is used where mouth-to-mouth
ventilation is unsuccessful, for example if an ob-
struction in the mouth cannot be relieved, or when
the rescuer is a child.
(b) • The airway is maintained with a head tilt, but the
mouth is closed with the fingers of the lower hand.
• The seal is made by the rescuer’s lips around the
base of the victim’s nose.
• Inspiration is as above, checking to ensure that
the chest rises.
• The victim’s mouth is opened to assist with expi-
ration, the rescuer watching to ensure that the
chest falls.
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Chapter 4 Management of perioperative emergencies and cardiac arrest
Common errors
Wrong hand position:
• too high: the heart is not compressed;
(b)
• too low: the stomach is compressed and risk of
Figure 4.6 (a,b) External cardiac compression. aspiration increased;
• too laterally: injures underlying organs, for
example liver, spleen, bowel.
Overenthusiastic effort:
• Central arteries are more reliable than periph- • causes cardiac damage;
eral ones as a pulse will be palpable even with a • fractures ribs which may damage underlying
very low cardiac output. organs, particularly lungs and liver.
• The carotid artery is usually the most accessi- Inadequate effort:
ble and acceptable. • the rescuer is not high enough above the patient
• Take no more than 10 s to make the check. to use his/her body weight;
• If there is no evidence of a spontaneous circula- • fatigue during prolonged resuscitation or be-
tion, then chest compressions will be required. cause of poor technique.
Failure to release between compressions:
Chest compressions • prevents venous return and filling of the heart.
This technique only results in a maximum cardiac When a collapsed person is not breathing and has
output 30% of normal, and in order to achieve this no spontaneous circulation, they will require both
the position of the hands is critical: rescue breathing and chest compressions; this is
• The rescuer positions him/herself on one side of often referred to as cardiopulmonary resuscitation
the victim. (CPR). A ratio of 15 chest compressions to 2 breaths
• The victim’s chest is exposed and the xiphister- should be used, irrespective of the number of per-
num identified. sons present. If two or more laypersons are present,
• The index and middle fingers of the rescuer’s they should take turns to provide single-person
lower hand are placed on the xiphisternum and CPR, to prevent fatigue and maintain quality. If
the heel of the other hand is placed adjacent to two or more healthcare professionals are present,
them on the sternum (Fig. 4.6a). then one person should perform chest compres-
• The fingers are then removed and the heel of the sions while another provides rescue breathing. The
102
Management of perioperative emergencies and cardiac arrest Chapter 4
103
Chapter 4 Management of perioperative emergencies and cardiac arrest
(b)
(a)
(d)
(c)
defibrillator, airway devices, oxygen, intravenous shockable rhythms, much of the remainder of the
cannulation and drugs, correcting reversible management is common to all rhythms. ALS man-
causes. The most important first step is to identify agement is summarized in the Universal Treatment
the cardiac arrest rhythm, which can belong to one Algorithm (Fig. 4.8). Only the key features of ALS
of two groups: not covered elsewhere are included here. The inter-
• Shockable: ventricular fibrillation (VF), pulseless ested reader should refer to the Resuscitation
ventricular tachycardia (VT). Council (UK) for further details and is encouraged
• Non-shockable: asystole and pulseless electrical to undertake the Resuscitation Council (UK) ALS
activity (PEA). course.
Apart from attempting to defibrillate patients in
104
Management of perioperative emergencies and cardiac arrest Chapter 4
Cardiac arrest
Precordial thump
if appropriate
BLS algorithm
if appropriate
Attach
defibrillator-monitor
Assess
rhythm
VF/VT Non-VF/
During CPR VT
Correct reversible causes
If not already:
Defibrillate x3 • Check electrodes, paddle
as necessary position and contact
• Attempt/verify:
airway and O2
intravenous access
• Give epinephrine every 3 min
CPR 3 min
CPR 1 min Consider: (1 min if immediately
amiodarone, atropine/pacing after defibrillation)
buffers
Figure 4.8 The Universal Algorithm. Courtesy of the Resuscitation Council (UK).
105
Chapter 4 Management of perioperative emergencies and cardiac arrest
Ventricular fibrillation
The onset of VF may be preceded by a period of VT.
The most effective treatment of both conditions is
identical — electrical defibrillation (a direct current,
DC, shock). The time to delivery of the first shock
is critical in determining the outcome, and there-
fore once the diagnosis has been made, defibrilla-
tion is the first manoeuvre to be carried out in ALS.
The only exception to this is when it is preceded by
a precordial thump. This manoeuvre should only
be used if the cardiac arrest was witnessed and/or
monitored. A sharp blow is delivered to the pa-
tient’s sternum with a closed fist. This delivers a
small amount of mechanical energy to the
myocardium and, if done early enough after the
onset of VF, may cause the rhythm to revert to one
capable of restoring the circulation.
Defibrillation
Defibrillation (and cardioversion) depolarizes a
critical mass of the myocardium, allowing the nat-
Figure 4.9 Paddle position for external cardiac
ural pacemaker of the heart to take over and restore defibrillation.
a normal coordinated contraction. Defibrillators
have a power source, either mains or battery,
which charges a capacitor to a predetermined level. Safety
This energy is discharged through specially de- The discharge of a defibrillator delivers enough
signed electrodes or ‘paddles’, usually 13–14 cm in current to cause as well as to treat VF. A manual de-
diameter, placed on the patient’s chest wall (see fibrillator must only be charged when the paddles
below). Success depends on the current flow are on the patient’s chest and must not be moved
through the myocardium and therefore to reduce between defibrillator and patient whilst charged.
the resistance between paddles and the chest wall, The user must ensure that nobody is in contact
‘gel’ pads are used. This is often referred to as with the patient or trolley, directly or indirectly
‘manual defibrillation’. Increasingly, ‘hands free’ (via spilt electrolyte solution), when the defibrilla-
systems consisting of two large, self-adhesive tor is discharged. Care must be taken to ensure that
electrodes are being used, particularly with the paddles are not touching when on the chest, or
AEDs. These allow both ECG monitoring and de- connected by misplaced gel pads, as this will cause
fibrillation without operator contact with the arcing on discharge, insufficient current delivery
patient. and the patient to be burned. Any nitrate patches
The paddles or self-adhesive electrodes are should be removed from the patient’s chest
placed anterolateral: one to the right of the ster- along with any high-flow oxygen to eliminate
num, just below the clavicle; and the other over the risk of fire. Finally, a clear verbal warning, usu-
the apex, below and to the left of the nipple. Al- ally a shout of ‘stand back’, and a visual check of
though the paddles are marked positive and nega- the area are mandatory before discharging the
tive, each can be placed in either position (Fig. 4.9). defibrillator.
An alternative is to place them anteroposterior to If further shocks are required, the paddles should
the heart. remain on the patient’s chest while the defibrillator
106
Management of perioperative emergencies and cardiac arrest Chapter 4
is recharged. If the defibrillator has been charged IV access cannot be obtained, larger doses (2–3 mg)
in error while the paddles are on the patient, most can be administered via a tracheal tube diluted to
devices will allow the charge to be ‘dumped’ safely 10 mL with sterile water.
by changing the energy level setting.
Amiodarone
Synchronized defibrillation
Defibrillation can be attempted at any point on the The main indication for this drug in cardiac arrest
VF waveform (an unsynchronized shock). How- is during shock-refractory VF or pulseless VT, when
ever, when the rhythm is pulseless VT, the shock is it should be considered as early as before the deliv-
best delivered co-ordinated with the ‘r’ wave, that ery of the fourth shock. The adult dose in cardiac
is, synchronized. This may also be referred to as arrest is 300 mg, diluted to 20 mL and given prefer-
cardioversion. If the shock is delivered on the ‘t’ ably via a central line, or alternatively a peripheral
wave when the heart is refractory, then VF may be line.
precipitated. Some defibrillators automatically de-
fault to synchronized mode when switched on,
Asystole
and unless cancelled this may delay delivery of a
shock if the patient is in VF. This represents electrical standstill of the heart
with no contractile activity and is seen on the ECG
as a gently undulating baseline. It is essential to
Technique of safe defibrillation
rule out the possibility of VF having been misdiag-
• Turn on the power switch (ensure the synchro- nosed before the diagnosis of asystole is made,
nization switch is set to ‘OFF’). consequently:
• Put gel pads on patient’s chest. • check equipment function;
• Place paddles firmly onto gel pads. • ensure that the ECG leads are connected;
• Select correct energy level. • check the gain setting;
• Check oxygen has been removed. • check the lead setting, lead I or II.
• Warn team members that you are charging the If there is any doubt about the diagnosis, treatment
defibrillator. should begin as for VF. The risks of not treating VF
• Charge the defibrillator. are greater than that of three unnecessary shocks. A
• Shout ‘stand back’ and make a visual check of precordial thump can be used under the same cri-
the area. teria as for VF. Occasionally, if monitoring the pa-
• Perform a final check of patient’s ECG rhythm. tient’s rhythm via the paddles, ‘spurious’ asystole
• Deliver shock by pressing both buttons on the may be seen after the delivery of a shock (more
paddles simultaneously. likely when successive sequences of shocks have
• Check patient’s rhythm. been delivered via the same pads). It is essential
that the rhythm is confirmed rapidly using ECG
electrodes. In general, the outcome from asystole is
Epinephrine (adrenaline)
poor unless there are ‘p’ waves present that may re-
This is a naturally occurring catecholamine, ad- spond to cardiac pacing.
ministered during CPR for its profound a-agonist
(vasoconstrictor) properties. This leads to an in-
Atropine
crease in the peripheral vascular resistance that
tends to divert blood flow to the vital organs An anticholinergic acting at muscarinic receptors,
(heart, brain). It is the first drug used in cardiac ar- causing block of the vagus nerve at both the sinoa-
rest of any aetiology. The adult dose is 1 mg intra- trial (SA) and atrioventricular (AV) nodes, causing
venously, that is, 1 mL of 1 : 1000 or 10 mL of an increase in heart rate. In cardiac arrest due to
1 : 10 000, administered during ALS every 3 mins. If asystole or PEA where the heart rate is less than
107
Chapter 4 Management of perioperative emergencies and cardiac arrest
Table 4.1 Causes of pulseless electrical activity of children. Furthermore, if the optimum support
is to be given, the techniques must be adjusted ac-
• Hypoxia
• Hypovolaemia cording to the size of the child. ‘Infant’ is used to
• Hypo/hyperkalaemia and metabolic disorders mean those less than 1 year old and ‘small chil-
• Hypothermia dren’ less than 8 years old.
• Tension pneumothorax The evaluation of the victim is as for adults, ac-
• Tamponade (cardiac) cepting that infants and very small children who
• Toxic/therapeutic disorders cannot yet talk, and older children who are very
• Thrombo-embolic and mechanical obstruction scared, are unlikely to reply meaningfully, but they
may make some sound or open their eyes to the
rescuer’s voice.
60 beats/min, the adult dose is 3 mg IV. A dose of
6 mg can be given via a tracheal tube.
Airway control
If the child is not breathing it may be because the
Pulseless electrical activity (PEA)
airway has been blocked by the tongue falling back
This is the term used to describe the situation when to obstruct the pharynx. Correction of this
there are recognizable complexes on the ECG com- problem may result in recovery without further
patible with a cardiac output but the patient is intervention.
pulseless. It is usually a result of conditions that • Head tilt plus chin lift A hand is placed on the
mechanically restrict cardiac filling or outflow, or forehead, and the head is gently tilted back as for
biochemically disrupt cardiac contractility. Com- an adult. In an infant, the tilt should be just suffi-
mon causes are listed in Table 4.1. The patient’s cient to place the head in a neutral position. The
best chance of survival is rapid identification and fingers of the other hand should then be placed
treatment of the underlying cause. under the chin, lifting it upwards. Care should be
taken not to injure the soft tissue by gripping too
hard. It may be necessary to use the thumb of the
Open chest cardiac compression
same hand to part the lips slightly.
The output generated by direct compression of the • Jaw thrust This is achieved by placing two or
heart is two to three times greater than closed chest three fingers under the angle of the mandible bilat-
compression and coronary and cerebral perfusion erally, and lifting the jaw upwards. This technique
pressures are significantly higher. The procedure is may be easier if the rescuer’s elbows are resting on
performed via a left thoracotomy through the the same surface as the child is lying on. A small de-
fourth or fifth intercostal space. It is of most use fol- gree of head tilt may also be applied.
lowing penetrating trauma, but unlikely to benefit The finger sweep technique often recommended
those in which cardiac arrest follows blunt trauma. for adults should not be used in children. The
It can also be considered in those patients in whom child’s soft palate is easily damaged, causing bleed-
closed chest compression is less effective, namely ing, and foreign bodies may become impacted in
severe emphysema, a rigid chest wall, severe valvu- the child’s cone-shaped airway and be even more
lar heart disease or recent sternotomy. There is no difficult to remove.
evidence to support its use as a routine procedure.
Breathing
Paediatric basic life support
Having created an airway using one of the above
The general principles are the same as for adult techniques, the adequacy of ventilation should
BLS, but specific techniques are required to take then be assessed rapidly in the same manner as for
into account the altered anatomy and physiology adults, by looking, listening and feeling for up
108
Management of perioperative emergencies and cardiac arrest Chapter 4
109
Chapter 4 Management of perioperative emergencies and cardiac arrest
Further reading
Adnet PJ, Gronert GA. Malignant hyperthermia:
advances in diagnostics and management.
Current Opinion in Anaesthesiology 1999; 12:
353–8.
Marik PE. Aspiration pneumonitis and aspiration
pneumonia. New England Journal of Medicine
2001; 344: 665–7.
Mendelson CL. The aspiration of stomach
contents into the lungs during obstetric
anesthesia. American Journal of Obstetrics and
Figure 4.11 Cardiac compression in a small child. Gynecology 1946; 52: 191–205.
Breathing 5 5 5
Initial slow breaths
Circulation
Pulse check Brachial or femoral Carotid Carotid
CPR
Ratio 1:5 1:5 1:5
Cycles per minute 20 20 20
110
Management of perioperative emergencies and cardiac arrest Chapter 4
111
Chapter 5
Recognition and management of the
critically ill patient
112
Recognition and management of the critically ill patient Chapter 5
Table 5.1 Levels of care for critically ill patients Table 5.2 Key features of an integrated approach to the
provision and organization of care of critically ill patients
Level 0
• Patients whose needs can be met through normal • Earlier recognition of the deteriorating condition of
ward care susceptible patients
• Earlier initiation of appropriate
Level 1
treatment/resuscitation
• Patients at risk of their condition deteriorating
• Earlier referral of patients to the critical care team
• Patients recently relocated from higher levels of care
• Extension of the resources of the ICU/HDU beyond
whose needs can be met with additional advice and
their geographical limits
support from the critical care team
These aims may be facilitated by the introduction of:
Level 2 (HDU)
• Improved training and education of clinical ward staff
• Patients requiring more detailed monitoring,
• Doctors
including support for a single organ system failure
• Nurses
• Certain postoperative patients (e.g. after major
• Healthcare assistants
surgery in high-risk patients)
• Use of clinical early warning scoring systems
• Patients stepping down from intensive care
• Provision of an outreach team
Level 3 (ICU)
• Patients requiring advanced respiratory support
(tracheal intubation and mechanical ventilation)
• Advanced Life Support (ALS) Focuses on the
• Patients with MOFS
prevention and management of cardiorespiratory
Adapted from Comprehensive critical care: a review of arrest.
adult critical care services. Department of Health, 2000.
• Advanced Trauma Life Support (ATLS) Focuses on
Reproduced with permission of the Controller of HMSO.
the management of major life-threatening acute
trauma.
• Advanced Paediatric Life Support (APLS) Focuses
in urine output, ultimately it will exacerbate the on recognition and management of the sick child.
dehydration and pre-renal failure, and may even Attendance on courses such as these is highly
precipitate acute cardiovascular collapse. Clinical recommended.
experience is essential to correctly identify the It is essential that all healthcare professionals
problem and institute appropriate management, recognize their limitations and know when to call
which in this case might include transfer of the for senior help, particularly when initial manage-
patient to a high dependency area, oxygen, chest ment has not led to a timely improvement in the
physiotherapy, a fluid challenge (perhaps guided condition of the patient. This assistance is often
by invasive CVP and arterial pressure monitoring), one’s immediate clinical superior (e.g. specialist
antibiotics and intravenous inotrope or vasopres- registrar or consultant) but may also include a
sor therapy. medical emergency team (MET), an outreach team
In an attempt to overcome the deficiencies in (see below) or a doctor/nurse from the ICU. How-
training and education, a diverse range of courses ever, as stated previously, these judgements are
is now available which aim to ‘short-circuit’ the often quite complex. Accordingly, formal clinical
knowledge and experience gap, including: scoring systems have been introduced in many
• Acute Life-threatening Event Recognition and Treat- hospitals to facilitate the process of assessing ill-
ment (ALERT) Focuses on the recognition and ness severity and response to treatment.
management of patients in the early stages of
developing critical illness.
Clinical scoring systems
• Care of the Critically Ill Surgical Patient (CCrISP)
Focuses on the management of critically ill surgical Several schemes have been described including:
patients. • The Medical Emergency Team Calling Criteria.
113
Chapter 5 Recognition and management of the critically ill patient
Score 3 2 1 0 1 2 3
HR: heart rate; BP: blood pressure; RR: respiratory rate; CNS: central nervous system.
* Normal for patient. ** Assessment of conscious level; A: alert; V: responsive to verbal stimulus; P: responsive to painful
stimulus; U: unresponsive.
Adapted from Stenhouse C, Coates S et al. Prospective evaluation of a modified Early Warning Score to aid earlier
detection of patients developing critical illness on a surgical ward. British Journal of Anaesthesia 2000; 84: 663P.
• The Patient At Risk Team (PART) Protocol. • that staff require a minimum of training;
• The Critical Care Liaison Service Protocol. • their applicability to trainee doctors, nurses
• The Early Warning Scoring System (EWSS). (both qualified and student) and other health
• The Modified Early Warning Scoring System professionals.
(MEWSS). With these systems, patients at risk of developing
All of these are based on recording observations re- critical illness are highlighted at an earlier stage
lating to the physiological and clinical status of the than perhaps they otherwise would be, and appro-
patient and the allocation of ‘points’ according to priate treatment commenced. The other advantage
the presence and severity of any derangement is that referral arrangements by nurses and inexpe-
from a reference range. The variables used include rienced doctors for more senior help and advice
heart rate, arterial blood pressure, respiratory rate, can be formalized into the protocol. Thus the ward
body temperature, conscious level and urine out- nurse may be required to contact the house officer
put. The points derived from each variable are to- for assistance if the trigger threshold is reached.
talled, and advice on further clinical management The house officer is then required to contact the
is sought either on the basis of a trigger threshold senior house officer or registrar if immediate
being reached or because of a continued adverse management does not result in an objective,
trend in a patient’s score. Another subjective cate- timely improvement in the patient’s condition
gory is sometimes added to include any patient based on an improving score. This leads ultimately
about whom there are serious concerns, independ- to direct clinical input from either a senior doctor
ent of the objective scoring assessment. The (consultant) or outreach team from critical care if
importance of this latter point cannot be overem- the patient is still not improving.
phasized, particularly when the concern is voiced The use of such scoring systems cannot and must
by an experienced nurse who ‘doesn’t like the look’ not substitute entirely for appropriate training and
of a particular patient. An example of one of these education of clinicians and there are several unre-
scoring systems is shown in Table 5.3. solved issues relating to their use. As their intro-
The main advantages of such scoring systems duction into clinical practice has been relatively
are: recent, there is as yet insufficient data available as
• their simplicity, with the need for only the basic to which physiological parameters are most impor-
monitoring equipment, normally present on acute tant, and the weighting of the variables to achieve
hospital wards; the overall score has not been validated. A doctor
• their reproducibility between different with experience in treating critically ill patients
observers; will not need to formally score his or her patients
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Recognition and management of the critically ill patient Chapter 5
Table 5.4 Aims of outreach patients and ideally be either an intensivist doctor
(consultant or experienced specialist registrar
• Early identification of patients with actual or potential
critical illness (SpR)) or a senior intensive-care nurse practitioner.
• Appropriate early intervention, which may prevent Other members of the team should include trainee
deterioration and avert the need for admission to doctors from acute medical and surgical special-
HDU or ICU ties. The team should have easy access to other spe-
• Liaison with the HDU and ICU cialized personnel such as physiotherapists,
• Facilitate early admission to HDU and ICU when pharmacists and dieticians. The proper resourcing
necessary of an effective outreach team is problematic in
• Identification of patients for whom HDU or ICU care many hospitals, and ad hoc arrangements may
is deemed inappropriate
then operate whereby patients giving rise to con-
• Appropriate early designation of patients as ‘not for
cern are referred to the ICU, and a ‘team’ consisting
attempted resuscitation’ in the event of
of an ICU trainee and/or nurse is dispatched to
cardiorespiratory arrest
• To assist ward nurses in the management of patients
assess the situation and act accordingly. Clearly
with actual or potential critical illness this is a less satisfactory approach and leads to a
• Education and training of trainee doctors and more fragmented level of care.
medical students
• Promote continuity of care following step-down of
patients to the ward from HDU and ICU Definition and causes of
critical illness
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Chapter 5 Recognition and management of the critically ill patient
gastrointestinal tract due to poor splanchnic level, leading inevitably to damage, dysfunction
perfusion and oxygenation in unresuscitated, and ultimately cell death.
shocked, hypoxic patients. The ischaemia
produces damage to the mucosal integrity of the
Initial assessment and
gut, a breach of its normal barrier function
management of critically
and translocation of bacteria into the circulation
ill patients
(septicaemia).
The causes of organ dysfunction may be classi- Cardiorespiratory arrest has a high overall morta-
fied as either primary or secondary: lity, even when it occurs in hospital. Patients who
• Primary organ dysfunction A result of direct tissue arrest secondary to severe myocardial ischaemia or
injury; for example, pneumonia in acute respira- infarction have a relatively better outcome as the
tory failure or myocardial infarction in acute car- presenting rhythm is more likely to be ventricular
diovascular failure (cardiogenic shock and/or acute fibrillation or pulseless ventricular tachycardia.
heart failure). Both are amenable to treatment by electrical defib-
• Secondary organ dysfunction Results from indirect rillation, particularly when a patient is in a moni-
tissue injury and is often the major contributor tored environment such as the coronary care unit
to MOFS. For example, diverticular perforation (CCU), due to rapid recognition and treatment.
of the colon may initially cause peritonitis and Unfortunately, the largest group of hospital pa-
septicaemia. However, the resulting release of in- tients who have a cardiac arrest do so as the final
flammatory and toxic mediators from bacteria step in a sequence of progressive deterioration of
and host tissues may go on to trigger an escalating their presenting illness. The arrest rhythm is more
cascade of inflammatory mediators throughout likely to be either asystole or pulseless electrical ac-
the body, causing widespread tissue damage tivity (when the ECG displays complexes that
and organ dysfunction (systemic inflammatory would normally be associated with a cardiac out-
response syndrome, SIRS). Secondary organ dys- put). Only a very small minority of these patients
function may also develop from hospital-acquired are successfully resuscitated and discharged home.
(nosocomial) infections. Critically ill patients Prevention of cardiac arrest in this situation is
are at greatly increased risk of these because their therefore the only approach likely to be successful.
immune cellular defence mechanisms are im- Studies have shown that in this latter group of
paired by the effects of SIRS and also because natu- patients cardiac arrest is often predictable, with
ral host defence barriers are breached by invasive most patients exhibiting signs of clinical deteriora-
monitoring lines, urinary catheters, tracheal tion over the preceding 12–24 h. Features are typi-
tubes, etc. cal of those listed above in clinical scoring systems,
and include:
• respiratory distress and tachypnoea (respiratory
SIRS
rate >30/min);
Any cause of systemic sepsis or major trauma may • tachycardia (heart rate (HR) >120/min);
activate inflammatory mediators giving rise to this • a fall in cardiac output manifest as hypotension,
condition. Within the lungs there are non-cardio- confusion, drowsiness and metabolic acidosis.
genic alveolar and interstitial oedema, ventila- If these warning signs are heeded and appropriate
tion–perfusion imbalance and respiratory failure resuscitative measures commenced, cardiac arrest
(acute respiratory distress syndrome, ARDS). Else- may be prevented and lives saved. Alternatively, if
where SIRS causes profound circulatory vasodilata- it is decided (by a senior clinician) in advance of
tion, hypotension, impaired control of regional the event that cardiac arrest is inevitable and that
perfusion, capillary leak and systemic oedema. The resuscitation is unlikely to benefit the patient, a
final outcome of this derangement is impaired DNAR (do not attempt resuscitation) order may be
oxygen delivery and consumption at a cellular made. It should be noted that a DNAR order does
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Recognition and management of the critically ill patient Chapter 5
not preclude appropriate resuscitative measures up very well, doctor’ tells you at the very least that the
to the point of actual cardiac arrest. patient has control of his or her airway, is breath-
ing, and has sufficient cerebral perfusion to process
the question and formulate an appropriate answer.
Action on receiving a call to a
Failure to respond appropriately to the question
sick patient
should immediately suggest the possibility of an
When requested to see a patient who is giving acute life-threatening physiological disturbance
cause for concern, it is helpful to have asked a few and the possibility of cardiorespiratory arrest.
pertinent questions of the referrer concerning the
patient’s recent history, so that you are already
Airway — assessment and management
thinking about potential diagnoses and treatment
as you make your way there. For example: Acute upper airway obstruction may be either
• How old is the patient? complete or partial. If left untreated the patient
• When was the patient admitted to hospital? may die within minutes. Assuming the patient is
• What did the patient come into hospital with? attempting to breath:
• Is the patient conscious, and if so what is he or • Look and listen for evidence of obstruction:
she complaining of? • partial obstruction results in noisy breathing
• How quickly has the patient deteriorated? (gurgling, snoring, crowing);
• What are the patient’s pulse rate, blood pressure, • complete obstruction is silent;
respiratory rate, temperature, skin colour? • movements of the chest are usually exaggera-
• Does the patient have a DNAR order? ted and a see-saw pattern is often observed, with
Do not attempt to acquire a comprehensive the chest being drawn in on inspiration as the
medical and surgical history since birth in a abdomen rises; the opposite movements occur
patient whose airway, breathing or circulation may during expiration;
be threatened, or in whom cardiorespiratory arrest • accessory muscles may be used, for example
is imminent! sternomastoids.
The effective management of these patients has Common causes of airway obstruction are listed in
two key elements: Table 5.5.
• A systematic approach must be used that deals On the general medical or surgical ward, im-
with the greatest potential threat first. paired consciousness is the most common cause of
• Call early for senior help if the situation appears airway obstruction. It can usually be relieved using
beyond your capabilities, or if the patient con- basic airway-opening manoeuvres such as the head
tinues to deteriorate despite what you consider to tilt plus chin lift or jaw thrust (see page 99). Inser-
be appropriate management. tion of simple airway adjuncts (Guedel oral airway
Initial approach
Table 5.5 Causes of upper airway obstruction
In assessing any critically ill patient, it is essential
to follow the ABC system, that is Airway, • Impaired conscious level—reduced muscle tone
Breathing, Circulation. The principles of ABC allows the tongue to fall back and occlude the airway
management are discussed in the chapter on car- • Blood, vomit or other secretions
diorespiratory arrest and the application of this • Trauma
• Laryngeal oedema due to anaphylaxis or thermal
system in relation to the patient who has not yet
injury
progressed to cardiac arrest is given below.
• Inhaled foreign body (e.g. food bolus)
On approaching the patient for the first time,
• Tumour
much useful information may be gleaned by sim- • Infection (e.g. retropharyngeal abscess)
ply asking: ‘Are you alright?’ The reply: ‘I don’t feel
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Chapter 5 Recognition and management of the critically ill patient
or nasopharyngeal airway) may also be required There are numerous causes of respiratory failure.
(see page 18). Airway obstruction due to vomit, They may be classified as to whether respiratory
blood, food or secretions in the mouth and phar- failure from lung disease is the primary problem or
ynx may be apparent on inspection and dealt with secondary to other problems (Table 5.6). Both pri-
by careful suction using a rigid, wide-bore sucker. mary and secondary causes may coexist in the
Even if these simple steps relieve the airway ob- same patient.
struction, it is vital to call for experienced help at The treatment for hypoxaemia is administration
this stage, often from an anaesthetist, who may de- of oxygen in high concentration, ideally to achieve
cide that tracheal intubation and transfer to the a normal PaO2 (12–14 kPa) or peripheral oxygen
ICU is necessary. Airway obstruction secondary to saturation (=95%). At the very least, minimum re-
pathology in and around the upper airway itself, spective targets of 8 kPa and 90% should be aimed
such as a laryngeal tumour or trauma to the head for. This is most easily achieved by using a face-
and neck, mandates a call for immediate expert mask with an attached reservoir bag connected to
assistance. oxygen at a flow rate of 15 L/min (see Fig. 3.2). En-
sure the reservoir is filled with oxygen before plac-
ing it on the patient’s face. This apparatus will
Breathing assessment and management
provide an inspired oxygen concentration of ap-
Breathing is initially assessed using the look, listen proximately 85%. Oxygen therapy per se does not
and feel approach (see page 100). Assuming the air- treat the cause of hypoxaemia and respiratory
way has been cleared and the patient is breathing: failure; the next step is to ascertain the cause and
• Count the respiratory rate: treat appropriately.
• Rapid breathing (>30 breaths/min) is an early
sign of clinical deterioration that may progress
The patient with chronic obstructive
to cardiac arrest.
pulmonary disease (COPD)
• Abnormally slow breathing (rate <8/min) may
indicate terminal exhaustion of the patient or The spectre of the patient with severe chronic res-
brain stem depression due to ischaemia, hypoxia piratory disease, chronic hypoxia and a hypoxic
or drugs (e.g. opioids). drive to breathing is a frequent cause of concern
• Look for the presence of cyanosis (peripheral or and confusion for the inexperienced. The worry is
central). that administration of a high concentration of
• Examine the chest, palpating, percussing and oxygen will remove the respiratory drive of such
auscultating for primary and secondary respiratory patients and produce hypoventilation with in-
problems. creasing hypercapnia, progressing to unrespon-
• Pulse oximetry and arterial blood gas analysis siveness and respiratory arrest. However, these
provide useful additional information. patients represent a minority. There are two key
Do not forget: points to remember:
• Severe respiratory failure may be masked by ad- • Patients will die as a consequence of withhold-
ministration of a high concentration of inspired ing oxygen in high concentration because of an
oxygen to the patient. A normal PaO2 (12–14 kPa) unwarranted concern about hypoxic drive.
breathing 100% O2 is NOT normal! • Patients do not die of hypercapnia — they die of
• When the oxygen saturation of arterial blood is hypoxia.
90% the PaO2 is only 8 kPa. Unless the patient’s history strongly suggests severe
• A hypoxaemic patient will usually hyperventi- chronic respiratory disease, give a high concentra-
late, resulting in a low PaCO2. tion of oxygen.
• A high PaCO2 in the presence of hypoxaemia is an Oxygen should be administered at a lower con-
ominous sign: it usually indicates exhaustion of centration (e.g. 28–40%) to patients in whom a hy-
the patient. poxic drive is strongly suspected and the response
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Recognition and management of the critically ill patient Chapter 5
• Pneumonia • Exhaustion
• Acute asthma • ARDS
• Acute exacerbation of COPD • Acute heart failure
• Emphysema • Pulmonary embolism
• Pulmonary fibrosis • Airway obstruction
• Pneumothorax/haemothorax • Neuromuscular problems
• Pulmonary contusion • Myopathies
• Neuropathies
• Guillain–Barré syndrome
• Myasthenia gravis
• CNS depression
• Drugs
• Head injury
• Meningitis/encephalitis
• Cerebral haemorrhage
• Cerebral tumour
• Cerebral hypoxia
• Diaphragmatic splinting
• Morbidly obese patients
• Abdominal pain
• Abdominal distension
carefully observed, both clinically and by repeat- flow greater than the patient’s peak inspiratory
ing arterial blood gas analysis at frequent intervals flow rate to minimize the work of breathing. The
(e.g. every 30 mins). The aim should still be to positive airway pressure improves oxygenation by
achieve the minimum targets stated above, al- increasing functional residual capacity (FRC, the
though it is acknowledged that in a small group of resting volume of the lungs at the end of a normal
patients with severe chronic respiratory disease, expiration), re-expanding collapsed areas of the
even lower target levels for PaO2 may be acceptable. lungs (recruitment) and reducing the tendency of
However, these patients require the early involve- airways to collapse during expiration. Nasal CPAP
ment of an expert to make what are complex may also be administered.
judgements of the risks/benefits of intervention. • NIPPV A mechanical ventilator is connected to a
In patients who fail to improve with simple close-fitting facemask to avoid leaks and allow
oxygen therapy, call for expert help early. They positive pressure assistance of the patient’s own
may require: respiratory efforts. A nasal mask can also be used
• continuous positive airway pressure (CPAP); and CPAP may be applied. The patient is not sedat-
• non-invasive positive pressure ventilation ed as this would inhibit spontaneous respiratory
(NIPPV); effort. Such patients may be managed on the med-
• invasive ventilation. ical HDU or a specific respiratory care unit.
• CPAP A breathing system is attached to a tightly • Invasive ventilation The patient is anaesthetized,
fitting facemask to ensure that a positive pressure is intubated and then sedated to tolerate the tracheal
maintained throughout the respiratory cycle dur- tube. Full mechanical ventilation is provided, in-
ing the patient’s spontaneous respiratory efforts dependent of the patient’s own efforts. Admission
(Fig. 5.1). The apparatus is designed to maintain a to the ICU is necessary.
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Chapter 5 Recognition and management of the critically ill patient
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Recognition and management of the critically ill patient Chapter 5
Table 5.7 Causes of systemic hypotension • Observe the patient for signs of improvement —
decreased pulse and respiratory rate, improved level
Hypovolaemia
• Dehydration/inadequate fluid intake of consciousness, increased blood pressure, etc.
• Haemorrhage • Repeat the fluid challenge, as indicated by the
• Severe vomiting/diarrhoea patient’s response.
• Burns The choice of what type of fluid to use at this stage
• Abnormal fluid losses into the gut (crystalloid or colloid) is probably less important
• High output fistula of the small bowel than the fact that fluid (any fluid) is being given.
Cardiogenic causes However, dextrose-containing solutions are not
• Acute myocardial ischaemia/infarction used for initial resuscitation as they rapidly dis-
• Severe valvular heart disease tribute throughout the entire intracellular and ex-
• Cardiomyopathy tracellular fluid compartments of the body, with
• Acute myocarditis little remaining in the circulation. Where there is
• Constrictive pericarditis evidence of significant blood loss or ongoing
Sepsis haemorrhage, give blood or arrange urgent
• Any cause of systemic sepsis cross-match.
The aim of this initial treatment is to buy time by
Neurogenic
stabilizing the condition of the patient in order to
• High spinal cord injury
make a definitive diagnosis and arrange for more
Anaphylaxis expert management. Patients who are unrespon-
sive to fluid resuscitation alone may have ongoing
fluid losses (e.g. bleeding or extravasation of circu-
condition of the patient as it may herald an im- lating fluid through leaky capillaries in sepsis syn-
pending cardiac arrest — the patient’s overall condi- drome) that require addressing, or complementary
tion and progress must be considered. treatment with inotropes, vasopressors and inva-
The causes of systemic hypotension are summa- sive haemodynamic monitoring (e.g. CVP and pul-
rized in Table 5.7. monary artery flotation catheter (PAFC); see page
It may be possible, from the history and clinical 125). These patients should be referred to the ap-
examination, to arrive at a reasonably certain work- propriate expert.
ing diagnosis and treat accordingly. For example: Patients with severe hypotension due to poor left
• A patient on the CCU with acute myocardial in- ventricular performance after acute myocardial in-
farction and severe hypotension probably has car- farction (cardiogenic shock) may not tolerate a
diogenic shock. rapid, large fluid bolus because the filling pressure
• A hypotensive patient found on a surgical ward of the left ventricle is already increased and its
on the day after major abdominal surgery with ab- muscle fibres are overstretched. If the clinical diag-
dominal distension and surgical drains full of nosis is fairly certain:
blood is probably hypovolaemic. • If not already done, establish intravenous access.
• A patient with pneumonia, a high pyrexia and • Give fluid in slower, smaller aliquots (250 mL).
elevated white cell count who is hypotensive with • Monitor the response very closely, preferably
a rapid, bounding pulse is probably septic. with the aid of invasive haemodynamic monitor-
As a general rule, nearly all patients with clinical ing (e.g. arterial line, CVP and PAFC).
signs of an inadequate circulation such as tachy- These patients often need:
cardia and hypotension respond well to a fluid • reduction of the high preload to the left ventricle
challenge: using diuretics and intravenous nitrates (e.g. glyc-
• If not already done, establish intravenous access. eryl trinitrate, GTN);
• Give a rapid bolus of 500 mL over approximately • reduction of afterload using intravenous arterial
15 mins. vasodilators;
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Chapter 5 Recognition and management of the critically ill patient
• inotropic support to assist in supporting the fail- A standard 12 lead ECG should also be per-
ing myocardium. formed in any patient with warning cardiorespira-
Dobutamine, a synthetic catecholamine, is most tory signs, and will provide valuable information
commonly used. Its actions are predominantly via of significant myocardial ischaemia or infarction.
b-adrenoceptors, increasing myocardial con- A rapid irregular pulse is likely to be due to atrial
tractility and causing arteriolar vasodilatation in fibrillation. This may need additional treatment
skeletal muscle reducing afterload via b2-adreno- with either anti-arrhythmic drugs (e.g. digoxin,
ceptors. amiodarone) or synchronized electrical cardiover-
Such patients should be considered as being at sion using a defibrillator (see page 106). Patients
very high risk of cardiac arrest from which the causing serious concern should be continuously
prognosis is likely to be poor. They must be monitored by ECG, pulse oximeter and invasive
managed in a high dependency area (e.g. CCU) by arterial monitoring.
experienced clinicians. Acute heart rhythm disturbances and their im-
mediate management are summarized in Table 5.8.
Cardiac arrhythmias
Common tachycardias and sinus bradycardia and
their causes have been covered on pages 77–78.
Table 5.8 Acute heart rhythm disturbances and their immediate management
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Recognition and management of the critically ill patient Chapter 5
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Chapter 5 Recognition and management of the critically ill patient
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Recognition and management of the critically ill patient Chapter 5
Table 5.9 Advantages and disadvantages of direct arterial Table 5.10 Uses of central vein catheterization
blood pressure measurement
• Measurement of central venous pressure
Advantages • Infusion of:
• Accuracy • irritant solutions, e.g. KCl
• Continuous measurement gives immediate warning • vasoconstrictor agents, e.g. noradrenaline,
of important changes in blood pressure dopamine
• Shape of arterial waveform gives information relating • parenteral nutrition
to myocardial contractility and other haemodynamic • Insertion of temporary cardiac pacing wire
variables • Insertion of pulmonary artery flotation catheter
• Facility for frequent arterial blood sampling • Venous access:
• for haemodialysis, haemofiltration,
Disadvantages
plasmaphoresis, etc.
• Complex to perform
• in the absence of peripheral veins
• Potentially inaccurate if apparatus is not set up
• during cardiac arrest
correctly
• Haematoma at puncture site
• Infection at puncture site/bacteraemia/septicaemia
• Disconnection haemorrhage
measured dose of lithium is injected intravenously
• Embolization
and cardiac output is calculated from the
• Arterial thrombosis
resultant lithium dilution curve. This value is used
to calibrate the pulse contour analysis and is nor-
for repeated puncturing of veins or arteries. The ad- mally performed only 2–3 times per day. The clear
vantages and disadvantages of direct measurement advantage of this system is that continuous cardiac
are shown in Table 5.9. A cannula is inserted percu- output monitoring of critically ill patients is pos-
taneously into a suitable artery, usually the radial sible without requiring an invasive technique
artery of the non-dominant hand (common alter- other than the arterial line itself, which is already
natives being the femoral and dorsalis pedis routinely inserted into nearly all patients on the
arteries, less commonly the brachial and axillary ICU.
arteries). The arterial blood pressure is transmitted
via a saline-filled catheter to a pressure transducer
Central venous pressure (CVP)
that converts the mechanical signal to a very small
electrical signal, proportional to the pressure. This This is an index of the patient’s circulating volume
signal is amplified and displayed on a monitor as (or more correctly right ventricular preload). It is
both a waveform and pressure readings: systolic, useful for directing fluid therapy in cases of
diastolic and mean. Exposing the transducer to at- dehydration, hypovolaemia due to haemorrhage
mosphere and ensuring that the monitor reads and sepsis syndrome, and in the diagnosis and
zero pressure ensures accuracy of the system. To management of heart failure. The routes com-
prevent the system becoming blocked, it is flushed monly used to measure CVP are discussed on page
constantly with heparinized saline at approxi- 58. A central venous cannula may also be used for
mately 3 mL/h from a pressurized source to prevent a variety of other purposes in the ICU, as shown in
backflow. Central venous and pulmonary artery Table 5.10.
pressures are measured using the same system. The main limitation in monitoring CVP is that
Recently, devices have become available that therapy is directed towards optimizing the filling
analyse the shape of the arterial waveform (pulse pressures on the right side of the heart. While the
contour analysis) and derive stroke volume, and, filling pressures of the right and left sides are nor-
by knowing heart rate, allow cardiac output to be mally closely related, this relationship may not
determined. The arterial line is modified to incor- always be reliable in critically ill patients,
porate an electrode sensitive to lithium. A particularly those with pre-existing cardiac or
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Chapter 5 Recognition and management of the critically ill patient
Figure 5.4 Pressure trace on insertion of PA catheter; (A) in right atrium, (B) in right ventricle, (C) in pulmonary artery, (D)
in pulmonary artery with balloon inflated (‘wedged’).
respiratory disease. In this situation it is of greater Table 5.11 Complications of pulmonary artery
therapeutic value to monitor and optimize condi- catheterization
tions for the left ventricle. • All of the complications associated with central
venous catheterization
• Ventricular dysrhythmias
Pulmonary artery pressures
• Pulmonary infarction
Pressures in the pulmonary artery are monitored • Pulmonary artery rupture
using a PAFC. This is a multi-lumen catheter with • Knot formation
an inflatable balloon and a temperature thermistor • Balloon rupture
at its distal end. • Subacute bacterial endocarditis
• Pericardial tamponade
A PAFC is inserted percutaneously via either the
• Damage to tricuspid or pulmonary valve
internal jugular or subclavian vein in the same
manner as inserting a CVP line. Once the catheter
is in a central vein, as indicated by the pressure
waveform, the balloon is inflated. The flow of cently, PAFCs have become available that incorpo-
blood through the heart carries the balloon for- rate two fibreoptic channels and measure mixed
ward so that it can be advanced through the right venous oxygen saturation continuously. One
atrium and ventricle until the tip lies in a main channel transmits near infrared light that is
branch of the pulmonary artery (Fig. 5.4). In this reflected by the passing red cells; a second fibreop-
position, an indirect assessment of the filling pres- tic channel conducts the reflected light to a pho-
sure in the left ventricle can be made. The pressure todetector that determines the oxygen saturation
obtained is commonly referred to as the wedge of the haemoglobin.
pressure because the balloon is advanced until it
‘wedges’ in the pulmonary artery. The wedge pres-
Pulse oximetry
sure is usually closely related to the left ventricular
end-diastolic pressure (LVEDP). This is a more ac- The pulse oximeter provides a simple, non-inva-
curate indication of the preload to the left ventricle sive, continuous assessment of the oxygenation of
than the CVP. The wedge pressure is influenced by the peripheral tissues (SpO2). It therefore gives a
many of the factors affecting CVP and trends are simultaneous indication of the degree of oxygena-
more useful than absolute values. Complications tion of the blood by the respiratory system and the
associated with PAFC insertion are listed in Table ability of the cardiovascular system to deliver it to
5.11. the tissues. By providing continuous monitoring it
In addition to invasive pressure data, the can be used to give an early warning of deteriora-
catheter can also be used to measure cardiac output tion in a patient’s condition. The principles of
and allow mixed venous blood to be sampled. Re- operation are described on page 50.
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Recognition and management of the critically ill patient Chapter 5
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Chapter 5 Recognition and management of the critically ill patient
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Recognition and management of the critically ill patient Chapter 5
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Chapter 5 Recognition and management of the critically ill patient
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Recognition and management of the critically ill patient Chapter 5
Table 5.15 Problems associated with deep sedation with Table 5.17 Indication for total parenteral nutrition and
paralysis associated complications
• Immunosuppression Indications
• Increased incidence of infection • Ileus following major bowel surgery
• Prolonged recovery times • Acute pancreatitis
• Loss of contact with reality, with an adverse effect on • Inflammatory bowel disease
psychological well-being • Short bowel syndromes
• Increased incidence of ICU neuropathy (weakness • Malabsorption syndromes
and wasting of skeletal muscle) • Multiple organ failure
• Postoesophagectomy
• Severe catabolic states, e.g. extensive burns, sepsis,
trauma
Table 5.16 Ramsay sedation scale
Complications
Level Conscious level • Central line sepsis
1 Restless and agitated • Acute gastric erosion
2 Co-operative, calm, orientated • Hyperglycaemia
3 Asleep, responds to verbal command • Specific mineral or vitamin deficiencies
4 Asleep, responds briskly to glabellar tap • Less satisfactory nutrition of the luminal mucosa of
5 Asleep, responds sluggishly to glabellar tap the gut
6 No response
produces calm, co-operative patients who are thus concentration of local anaesthetic and opioid (see
easier to nurse and treat. Similarly, patients admit- page 86). This technique is suitable for pain relief
ted to the ICU following major surgery or trauma following surgery or trauma to the thorax, ab-
will suffer if good analgesia is not provided. Many domen, pelvis and lower limbs. It is often easier to
of the invasive procedures that are undertaken on wean patients off mechanical ventilation more
patients are also painful and, as mentioned above, quickly in the presence of epidural analgesia as
even the presence of the tracheal tube itself can be they are more able to take deep breaths and cough
distressingly uncomfortable. As recently as 10–20 forcefully, uninhibited by pain or the respiratory
years ago, it was common practice to deeply sedate depressant effects of systemic opioids.
and paralyse all patients so that they were com-
pletely unaware of their surroundings. It is now
Nutrition
realized that such deep sedation is not only unnec-
essary, but may also be harmful (Table 5.15). Maintenance of adequate nutrition is an essential
The ideal level of sedation is one in which the pa- element of the care of critically ill patients. Where
tient is calm, awake and orientated during appro- possible, patients should be fed enterally and there
priate periods of the day. The Ramsay sedation is no reason why feeding cannot be commenced
scale (Table 5.16) is used on many ICUs, a score of on day one in many patients. If the gut is working,
2–4 being considered satisfactory depending on use it! Enteral feeding is simpler to administer, less
the clinical situation, time of day, etc. expensive, more physiological and associated with
The most commonly used sedative drugs are mi- fewer complications than total parenteral nutri-
dazolam and propofol. Opioids such as morphine, tion (TPN). The presence of food within the gut
fentanyl, alfentanil and remifentanil are used also stimulates blood flow and facilitates earlier re-
when analgesia is required. Regional anaesthetic covery of normal gastrointestinal function. Indica-
techniques are also used, particularly continuous tions for TPN and associated complications are
epidural analgesia using a combination of a low listed in Table 5.17.
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Chapter 5 Recognition and management of the critically ill patient
Table 5.18 Risk factors for nosocomial infection on the Table 5.19 Prevention of nosocomial infection on the ICU
ICU
Good basic hygiene standards
• Extremes of age • Scrupulous washing of hands immediately before
• Pre-existing medical conditions and after contact with patient; wearing of gloves and
• Poor nutritional status aprons
• Immunosuppressive effect of illness, drugs • Regular disinfection of ventilator tubing or use of
• ICU is a breeding site for antibiotic-resistant strains of disposable equipment
bacteria • Use of bacterial/viral filters between patient and
• Breach of body surface defences: ventilator
• Tracheal intubation • Insertion of IV lines, catheters under full asepsis
• Urinary catheter • Regular toileting of patient, particularly surgical
• IV and arterial lines wounds and sites of insertion of IV lines, catheters
• Raised intragastric pH due to H2-antagonists • Routine changing of IV and arterial lines after a
defined period (not proven to be effective)
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Recognition and management of the critically ill patient Chapter 5
to remember that it is the partial pressure of oxy- Appropriate antibiotics should be given in the
gen in arterial blood (PaO2) that is responsible for presence of a chest infection. It is essential to ob-
respiratory drive, not the inspired oxygen concen- tain a specimen of sputum for microbiological
tration. If there are serious concerns regarding a se- examination and antibiotic-sensitivity testing,
verely hypoxic patient with chronic respiratory ideally from the lower respiratory tract. Bron-
disease and a suspected hypoxic ventilatory drive, chodilators may be useful in patients with bron-
immediate referral to an expert is advised. chospasm associated with asthma or chronic
Although pulmonary oxygen toxicity may occur obstructive airways disease, chest infection, pul-
when oxygen is administered in a concentration monary aspiration or ARDS. Bronchodilators are
>40% for a prolonged period, it is both illogical and commonly administered as a nebulized mist di-
dangerous to withhold higher concentrations in rectly to the respiratory tract (e.g. salbutamol,
hypoxic patients with severe respiratory failure. In ipratropium). They may also be given by IV
any case, oxygen toxicity is more closely correlated infusion (salbutamol, adrenaline, aminophylline),
with PaO2 than inspired oxygen concentration. although there is a greater risk of arrhythmias.
The majority of patients admitted to the ICU re- Effective physiotherapy is an essential part of
quire mechanical ventilation. Many of these have respiratory care for all patients on the ICU. Tech-
ARDS and require the use of high inflation pres- niques used by physiotherapists in helping to
sures to provide an adequate tidal volume. In expectorate secretions from the lungs include
ARDS, the lungs become very stiff (decreased com- the positioning of patients to facilitate postural
pliance) due to alveolar and interstitial oedema, drainage of secretions and percussion of the chest
acute inflammatory infiltrates, atelectasis and pul- to help loosen secretions. Suctioning of the trachea
monary fibrosis. Although it is obvious that these and upper airways is important as nearly all criti-
patients would die without mechanical ventila- cally ill patients, whether sedated and paralysed or
tion, in recent years it has become increasingly ap- not, are incapable of coughing effectively because
parent that mechanical ventilation itself may of generalized muscle weakness.
further injure the lung in critically ill patients. This Two other techniques practised on many ICUs in
lung damage is caused by high inflation pressures severe respiratory failure and ARDS are:
(barotrauma), over-distension of more compliant
areas of the lung (volutrauma) and trauma due to
Pulmonary arterial vasodilator therapy
repeated ‘snapping’ open and closed of collapsed
(inhaled nitric oxide (NO) gas or
alveoli during inspiration and expiration (atelec-
nebulized prostacyclin)
trauma). There is now good evidence that limiting
inflation pressures by accepting lower tidal The rationale for vasodilator therapy is that the
volumes (e.g. 6 mL/kg rather than 10–12 mL/kg) inhaled drug is delivered only to well-ventilated
may reduce ICU length of stay and mortality. Ap- alveoli where it is a potent pulmonary arterial va-
plication of a high PEEP pressure (approximately sodilator. Pulmonary arterioles associated with
15 cmH2O) also helps to minimize the extent of poorly ventilated alveoli remain unaffected. It may
alveolar collapse and atelectrauma. This ‘protec- be anticipated that this will lead to an improve-
tive ventilatory strategy’ is therefore becoming ment in the ventilation to perfusion ratio and in
more widespread in the UK, using a combination practice the initial response of the patient is often
of a specialized mode of ventilation called pres- a significant improvement in oxygenation. How-
sure-controlled ventilation (PCV), a reversed I : E ever, the results of clinical trials have been disap-
ratio and high PEEP. One of the consequences of pointing and there is as yet insufficient data
protective ventilation is an increased PaCO2 and available to demonstrate a beneficial effect on
respiratory acidosis — permissive hypercapnia. actual mortality from ARDS.
However, this is tolerated by most critically
ill patients.
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Chapter 5 Recognition and management of the critically ill patient
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Recognition and management of the critically ill patient Chapter 5
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Chapter 5 Recognition and management of the critically ill patient
Table 5.20 The systemic inflammatory response syndrome result of all these derangements is lactic acidosis
due to oxygen supply–demand imbalance, the de-
Defined as the presence of two or more of the
following: velopment of an oxygen debt and an increase in
• Temperature >38°C or <36°C anaerobic metabolism.
• Heart rate >90 beats/min Like any other inflammatory response, SIRS is a
• Tachypnoea >20 breaths/min or PaCO2 <32 mmHg physiological mechanism for defence of the body
• White blood cell count >12 ¥ 109/L, or <4 ¥ 109/L, or after a major insult, facilitating eradication of in-
>10% immature forms fection and tissue repair. The problem is that the
host response becomes amplified and uncon-
week) episodes of standard haemodialysis. How- trolled, contributing to further tissue damage and
ever, as alluded to above, this disadvantage is also dysfunction.
an advantage in that it promotes haemodynamic The principles of treating sepsis syndrome and
stability. SIRS are the provision of support for failing organ
systems (optimization of oxygenation of arterial
blood, mechanical ventilation, fluid resuscitation,
Sepsis syndrome and SIRS
inotropic and vasopressor drugs, haemofiltration,
These two terms are often used interchangeably. clotting factors, etc.), and targeting any infecting
Although there is considerable overlap between organism with appropriate antibiotic therapy. This
them, they describe subtly different clinical may require repeated blood cultures and analysis
conditions. of specimens of sputum, urine, and wound and
• Sepsis syndrome A condition in which the host is catheter sites to identify the organism responsible.
overwhelmed by an infecting organism, classically If a collection of pus within the thorax, abdomen,
a Gram-negative bacterium, producing endotoxin pelvis or elsewhere is a clinical possibility, it must
and/or exotoxins. Endotoxin is a lipopolysaccha- be sought aggressively using ultrasound scanning,
ride component of the cell membrane of computerized tomography (CT) scan or laparo-
Gram-negative organisms, whereas exotoxins are tomy. Such patients do not recover if surgical
bacterial products that may be released into the drainage is not undertaken.
circulation. There have been attempts to target the abnormal
• SIRS The clinical manifestations of the hyper- inflammatory cascade caused by the circulating in-
metabolic state seen after any major insult to the flammatory mediators. Earlier studies examining
body, and defined in Table 5.20. The insult may be the efficacy of monoclonal antibodies to one of the
infection in which case SIRS and sepsis syndrome principle cytokines, tumour necrosis factor (TNF)
describe the same pathophysiology. However, in- were disappointing and failed to demonstrate any
fection is not the only trigger for SIRS and other clinical advantage. However, it is possible that ad-
causes include major trauma, burns and acute vances in this area may be made as further research
pancreatitis. elucidates more detailed information concerning
The clinical features of sepsis syndrome and SIRS the pathophysiology of sepsis syndrome and SIRS.
are similar, with hypermetabolism, circulatory More recently, evidence has emerged of the effi-
shock due to systemic vasodilatation and extrava- cacy of activated protein C (APC), a natural circu-
sation of fluid (via leaky capillaries). In the lungs, lating anticoagulant. APC levels are decreased in
these manifestations present as ARDS. Elsewhere, severe sepsis due to both excessive consumption
oxygen delivery to cells is compromised by shunt- and reduced activation, and the size of the decrease
ing of blood away from capillary beds through ar- correlates with mortality. Consequently, micro-
teriovenous channels that open in response to the thrombi develop throughout the circulation in
inflammatory response. Oxygen consumption by sepsis syndrome and this is one of the main causes
cells may also be reduced as a consequence of in- of end-organ dysfunction. The process is inhibited
tracellular dysfunction of the mitochondria. The by APC. In a recent large double-blind, placebo-
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Recognition and management of the critically ill patient Chapter 5
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Chapter 5 Recognition and management of the critically ill patient
138
Chapter 6
Anaesthetists and chronic pain
Anaesthesia is concerned with reducing sensation • Distraction A kick on the shin during a game of
during surgery; it does not in itself cure patients football is likely to provoke very different pain be-
but enables important treatment to take place haviour when possession is maintained with a
without the experience of pain. This is achieved by clear shot at goal compared to losing the tackle and
the careful application of clinical physiology, phar- with it the chance of victory!
macology and therapeutics. With this expertise in • Meaning of pain In the previous example, the
pain and symptom control, some anaesthetists football injury and the sensations that go with it
have specialized in the management of pain as a will have a positive meaning. A display of pain be-
problem in its own right, leading to the establish- haviour may bring about a reward, particularly for
ment of modern pain relief clinics where they work being brought down in the penalty area. Similar
with a team of nurses, physiotherapists and sensations in a cancer patient with a bone metasta-
psychologists. sis in the tibia may provoke anxiety, and fear of
pain as yet another problem to be endured — cer-
tainly a negative meaning.
The definition of pain
• Significance of pain The symptoms of headache,
The International Association for the Study of Pain photophobia and vomiting in a medical student
defines pain as: would normally result in presentation at the local
‘An unpleasant sensory and emotional experience casualty department with a self-made diagnosis of
associated with actual or potential tissue damage meningitis. Exactly the same symptoms would be
or described in terms of such damage’. ignored in the knowledge that he (or she) had
Many interactions within the central nervous drunk 10 pints of lager the night before! Thus pain
system, previous experiences and present emo- behaviour is conditioned by knowledge and
tional state will all determine the reactions to tis- understanding.
sue injury. • Memory and culture of pain Pain may leave a
The following are examples of this: memory that will discourage repeating an action.
• Effect of changed environment A hospital admis- Alternatively a response may be learned from ob-
sion where painful treatment is expected may re- serving the behaviour and attitudes of others. This
sult in an apparently minor stimulation, such as can have both beneficial and detrimental effects.
venepuncture, which may otherwise be tolerated, Cultural differences are important when treating
initiating an overwhelming state of distress. patients of different nationality and race. Age is
139
Chapter 6 Anaesthetists and chronic pain
important: children may not have the means to may not resolve with healing of the tissues; in
understand pain, or otherwise they express both other words the protective mechanisms have not
pain and distress by crying. The elderly may be too extinguished themselves. This may lead to confu-
ashamed to admit to needing help with pain. sion for both doctors and patients, with repeated
attempts at surgical intervention which only ex-
acerbate the problem (e.g. postsurgical back pain
Acute versus chronic pain does not usually respond to further operations).
Chronic benign pain can also occur without injury
if hyperaesthesia and allodynia occur for reasons
Acute pain
other than injury; a similar pain state will result as
When injury has taken place, pain normally limits when injury is responsible.
activity and promotes healing. The pain from a • Cancer pain (pain associated with a malignant
blister on the heel when wearing new shoes is a tumour) This is usually included as a chronic pain
warning in an attempt to prevent more severe but it is best thought of as a combination of
damage to the skin. A healing wound is guarded, several acute pains from destructive effects of the
preventing stress on newly formed connective tis- tumour. Once established, even with treatment,
sues and the risk of wound breakdown. The region pain is usually a feature of remaining life.
of the body surrounding the injury, even the whole We live in a society with high expectations of med-
limb, may also undergo change, becoming sensi- ical intervention for injury and illness. Severe pain
tive to even minor stimulation. The changes normally elicits sympathy and naturally we strive
comprise: to relieve it whenever possible. Once severe pain is
• hyperaesthesia: increased appreciation of any established, however, the resistance to further pain
stimulus; is reduced — the physiological pain threshold is
• hyperalgesia: more intense appreciation of a lowered and normally innocuous stimuli may not
painful stimulus; be tolerated. Symptoms from mild degenerative
• allodynia: sensation of pain in response to a nor- conditions may be amplified. Prolonged illness or
mally non-painful stimulus. distress results in emotional changes, particularly
They are mediated partly by locally released sub- depression of mood. The questioning of the sever-
stances in the tissues (inflammation), but also by ity of pain exacerbates depression in patients with
changes in the spinal cord processing of neuronal chronic pain.
information. Hyperaesthesia, hyperalgesia and al- To summarize:
lodynia usually resolve as injuries heal. These pro- • Acute pain: the normal body responds to nox-
tective and incapacitating functions are an acute ious stimuli with the experience of pain.
response to trauma, surgery or acute illness. • Chronic pain: the sensitized nervous system re-
sponds more readily to both noxious and innocu-
ous stimuli.
Chronic pain
The remainder of this chapter considers the under-
This suggests persistence of the pain for a long standing, mechanisms and management of the
time. There are several useful subdivisions: pain problems seen in pain relief clinics.
• Pain from continuing tissue damage Rheumatoid
arthritis pain is an example. Pain usually restricts
Mechanisms of pain generation
movement and is useful in preventing further
damage to the joint. In contrast, neuropathic The following account separates pain mechanisms
joints that have lost sensation, for example in dia- into distinct entities, but it must be remembered
betes, degenerate rapidly. that in reality most pain results from activation of
• Chronic benign pain (pain despite tissue healing) several mechanisms, such that the final experience
The hyperaesthesia and allodynia of acute injury is complex.
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Anaesthetists and chronic pain Chapter 6
• 5-hydroxytriptamine (5-HT);
• hydrogen and potassium ions.
• Prostaglandins These sensitize nerve endings to
Experience and
expression of pain react more intensely to further stimulation; for ex-
ample a fingernail when hit with a hammer, al-
though perhaps not showing signs of damage, is
very sensitive to further touch and movement.
• Other stimuli Impulses from pain and tempera-
Higher pains ture receptors are carried in similar small nerve
BRAIN
fibres and the threshold for stimulation may be re-
duced at low temperatures. For example, arthritis
patients commonly complain of increased pain
Central pain during cold weather. It is not necessary for there to
-brain injury
be tissue damage to elicit pain from the periphery;
-thalamic pain
pathways may be stimulated by unusual stimuli:
eating ice-cream too quickly often provokes an in-
Denervation SPINAL tense headache but is not usually perceived as a
CORD threat to bodily integrity!
• Peripheral nerve damage Damage to the nerves
Peripheral supplying an area of the body may result in pain.
nerve injury Peripheral nerves are not normally sensitive to
mechanical stimuli, but attempts at regeneration
Prostaglandins
within a damaged nerve may result in a neuroma
Tissue injury that can be exquisitely tender. The pain will
Simple stimuli
be referred to the area served by the nerve, al-
TISSUES though obviously there is no damage to the painful
Other stimuli
(temperature) area.
• Denervation Pain may occur even when sensory
receptors are absent, for example after amputation.
Figure 6.1 Mechanisms of pain generation. Sensation can be attributed to an area of the body
that does not exist because the brain still has a rep-
resentation of the absent part (e.g. the painful
‘phantom limb’).
Pain may be generated in a number of ways • Central pain Damage of the thalamic pathways
(Fig. 6.1): which carry nociceptive information can lead to
• Simple stimulation Normal activity causing the experience of pain. As with many chronic
stimulation of tissues can lead to pain; for example pains, the problem is within the central nervous
the sensation of pressure when maintaining an system and it rarely responds to conventional
uncomfortable posture is relieved on shifting analgesia.
position. It is often subconscious and protects us • Higher pains We have probably all suffered grief,
from damage when attention may be focused perhaps the death of a loved relative or failure in
elsewhere. an important examination. We describe this as
• Tissue injury This results in structural elements painful and although the pain cannot be localized
being damaged and an inflammatory response to a particular body part, it is nevertheless very real.
occurs. Many chemicals are released, including: This pain exists with no physical input to the body.
• histamine; The pain of a broken heart is no less real than the
• bradykinin; pain of a broken leg.
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Chapter 6 Anaesthetists and chronic pain
CENTRAL
CONTROL
Large fibres
+ - +
ACTION
IN
INPUT SG T SYSTEM
(brain)
- - +
Small fibres
Synapses
+ excitatory
- inhibitory
IN, inhibitory interneurones;
SG, substantia gelatinosa;
T, transmission cell
Figure 6.2 The gate theory of pain.
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Anaesthetists and chronic pain Chapter 6
taking a full history and performing a physical used to help patients choose a suitable description
examination prior to ordering investigations and (e.g. the McGill pain questionnaire). Trigeminal
initiating treatment. Chronic pain is a specific neuralgia may be described as shooting, fibromyal-
condition that must be recognized and treated, gia as exhausting, burning and nauseating.
rather than a diagnosis of exclusion because • The pain history Past treatment and investiga-
nothing else will account for the pain. Patients’ tions are often long and complex, and involve dif-
symptoms may previously have been dismissed — ferent hospitals and specialists. A complete history
listening and understanding are as important as will include:
any prescription. • the time-course of the pain;
• accentuating or relieving factors;
• the pattern of activity and relation to pain;
History
• the effect on sleep;
• Site This may be obvious and related to a • previous and current treatment, including:
previous injury. Diffuse or non-dermatomal pat- • medications;
terns of pain distribution are related to central • type and effects of physiotherapy;
sensitization and do not imply that the symptoms • aids and appliances;
are not genuine. Pain may be felt in structures • alternative therapies tried;
with common innervation (e.g. heart with left • the effect on employment;
arm, leg with low back). Pain diagrams are helpful • financial support:
(Fig. 6.3). • invalidity benefits;
• Character Some conditions are associated with • pensions;
pain of a particular nature. Lists of words have been • Disability Living Allowance, etc.;
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Chapter 6 Anaesthetists and chronic pain
• social and family losses because of pain; • skin: signs of sympathetic dysfunction:
• concerns about the future; • temperature change;
• uncertainties about diagnosis and treatment; • loss of hair growth;
• past medical history, including episodes of • vascular changes and discoloration;
vague or unexplained illnesses; • disorders of sensation.
• family history, which may reveal clues as to In addition, loss of confidence in movements,
coping mechanisms and attitude to chronic ill- guarding and abnormal posture are noted as possi-
ness within the family. ble contributions to maintaining chronic pain.
Some patients have no physical signs despite se-
vere symptoms — again this does not imply that the
Psychological assessment
pain is not genuine.
An assessment of mood is important and fre-
quently reveals evidence of depression. This may
Measurement of pain
be related to the pain itself, but is also associated
with frustration or anger at many previous at- It is impossible to measure an experience directly
tempts at treatment or the failure of treatment, so we rely on written or verbal self-report, as well as
lack of a clear diagnosis or disease, and loss of social facial expression, body language and behaviour to
and financial status. These are all common with assess pain. Surrogate measures such as the number
chronic pain. The assistance of a psychologist is in- of breakthrough analgesia tablets taken may be
valuable to explore emotional issues associated useful as a measure of pain or of the effectiveness of
with, or caused by, the pain. Wherever possible, treatment. Psychological measures of coping, dis-
patients should be seen with a partner in order to tress and depression are all valuable tools in
assess independently the degree of physical and exploring the pain; however, they should be
emotional disturbance at home and with the interpreted carefully in conjunction with a clinical
family. Depression is a normal human response to psychologist.
an uncertain future full of pain.
Investigations
Physical examination
Patients with chronic pain have usually had many
It is unusual for patients to present with ‘put on’ investigations and may be frustrated that nothing
symptoms of pain. Malingering is very rare. Often has been found. They may not understand that
symptoms and the reaction to examination are ex- pain cannot be seen on their scans and X-rays. Care
aggerated, but this is not surprising considering must be taken to explain that the absence of posi-
that most patients with years of suffering are likely tive findings does not mean that the pain is in any
to be distressed and anxious. Exaggeration may be way ‘imaginary’, ‘all in the mind’ or ‘psychologi-
to convince rather than to deceive. Most patients cal’. One danger of sensitive tests, such as MRI, is
experience worse pain after even limited clinical that abnormalities that are coincidental to the pain
examination. may be revealed — careful feedback of information
Pain may be associated with the following is always required. Figure 6.4 demonstrates that
structures: disease does not always cause pain.
• bones: deformity, tenderness; Some well-meaning explanations may increase
• joints: swelling, tenderness, limitation of anxiety. Using terms such as ‘crumbling spine’ or
movement; ‘degenerative changes’ in chronic low back pain
• nerves: function, swelling or tenderness over the may invoke fear for the future and a life of increas-
course of a peripheral nerve; ing disability, whereas in fact both back pain and
• muscles: power and tone, localized or general- the preferable term ‘age-related change’ are com-
ized tenderness; mon and are not well correlated.
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Anaesthetists and chronic pain Chapter 6
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Chapter 6 Anaesthetists and chronic pain
tramadol, codeine or dihydrocodeine are com- postherpetic neuralgia (PHN) are all examples
monly prescribed for chronic pain. They have the of pain syndromes that may respond to
same effects and side-effects as morphine but the anticonvulsants.
maximum analgesic effect is limited.
There is no doubt that the proper (generous) use
of opioids in cancer pain has revolutionized re- Steroids
maining life for cancer patients. Debate continues, These are often injected into joints or tendon
however, about the use of opioids in chronic be- sheaths for arthritis or inflammatory pain, but are
nign pain (such as low back pain). Modest doses of not generally indicated for chronic benign pain be-
opioids continued on a regular prescription with cause of the risk of osteoporosis and gastric ulcera-
careful monitoring of dose and effect appear to be tion. Injections of steroid into the epidural space
safe and very helpful for some patients, especially may be tried when nerve roots are thought to be
if other physical and psychological treatments are compressed or inflamed: the benefit may be due to
made available. a reduction in nerve root oedema. There may be a
useful reduction in swelling and compression from
solid tumours associated with improved appetite
Non-steroidal anti-inflammatory drugs
and well-being in cancer patients.
NSAIDs are often used alone or in combination
with opioids, particularly where there is inflamma-
tory or bone pain. Their mechanism of action and Capsaicin
side-effects are discussed on page 40. A wide range Applied topically as a cream, this extract of the
of both non-specific and COX-2 inhibitors are chilli pepper can depress C-fibre nerve function. It
available; the latter are preferable for long-term use has been found useful in cutaneous pain problems
in vulnerable groups, for example the elderly and such as scar pain and postherpetic neuralgia. It pro-
those on steroids. duces a burning sensation, so may be used with a
topical local anaesthetic.
Tricyclic antidepressants
The mechanism of action is thought to be due to Non-pharmacological interventions
the potentiation of serotonin and noradrenaline in (Fig. 6.5)
the CNS. Amitriptyline is the most commonly used
drug, and has been used extensively to treat neuro-
Nerve blocks
pathic pain. The sedative effect may be useful for
sleep disturbance where this is a problem. The an- These may be performed on any nerves thought to
tidepressant effect may be an additional benefit. be part of the pain pathway and may help in the
Newer antidepressants with fewer anticholinergic understanding of the contribution of peripheral
side-effects are not as useful for chronic pain. input to the overall pain. Sometimes simple nerve
blocks with local anaesthetic give prolonged relief,
perhaps by reducing central sensitization. At-
Anticonvulsants
tempts to make blocks permanent with neurolytic
Carbamazepine, phenytoin and, more recently, agents (alcohol or phenol) often result in worse
gabapentin have been shown to be useful for pain pain, as central neurones lose peripheral inhibi-
associated with nerve damage and are now also tory input and become spontaneously active or
often tried for other pain syndromes where there respond to previously non-painful stimuli from
may be sensitization of the central nervous system. other pathways (allodynia). Indwelling epidural or
Trigeminal neuralgia, denervation of the upper intrathecal catheters delivering local anaesthetic
limb following avulsion of the brachial plexus and or opioid can provide sustained analgesia, for
146
Anaesthetists and chronic pain Chapter 6
Brain Thalamic
stimulation
Cordotomy
Spinal cord
Sympathectomy
Sympathetic nerve
Spinal cord
and ganglion
stimulation
Dorsal root (epidural
ganglion electrodes)
Alcohol or phenol
rhizolysis
Thermocoagulation of
Peripheral dorsal root ganglion
nerve Guanethidine block
Transcutaneous electrical
Tissue nerve stimulation (TENS)
Manipulation
Massage
Vibration
Counter irritation
Figure 6.5 Non-pharmacological Acupuncture
methods of providing analgesia.
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Chapter 6 Anaesthetists and chronic pain
monly sought by patients for chronic muscu- relaxation, with the object of helping the patient
loskeletal pain, usually following unsuccessful to return to useful function with less impact from
conventional treatment. The Alexander Technique the persistent pain.
or yoga offer self help for motivated patients.
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Anaesthetists and chronic pain Chapter 6
spontaneously or with pressure. They are a particu- spinal degenerative changes are common, but
lar problem if compressed by a prosthesis and may these changes do not correlate well with back pain
then have to be surgically resected or repositioned. symptoms. Unfortunately, treatment is not avail-
able for most degenerative changes — there is little
evidence that replacing worn discs or fusing spinal
Complex regional pain syndrome
segments has long-term beneficial effects. Most
(previously known as reflex
important is early exclusion of specific causes of
sympathetic dystrophy)
back pain. These are:
Sometimes the neuronal processes of acute pain • prolapsed intervertebral disc with spinal cord or
(see page 140) do not extinguish themselves after nerve root compression;
an injury and when tissues have apparently • tumour of bone, meninges or nerves;
healed. This results in continued sensitivity and • infection of the spine.
pain. The condition may progress, with signs of New episodes of back pain should be properly
severe tissue inflammation and later atrophy. The investigated and the patient reassured if appropri-
pathophysiology is not fully understood but it ate. Early mobilization and activity are important
can be a severe and very disabling problem. Early to prevent dysfunction and guarding of move-
mobilization appears to be important in prevent- ments of the back. Even 2 days of bed rest may be
ing progression and analgesia is provided to harmful. Most patients are given advice to rest
encourage this. Specific treatment may involve until the pain subsides, and investigation is under-
sympathectomy. taken only after a long delay. This leads to unnec-
essary suffering and dissatisfaction with the
medical profession. Treatment involves acknowl-
Trigeminal neuralgia
edging the pain, education, gradual return to activ-
Many cases are thought to be caused by vascular ity under strict supervision and the introduction of
compression of the trigeminal nerve as it emerges coping skills for pain.
from the pons in the posterior fossa — in fit pa-
tients, surgical decompression may be considered.
Fibromyalgia
In others, anticonvulsant medication or injection
of the trigeminal ganglion with phenol or glycerol A generalized disorder of pain sensation probably
is usually effective. related to abnormal central neuronal activity. It in-
volves widespread tenderness accompanied by
sleep disturbance, fatigue and, not surprisingly, de-
Arthritis
pression. Most common in women in their middle
In this debilitating condition, pain is a frequent years and associated with other pain problems
symptom of joint inflammation and destruction. such as migraine and irritable bowel syndrome. Pa-
Most patients are managed by general practitioners tients benefit most from explanation and reassur-
or by rheumatologists. Patients with severe arthri- ance. Amitriptyline may help restore more normal
tis have visible deformity and disability, which sleep.
leads to their suffering and pain being understood
by others and it is often well tolerated. NSAIDs and
Cancer pain
opioids are usually effective when used in addition
to specific therapy for the disease. Cancers involving destruction of tissue are painful.
Two-thirds of patients with cancer as a terminal ill-
ness have significant pain. Modern chemotherapy,
Back pain
radiotherapy and surgery can reduce the growth of
More than half the population will suffer back pain tumour, but pain may persist even despite techni-
at some time in their lives. With advancing age, cally successful therapy. Pain may be feared more
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Chapter 6 Anaesthetists and chronic pain
than death itself. Symptoms can become over- aimed at coping with pain, which in turn depends
whelming — a mixture of pain, fear, depression, on:
panic and denial — the so-called ‘total pain • understanding that chronic pain is harmless (but
syndrome’. painful);
Unfortunately morphine is not easily available • stopping looking for a cure;
for clinical use in many developing countries. Even • accepting some limitations;
in Western countries, use is inadequate due to fear • knowing that nothing is being hidden;
of side-effects. Large doses of morphine may be re- • a willingness to change (that effort is required).
quired (compared to those used to treat acute
pain), but when correctly used it is safe and effec-
tive for most cancer pain. Preventing chronic pain
It is always possible to do something for cancer
It may be possible to prevent chronic benign pain
pain, and it may be reassuring for patients to know
by more aggressive treatment of acute pain. Identi-
that there are alternative treatments should their
fication of risk factors, early education and discus-
symptoms progress.
sion may help to prevent the loss of function and
frustration that often lead to chronic pain.
The chronic pain syndrome
The precise cause and mechanism of many pain
Useful websites
syndromes remains unknown. Many chronic pain-
clinic patients have the following characteristics: http://www.jr2.ox.ac.uk/bandolier/booth/
• a long history; painpag/
• many consultations; [The Oxford Pain website. An excellent site for
• multiple negative investigations; the latest evidence-based reviews in pain.]
• a high incidence of functional disturbance, for http://www.theacpa.org/resources/
example headache, irritable bowel syndrome; ACPAdrugsupplement2003.pdf
• few standard physical findings; [The American Chronic Pain Association guide
• distress; on drugs used in chronic pain. Although
• depression. primarily aimed at patients, it is full of useful
Medicolegal proceedings are common but only information and links to other sites.]
rarely result in deliberate exaggeration of symp- http://www.nysora.com/
toms. The medical examination of these patients [This is the best website for information about
requires experience and understanding of the con- regional anaesthesia techniques.]
text in which the pain is being experienced. Even http://www.painsociety.org/
experienced clinicians have been known to accuse [The UK Pain Society website gives guidance on
these patients of malingering. UK practice.]
Patients may have coped well with the pain for a http://www.iasp-pain.org/index.html
long period of time — it is usually a series of events [The International Association for Study of Pain
as a consequence of the pain that precipitates re- (IASP), giving guidance on international
ferral. Measures aimed at dealing with the pain practice.]
may be useless if, for example, the patient has be- http://www.ninds.nih.gov/health_and_medical/
come depressed, is dependent on medication, has disorders/chronic_pain.htm
lost his or her employment and self-respect, and [The National Institute of Neurological
has been accused of malingering. Treatment is Disorders and Stroke chronic pain homepage.]
150
Index
Page numbers in italics refer to figures and those in bold to tables; note that figures and tables are only
indicated when they are separated from their text references.
151
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152
Index
Care of the Critically Ill Surgical postoperative pain intensity coronary care unit (CCU) 116,
Patient (CCrISP) 113 and 81 122, 123
carotid artery pulse 102, 109 prevention 150 corticosteroids see steroids
catheters psychological assessment 144 creatinine clearance (CLCR) 127
central venous 58 specific problems 148–50 cricoid pressure 26
over needle 58 treatment 145–8 cricothyroidotomy
terminology 55 vs acute pain 140 needle 27, 28, 94
through needle 58 chronic pain syndrome 150 surgical 27, 29
cell savers 60 circle system 43–4, 45 critical care 112–38
central nervous system (CNS) circulation integrated approach 112, 113
disease 69 acute severe allergic reactions levels 113
central neural blockade 64 91 organization 112
complications 68 assessment 101–2, 120 outreach teams 115
see also epidural basic life support 101–2 training and education 112–13
anaesthesia/analgesia; critically ill patient 120–2 useful websites 137–8
spinal local anaesthetic toxicity 63 see also intensive care unit
anaesthesia/analgesia paediatric basic life support critical illness
central pain 141 109–10 clinical scoring systems
central venous cannulation recovery room equipment 71 113–15
57–8 severe hypotension 97 definition and causes 115–16
complications 58 clinic, preoperative assessment 2 initial assessment and
equipment 58 clotting tests 8, 61 management 116–22
routes 58 coagulopathy, regional cryoprecipitate 60
uses 125 anaesthesia 69 crystalloids 59
central venous pressure (CVP) co-codamol 83 cultural differences, pain response
factors affecting 53 codeine 83, 146 139–40
ICU monitoring 125–6 colloids 59–60 Cushing’s disease 9
monitoring during anaesthesia complex regional pain syndrome cyanosis 72, 95, 118
52–3 149 cyclizine 16, 78
postoperative monitoring 76–7, complications, postoperative cyclo-oxygenase (COX) inhibitors
80 72–9 40
cephalic vein 54 conduction defects 3 cyclo-oxygenase type 2 (COX-2)
cerebral haemorrhage 72 Confidential Enquiry into inhibitors 40, 85
cerebral ischaemia 72 Perioperative Deaths cylinders, medical gas 41
cervical spine X-ray 8 (CEPOD) 9–10, 12
chest compressions, external congenital heart disease 9 dantrolene 98, 99
adult 102 consent 12–13 day case surgery 2
infants, children 109–10 defined 12 dead space, ventilation 72
chest drain 96 information required 13 defibrillation 106–7
chest X-ray obtaining 13 safety 106
acute severe asthma 95 unconscious patient 12 synchronized 107
after central venous useful websites 14 technique 107
cannulation 58 written evidence 13 defibrillators, automated external
preoperative 7–8 continuous arteriovenous (AEDs) 106
children haemofiltration (CAVH) denervation pain 141
basic life support 108, 109–10 135 depression 144, 148
see also paediatric patients continuous positive airways desflurane 31, 32
chiropractic techniques 147–8 pressure (CPAP) 119, 120 dexamethasone 79
chlorpheniramine 91 continuous venovenous dextropropoxyphene 145–6
chronic obstructive pulmonary haemofiltration (CVVH) diabetes 4, 9
disease (COPD) 135 dialysis, ICU patients 135
critical care 118–20, 132–3 controlled drugs 39–40 diamorphine
preoperative assessment 4, 9 convulsions, local anaesthetic chronic pain 140
chronic pain 139–50 toxicity 63 epidural anaesthesia 87
benign 140 cooling measures 98 see also morphine
clinical assessment 142–4 COPD see chronic obstructive diaphragmatic splinting 73
history 143–4 pulmonary disease diazepam 15, 63
investigations 144, 145 coproxamol 145–6 dihydrocodeine 146
physical examination 144 cordotomy 147 distraction 139
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154
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155
Index
intubating laryngeal mask airway loss of resistance technique 65–6 Modified Early Warning Scoring
(ILM) 20, 21, 24–5, 26 lung disease, pre-existing 4 System (MEWSS) 114
investigations, preoperative 7–9 monitoring
additional 7–9 Magill’s forceps 22, 24 during general anaesthesia
baseline (ASA 1) 7, 8 magnesium sulphate 95 47–54
ipratropium bromide 95, 133 maintenance of anaesthesia additional 49, 52–3
ischaemic heart disease 29–33 blood loss 53
postoperative complications major surgery breathing systems 53–4
76, 77–8 postoperative fluid therapy essential 49–51
preoperative assessment 3, 9 79–80 immediately available 49,
isoflurane 31, 32 risk of major cardiac 52
complication 11 integrated systems 50, 51
jaundice 4 malignant hyperpyrexia oxygen supply 53
jaw thrust 17, 99, 100 (hyperthermia) (MH) 5, 34, potential hazards 49
paediatric patients 108 98–9, 111 intensive care unit 124–8
anaesthesia for susceptible during local and regional
ketamine 30, 33 patients 99 anaesthesia 67
ketorolac 40, 85 management 98 perioperative emergencies 91
monitoring during anaesthesia recovery room 71
lactate, serum 128, 134 51, 52 morphine 38
laryngeal mask airway (LMA) Mallampati criteria 6, 7 cancer pain 150
19–21, 26, 70 manipulation 147–8 chronic pain 145
insertion technique 20–1, 22 Mapleson breathing systems 43 patient-controlled analgesia
intubating (ILM) 20, 21, 24–5, masks see facemasks (PCA) 85
26 MC mask 75 postoperative analgesia 82
relative contraindications 20 mean arterial pressure (MAP) routes of administration 84
types available 20, 21 124–5, 134 mortality, perioperative 10
laryngeal spasm 26 targets in ICU patients 134–5 risk indicators 10–12
laryngoscope 22 median cubital vein 54–5 mouth-to-mouth ventilation
laryngoscopy 24, 26 median nerve 55 100–1, 109
latex allergy 90, 91 median vein of forearm 54, 55 mouth-to-nose ventilation 101,
left ventricular failure medical problems, coexisting 109
ICU management 129, 134 history taking 3–4 multiple organ failure syndrome
postoperative 76–7 preoperative assessment 2 (MOFS) 115–16
see also heart failure preoperative referral 9 MAP and cardiac output targets
left ventricular function, medical staff, critical care training 134–5
preoperative assessment 112–13 muscle relaxants see
8–9 Medicines and Healthcare neuromuscular blocking
legs, numbness and weakness products Regulatory Agency drugs
87 70, 111 muscle rigidity 98
leukaemias 9 memory, pain 139 musculoskeletal disorders 6
levo bupivacaine 62 metaraminol 68 myocardial contractility
lignocaine 62, 64 methadone 145 reduced 76–7, 97
liver function tests 7, 128 methaemoglobin 51 therapy to improve 134
LMA see laryngeal mask airway methicillin-resistant myocardial infarction (MI)
local anaesthesia 61–7 Staphylococcus aureus acute 77, 121–2, 123
monitoring during 67 (MRSA) 132 perioperative risk 10–12
peripheral venous cannulation methylprednisolone 91 previous history 3
56 metoclopramide 16, 78–9
role 63–4 midazolam 30 nalbuphine 37
techniques 64–5 minimum alveolar concentration naloxone 39, 82
local anaesthetic drugs 62 (MAC) 29–32, 32 nasal cannulae 74–5
calculation of doses 63 minor surgery nasopharyngeal airway 18, 20
epidural anaesthesia 66, 87 postoperative fluid therapy National Institute for Clinical
inadvertent overdose 63 79 Excellence (NICE) 7, 8,
known allergy 69 risk of major cardiac 69
techniques using 64–7 complication 11 nausea
toxicity 63 Misuse of Drugs Act 1971 39 complicating spinal anaesthesia
lorazepam 15 mivacurium 36 68
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Index
drugs used to treat see operating theatre peripheral arterial (SpO2) 50,
anti-emetic drugs delivery of gases 40–2 126
postoperative 15, 78 minimizing pollution 46–7 oxygen therapy
neostigmine 35 operations COPD 118–19
nerve blocks 146–7 classification 12 critical illness 118
peripheral 85, 146 previous history 4–5 perioperative emergencies 92,
nerve stimulation, peripheral opioid analgesics 37–40 93, 95
35–7 antagonists 39 postoperative hypoxaemia 74
neurological assessment central and peripheral actions respiratory failure 132–3
ICU patients 128 38 oxyhaemoglobin dissociation
preoperative 6 chronic pain 145–6 curve, hypocapnia and
neuroma 148–9 complications 38, 72, 82 46
neuromuscular blockade epidural anaesthesia 66–7, 87
assessment 35–7 ICU patients 131 paediatric patients
residual postoperative 73 less potent 83 basic life support 108–10
reversal 35 overdose 82 monitoring of blood loss 53
neuromuscular blocking drugs partial agonists and mixed tracheal intubation 23
34–7 agonists/antagonists 37–9 pain
depolarizing 34 postoperative analgesia 82–3, acute 140
non-depolarizing 34–5, 36 84 assessment 81–2
neuromuscular disorders 4 premedication 16 cancer 140, 146, 149–50
neuropathic pain 148 pure agonists 38 chronic see chronic pain
neurosurgical patients 123 regular preoperative users 88 continuing tissue damage 140
New York Heart Association regulation 39 definition 139
(NYHA) functional spinal anaesthesia 67, 88 experience 142
classification 3, 4 supply and custody 39–40 factors affecting 81, 139–40
nitric oxide (NO), inhaled 133 opioid receptors 37 gate control theory 142
nitrous oxide 29, 32–3 oral contraceptive pill (OCP) 5 management programmes 148
anaesthetic machine 42 oral fluid intake, postoperative 79 measurement 144
diffusion hypoxia 33, 74 oropharyngeal (Guedel) airway mechanisms of generation
and oxygen see Entonox 18, 19 140–1
in pneumothorax 96 osteopathy 147–8 postoperative see postoperative
supply to operating theatre outreach teams, critical care 115 pain
41 oxycodone 82, 145 useful websites 70, 89, 150
systemic effects 32–3 oxygen variability 142
non-invasive positive pressure alveolar concentration 74 pancuronium 36
ventilation (NIPPV) 119 anaesthetic machine 42 paracetamol 40, 83–4, 85
non-steroidal anti-inflammatory arterial partial pressure (PaO2) parecoxib 40, 85
drugs (NSAIDs) 40, 83–4, 118 parenteral nutrition, total (TPN)
85 delivery devices 74–5 131
chronic pain 146 inspired concentration 43–4, 46 patient-controlled analgesia (PCA)
COX-2 specific 40, 85 anaesthetic machine controls 84–5
nosocomial infections 116, 42 peak expiratory flow (PEF) 95
132 continuous monitoring 53 pericardiocentesis, needle 97
nurses COPD 118–19 peripheral nerve blocks 85, 146
critical care training 112–13 critical illness 118 peripheral nerve damage 141
preoperative assessment 2 delivery devices 74–5 peripheral nerve stimulation 35–7
nutrition, ICU patients 131–2 postoperative hypoxaemia peripheral perfusion, assessment
72, 73–4 76, 120
obesity 17 reduced 74 peripheral resistance, reduced 97
oesophageal detector 25 respiratory failure 132–3 peripheral vascular disease 3, 6
oesophageal intubation, masks 74–5 pethidine 38
inadvertent 25 nasal cannulae 74–5 phantom limb pain 148
older patients supply to operating theatre 41 phenothiazine derivatives 79
epidural anaesthesia 87 toxicity 133 phenytoin 146
postoperative analgesia 81 oxygen saturation physiotherapy 133, 148
oliguria, postoperative 76 after tracheal intubation 25 piped medical gas and vacuum
omeprazole 16 mixed venous, monitoring system (PMGV) 40–2
ondansetron 16, 78 126 platelet concentrates 60, 61
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159
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160