FOURTH EDITION How to Survive

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George Hall MBBS, PhD DSc, FRCA, Department of Anaesthesia, St George’s, University of London, London, UK William Fawcett MBBS, FRCA, FFPMRCA, Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, UK Anaesthesia can be daunting for the novice. How to Survive in Anaesthesia is a pocket-sized book written by three authors with over 90 years of experience in the specialty. It covers basic aspects of airway and fluid management, anaesthetic equipment, common emergencies and a step-by-step guide to anaesthesia for the surgical specialties. It is always practical, ever contemporary and frequently amusing. The safe and practical advice given in this book will help novices not only survive their first few months in anaesthesia but also enjoy them.

Lecture Notes: Clinical Anaesthesia, 3rd Edition Carl L. Gwinnutt 978-1-4051-7038-3

Anatomy for Anaesthetists, 8th Edition Harold Ellis, Stanley J. Feldman, William Harrop-Griffiths 978-1-4051-0663-4

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A Guide for Trainees Neville Robinson George Hall William Fawcett

Robinson, Hall, Fawcett

Anaesthesia Science Nigel Webster, Helen F. Galley 978-0-7279-1773-7

How to Survive in Anaesthesia

FOURTH EDITION

Titles of related interest

How to Survive in Anaesthesia

Neville Robinson MBCh, FRCA, Department of Anaesthesia, Northwick Park and St Mark’s Hospitals, Harrow, Middlesex, UK

FOURTH EDITION

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How to Survive in Anaesthesia

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How to Survive in Anaesthesia A guide for trainees FO U R T H E D I T I O N

Neville Robinson Department of Anaesthesia Northwick Park and St Mark’s Hospitals Harrow, Middlesex UK

George Hall Department of Anaesthesia St George’s University of London London UK

William Fawcett Department of Anaesthesia Royal Surrey County Hospital Guildford, Surrey UK

A John Wiley & Sons, Ltd., Publication

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C 2012 by John Wiley & Sons, Ltd. This edition first published 2012 

BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell. Registered Office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Robinson, Neville. How to survive in anaesthesia : a guide for trainees. – 4th ed. / Neville Robinson, George Hall, William Fawcett. p. ; cm. Includes index. ISBN 978-0-470-65462-0 (pbk.) 1. Anesthesiologists–Training of. 2. Anesthesiology–Study and teaching. I. Hall, George M. (George Martin) II. Fawcett, William, 1962- III. Title. [DNLM: 1. Anesthesia–methods. WO 200] RD81.R655 2011 617.9 6092–dc23

3. Anesthesia.

2011018481

A catalogue record for this book is available from the British Library. This book is published in the following electronic formats: ePDF 9781119950431; Wiley Online Library 9781119950462; ePub 9781119950448 Set in 9.5/12pt Minion by Aptara Inc., New Delhi, India

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This book is dedicated to Charlotte Fawcett

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Contents

List of boxes, ix List of figures, xiii List of tables, xiv Preface to the fourth edition, xv Preface to the third edition, xvi Preface to the second edition, xvii Preface to the first edition, xviii Let’s start at the very beginning . . . , xix Part I: Nuts and bolts, 1

Chapter 1: Evaluation of the airway, 3 Chapter 2: Control of the airway, 9 Chapter 3: Tracheal intubation, 15 Chapter 4: Failed intubation drill, 21 Chapter 5: Vascular access, 25 Chapter 6: Intravenous fluids, 29 Chapter 7: The anaesthetic machine, 33 Chapter 8: Anaesthetic breathing systems, 41 Chapter 9: Ventilators and other equipment, 47 Chapter 10: Monitoring in anaesthesia, 51 Part II: Crises and complications, 57

Chapter 11: Cardiac arrest, 59 Chapter 12: Haemorrhage and blood transfusion, 69 vii

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viii Contents

Chapter 13: Chapter 14: Chapter 15: Chapter 16: Chapter 17: Chapter 18: Chapter 19: Chapter 20:

Anaphylactic reactions, 77 Malignant hyperthermia, 81 Local anaesthetic toxicity, 87 Stridor – upper airway obstruction, 93 Pneumothorax, 99 Common intraoperative problems, 103 Postoperative problems, 111 Anaesthetic mishaps, 121

Part III: Passing the gas, 125

Chapter 21: Chapter 22: Chapter 23: Chapter 24: Chapter 25: Chapter 26: Chapter 27: Chapter 28: Chapter 29: Chapter 30: Chapter 31: Chapter 32: Chapter 33: Chapter 34: Chapter 35:

Preoperative evaluation, 127 Recognition and management of the sick patient, 133 Principles of emergency anaesthesia, 137 Epidural and spinal anaesthesia, 145 Anaesthesia for gynaecological surgery, 153 Anaesthesia for urological surgery, 161 Anaesthesia for abdominal surgery, 169 Anaesthesia for dental and ENT surgery, 175 Anaesthesia for orthopaedic surgery, 183 Anaesthesia for day case surgery, 191 Management of the patient in the recovery area, 195 Postoperative analgesia, 201 Management of head injuries, 207 Anaesthesia in the corridor, 211 Anaesthetic aphorisms, 217

And finally. . ., 221 Index, 223

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List of boxes

1.1 Assessment of the airway, 3 1.2 Medical features of difficult airway intubation, 4 1.3 Anatomical features of difficult airway control and intubation, 4 2.1 Methods of airway control, 9 3.1 Intubation techniques, 15 3.2 Clinical signs used to confirm tracheal intubation, 16 3.3 Technical tests to confirm intubation, 17 3.4 Complications of tracheal intubation, 18 4.1 Initial course of action for failed intubation, 21 4.2 Subsequent decisions for consideration after failed intubation, 22 5.1 Complications of internal jugular vein catheterisation, 27 5.2 Variants in central venous pressure, 27 7.1 Anaesthetic machine components, 33 7.2 One atmosphere of pressure (various units), 33 7.3 Anaesthetic machine checklist, 37 8.1 Anaesthetic breathing circuit components, 41 8.2 Functions of bags in breathing systems, 42 9.1 Types of ventilators, 47 9.2 Suction device components, 49 9.3 Scavenging system components, 49 10.1 Anaesthesia monitoring requirements, 51 10.2 Patient monitoring devices (essential), 53 10.3 Specialised patient monitoring devices, 53 10.4 Causes of low oxygen saturation, 55 10.5 Common causes of high and low Pa CO2 , 56 12.1 Blood loss estimation, 69 12.2 Additives used in red cell storage, 70 12.3 Blood transfusion complications, 72 ix

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x List of boxes

12.4 12.5 13.1 13.2 13.3 14.1 14.2 14.3 14.4 15.1 15.2 15.3 15.4 15.5 15.6 16.1 16.2 17.1 17.2 18.1 18.2 18.3 18.4 18.5 18.6 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 19.9 19.10 21.1 21.2 21.3

Blood volume formulae, 74 Blood transfusion checks, 75 Signs of severe allergic drug reactions, 77 Anaphylaxis – immediate management, 78 Anaphylaxis – secondary management, 79 Clinical signs of malignant hyperthermia (MH), 83 Metabolic signs of malignant hyperthermia, 83 Overall management plan for malignant hyperthermia, 84 Anaesthesia in suspected malignant hyperthermia, 85 Recommendations for the safe use of adrenaline in local anaesthetic solutions, 88 Signs of mild local anaesthetic toxcity, 89 Signs of severe local anaesthetic toxicity, 89 Immediate management of severe local anaesthetic toxicity, 90 Treatment of severe local anaesthetic toxicity without circulatory arrest, 90 Management of cardiac arrest associated with local anaesthetic injection, 90 Common causes of upper airway obstruction, 93 Symptoms and signs of upper airway obstruction, 94 Causes of pneumothorax, 99 Signs of pneumothorax in anaesthesia, 100 Common causes of intraoperative problems, 104 Management of laryngospasm, 105 Differential diagnoses of wheeze, 105 Drug treatment of life-threatening arrhythmias, 107 Major causes of intraoperative hypotension, 108 Causes of intraoperative hypertension, 109 Signs of airway obstruction, 111 Common causes of postoperative airway obstruction, 112 Common causes of failure to breathe, 113 Unusual causes of failure to breathe, 113 Signs of adequate neuromuscular function, 114 Factors associated with postoperative vomiting, 115 Causes of delayed recovery, 116 Factors predisposing to postoperative hypothermia, 117 Prevention of body heat loss, 117 Causes of hyperthermia, 118 Classification of operations, 127 ASA physical status classes, 128 Specific assessment of obesity, 129

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List of boxes xi

21.4 21.5 22.1 23.1 23.2 23.3 23.4 23.5 23.6 23.7 23.8 24.1 24.2 24.3 24.4 24.5 24.6 25.1 25.2 25.3 25.4 25.5 25.6 26.1 26.2 26.3 26.4 26.5 26.6 26.7 26.8 26.9 26.10 27.1 27.2

Basic and advanced preoperative tests, 129 Reasons for premedication, 131 Principles of care in the sick surgical patient, 133 Components of general anaesthesia, 137 Classification of anaesthetic techniques, 138 Methods of facilitating tracheal intubation, 139 Management of tracheal intubation when risk of aspiration, 140 Major side effects of suxamethonium, 142 High risk factors for regurgitation, 143 Signs of pulmonary aspiration, 143 Levels of care, 144 Requirements before starting regional anaesthesia, 145 Absolute and relative contraindications to epidural anaesthesia, 146 Major complications of epidural anaesthesia, 149 Other complications of epidural anaesthesia, 149 Complications of epidural opioids, 150 Factors influencing distribution of local anaesthetic solutions in CSF, 151 Advantages of CO2 use for pneumoperitoneum, 153 Problems arising from gas insufflation, 154 Complications from needle or trochar insertion, 155 Anaesthetic problems of laparoscopic surgery, 155 Anaesthetic considerations in ectopic pregnancy, 156 Anaesthetic considerations for ERPC, 157 Requirements for urological irrigating fluid, 161 Factors influencing the absorption of glycine, 162 Anaesthetic problems for TURP, 162 Symptoms and signs of acute water intoxication (TURP syndrome), 163 Blood tests in suspected TURP syndrome, 163 Management of water intoxication in TURP syndrome, 164 Anaesthesia for TURP, 165 Advantages and disadvantages of regional anaesthesia for TURP, 166 Advantages and disadvantages of general anaesthesia for TURP, 166 Specific considerations in renal surgery, 168 Specific preoperative problems in abdominal surgery, 169 Complications of hypokalaemia, 170

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xii List of boxes

27.3 27.4 27.5 28.1 28.2 28.3 28.4 28.5 28.6 29.1 29.2 29.3 29.4 29.5 29.6 30.1 30.2 31.1 31.2 31.3 31.4 32.1 32.2 32.3 32.4 32.5 33.1 33.2 33.3 34.1 34.2 34.3

Perioperative considerations in abdominal surgery, 170 Specific postoperative problems in abdominal surgery, 171 Anaesthetic problems of anal surgery, 173 Anaesthetic techniques for dental surgery, 176 Considerations for general anaesthesia in dental surgery, 176 Anaesthetic considerations for tonsillectomy, 178 Anaesthetic problems in the bleeding tonsil, 179 Anaesthetic considerations for middle ear surgery, 180 Techniques for induced hypotension, 180 General considerations in orthopaedic anaesthesia, 183 Anaesthetic considerations and techniques for arm surgery, 185 Anaesthetic considerations and techniques for hip and knee surgery, 186 Advantages and disadvantages of regional anaesthesia for hip and knee surgery, 186 Advantages and disadvantages of general anaesthesia for hip and knee surgery, 187 Anaesthetic considerations for spinal surgery, 188 Selection guidelines for day case surgery, 191 Discharge criteria for day case surgery, 192 Main objectives of care in the recovery area, 195 Causes of early postoperative hypoxaemia, 196 Delayed recovery problems, 198 Typical criteria for discharge from recovery, 199 Claimed advantages of good postoperative analgesia, 201 Factors influencing postoperative pain, 202 General plan of postoperative analgesia, 202 Main side effects of NSAIDs, 204 Major side effects of systemic opioids, 204 Causes of secondary brain damage after trauma, 207 Indications for tracheal intubation in the head-injured patient, 208 Guidelines for transferring head-injured patients, 210 Minimum requirements for conduct of anaesthesia, 211 Considerations for electroconvulsive therapy anaesthesia, 212 Anaesthetic considerations for patient transfer, 214

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List of figures

1.1 Structures seen on opening of mouth for Mallampati grades 1–4, 5 1.2 Line shows the thyromental distance from the thyroid cartilage to the tip of the chin, 6 2.1 Laryngeal mask correctly positioned before inflation, with the tip of the mask in the base of the hypopharynx, 10 2.2 Typical tracheal tube, 11 2.3 View of the larynx obtained before intubation, 12 7.1 A pressure-reducing valve, 35 8.1 Mapleson classification of rebreathing systems. Arrows indicate direction of fresh gas flow (FGF), 44 8.2 Coaxial systems of (A) Bain and (B) Lack. FGF, fresh gas flow, 45 11.1 Adult basic life support algorithm, 61 11.2 Adult advanced life support algorithm, 62 11.3 Adult bradycardia algorithm, 64 11.4 Adult tachycardia algorithm, 65 11.5 Paediatric basic life support (healthcare professionals with a duty to respond), 66 11.6 Paediatric advanced life support, 67 23.1 Application of cricoid pressure, 141 24.1 Anatomy of the epidural space, 146 24.2 Tuohy needle, epidural catheter and filter, 148

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List of tables

5.1 6.1 6.2 12.1 15.1 24.1 30.1 32.1 33.1

xiv

Flow rates through typical venous cannulae, 25 Electrolytic composition of intravenous solutions (mmol/l), 30 Properties of colloid solutions, 31 Blood products in common use, 71 Characteristics of local anaesthetic drugs, 87 Dermatomal levels at various anatomical landmarks, 152 Discharge scoring criteria, 192 Typical regimen for intravenous morphine PCA pump, 205 The Glasgow Coma Scale (GCS): neurological assessment, 209

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Preface to the fourth edition

We have updated the content for this edition and added one essential chapter. We wish to thank readers for their helpful comments, and hope that our ideal of assisting anaesthetic novices in providing safe anaesthetic skills and practice is still achieved. William Fawcett has generously agreed to assist with authorship of the book and has provided the text with a new freshness. He has added some case studies to the clinical sections and has contributed to the content of the whole text. Neville Robinson George Hall William Fawcett

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Preface to the third edition

We have added two chapters in response to discussion with trainees who asked for examples of anaesthetic mishaps and help in assessing sick patients. The emphasis remains on providing an introductory text to safe clinical practice. We are grateful to our many colleagues, senior and junior, for their support and advice, particularly Neville Goodman. Neville Robinson George Hall

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Preface to the second edition

We are grateful for the many comments received about the contents and style of the first edition. We have taken the opportunity to decrease the size of the book to make it more of a ‘pocket book’ and we have revised the text and added two new chapters. Our main aim remains to provide a concise readable text that will introduce the new trainee in anaesthesia to safe clinical practice. In addition, the contents of the book are applicable to many clinical aspects of the primary Fellowship examination of the Royal College of Anaesthetists. Neville Robinson George Hall

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Preface to the first edition

If you are a trained anaesthetist, you should not be reading this. If you have just started anaesthesia, congratulations on your choice; you have joined the most interesting specialty in medicine which contains some of the most intelligent, well-adjusted consultants to be found in hospitals (we can think of at least two). In your first few weeks of anaesthesia you will be given much advice, some of which may even be good, and will be influenced by the current issues affecting the specialty. It is easy to believe that audit, high dependency units, acute pain teams, et cetera, are areas of essential knowledge for the newcomer. They are not. They only become relevant when you are capable of conducting a safe anaesthetic. We hope that this short book will help trainees in the first year of anaesthesia by emphasising basic principles and key concepts. Full explanations have been left for ‘proper’ textbooks. We thank the many trainees who over the years have kept us entertained, enthused, sometimes informed, occasionally frightened, and whose ingenuity in devising new mistakes never ceased to amaze. Neville Robinson George Hall

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Let’s start at the very beginning . . .

If you are starting as a trainee in anaesthesia with little knowledge of how operating theatres work, read this. If you understand the theatre environment, go to Chapter 1.

What you need You will need your ID badge, two pens (one invariably runs out of ink or is borrowed), a stethoscope and a copy of this book.

Where to go You need to find the correct changing room, male or female, and change into theatre scrubs, hat and suitable footwear. Do not leave anything valuable in your clothes; lock it away or take it with you. Do not enter the wrong changing room ‘by mistake’ more than once. Do not borrow theatre shoes: the pair you take will belong to one of the senior surgeons, who will make your life a misery for the next few months when (s)he finds that they are missing. Face masks are usually unnecessary except in theatres in which a prosthesis is inserted, such as orthopaedics. You will see staff wandering round the hospital and even local shops in theatre scrubs. One author even saw a person wearing theatre scrubs in an international airport. This is inappropriate, and you should change each time you leave the operating theatres.

How to behave You should be punctual, polite and pleasant to all theatre staff. As a new anaesthetic trainee you are at the very bottom of the theatre hierarchy.

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xx Let’s start at the very beginning . . .

Key people in theatres In each operating theatre there is a scrub nurse and a runner, who is not scrubbed, who fetches instruments for the surgical team. There is usually a theatre sister in overall charge. In the UK the anaesthetist always works with a trained assistant. They may be called an operating department practitioner (ODP), operating department assistant (ODA) or anaesthetic nurse. They will have undergone at least two years of training and are often skilled in resuscitation and trauma assessment. Watch carefully how they prepare for cases and listen to any advice they may give. Very few ODPs are unhelpful to new trainees and the best are outstanding. We have learnt much from experienced ODPs and value their knowledge, commitment and friendship. The theatre manager is an important person, so introduce yourself and try to gain their support (see How to behave). The theatre receptionist/secretary has to deal with the running of the theatres and is often very knowledgeable about the likes and dislikes of senior staff. Time spent in idle chat is usually time well spent.

Key people in anaesthetic departments The most important person in the anaesthetic department is the secretary/ rota organiser. You must not upset them – they can make your life miserable. Other people in the department, who think that they are important, include the College tutor, educational supervisors, module supervisors, clinical supervisors, mentors and the head of department. It is very difficult to find any consultant without a label. The longer the title, the less important the position. You should not need to bother these people in the first few weeks. In many departments you will work with a few senior staff who will guide you gently through the basics of anaesthesia. They are chosen for their kindness, imperturbability and good humour in the presence of the chaos of your initial attempts at anaesthesia. It is their job to imprint safe anaesthetic practice into your receptive brain. You will remember them long after you have forgotten the name of the head of department.

Cleanliness and sterility Cleanliness is important for all theatre staff. Hands must be washed, or an alcohol handrub used, before and after touching patients. This boring ritual is necessary to minimise infections acquired in theatres.

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Let’s start at the very beginning . . . xxi

The patient’s skin should be cleaned with chlorhexidine 2% in isopropyl alcohol 70% before the insertion of needles and cannulae. For central venous cannulation and neuraxial blockade the anaesthetist should adopt surgical sterility: gown, gloves, hat and mask.

Controlled drugs The supply and use of drugs that can cause dependency or abuse, such as opioids, benzodiazepines and cocaine, is tightly controlled by law. These drugs are kept in a locked cupboard, and when they are used you must: r sign the controlled drug register. This is countersigned by another qualified person (nurse/qualified ODP). Your signature confirms that the number of remaining ampoules is correct. r record the amount of drug given to the patient on the anaesthetic chart. r return unopened ampoules to the locked cupboard. r not use the contents of an ampoule for more than one patient. r discard any drug not used, ideally in the presence of a third party. Although these regulations may appear onerous, they have contributed to the very low prevalence of drug dependency among anaesthetists in the UK.

Consent/WHO checklist Anaesthesia is not overburdened with paperwork but there are two key documents that must be checked before surgery starts. The consent form, which gives details of the surgical procedure, must have been signed by the patient and witnessed by a member of the surgical team. The identity of the patient must be determined to ensure that the right patient is in the right place for the right operation. Most hospitals have adopted the WHO Surgical Safety Checklist, which aims to prevent wrong-site surgery and decrease surgical complications. Although most of the details are surgical, the anaesthetist is asked for the ASA status of the patient (see Chapter 21) and if they have any concerns. The latter refers to medical, not personal, concerns so it is inappropriate to mention your doubts about the possible health hazards of your recent social life. All members of the theatre team are introduced by name and role, which is a rapid way of integrating new trainees.

Anaesthetic charts The anaesthetic chart is a contemporaneous record of what happened to the patient while they were your responsibility. It is a very important document

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xxii Let’s start at the very beginning . . .

that must be completed legibly, accurately and in appropriate detail. The chart may be analysed very closely in the future by the legal profession, who will emphasise any omissions, errors and illegibility. A scruffy chart with coffee stains creates a bad impression. Anaesthetic charts vary slightly from hospital to hospital but contain the following basic information: r patient details r preoperative assessment r intraoperative management r postoperative instructions The chart should contain enough information so that another anaesthetist could give an identical anaesthetic from the information recorded.

Enthusiasts The senior anaesthetists who supervise your intitial training will protect you from the more eccentric members of the profession. However, you will encounter enthusiasts who believe passionately that their anaesthetic techniques are superior to those of others. Three groups are easily recognised: regional anaesthesia enthusiasts (always needing the ultrasound machine), infusion enthusiasts (the more infusion pumps the better the anaesthetic) and technology enthusiasts (always using the latest equipment with many totally unnecessary functions). They all have useful knowledge to impart but should be avoided until you can give a safe simple anaesthetic. . . . when you read you begin with A-B-C (airway-breathing-circulation) so read on. (with apologies to The Sound of Music)

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Part I Nuts and bolts

The first section of this book deals with two fundamental aspects of anaesthetic practice: the airway and vascular access. General anaesthesia has been summarised by the simple phrase put up a drip, put down a tube and give plenty of oxygen. Although many anaesthetists resent this glib description of their work, it does have the virtue of emphasising the importance of venous cannulation and control of the airway, which are essential for the safe conduct of anaesthesia. Difficulties arise in anaesthesia when one of these fundamental areas is not secure, and if both fail then disaster is close at hand. Therefore, in the first 10 chapters we concentrate on evaluation and control of the airway, the anaesthetic machine and circuits, basic anaesthetic monitoring, vascular access, and the choice of intravenous fluids. We have not given detailed instructions on how to undertake the practical procedures. There is no substitute for careful instruction from a senior anaesthetist as part of the anaesthetic procedure. At the start of training the application of physiology and pharmacology to anaesthesia is exciting, and knowledge of the equipment may seem mundane and even boring. It is imperative that you have a basic understanding of the equipment you use – failure to do so will put the patient at risk.

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