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Cardiovascular system

The autonomic nervous system The term autonomic nervous system (ANS) refers to the nervous and humoral mechanisms that modify the function of the autonomous or automatic organs. These include heart rate (HR) and force of contraction; calibre of blood vessels; contraction and relaxation of smooth muscle in gut, bladder, bronchi; visual accommodation and pupillary size. Other functions include regulation of secretion from exocrine and other glands…

Muscle function and neuromuscular blockade

In the last 70 years, neuromuscular blocking drugs have become an established part of anaesthetic practice. They were first administered during abdominal surgery in 1942, when Griffith and Johnson in Montreal used Intocostrin, a biologically standardised mixture of the alkaloids of the Indian rubber plant chondrodendron tomentosum to facilitate muscle relaxation during cyclopropane anaesthesia. Previously, only inhalational agents had been used during general anaesthesia, making surgical…

Postoperative nausea and vomiting

It is estimated that up to 80% of patients experience postoperative nausea and vomiting (PONV) within the first 24 h after surgery. If risk factors are identified and acted upon, PONV can be easily managed, but for a small, high-risk cohort of patients, symptoms can be extremely distressing and disabling. Fortunately, the aetiology of PONV is multifactorial; therefore a variety of different treatments and interventions can be…

Physiology and pharmacology of pain

The International Association for the Study of Pain (IASP) defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. It is clear from this definition that the degree of tissue damage and perception of pain are not necessarily correlated. Pain perception is a complex phenomenon, involving sensory, emotional and cognitive processes. Thus, although…

Local anaesthetic agents

Local anaesthetics are analgesic drugs that suppress action potentials by blocking voltage-activated sodium ion (Na + ) channels (VASCs) in excitable tissues. Examples include the amides (e.g. lidocaine, bupivacaine, levobupivacaine, ropivacaine) and esters (e.g. cocaine and procaine) ( Table 5.1 ). Other drugs that can inhibit VASCs, such as diphenhydramine (a first-generation histamine H 1 receptor antagonist) and amitriptyline (a tricyclic antidepressant), also have local anaesthetic…

Intravenous anaesthetic agents and sedatives

A wide variety of therapeutic and non-therapeutic substances will obtund cerebral function and produce a continuum of cognitive states from almost fully awake to unexpected death ( Table 4.1 ). The clinically useful part of this spectrum is characterised by the American Society of Anaesthesiologists as levels of sedation and general anaesthesia ( Table 4.2 ). Any centrally acting depressant agent may produce sedation or general…

anaesthetic agents and medical gases

Inhalational and volatile anaesthetic agents are used widely for the induction and maintenance of general anaesthesia throughout the world. Since the famous demonstration of an ether anaesthetic by William Morton in 1846, the development of volatile anaesthetic agents paved the way for the introduction of modern surgical practices, procedures and techniques. Early agents such as diethyl ether, chloroform, ethyl chloride, cyclopropane and trichloroethylene, although effective, were…

Data, statistics and clinical trials

Statistics is the science of learning from data – from collection and organisation through to analysis, presentation and dissemination. Like all sciences, it has its own vocabulary and can sometimes appear somewhat impenetrable to the uninitiated. This chapter gives an overview of statistical processes and methods, but readers are advised to consult more detailed texts on medical statistics for further information. Whenever data are collected, in…

General principles of pharmacology

Basic principles A drug is a molecule or particle that produces a therapeutic effect by modifying how a biological system responds to a physical or chemical stimulus. This effect can occur locally at the site of administration or after absorption and delivery to a more distant site of action through carriers or mass transit. Most drugs undergo passive or active transport across membranes as part of…

Acute Leg Pain in a Patient With Cellulitis

Case Study A rapid response was initiated by the bedside nurse (RN) for a patient with severe leg pain. Upon the arrival of the rapid response team, the patient was a 48-year-old male with a known history of type 2 diabetes mellitus with insulin dependence, stage III chronic kidney disease, and chronic hypertension. The patient had been admitted two days earlier for lower extremity cellulitis, for…

Acute Foot Discoloration in a Patient With Peripheral Vascular Disease

Case Study A rapid response event was initiated by the bedside nurse after the patient had symptoms of sudden pain in his left foot. Prior to calling the condition, the nurse assessed the patient’s pulse in the affected foot, and she did not feel it. On prompt arrival of the rapid response team, a quick chart review suggested that the patient was a 55-year-old male with…

Muscle Spasms in a Patient With a History of Thyroidectomy

Case Study A rapid response was initiated by the bedside registered nurse for uncontrollable spasms in the hands and feet. Upon the arrival of the rapid response team, the patient was a 72-year-old gentleman with a known history of coronary artery disease, diabetes, hypothyroidism, and morbid obesity. The patient had been admitted earlier for viral gastroenteritis associated with intractable nausea and vomiting. The patient had been…

Muscle Spasms in a Patient With a History of Thyroidectomy

Case Study A rapid response was initiated by the bedside registered nurse for uncontrollable spasms in the hands and feet. Upon the arrival of the rapid response team, the patient was a 72-year-old gentleman with a known history of coronary artery disease, diabetes, hypothyroidism, and morbid obesity. The patient had been admitted earlier for viral gastroenteritis associated with intractable nausea and vomiting. The patient had been…

Tachycardia in a Patient on Amiodarone

Case Study A rapid response event was initiated for a patient who complained of worsening shortness of breath and was found to be tachycardic. Upon the arrival of the rapid response team, the patient was found to be a 65-year-old female with a history of atrial fibrillation, ischemic cardiomyopathy (the last known left ventricular ejection fraction was 40%), and chronic kidney disease. She was admitted to…

Tachycardia in a Patient on Amiodarone

Case Study A rapid response event was initiated for a patient who complained of worsening shortness of breath and was found to be tachycardic. Upon the arrival of the rapid response team, the patient was found to be a 65-year-old female with a history of atrial fibrillation, ischemic cardiomyopathy (the last known left ventricular ejection fraction was 40%), and chronic kidney disease. She was admitted to…

Tachycardia in a Patient on Amiodarone

Case Study A rapid response event was initiated for a patient who complained of worsening shortness of breath and was found to be tachycardic. Upon the arrival of the rapid response team, the patient was found to be a 65-year-old female with a history of atrial fibrillation, ischemic cardiomyopathy (the last known left ventricular ejection fraction was 40%), and chronic kidney disease. She was admitted to…

Hypotension in a Patient With Progressive Neurological Decline

Case Study A rapid response was called for a patient because of new-onset hypothermia and hypotension. Upon the rapid response team's arrival, the patient was noted to be a 78-year-old female with a known history of hypertension treated with amlodipine and osteoporosis. She was admitted earlier in the day as a direct admission from the clinic for failure to thrive. Her daughter had found her unable…

Hypotension in a Patient With Progressive Neurological Decline

Case Study A rapid response was called for a patient because of new-onset hypothermia and hypotension. Upon the rapid response team's arrival, the patient was noted to be a 78-year-old female with a known history of hypertension treated with amlodipine and osteoporosis. She was admitted earlier in the day as a direct admission from the clinic for failure to thrive. Her daughter had found her unable…

Altered Mental Status in a Patient With Insulin-Dependent Diabetes

Case Study A rapid response event was initiated for a patient with a blood glucose reading by finger stick of <10 mg On arrival of the rapid response team, the patient was somnolent but arousable to tactile stimuli. Nursing staff reported that the patient was a 75-year-old male with a history of end-stage renal disease on hemodialysis, type 2 diabetes mellitus, and congestive heart failure, who…