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Anaesthesia outside the operating theatre

General anaesthesia outside the operating theatre suite is often challenging for the anaesthetist. Although the principles of remote site anaesthesia are common to many situations, each specialised environment poses its own unique problems. In hospital the anaesthetist must provide a service for patients with standards of safety which are equal to those in the main operating theatre department. Outside the hospital, this level of service may…

Anaesthesia in resource-poor areas

Background The variation in resources available to healthcare systems in regional populations of the world is widely acknowledged. The terms developed and developing world mislead, suggesting binary options and inevitable progress to a complete state. The reality is a skewed spectrum of resource and development dictated by the combined influences of geography, climate, economics, politics, culture and conflict. Development at the weakest end of the spectrum…

Emergency and trauma anaesthesia

Patients scheduled for elective surgery are usually in optimal physical and mental condition, with a definitive surgical diagnosis; any coexisting medical disease is defined and well controlled. These patients have often discussed plans for surgery and anaesthesia (including postoperative care) in advance and may be better prepared from a psychological perspective for the challenges of the perioperative period. In contrast, the patient with a surgical emergency…

Obstetric anaesthesia and analgesia

Obstetric anaesthesia and analgesia involve caring for women during childbirth in three situations: Provision of analgesia for labour, usually by epidural or spinal analgesic techniques Anaesthesia for peripartum operative procedures such as instrumental (e.g. forceps or Ventouse) or caesarean delivery Care of the critically ill parturient The obstetric anaesthetist is involved in the care of the parturient as part of a multidisciplinary team including obstetricians, midwives,…

Anaesthesia for cardiac surgery

In the UK and much of the developed world, more than half of all cardiac surgical procedures are undertaken to revascularise ischaemic myocardium. Of the remainder, surgery for acquired valvular disease, congenital anomalies and disorders of the great vessels comprise the majority. Impaired ventricular function is not uncommon in this group of patients, the severity of which may greatly affect the conduct of anaesthesia and surgery…

Anaesthesia for thoracic surgery

In thoracic anaesthesia there are a number of key areas that require specific consideration in the preoperative, intraoperative and postoperative phases of care. They include understanding of pulmonary anatomy, assessment of fitness for lung surgery, understanding the indications and methods of lung isolation, management of hypoxaemia during one-lung ventilation, and provision of pain relief after thoracotomy. Oesophagectomy is also performed as a thoracic procedure. Anatomy The…

Neurosurgical anaesthesia

Neurosurgical procedures include elective and emergency surgery of the CNS, its vasculature and the CSF, together with the surrounding bony structures, the skull and spine. Almost all require general anaesthesia; however, some procedures require an awake patient. In addition to a conventional anaesthetic technique which pays meticulous attention to detail, the essential factors are the maintenance of cerebral perfusion pressure and the facilitation of surgical access…

Anaesthesia for vascular, endocrine and plastic surgery

Major vascular surgery Many aspects of vascular surgery have changed during the last two decades, largely as a result of advances in radiological practice and cardiology. Examples include improvements in the treatment of myocardial infarction, the development of endovascular aortic surgery and lower limb angioplasty; such progress is likely to continue. However, anaesthesia for major vascular surgery remains a challenging area of practice. In addition to…

Ophthalmic anaesthesia

Patients who present for eye surgery are often at the extremes of age. Neonatal and geriatric anaesthesia both present special problems (see Chapters 33 and 31 , respectively). Some eye surgery may last many hours, and repeated anaesthetics at short intervals are often necessary. The anaesthetic technique may influence intraocular pressure (IOP), and skilled administration of either local or general anaesthesia contributes directly to the successful…

Anaesthesia for ENT, maxillofacial and dental surgery

Ear, nose and throat (ENT), maxillofacial and dental surgical procedures account for a significant proportion of work in most anaesthetic departments. Recent cost–benefit and evidence-based analyses have reduced the number of common procedures performed, such as tonsillectomy, insertion of grommets and removal of impacted wisdom teeth. Other trends in surgical practice have offset this reduction, such as the prevalence of alcohol-related facial trauma and the increasing…

Anaesthesia for orthopaedic surgery

One in five operations in the UK is for orthopaedic, spinal or trauma surgery. This chapter provides a framework for the conduct of anaesthesia for orthopaedic surgery. The patient population A large proportion of patients presenting for orthopaedic surgery are young and healthy. Sporting injuries and disease processes without systemic impact are common, and these patients are at low risk of complications relating to anaesthesia or…

Anaesthesia for general, gynaecological and genitourinary surgery

One-third of all anaesthetics delivered are for general, gynaecological or genitourinary surgery. In all three disciplines there are increasing numbers of frail or older patients. There is also widespread adoption of endoscopic techniques as well as emphasis on anaesthetic techniques which allow day-case surgery or fast-track recovery programmes. Anaesthetic considerations Patient positioning Patient positioning is also discussed in detail in Chapter 22 . Head-down Many abdominal…

Anaesthesia for day surgery

Introduction Day surgery is defined as surgery where patient discharge occurs on the same day as admission. Twenty-three-hour discharge and enhanced recovery have the same underlying principles as day surgery but are considered separately. Organisations such as the British Association for Day Surgery (BADS), working with the RCoA and the Association of Anaesthetists, have been central in moving day surgery services forward to encompass more operations…

Paediatric anaesthesia

The delivery of safe paediatric anaesthesia requires an appreciation of the anatomical and physiological characteristics of children at various stages of development, ranging from neonates younger than 44 weeks postconceptional age to infants 1–12 months old to children and young people. Anaesthetic risk is inversely related to age and ASA status with the highest risk in younger, smaller patients. In general terms immature (or impaired) organ…

Anaesthesia for the obese patient

Obesity rates have increased from 15% in 1993 to 27% in 2015, and morbid obesity has tripled to affect 2% of men and 4% of women. Figures are projected to rise, with 50% of UK adults expected to be obese by 2030. The scale of demographic changes and associated multisystem comorbidity means that the obese patient presents across the spectrum of healthcare and not simply to…

Surgery under anaesthesia for the older surgical patient

Increasing numbers of older people are undergoing emergency and elective surgery. This is due to changing demographics, advances in surgical and anaesthetic techniques and changing attitudes and expectations of the older population. Furthermore, degenerative, metabolic and neoplastic conditions, for which surgery is often the definitive management, increase in incidence with age. All these factors contribute to the higher numbers of older patients presenting for surgery, the…

Managing the high-risk surgical patient

A high-risk surgical procedure can be considered as one in which there is an accepted postoperative mortality rate of more than 1%. Whether a procedure for a given patient is high risk depends on consideration of the technical hazards of the surgical procedure itself – for example, the construction of a gastrointestinal tract anastomosis and the potential for it to break down – and, secondly, the…

Postoperative and recovery room care

In anaesthetic practice the patient is monitored closely and continuously from before induction and throughout the operative procedure. However, many problems associated with anaesthesia and surgery occur in the immediate postoperative period. The 2001 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Changing the way we operate’ stated, ‘Immediately after surgery all patients not returning to a special care area (e.g. ICU or HDU)…

Resuscitation

Without intervention, cardiac arrest may lead to permanent neurological injury after just three minutes. The interventions that contribute to a successful outcome after a cardiac arrest can be conceptualised as the ‘chain of survival’ ( Fig. 28.1 ). The four links in this chain are: early recognition – to potentially enable prevention of cardiac arrest – and call for help; early cardiopulmonary resuscitation (CPR); early defibrillation;…