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Complications arising from anaesthesia

Complications are undesirable events arising from anaesthesia. They occur in approximately 10% of anaesthetics. Only the minority of these complications cause lasting harm to the patient. Death complicates five anaesthetics per million given in the UK (0.0005%). Every complication has the potential to cause lasting harm to the patient. Therefore deviations from the norm must be recognised, and managed promptly and appropriately. Certain complications of anaesthesia…

Regional anaesthetic techniques

Regional anaesthetic techniques are used for both operative anaesthesia and postoperative analgesia. They are becoming more popular as a result of advances in drugs and equipment and improved techniques of anatomical localisation, particularly ultrasonic location. In addition, there is a greater appreciation of the need to improve postoperative pain control using techniques that not only reduce pain but also have the ability to abolish it and…

Pain

The experience of pain is much more complex than nociception, where there is a reflex response to a noxious stimulus. The total pain experience is influenced by several factors, as outlined in the biopsychosocial model of pain ( Fig. 24.1 ). Successful pain management depends on addressing all these aspects. Neuroimaging studies of pain reveal that multiple areas in the brain are activated in acute and…

Airway management

This chapter is divided into four parts: 1. Airway equipment 2. Routine airway management 3. Emergency airway management 4. Difficult airway management It does not cover airway management in paediatric, obstetric or emergency anaesthesia. These are covered in Chapter 33, Chapter 43, Chapter 44 , respectively. Section 1 Anaesthetic airway equipment Anaesthetists must have a sound understanding and firm knowledge of the functioning of all anaesthetic…

The practical conduct of anaesthesia

The conduct of anaesthesia is planned after obtaining details of the surgical procedure and medical condition of the patient. All patients should be visited preoperatively for anaesthetic assessment, including review of the results of relevant investigations. This is also an important opportunity to form a rapport, gain patients’ trust and answer any questions about their anaesthetic and postoperative pain relief. Preoperative assessment and selection of appropriate…

Consent and information for patients

Whenever we seek consent from a patient before medical examination, investigation or treatment, we demonstrate our respect for the ethical principles of autonomy and the patient's right to self-determination. Consent is always given or withheld by the patient; it is not something done to a patient, and anaesthetists, along with other healthcare professionals, should avoid using phrases such as consenting the patient. Seeking consent is a…

Intercurrent disease and anaesthesia

The number of surgical procedures carried out in patients previously considered unfit for surgery is increasing. A growing proportion have significant coexisting medical conditions, are older and may have a limited physiological reserve. These factors influence the conduct of anaesthesia and surgery and must be considered when assessing and managing an individual patient. Intercurrent disease and drug therapy may affect anaesthesia and surgery in a number…

Preoperative assessment and premedication

All patients scheduled to undergo surgery should be assessed in advance to ensure optimal preparation and perioperative management. This is a standard of care proposed by the Association of Anaesthetists, RCoA and similar bodies worldwide. It is one mechanism by which the standard and quality of care provided by an individual anaesthetist or an anaesthetic department may be measured. Failure to undertake this activity places the…

Quality and safety in anaesthesia

Quality in healthcare is hard to define. One approach is based around six goals: safety; effectiveness; patient focus; timeliness; efficiency; and equity ( Table 18.1 ). Although errors and incidents are commonly discussed in relation to safety, the same fundamental principles apply to all aspects of healthcare quality. Table 18.1 Aims of a high-quality healthcare system 1. Safe Prevention of injuries to patients from the care…

Clinical measurement and monitoring

The ability to measure and monitor patients’ physiology is fundamental to modern anaesthetic practice, and a variety of sophisticated instruments are available. It is crucial that the anaesthetist understands not only the data being generated but also the limitations of any equipment and potential sources of error. Furthermore, the anaesthetist must have the knowledge and experience to integrate multiple clinical measurements. A comprehensive understanding of each…

Anaesthetic apparatus

Anaesthetists must have a sound understanding and knowledge of the functioning of all the anaesthetic equipment they use. Failure to understand the use of or check equipment before use is an important recognised cause of complications and death. This is especially true of ventilators, where lack of knowledge may result in a patient being subjected to hypoxaemia, hypercapnia, pulmonary barotrauma and volutrauma. It is essential that…

Basic physics for the anaesthetist

Knowledge of some physics is required to understand the function of many items of apparatus for anaesthesia delivery and physiological monitoring. This chapter emphasises aspects of physical principles, but the reader should expand on this by further reading ( ; ) and by reading relevant chapters on equipment. Sophisticated measurement techniques may be required for more complex types of anaesthesia in intensive care and during anaesthesia…

Blood, coagulation and transfusion

Haematological conditions and drugs can have a significant impact on the conduct of anaesthesia. Anaesthetists need to have an understanding of the pathophysiology associated with various haematological diseases and drugs that are known to increase the risk of thrombosis, infection, or haemorrhage. In addition, as one of the largest groups of clinicians responsible for the transfusion of various blood products, anaesthetists need to be familiar with…

Metabolism, the stress response to surgery and perioperative thermoregulation

Metabolism Metabolism may be defined as the chemical processes that enable cells to function. Basal metabolic rate (BMR) is the minimum amount of energy required to maintain basic autonomic function and normal homeostasis at rest. In a healthy resting adult, BMR is in the region of 2000 kcal day –1 (equivalent to 40 kcal m –2 h –1 ). One calorie is the energy to raise the temperature of…

Fluid, electrolyte and acid–base balance

The realisation that the enzyme systems and metabolic processes responsible for the maintenance of cellular function are dependent on an environment with stable electrolyte and hydrogen ion concentrations led Claude Bernard to describe the milieu interieur more than 100 years ago. Complex homeostatic mechanisms have evolved to maintain the constancy of this internal environment and thus prevent cellular dysfunction. Physiology of electrolytes and water balance Mammalian…

Renal physiology: Function and anatomy

The kidneys have a number of diverse functions. The main roles are as follows: Filtration and elimination of metabolic waste products Maintenance of fluid and electrolyte homeostasis Control of acid–base status Production of erythropoietin to stimulate red cell synthesis Hydroxylation of circulating calcifediol (25-hydroxyvitamin D3) to calcitriol (1,25-dihydroxyvitamin D3), the active form of vitamin D, for calcium homeostasis Blood pressure maintenance and control of sodium and…

Respiratory system

Control of breathing Breathing is primarily concerned with the homeostasis of blood O 2 and CO 2 to ensure that both remain at appropriate concentrations despite wide variations in the body's metabolic needs. Breathing control is also vital for speaking and singing; it must also be modified to allow protective reflexes such as coughing, sneezing and vomiting. Unusually for such a fundamental function, breathing can be…

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…