Westmead Anaesthetic Manual

Anthony Padley, MBBS (UNSW), FANZCA, is a Senior Staff Specialist Anaesthetist at Westmead Hospital and a VMO Anaesthetist at Westmead Private Hospital, Sydney, Australia

Contents
Abbreviations xvi
Preface to the fourth edition xxi
Acknowledgments xxii
A
Abciximab 1
Abdominal aortic aneurysm
(AAA) surgery 1
Abdominal pregnancy 6
Abruptio placentae 7
Activated clotting time (ACT) 7
Activated factor VIIa (NovoSeven) 7
Activated factor X inhibitors 7
Activated partial
thromboplastin time (APTT) 7
Acute dystonic reaction 7
Acute fatty liver of pregnancy 7
Acute intermittent porphyria 7
Adenosine 8
Adrenaline 9
Adrenergic receptors 10
Air embolism 10
Airway anaesthesia 10
Airway fire 10
Airway haemorrhage 10
Airway injury 11
Airway obstruction 11
Albumin solution 11
Alfentanil 11
Allergic reaction prevention 12
Alzheimer’s disease
medication 12
American Society of
Anesthesiologists grading 13
Aminophylline 13
Amiodarone 13
Amniotic fluid embolus (AFE) 14
Amrinone 15
Anaphylaxis/anaphylactoid
reactions 16
Angioedema 19
Angioplasty for cerebral
vasospasm 20
Angiotensin-related
antihypertensive drugs
and anaesthesia 20
Ankle blocks and innervation
of the foot 20
Anticholinergic crisis 21
Anticholinergic syndrome 21
Anticoagulation/antiplatelet/
thrombolytic therapy and
surgery and neuraxial
anesthesia 22
Anticoagulation therapy and
epidurals 26
Antiplatelet drugs 26
Antiseptic solutions 26
Aortic dissection 27
Aortic valve incompetence
(AI)/regurgitation (acute) 28
Aortic valve incompetence
(AI)/regurgitation (chronic) 28
Aortic valve stenosis (AS) 29
Apixaban 31
Aprepitant 32
Argatroban 32
Arterial blood gas (ABG)
analysis 32
Arterial injection of drugs 33
Arterial switch procedure 33
ASA (American Society of
Anesthesiologists)
grading 33
vi Contents
Aspiration, prevention and
treatment 33
Aspirin 36
Asthma 37
Atenolol 41
Atrial fibrillation (AF), acute 41
Atrial flutter, acute 43
Atrial septal defect (ASD) 44
Atrial switch procedure 44
Atrio-ventricular block 44
Atropine 44
Automated external
defibrillators 45
Autonomic dysreflexia 45
Awake intubation 45
Awareness and awareness
monitoring 48
B
Bacterial endocarditis (BE)
prophylaxis 55
Beta (ß)-blocker therapy and
reduction of cardiac risk 57
Betamethasone 58
Bidirectional Glenn shunt 58
Bier block 58
Biphasic defibrillators 59
Bispectral index (BIS) EEG
monitor 59
Bivalirudin 59
Blalock-Taussig shunts 59
Bleomycin (BLM) 59
Blind nasal intubation 59
Blood 60
Blood groups 60
Blood loss, assessment,
management and
anaesthetic approach 61
Blood loss prevention 65
Blood patching 66
Blood transfusion 66
Blood volume and its
distribution 68
Blunt airway trauma 68
Body mass index (BMI) and
obesity 68
Bone cement implantation
syndrome 68
Brachial plexus block 69
Bradycardia 76
Brainstem anaesthesia 78
Breast feeding and anaesthesia 78
Broad complex tachycardia 79
Bronchial blockers 79
Bronchopleural fistula (BPF) 79
Bronchospam 80
Brugada syndrome 80
Bupivacaine 82
Buprenorphine 83
Burns 84
C
Caesarean section (CS) 92
Calcium 98
Calcium chloride/calcium
gluconate 100
Can’t intubate, can’t oxygenate 100
Carbetocin 100
Carbon monoxide poisoning 100
Carcinoid tumours and
carcinoid syndrome 100
Cardiac arrest 102
Cardiac conduction
abnormalities 110
Cardiac failure 110
Cardiac investigations 110
Cardiac ischaemia 110
Cardiac output monitors,
minimally invasive 110
Cardiac risk factors 111
Cardiac tamponade 111
Cardiac tests 113
Cardiac transplant and
subsequent non-cardiac
surgery 113
Cardiogenic shock 113
Cardiomyopathy 113
Cardiomyopathy of pregnancy 113
Contents vii
Cardiovascular peri-operative
risk prediction for
non-cardiac surgery 113
Cardioversion 119
Carotid artery angioplasty/
stenting 120
Carotid endarterectomy
(CEA) 120
Caudal anaesthesia 123
Celecoxib 124
Cell salvage/Cell Saver® 125
Cement implantation
syndrome 126
Central anticholinergic
syndrome 126
Cerebral aneurysm—
anaesthetic management 126
Cerebral arteriovenous
malformation (AVM)
obliteration 131
Cerebral oedema 132
Cerebral perfusion pressure
(CPP) 132
Cerebral vasospasm
angioplasty 132
Cervical plexus (CP) block 132
Chemotherapy drugs and
anaesthesia 135
Chest drain 135
Chlorhexidine 136
Cholestasis of pregnancy 136
Cholesterol-lowering drugs 137
Cholinergic crisis 137
Cholinergic receptors 137
Cinchocaine 137
Cisatracurium 137
Citrate toxicity 138
Clevidipine 138
Clonidine 139
Clopidogrel 140
Coarctation of the aorta 140
Cocaine 141
Codeine phosphate 141
Combined spinal/epidural
technique 142
Common peroneal nerve block 142
Compound sodium lactate 142
Confusion, agitation,
decreased level
of consciousness
postanaesthetic 142
Congenital heart disease
(CHD) in adults and
non-cardiac surgery 143
Congestive cardiac failure
(CCF)/cardiogenic shock 145
Coning 148
Conn’s syndrome and
anaesthesia 149
Coronary artery balloon
angioplasty and
non-cardiac surgery 150
Coronary artery stents and
non-cardiac surgery 150
COX 2 inhibitors 152
Creatinine clearance (CrCl) 152
Creutzfeldt-Jakob disease (CJD) 152
Cricoid pressure 153
Cricothyroid puncture and
cricothyrotomy 153
Cryoprecipitate and
cryodepleted plasma 153
Cyanide poisoning treatment 154
Cyclizine (Valoid) 154
Cyclokapron 154
Cytotoxic Drugs 154
D
Dabigatran etexilate (Pradaxa) 159
Dalteparin 160
Danaparoid 160
Dantrolene 160
Deep venous thrombosis
(DVT) detection/diagnosis 160
Deep venous thrombosis
(DVT) prophylaxis 160
viii Contents
Defibrillation 162
Defibrillators 162
Depodur 164
Dermatomes 164
Desflurane 164
Desirudin (Iprivask) 166
Desmopressin (DDAVP) 166
Dexamethasone 167
Dexmedetomidine 167
Diabetes mellitus,
preparation for surgery 168
Diacetylmorphine/diamorphine 170
Diazepam 171
Diazoxide 171
Diclofenac 172
Difficult airway prediction
and management 172
Digital nerve block 178
Digoxin 178
Dilated cardiomyopathy 178
Dilaudid 180
Direct-acting thrombin
inhibitors (DTI) 180
Disseminated intravascular
coagulation (DIC) 181
Dobutamine 182
Dolasetron mesylate 183
Dopamine 183
Dopexamine 184
Double lumen endotracheal
tubes 184
Drixine 184
Droperidol 185
Dynastat 185
Dystonic reaction, acute 185
E
Ebstein’s anomaly 189
ECG monitoring 189
Eclampsia 189
EDLA 189
Eisenmenger’s syndrome/
Eisenmenger complex 189
Elbow blocks 193
Electrocardiography 196
Electromechanical
dissociation (EMD) 200
Eliquis 200
Embolism 200
Emergence agitation 200
EMLA 200
Endocarditis 201
Endotracheal intubation,
attenuating hypertensive
response to 201
Endotracheal tube sizes 201
Enoxamine 202
Enoxaparin 202
Entropy 202
Ephedrine 203
Epidural abscess 203
Epidural anaesthesia 205
Epidural haematoma 215
Epiglottitis 215
Epilepsy, status 217
Eptacog alpha (activated) 218
Eptifibatide 218
Ergometrine maleate 218
Esmolol 219
Etomidate 219
Extracorporeal membrane
oxygenation (ECMO) 220
Ex-utero intrapartum
treatment (EXIT)
procedure 221
Eye blocks 223
Eye injury, penetrating 226
EZ-IO® intraosseous needle
system 227
F
Failed intubation 231
Failure to regain
consciousness after
general anaesthesia 231
Fasting pre-operatively 231
Contents ix
Fat embolism syndrome and
bone cement implantation
syndrome 231
Fatty liver of pregnancy,
acute (AFLP) 233
Femoral nerve block and
3-in-1 (triple nerve) block 234
Fenoldopam 236
Fentanyl 237
Fetal death in utero 238
Fetal resuscitation in utero 238
Fetal scalp pH/blood sampling 238
Fibre-optic intubation 238
Fibrinogen 238
Fibrinogen concentrate 239
Fist pacing 239
Fitting 239
Fluid replacement therapy 239
Flumazenil 239
Fondaparinux 240
Fontan procedure 240
Forehead block 244
Freeze-dried and secured
plasma (FDSP) 244
Fresh frozen plasma (FFP) 244
Frozen blood 245
Frozen plasma, deep (DFP) 246
Frozen platelets 246
G
Gabapentin and pregabalin 248
Gas embolism, venous and
arterial 248
Gelofusin 250
Glasgow coma scale (GCS) 250
Glenn shunt 251
Glomerular filtration rate 251
Glucagon 251
Glucose-6-phosphate
dehydrogenase (G6PD)
deficiency 252
Glyceryl trinitrate (GTN) 252
Glycopyrronium/glycopyrrolate 253
Granisetron 253
H
Haemaccel 255
Haematoma block 255
Haemoglobin levels 256
Haemophilia 256
Haemoptysis, massive 257
Haemorrhage 259
Haloperidol 259
Halothane 259
Hartmann’s solution 260
Heart block (HB) 260
Heart failure 261
Heart transplant patients,
anaesthetic considerations
for non-cardiac surgery 261
HELLP syndrome 264
Heparin (unfractionated
and low molecular
weight heparins) 264
Heparin-induced
thrombocytopenia (HIT)
syndrome 266
Hepatitis B and C 266
Hepatorenal syndrome (HRS) 266
Herbal medicines and
anaesthesia 268
Hereditary angioedema (HAE) 270
Heroin 270
HIT 270
Human immunodeficiency
virus (HIV) 270
Human prot
hrombin complex 270
Humate-P 270
Hydralazine 271
Hydromorphone (Dilaudid) 271
Hydroxyethylated starch
(hydroxyethyl starch, HES) 272
Hypercapnia 272
Hyper/hypocalcaemia 273
Hyper/hypokalaemia 273
Hyperperfusion syndrome 273
x Contents
Hypertension 273
Hypertensive response to
intubation (attenuation of) 274
Hypertrophic cardiomyopathy
(HCM) 275
Hyperviscosity syndrome 279
Hypocapnia 279
Hypoglycaemia 279
Hypotension 280
Hypoxia/hypoxaemia 281
I
Ideal body weight (IBW) 286
Immunosuppressive and
chemotherapy drugs,
anaesthetic implications 286
Ilioinguinal and
iliohypogastric nerve
block 287
Infraorbital nerve block 288
Insulin/glucose infusion 288
Intercostal drain 288
Intercostal nerve block 289
Internal jugular vein (IJV)
catheterisation 289
International normalised
ratio (INR) 292
Interventional
neuroradiological (INR)
suite 292
Intra-arterial injection of
drugs, accidental 293
Intracranial pressure (ICP)
and treatment of raised ICP 294
Intracranial stenting and
angioplasty 294
Intracranial venous
thrombosis (ICVT) 295
Intrahepatic cholestasis of
pregnancy 296
Intralipid for the treatment of
bupivacaine/ropivacaine
toxicity 296
Intraoperative myocardial
ischaemia 296
Intraosseous (IO) access 296
Intrapleural anaesthesia 297
Intrathecal anaesthesia 298
Intrauterine fetal death 298
Intravenous regional
anaesthesia 298
Intubation, hypertensive
response 298
Isoflurane 298
Isoprenaline 299
J
Jehovah’s Witnesses (JW) 301
Jet ventilation 302
Junctional tachycardias 302
K
Ketamine 304
Ketorolac 305
L
Labetalol 307
Lactate 307
Laparoscopic surgery 307
Laryngeal anatomy 310
Laryngoscopy 310
Laryngoscopy view grading 310
Laryngospasm 311
Larynx, anatomy and
innervation 312
Laser surgery 314
Lateral cutaneous nerve of
thigh block 315
Left ventricular ejection
fraction 316
Left ventricular failure, acute 316
Lepirudin 316
Levobupivacaine 316
Levosimendan 316
Lignocaine 317
Lipid lowering drugs 319
Contents xi
Lipid treatment for local
anaesthetic toxicity 319
Liquid plasma 319
Lithium 319
Local anaesthetic toxicity 320
Long QT syndrome (LQTS) 320
Lorazepam 322
Ludwig’s angina: anaesthetic
management 323
Lumbosacral plexus (psoas
compartment) block 324
Lung function tests 324
Lung volumes 325
Lyophilised plasma 325
M
Magnesium 328
Magnesium sulfate 328
Magnetic resonance imaging
(MRI) anaesthesia 329
Malignant hyperthermia (MH) 331
Mallampati score 336
Mannitol 336
Masseter spasm 336
Massive blood transfusion/
massive transfusion
protocol 337
Massive blood loss 337
Mediastinal mass and
anaesthesia 337
Melker airway 341
Mental nerve block 341
M-entropy 341
Metabolic acidosis 341
Metabolic equivalent (MET) 342
Metaraminol 342
Methadone 342
Methaemoglobin 343
Methoxamine 344
Methoxyflurane inhaler 344
Methylene blue 345
Metoclopramide 345
Metoprolol 345
Midazolam 345
Milrinone 346
Minute volume 347
Mitral regurgitation/
incompetence (MR/MI) 347
Mitral stenosis (MS) 349
Mitral valve prolapse (MVP) 352
Mivacurium 353
Monoamine oxidase (MAO)
inhibitor drugs 354
Morphine 355
Multifocal atrial tachycardia 357
Muscarinic receptors 357
Myasthenia gravis 357
Myocardial ischaemia/
infarction (MI),
peri-operatively 360
N
Naloxone 366
Nasal mucosa vasoconstrictors 366
Nausea and vomiting,
postoperative 366
Neck haematoma
management 366
Needle-stick injury 367
Negative pressure pulmonary
oedema (NPPO) 368
Neonatal resuscitation 370
Neopuff infant resuscitator 370
Neostigmine 370
Nerve stimulator positions 371
Neuroanaesthesia 371
Neuroleptic malignant
syndrome (NMS) 374
Newborn and neonatal
resuscitation 375
New York Heart Association
(NYHA) functional
classification of patients
with heart failure 378
Nicardipine 378
Nifedipine 379
xii Contents
Nifekalant 379
Nimodipine 379
Nitrous oxide 380
Non-steroidal anti-inflammatory
drugs (NSAIDs) 381
Noradrenaline 383
Normal saline 384
NovoSeven 384
Nupercaine 384
O
Obesity 387
Obstetric cholestasis 387
Obstetric sepsis 387
Obstructive sleep apnoea
(OSA) syndrome 388
Occipital nerve block 390
Oculogyric crisis 390
Ondansetron 390
One lung ventilation (OLV) 391
Opioid receptors 396
Opioids: relative potencies 396
Oxycodone 397
Oxygen content of blood 397
Oxymetazoline 397
Oxytocin 397
P
Pacing, pacemakers and
anaesthesia 399
Packed cells 406
Palonosetron 406
Pancuronium 406
Paracetamol 406
Paravertebral block 407
Parecoxib (Dynastat) 408
Parkinson’s disease (PD) 409
Patient-controlled analgesia
(PCA) 411
Penetrating eye injury 412
Penile block 412
Pentasaccharide 413
Pericardial effusion 413
Pericardial tamponade/
pericardiocentesis 413
Peripartum cardiomyopathy 414
Peripheral venous access
using ultrasound 416
Peritonsillar abscess 417
Pethidine 418
Phaeochromocytoma 419
Phentolamine 422
Phenylephrine (neo-synephrine) 423
Phenytoin 423
Physostigmine 424
Placental abruption 424
Placenta accreta/increta/
percreta 425
Placenta praevia 427
Plasmalyte A 428
Platelet adenosine
diphosphate (ADP) receptor
antagonists 428
Platelet glycoprotein IIb/IIIa
receptor antagonists 429
Platelet therapy 430
Pneumothorax/tension
pneumothorax 431
Polycythaemia 434
Porphyria 435
Postanaesthetic confusion 437
Postdural puncture
headache (PDPH) 437
Posterior reversible
encephalopathy syndrome
(PRES) 437
Postoperative nausea and
vomiting (PONV) 438
Postpartum haemorrhage
(PPH) 438
Potassium 440
Pradaxa 441
Prasugrel 441
Predicted body weight (PBW) 441
Pre-eclampsia/eclampsia 442
Pregabapentin 449
Contents xiii
Pregnancy and non-obstetric
surgery—anaesthetic
considerations 449
PRES 452
Prilocaine 452
Procainamide 453
Prochlorperazine (Stemetil) 453
Promethazine 454
Propofol 454
Propranolol 457
Prostoglandin F2 alpha 457
Prostaglandin therapy 458
Prostate surgery 458
Protamine 458
Prothrombinex-VF® 459
Prothrombin time 459
Pruritus, due to opioids 459
Pseudocholinesterase
deficiency 459
Pulmonary embolism (PE) 459
Pulmonary hypertension 461
Pulmonary oedema 465
Pulmonary stenosis 467
Pulmonary valve and
subvalvular stenosis 467
Q
Quadraplegia/paraplegia
(chronic) and anaesthesia 477
R
Radiological procedures and
pregnancy 478
Raised intracranial pressure 478
Rapid infusion catheter
exchanger set 478
Rapid sequence induction
(RSI) 478
Recombinant activated factor
VII (rFVIIa) 479
Rectus abdominus sheath
block 480
Red cells 481
Reflexes 482
Remifentanil 483
Renal function tests 484
Renal transplant surgery 485
Respiratory failure 487
Respiratory function tests 487
Restrictive cardiomyopathy 488
Resuscitation of the newborn 489
Retained placenta 489
Retrograde intubation 489
Ringers lactate solution 490
Rivaroxaban (Xarelto) 490
Robotic surgery 490
Rocuronium 491
Ropivacaine (Naropin) 492
Ross procedure 494
Rotem 495
S
‘Saddle’ block 497
Salbutamol 497
Saphenous nerve block 498
Scalp block 498
Scalp capillary pH
measurement 499
Sciatic nerve block 499
Sciatic nerve sheath catheter 502
Sedation and sedation scores 502
Seizures 502
Serotonin syndrome 503
Sevoflurane 503
Shivering postoperatively 504
Sickle cell disease 505
Single ventricle repair 508
Sleep apnoea syndrome 508
Sodium bicarbonate 508
Sodium nitroprusside (SNP) 509
Sotalol 510
Spina bifida occulta 511
Spinal anaesthesia 511
Spinal anatomy 511
Spinal catheter in labour 512
Spinal cord injury (pre-existing)
and anaesthesia 512
xiv Contents
Spirometry 514
Statin therapy 514
Status epilepticus 514
Steroid ‘cover’ for surgery/
anaesthesia for patients
on chronic glucocorticoid
therapy 514
Steroid equivalents 515
Stiff man/person syndrome
(SPS) 515
ST segment analysis 516
Subarachnoid block (SAB) 516
Subarachnoid haemorrhage 520
Subclavian vein central line 520
Sub-Tenon’s block 521
Succinylcholine 521
Sufentanil 521
Sugammadex 522
Superior vena cava
syndrome 523
Supine hypotensive
syndrome 523
Supraorbital and
supratrochlear nerve
blocks 523
Supraventricular tachycardias
(SVT) 523
Surgical airway 526
Suxamethonium 526
Sux apnoea 527
Syntocinon 528
Syntometrine 528
T
Takotsubo syndrome 533
TAP block 534
Targin® 534
Tension pneumothorax 534
Tetralogy of Fallot 534
Thienopyridine drugs 536
Thiopentone 536
Thoracic aortic dissection 537
Thoracic epidural 537
Thoracoabdominal
and thoracic aortic
aneurysm repair 537
Thromboelastography (TEG®)
and thromboelastometry
(TEM) 540
Thrombolytic therapy 542
Thrombophilia 542
Thyroid storm/thyrotoxic crisis 542
Thyromental distance 543
Tibial nerve sheath catheter 543
Ticagrelor 544
Ticlopidine 544
TIPS procedure 544
Tirofiban 544
TIVA 544

Tonsillectomy, bleeding after
surgery 544
Torsades de pointes 545
Total intravenous
anaesthesia (TIVA) 545
Total ‘spinal’ 545
Tracheal rupture 545
Tracheostomy, elective 547
Tracheostomy obstruction 547
Tramadol hydrochloride 548
Tranexamic acid 549
Transcutaneous cardiac pacing 550
Transfusion-related acute
lung injury (TRALI) 550
Transjugular intrahepatic
portosystemic shunt (TIPS) 551
Transposition of the great
vessels 551
Transtracheal jet ventilation 552
Transurethral resection of
prostate (TURP) 552
Transversus abdominis plane
block 554
Tricuspid regurgitation and
Ebstein’s anomaly 556
Trimetaphan 559
Triple ‘whammy’ 559
Contents xv
Tropisetron 559
Turner’s syndrome 559
U
Ultrasound-guided regional
anaesthesia 563
Umbilical vein catheterisation 564
Unfractionated heparin 564
Unifocal atrial tachycardia 564
Unwashed shed blood
transfusion 564
Upper airway obstruction—
causes 564
Uterine atonia, postpartum 565
Uterine inversion 565
Uterine relaxation 566
Uterine rupture 567
V
Vagal manoeuvres 569
Valdecoxib 569
Vasa praevia 569
Vasopressin 569
Vecuronium 570
Veins of the upper limb 571
Venous gas embolism 571
Venous thromboembolism 571
Ventilation and spontaneous
ventilation support: terms,
modes and settings 571
Ventricular ejection fraction 575
Ventricular fibrillation 576
Ventricular septal defect
(VSD) 576
Ventricular tachycardia (VT) 576
Verapamil 577
Von Willebrand disease (vWD) 578
W
Warfarin 580
Weight 581
Weights of children, average 581
Well leg compartment
syndrome 581
Wolff–Parkinson–White
(WPW) syndrome 582
Wrist blocks 583
X
Xarelto 586
Xenon 586
X-Rays, radiation and risk of
exposure 586
Appendix 1: Drug infusion
regimens summary 588
Appendix 2: Some important
biochemical and
haematological reference
ranges 589