Fundamentals of Anaesthesia

 

Description:

Fundamentals of Anaesthesia is the gold standard text for the Primary FRCA, encapsulating the basic principles of modern anaesthesia in one easily accessible volume. Written and edited by experts with extensive FRCA examination experience, this text deliberately blends the expertise of invited authors in an unrivalled consistency of style more akin to that of a single author text. All of the subject matter required to pass the exam is condensed into an easy-to-read format. This fully updated fourth edition includes new guidelines, an improved chapter structure, and a new section on clinical ultrasound. The generous use of summary boxes, bullet points, tables and diagrams creates a text that is clear, concise and easy to navigate. Each section covers one of the four components of the SOE. This is a unique revision aid for the Primary FRCA and an essential companion for all exam candidates.

 

 

Table of Contents:

 

 

 

Preface to the first edition

 

Preface to the second edition

Preface to the third edition

Preface to the fourth edition

Acknowledgements

Alma Medical

Chapter 5

American College of Cardiology/American Heart Association

Chapter 1

Association of Anaesthetists of Great Britain and Ireland

Chapter 2

Chapter 4

Chapter 5

Chapter 7

Chapter 46

British Journal of Anaesthesia

Chapter 46

Difficult Airway Society (UK)

Chapter 2

Joint British Diabetes Societies

Chapter 5

Resuscitation Council (UK)

Chapter 8

The Sourcebook of Medical Illustration, ed. P. Cull. Carnforth: Parthenon Publishing Group, 1989

Chapter 7

Chapter 18

Abbreviations

Section 1 Clinical anaesthesia

Chapter 1 Preoperative management

Contents

Preoperative assessment

Screening

Preoperative assessment clinic

Preoperative assessment of functional capacity

Preoperative visit

The airway

Airway assessment

American Society of Anesthesiologists (ASA) scoring system

Preparation for anaesthesia

Premedication

Preoperative factors

Starvation

Fluid status

Correction of fluid balance

Electrolyte disturbances

Smoking

Concurrent medical disease

Respiratory disease

Viral infection

Asthma

Chronic obstructive pulmonary disease (COPD)

Pulmonary function tests

Cardiovascular disease

Hypertension

Drug treatment

Ischaemic heart disease (IHD)

Perioperative assessment of cardiac risk

The electrocardiogram

Other cardiac investigations

Implantable pacemakers and implantable cardioverter defibrillators (ICDs)

Surgical diathermy and pacemakers

Valvular heart disease

Aortic stenosis

Aortic regurgitation

Mitral stenosis

Mitral regurgitation

Tricuspid valve lesions

Pulmonary valve lesions

Haematological disease

Anaemia

Sickle cell disease

Clotting abnormalities

Musculoskeletal disease

Rheumatoid arthritis

Renal disease

Endocrine disease

Diabetes mellitus

Alcohol-related disease

Obesity

Cardiac disease

Respiratory disease

Metabolic disease

Venous thromboembolism

General considerations

Concurrent medication

Concurrent surgical disease

Intestinal obstruction

Acute abdominal emergencies

References and further reading

Chapter 2 Conduct of anaesthesia

Contents

Preoperative preparation

Induction

Inhalational induction

Intravenous induction

Alternative routes of induction

Airway management

Face mask

Supraglottic airway devices

Tracheal intubation

Indications

Technique

Direct laryngoscopy

Positioning

Laryngoscopy technique

Management of the difficult airway

Preoperative assessment

Preoxygenation

Awake fibreoptic intubation

Inhalational induction

Difficult intubation

Complications at induction

Allergic reactions

Management

Investigation

Malplaced endotracheal tube

Clinical signs

Objective measures

Intra-arterial injection

Special patient circumstances

Traumatic brain injury

The shocked patient

The patient with a full stomach

Risk factors

Prevention of aspiration

Rapid sequence induction

Management of pulmonary aspiration

References and further reading

Chapter 3 Intraoperative management

Contents

Positioning

Monitoring

Maintenance of anaesthesia

General anaesthesia

Awareness

Inhalational anaesthesia

Intravenous anaesthesia

Local anaesthesia

Analgesia

Ventilation

Mode of mechanical ventilation

Management of intraoperative fluid therapy

Critical incidents during anaesthesia

Hypoxia

Bronchospasm

Emboli

Hypotension

Cardiac arrhythmias

Bradycardia

Tachycardia

Massive haemorrhage

Malignant hyperthermia

Pathophysiology

Diagnosis and management

Safe discharge

Chapter 4 Postoperative management

Contents

Care of the unconscious patient

The recovery room

Patient transfer from operating theatre

Management

Patient discharge

Postoperative complications

Postoperative hypoxaemia

Clinical features

Upper airway obstruction

Clinical features

Management

Ventilation/perfusion (˙V/˙Q) mismatch

Atelectasis

Bronchopneumonia

Aspiration

Pulmonary oedema

Pneumothorax

Diffusion hypoxia

Inadequate pulmonary ventilation

Decreased ventilatory drive

Inadequate mechanical function of the respiratory muscles

Incomplete reversal of non-depolarising muscle blockade

Suxamethonium apnoea

Mivacurium apnoea

Neuromuscular disease

Diaphragmatic splinting

Pre-existing lung disease

Other causes of hypoxaemia

Hypertension

Hypotension

Cardiac arrhythmias

Thromboembolism

Deep venous thrombosis

Prophylaxis

Pulmonary embolus

Hypothermia and shivering

Failure to regain consciousness and confusion

Oxygen therapy

Indications

Techniques of administration

Humidification

Duration

Complications

Barotrauma

Loss of hypoxic ventilatory drive

Postoperative analgesia

Treatment of pain

Opioids

Intravenous opioids

Oral opioids

Spinal opioids

Non-steroidal anti-inflammatory drugs (NSAIDs)

Local anaesthetics

Pain assessment

Acute pain service

Postoperative nausea and vomiting

Prevention

Treatment

Postoperative fluid therapy

Physiology

Postoperative fluid loss

Clinical assessment

Fluid replacement

Sequelae of anaesthesia

Eye trauma

Airway trauma

Musculoskeletal trauma

Skin damage

Medico-legal issues

References and further reading

Chapter 5 Special patient circumstances

Contents

The pregnant patient

Analgesia in labour

Psychological methods

Complementary methods

Systemic analgesia

Epidural analgesia

Contraindications to epidural analgesia

Epidural technique

Ultrasound-guided epidural needle placement

Combined spinal–epidural in labour

Epidural test doses

Complications

Operative anaesthesia

Regional anaesthesia

General anaesthesia

Non-obstetric surgery in the pregnant patient

When to consider a patient pregnant

Non-obstetric surgery

Cell salvage in obstetric care

The paediatric patient

Assessment

Equipment

Fluid therapy

Analgesia

Specialist surgery

General and urological surgery

Orthopaedic surgery

Dental and ENT surgery

Dental surgery

ENT surgery

Ophthalmic surgery

Child protection

The elderly patient

Postoperative cognitive deficit

The head-injured patient

Applied physiology

Arterial PCO2

Arterial PO2

Cerebral perfusion pressure

Intracranial pressure

Temperature

Drugs

Management of head injury

Practical technique

Transfer of the head-injured patient

The day-case patient

Social circumstances

Surgical procedure

Medical fitness

Anaesthetic technique

Intraoperative

Postoperative

Admission facilities

The morbidly obese patient

Applied physiology

Anaesthesia

The metabolically compromised patient

Liver disease

Applied physiology

Assessment of patients with liver disease

Fluids

Anaesthetic technique

A note on repeat anaesthesia

Renal disease

Applied physiology

Anaesthetic technique and drugs

Diabetes mellitus

Complications

Effect of complications on anaesthesia

Elective surgery and the diabetic patient

Guidelines for the management of diabetic patients undergoing elective surgery

Preoperative

Perioperative

Postoperative

Day-case surgery

Emergency surgery

The management of fluids for diabetics during surgery

The management of diabetic drugs during surgery

Oral hypoglycaemics

Insulin

Continuous variable rate intravenous insulin infusion (CCVRIII)

Administration of CVRIII

Diabetic management under specific conditions

Patients undergoing surgery with a short starvation period (one missed meal)

Patients anticipated to have a long starvation period (two or more missed meals) or decompensated diabetes

Management of hyperglycaemia

Management of hypoglycaemia

Infective risk groups

Prion diseases

Hepatitis A

Hepatitis B

Hepatitis C

HIV/AIDS

Universal precautions

Needlestick injury

Latex allergy

Perioperative care

Jehovah’s Witnesses

Magnetic resonance imaging

References and further reading

Chapter 6 The surgical insult

Contents

General surgery

Laparotomy

Head and neck surgery

Rectum and anus

Laparoscopic cholecystectomy

Urological surgery

Transurethral resection of the prostate (TURP)

Radical prostatectomy

Cystectomy

Transurethral resection of bladder tumour (TURBT)

Nephrectomy

Percutaneous nephrolithotomy (PCNL)

Transvaginal tension-free tape (TVT)

Orthopaedic surgery

Joint replacement surgery

Laminectomy

Fractured neck of femur

Gynaecological surgery

Hysterectomy

Laparoscopy

Evacuation and termination (ERPC/STOP)

Ear, nose and throat surgery

Laryngoscopy

Tonsillectomy

Middle ear surgery

Tracheostomy

Ophthalmic surgery

Cataract surgery

Squint surgery

Retinal surgery

Penetrating eye injury

Dacryocystorhinostomy (DCR)

Oral and maxillofacial surgery

Dental extraction

Removal of wisdom teeth

Fractured mandible

Fractured zygoma

Fractured maxilla

Trismus

References and further reading

Chapter 7 Regional anaesthesia

Contents

General principles of management

Patient preparation

Local anaesthetic toxicity

Clinical effects of local anaesthetic toxicity

Systemic effects

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Anaphylactoid reactions

Factors affecting toxicity of local anaesthetics

Dose

Absorption

Distribution

Metabolism

Plasma protein binding

Pregnancy

Management of local anaesthetic toxicity

Prevention

Treatment

Lipid emulsion

Insulin/glucose/potassium infusions

Performing the block

Perioperative management

Central neural blockade

Spinal anaesthesia

Indications for spinal anaesthesia

Anatomy

Physiology

Nervous system

Respiratory system

Cardiovascular system

Gastrointestinal system

Equipment

Technique

Drugs, doses and volumes

Complications

Headache

Neurological sequelae

Epidural anaesthesia

Indications

Anatomy

Physiology

Equipment

Technique

Drugs, doses and volumes

Injection of the local anaesthetic agent

Complications

Post-dural puncture headache

Back pain

Vertebral canal haematoma

Caudal anaesthesia

Indications

Anatomy

Physiology

Equipment

Technique

Drugs, doses and volumes

Complications

Ultrasound-guided regional anaesthesia (USGRA)

Advantages and disadvantages of USGRA

Performing a block with ultrasound guidance

Selection of ultrasound probe

Obtaining the best scan

Selection of needle and trajectory

Probe manoeuvres to optimise ultrasound images (P.A.R.T.)

Wrong-sided blocks

Injection of local anaesthetic

Peripheral nerve blockade

Brachial plexus block

Indications

Anatomy

Equipment

Techniques

Drugs, doses and volumes

Complications

Femoral nerve block

Indications

Anatomy

Technique

Drugs, doses and volumes

Complications

Ankle block

Indications

Anatomy

Technique

Drugs, doses and volumes

Complications

Abdominal wall blocks

Inguinal field block

Indications

Anatomy

Technique

Drugs, doses and volumes

Complications

Transversus abdominal plane (TAP) block

Indications

Anatomy

Technique

Drugs, doses and volumes

Complications

Penile block

Indications

Anatomy

Technique

Drugs, doses and volumes

Local anaesthesia of the upper airway

Indications

Anatomy

Technique

Intravenous regional anaesthesia (IVRA)

Indications

Equipment

Technique

Drugs, doses and volumes

References and further reading

Chapter 8 Principles of resuscitation

Contents

Cardiorespiratory arrest

Causes

Recognition

Cardiopulmonary resuscitation

Basic life support

Airway

Circulation

Rescue breathing

Special situations

Foreign-body airway obstruction

Cardiorespiratory arrest secondary to hypoxia

Advanced life support

Airway

Ventilation

Circulation

Shockable rhythms (VF/VT)

Electrical defibrillation

Non-shockable rhythms (pulseless electrical activity and asystole)

Drug usage

Adrenaline

Vasopressin

Atropine

Amiodarone

Lidocaine

Sodium bicarbonate

Calcium

Intralipid

Magnesium

Aminophylline

Fibrinolytics

Complications of CPR

Complications associated with defibrillator use

Transmission of infection

Neurological injury

Management of life-threatening peri-arrest arrhythmias

Bradycardias

Tachycardias

Broad complex tachycardia

Narrow complex tachycardia

Resuscitation of the pregnant patient

Causes

Basic life support

Advanced life support

Drug usage

Resuscitation of infants and children

Causes

Basic life support

Airway

Breathing

Circulation

Foreign-body airway obstruction

Advanced life support

Airway

Ventilation

Circulation

Non-shockable rhythms (asystole or PEA)

Shockable rhythms (VF/VT)

Drug usage

Adrenaline

Amiodarone

Atropine

Calcium

Magnesium

Sodium bicarbonate

Ethical considerations in CPR

Justification of resuscitation

Whose decision?

Withholding and withdrawing resuscitation

DNACPR orders in patients presenting for surgery

Presence of relatives during resuscitation attempts

References and further reading

Chapter 9 Major trauma

Contents

Pathophysiology of trauma and hypovolaemia

Physiological responses to haemorrhage

Systemic inflammatory response syndrome

Assessment and management of the trauma patient

Prehospital phase

Trauma networks

Preparation for resuscitation

Primary survey and resuscitation

Airway and cervical spine

Care of the cervical spine

Advanced airway management

Breathing

Tension pneumothorax

Open pneumothorax

Flail chest

Massive haemothorax

Cardiac tamponade

Chest drainage

Circulation

Intravenous access

Fluids

Fluid warming

Resuscitation end points

Hypotensive resuscitation

Disability

Exposure and environmental control

Tubes

Radiology

Secondary survey

Head

Face and neck

Thorax

Pulmonary contusion

Cardiac contusion

Blunt aortic injury

Rupture of the diaphragm

Oesophageal rupture

Tracheobronchial injury

Abdomen

Extremities

Spinal column

Medical history

Analgesia

Systemic analgesia

Local and regional analgesia

Management of burns

Anaesthesia for patients with severe trauma

Induction of anaesthesia

Intraoperative management

References and further reading

Section 2 Physiology

Chapter 10 Cellular physiology

Contents

Organisation and control

Cell functions

Intracellular functions

Extracellular functions

Local homeostatic responses

Intracellular control

Organ systems and homeostatic control

Negative feedback systems

Positive feedback systems

Cell structure

Basic cell morphology

Cytoplasm

Cytosol

Organelles

Cytoskeleton

Mitochondria

Endoplasmic reticulum (ER)

Ribosomes

Centrosome

Golgi apparatus

Intercellular junctions

Cilia

The cell membrane

Membrane functions

Membrane structure

Integral membrane proteins

Cell adhesion molecules (CAMs)

G proteins

Second messenger enzymes

Membrane transport of substances

Membrane transport mechanisms

Diffusion

Osmosis

Osmolarity

Osmotic pressure

Tonicity

Ion diffusion

Active transport

Primary active transport

Secondary active transport

Facilitated diffusion

Exo- and endocytosis

Cell nucleus

Nucleus and nucleolus

Nucleic acids

The human genome

Cell division

Protein synthesis

Control of protein synthesis

Cell communication

Chemical messengers

Properties of a ligand

Receptors

Receptor properties

Binding site modulation

Allosteric modulation

Covalent modulation

Membrane signal transduction

Membrane signal transduction mechanisms

Intracellular transduction

Second chemical messengers

Intracellular calcium

Ageing

Ageing and dyshomeostasis

Theories of ageing

Wear and tear

Adaptive evolution

Non-adaptive evolution

Chapter 11 Body fluids

Contents

Fluid compartment volumes

Total body water (TBW)

Intracellular fluid (ICF)

Extracellular fluid (ECF)

Plasma

Transcellular fluid

Measurement of fluid compartment volumes

Solutions and semipermeable membranes

Concentration of a solution

Amount of solute

Chemical and electrochemical activity of a solution

Equivalent weight

Movement of water across a membrane

Osmotic pressure

Calculation of osmotic pressure from molality of a solution

The osmole

Osmolality and osmolarity of a solution

Osmolality of body fluids

Regulation of body fluid osmolality

Measurement of osmolality

Tonicity of a solution

Plasma colloid osmotic pressure

Distribution of a solute across a membrane

Gibbs–Donnan effect

Composition of body fluids

Intracellular fluid

Interstitial fluid

Plasma

Albumin

Immunoglobulins

Transcellular fluids

Intravenous fluids

Composition of IV fluids

Distribution of IV fluids in fluid compartments

Maintenance fluid requirements

Fluid requirements in the perioperative period

Disorders of water and electrolyte balance

Sodium and water

Disturbances of total body water

Abnormalities of plasma sodium

Hypernatraemia

Treatment of hypernatraemia

Hyponatraemia

Treatment of hyponatraemia

Potassium

Calcium

Magnesium

Acid–base imbalance and electrolyte replacement

Metabolic acidosis

Metabolic alkalosis

Strong ions

Special fluids

Lymph and the lymphatic system

Cerebrospinal fluid (CSF)

Circulation of CSF

Composition of CSF

Ionic homeostasis

CNS chemoreceptor respiratory control

Intraocular fluid

Pleural fluid

Chapter 12 Haematology and immunology

Contents

Red blood cells

Erythropoiesis

Haemoglobin

Structure and function of haemoglobin

Effect of CO2, H+

Effect of 2,3-DPG

Genetic control of haemoglobin and haemoglobinopathies

Sickle cell disease

Pathophysiology

Clinical features: sickle trait

Clinical features: sickle cell disease

Diagnosis

Medical management

Perioperative management

Thalassaemias

Alpha-thalassaemia

Beta-thalassaemia

Homozygous β-thalassaemia – thalassaemia major (Cooley’s anaemia)

Beta-thalassaemia trait

Transfusion medicine

ABO system

Rhesus system

Group and screen

Red cell selection and cross-matching

Emergency situations

Transfusion reactions

Immediate life-threatening reactions

Immediate haemolytic transfusion reactions

Anaphylaxis

Delayed life-threatening reactions

Bacterial contamination

Transfusion-related acute lung injury (TRALI)

Congestive cardiac failure (usually LVF)

Non-life-threatening reactions

Febrile non-haemolytic transfusion reactions (FNHTR)

Urticarial reactions

Delayed haemolytic transfusion reactions

Use of blood components

Haemostasis

Extrinsic pathway

Prothrombin time (PT)

Intrinsic pathway

Activated partial thromboplastin time (APTT)

Final common pathway

Thrombin time (TT)

‘In vivo’ coagulation

Natural inhibitors of coagulation

Tissue factor pathway inhibitor

Antithrombin

Protein C system

Fibrinolysis

Platelets

Platelet aggregation

Prostaglandin metabolism in platelets

Platelet adhesion

Platelet shape change

Platelet release reaction

von Willebrand factor

The immune system

Innate defences

Phagocytosis

Cytokines

The complement cascade

Formation of the membrane attack complex

Adaptive defences

Antigen presentation

MHC proteins

Antibody-mediated response

Antibody structure, subtypes and diversity

Primary and secondary antibody responses

Cell-mediated immunity

T-cell receptors (TCRs)

Interaction between antigen-presenting cells (APCs) and T lymphocytes

CD4 and CD8 co-receptors

T-cell mechanisms

Cytotoxic T cells (Tc)

Other cytotoxic cells

The inflammatory response

Mediators of inflammation

The kinin system

Histamine and leukotrienes (B4 and D4)

Neutrophil adhesion and migration across the endothelium

Tumour necrosis factor

Complement

Hypersensitivity

Type I

Type II

Type III

Type IV

Immunodeficiency

HIV and AIDS

Chapter 13 Muscle physiology

Contents

Skeletal muscle

Anatomy of skeletal muscle

Macroscopic structure

Microscopic structure

Thin myofilament

Thick myofilament

Muscle contraction

Excitation–contraction coupling

Mechanics of skeletal muscle contraction

Single fibre

Motor unit

Motor unit summation

Frequency summation

Muscle tone

Rigor mortis

Skeletal muscle fibre types

Modulation of the motor response

Muscle spindles

Golgi tendon organs

Muscle metabolism

Phosphorylation of ADP by creatine phosphate

Glycolytic phosphorylation

Oxidative phosphorylation in mitochondria

Metabolic fuel

Smooth muscle

Anatomy of smooth muscle

Speed and force of contraction in smooth muscle

Smooth muscle control

Chapter 14 Cardiac physiology

Contents

The heart

Structure of cardiac muscle

Sarcoplasmic reticulum

Differences between cardiac muscle and skeletal muscle

Excitation–contraction coupling

Cardiac action potentials

Fast-response action potential

Resting membrane potential (RMP)

Phase 0 – rapid depolarisation

Phase 1 – early rapid repolarisation

Phase 2 – plateau phase

Phase 3 – final rapid repolarisation

Phase 4 – restoration of ionic concentrations and resting state

Atrial cell action potentials

Excitability of cardiac cells

Refractoriness

Pacemaker cells

Slow-response action potential

Phase 4 – restoration of ionic gradients and resting state

Phase 0 – rapid depolarisation

Phase 3 – repolarisation

Ion channels and action potentials

Automaticity of pacemaker cells

Pacemaker discharge rate

Conduction system anatomy

Conduction system defects

The electrocardiogram

ECG waves and the cardiac cycle

Electrical axis of the heart

ECG leads

Standard limb leads I, II, III

Unipolar limb leads aVR, aVL, aVF

Precordial chest leads

Anatomical orientation of ECG electrodes

Calculation of cardiac axis

Monitoring in the operating room

Physiological cardiac arrhythmias

Sinus rhythm

Sinus arrhythmia

Sinus bradycardia

Sinus tachycardia

Effects of electrolyte changes on the ECG

Hypokalaemia

Hyperkalaemia

Hypocalcaemia

Hypercalcaemia

Hypomagnesaemia

Hypermagnesaemia

Hyponatraemia

Alkalosis and acidosis

The cardiac cycle

The ventricles

Systolic function

Left ventricular pressure

Right ventricular pressure

Ventricular volume

Aortic pressure

Atrial pressure

Diastolic function

The cardiac valves

Heart sounds and murmurs

Central venous pressure (CVP)

The cardiac pump

The ventricular pressure–volume loop

Ventricular end-diastolic pressure–volume relationship

Ventricular end-systolic pressure–volume relationship

The Frank–Starling curve

The Frank curve

The Starling curve

The Frank–Starling relationship

The Frank–Starling curve and cardiac failure

The force–velocity curve for cardiac muscle

Stroke volume

Ejection fraction

Measurement of stroke volume

Ventriculography

Echocardiography

Transoesophageal echocardiography

Thoracic impedance

Cardiac output

Cardiac output measurement

Indicator dilution techniques

Thermodilution

Dye dilution

Fick method

Doppler techniques

Control of cardiac pump function

Factors determining stroke volume

Preload

Factors affecting preload

Measurement of preload

Limitations of CVP and PCWP as measures of preload

Afterload

Factors affecting afterload

Measurement of afterload

Contractility

Factors affecting contractility

Ventricular work done during systole

Other methods of measuring contractility

Heart rate

Autonomic control of pacemaker discharge rate

Cardiovascular reflexes

Effects of heart rate on cardiac output

Cardiovascular coupling

Ventriculoarterial coupling

Ventriculovenous coupling

Ventricular interdependence

Cardiac failure

Chapter 15 Physiology of the circulation

Contents

Blood vessels

Structure and function

Blood vessel diameter and wall thickness

Blood vessel function

Pressure and flow in the vascular system

Flow and flow velocity

Flow through the systemic circulation

Vascular resistance

Flow in a single vessel

Blood viscosity

Arterial system

Arterial factors

Flow velocity

Pressure wave

Mean arterial pressure

Compliance

Determination of arterial compliance

Determinants of systolic and diastolic pressures

Technological factors affecting arterial blood pressure

Venous system

Venous circulation

Gravity and the venous system

Jugular venous pressure (JVP)

Cerebral venous pressure and air embolism

Thoracic pump

Microcirculation and lymphatic system

Structure of a capillary network

Capillaries and endothelium

Capillary exchange

Diffusion across capillary walls

Starling forces and filtration

Capillary filtration equilibrium

The lymphatic system

Lymphatic vessels

Tissue oedema

Control of the circulation

Resistance vessels and capacitance vessels

Arterioles

Vascular smooth muscle

Intrinsic mechanisms controlling blood flow

Autoregulation

Metabolic regulation

Mechanical responses of smooth muscle

Myogenic mechanism

Endothelial mechanism

Endothelial factors

Extrinsic humoral control of blood flow

Catecholamines

Vasopressin

Angiotensin

Atrial natriuretic peptide (ANP)

Kinins

Histamine

Other polypeptides

Extrinsic neurological control of blood flow

Vasomotor centres in the CNS

Efferent pathways

Afferent pathways

Influence of higher centres on vasomotor tone

Baroreceptors

Carotid and aortic baroreceptor reflex

Cardiopulmonary baroreceptor reflex

Bainbridge reflex

Pulmonary stretch receptors

Chemoreceptor reflexes

Pain reflexes

Blood volume

Central venous pressure and blood volume

Control of blood volume

Circulatory control under special circumstances

Haemorrhage

Valsalva manoeuvre

Exercise

Moderate exercise levels

Regional blood flow during exercise

Skeletal muscle during exercise

Cardiac output in exercise

Venous return and blood volume in exercise

Arterial pressure

Severe exercise and exhaustion

Special circulations

Coronary circulation

Coronary blood flow

Factors determining coronary blood flow

Cardiac ischaemia

Cerebral circulation

Cerebral blood flow

Regulation of cerebral blood flow

Raised intracranial pressure (ICP)

Blood–brain barrier

Chapter 16 Renal physiology

Contents

Anatomy

Blood supply of the kidneys

Nerve supply of the kidneys

The nephron

The glomerular filter

The tubular system

The urogenital system

Renal excretion of waste products

Glomerular filtration

Size of molecules for filtration

Charge of the glomerular basement membrane

The glomerular capillary coefficient (KF)

GFR and colloid osmotic pressure gradient

GFR and renal plasma flow (RPF)

GFR and hydrostatic pressure gradient

GFR and blood pressure

The juxtaglomerular complex

Tubular reabsorption and secretion

The proximal tubule

The loop of Henle

The countercurrent mechanism

Long and short loops of Henle

The distal tubule

Tubular transport

General mechanisms of transport

Water reabsorption

Rates of tubular reabsorption

Peritubular capillary reabsorption

Measurement of renal function

Glomerular filtration rate (GFR)

Renal clearance

Renal plasma flow

Renal control of extracellular osmolarity

Hyperosmolar medullary interstitium

Sodium chloride

The countercurrent mechanism

Urea

Vasa recta

Control of water reabsorption by antidiuretic hormone

Water clearance

Renal control of sodium

Renal control of extracellular fluid volume

Reduction in extracellular fluid volume

Renal effects of angiotensin II

Increase in extracellular fluid volume

Hypertension

Renal control of acid–base balance

Physiological buffers

The bicarbonate buffer system

Renal mechanisms for pH control

Reabsorption of filtered bicarbonate

Generation of bicarbonate in the tubular cells

Secretion of H+ in exchange for sodium

H+ buffering by ammonia

H+ buffering by phosphate

Metabolism of glutamine

Renal changes occurring in acidosis and alkalosis

Persisting acidosis

Renal control of extracellular potassium

In hyperkalaemia

In hypokalaemia

Renal control of calcium and phosphate metabolism

Calcium regulation

Phosphate reabsorption

Hypocalcaemia

Actions of 1,25-dihydroxycholecalciferol

Actions of parathyroid hormone

Calcium and phosphate in chronic kidney disease

Pathophysiological mechanisms in the nephron

Glomerular disease

Acute tubular necrosis

Acute tubulointerstitial nephritis

Acute cellular rejection

Chronic tubulointerstitial nephritis

Renal stones

Micturition

Drugs and the kidney

Chapter 17 Respiratory physiology

Contents

Functional anatomy

Upper airway and larynx

Conducting airways

Adult trachea (generation 1)

Major bronchi (generations 2–4)

Small bronchi (generations 5–11)

Bronchioles (generations 12–16)

Respiratory areas of the lung

Respiratory bronchioles (generations 17–19)

Alveolar ducts and sacs (generations 20–23)

Alveolar–capillary membrane

Blood vessels and lymphatics

Lung volumes

Lung volumes derived from spirometry

Vital capacity

Functional residual capacity

Measurement of FRC

Closing capacity

Dynamic lung volumes

Ventilation

Dead space

Anatomical dead space

Alveolar dead space

Alveolar volume

Alveolar ventilation

Physiological dead space

Respiratory mechanics

The respiratory muscles and their actions

Inspiration

Diaphragm

Accessory respiratory muscles

Expiration

Compliance of the chest wall and lungs

Intrapleural pressure

Transpulmonary pressure

Lung compliance

Chest wall compliance

Total respiratory system compliance

Measurement of respiratory system compliance

Static compliance

Dynamic compliance

Factors decreasing respiratory system compliance

Pressure–volume loop for the respiratory system

Surfactant

Distribution of ventilation

Gravitational model for distribution of ventilation and perfusion

Structural model for distribution of ventilation and perfusion

Gas flow in the airways

Airway resistance

Pattern of gas flow

Turbulent flow

Location of airway resistance

Measurement of airway resistance

Work of breathing

Gas exchange

Alveolar oxygen tension

Alveolar carbon dioxide tension

Gas diffusion from alveoli to blood

Oxygen transport in the blood

Haemoglobin

Oxygenation of haemoglobin

Oxyhaemoglobin dissociation curve

‘Left shift’ of the ODC

‘Right shift’ of the ODC

Bohr effect

Oxygen content of blood

Oxygen delivery (ḊO2) and oxygen uptake (V̇O2)

Carbon dioxide transport

Haldane effect

Body stores of oxygen and carbon dioxide

Pulmonary circulation

Pulmonary vascular resistance

Hypoxic pulmonary vasoconstriction

Pulmonary hypertension

Distribution of perfusion

Functional zones of the lung

Zone 1

Zone 2

Zone 3

Ventilation/perfusion ratio (V̇/Q̇)

Distribution of V̇/Q̇ ratios in the lung

Alveolar–arterial PO2 difference

Physiological shunt (venous admixture, shunt fraction)

Control of ventilation

Central control of ventilation

Medullary centres

Pontine centres

Respiratory control by higher centres

Reflexes in the control of ventilation

Chemoreceptors

Chemical and irritant receptors

Pressure-sensitive receptors

‘J’ receptors

Pulmonary stretch receptors

Golgi tendon organs

Muscle spindles

Response of ventilation to carbon dioxide tension

Response of ventilation to oxygen tension

Non-respiratory lung functions

Defence mechanisms

Blood filtration

Metabolic functions of the lung

Lung function at high altitude

Inspired oxygen tension (PIO2) at high altitude

Hyperventilation at altitude

Acclimatisation

Ventilation/perfusion matching at altitude

High-altitude disease

References and further reading

Chapter 18 Physiology of the nervous system

Contents

Structure and function of neurones

The ionic basis of membrane potential

Membrane potential at rest

Characteristics of the action potential

Synaptic transmission

Structure of a synapse

Synaptic mechanism

Sensory receptors

Organisation of the nervous system

Coverings of the central nervous system

Cortex

Higher functions of the cerebral cortex

Consciousness

Language

Memory

Basal ganglia

Cerebellum

Brainstem

Cerebral circulation

Regulation of cerebral blood flow

Pressure autoregulation

Flow–metabolism coupling

Arterial blood gases

Carbon dioxide tension

Arterial oxygen tension

Neurogenic regulation

Spinal cord

Structure of the spinal cord

Descending tracts

Ascending tracts

Spinal cord transection

Complete transection

Hemisection of the spinal cord (Brown-Séquard syndrome)

Blood supply of the spinal cord

The reflex arc

Monosynaptic stretch reflex

Polysynaptic withdrawal reflex

Structure of muscle spindles

Function of muscle spindles

Motor function

Cerebral cortex

Cerebellum

Basal ganglia

Control of posture

Spinal cord components

Brainstem components

Midbrain components

Cortical components

Cerebrospinal fluid (CSF)

Intracranial pressure (ICP)

Factors affecting ICP

The relationship between ICP and volume

Cerebrospinal fluid (CSF)

Cerebral blood volume

Arterial blood gases

Cerebral metabolism

Jugular venous pressure

Special senses

Vision

Structure of the eye

The retina

The visual pathway

Hearing

Structure of the ear

Mechanism of hearing

Taste and olfaction

Taste

Olfaction

Autonomic nervous system

Sympathetic nervous system

Parasympathetic nervous system

Neurotransmitters and receptors in the autonomic nervous system

Consequences of autonomic stimulation

Limbic system

Hippocampus and amygdala

Hypothalamus

Control of body temperature

Control of pituitary secretion

Water balance

Food intake

Behavioural functions

Chapter 19 Physiology of pain

Contents

Nociception

Nociceptors

Cellular functions of nociceptors

Nociceptor ion channels

Nociception and inflammatory mediators

The dorsal root ganglion

The dorsal horn

Interneurones

The primary synapse

Neurotransmitters in the pain system

Receptors in the primary synapse

Ascending tracts

Sensory discriminative pathways

Affective pathways

The thalamus

Cortical sites of pain projection

Sensitisation of the pain system

Peripheral sensitisation

Central sensitisation

Modulation of pain

The ‘gate control’ theory

Examples of ‘gating’ at spinal level

Descending modulatory system

Neuromodulators in the pain system

Endogenous opioids

Clinical aspects of pain

Phasic pain, acute pain and chronic pain

Phasic pain

Acute pain

Chronic pain

Chronic pain conditions

Physiological and pathological pain

Physiological pain

Pathological pain

Hyperalgesia

Neuropathic pain

Pain descriptors and localisation

Joint pain

Muscular pain

Visceral pain

Headache

Qualitative descriptors of pain

Psychology of pain

Emotional response

Cognitive response

Behavioural response

Pain management

Acute (postoperative) pain management

Chronic pain management

Pharmacology

Local anaesthetic techniques

Physiotherapy

Complementary techniques

Psychological techniques and pain management programmes

Chapter 20 Gastrointestinal physiology

Contents

Gastrointestinal motility

Patterns of motility

Basal electrical rhythm (BER)

Peristalsis

Regulation mechanisms

Swallowing

Oral stage

Pharyngeal stage

Oesophageal stage

Oesophagus

Barrier pressure

Stomach

Gastric emptying

Small and large bowel

Secretory functions

Salivary glands

Gastric secretion

Constituents of gastric secretion

Hydrochloric acid

Pepsinogens

Mucus

Intrinsic factor

Phases of gastric secretion

Pancreatic secretion

Pancreatic juice

Control of pancreatic secretion

Biliary secretion

Bile

Control of biliary secretion

Digestion and absorption

Carbohydrate

Protein

Lipid

Fluid and electrolytes

Water absorption

Sodium and chloride

Vitamins and minerals

Nausea and vomiting

Vomiting reflex

Pre-ejection

Ejection

References and further reading

Chapter 21 Metabolism and temperature regulation

Contents

Nutrition

Carbohydrates

Proteins

Lipids

Vitamins and minerals

Energy balance

Basal metabolic rate (BMR)

Measurement of BMR

Respiratory quotient (RQ)

Metabolism

Organisation

Adenosine triphosphate (ATP)

Activated carriers

Control of metabolism

Insulin

Glucagon

Adrenaline and noradrenaline

Carbohydrate metabolism

Glycolysis

Rapoport–Leubering shunt

Glycogenolysis

Gluconeogenesis

Pentose phosphate pathway

Oxidation of pyruvate to acetyl-CoA

Citric acid cycle

Oxidative phosphorylation

Defects in carbohydrate metabolism

Protein metabolism

Amino acid pool

Transamination and deamination

Defects in amino acid metabolism

Nitrogen balance

Urea cycle

Creatine and creatinine

Purines and pyrimidines

Purines

Pyrimidines

Lipid metabolism

Free fatty acids (FFAs)

Beta-oxidation of fatty acids

Fatty acid synthesis

Plasma lipoproteins

Cholesterol

Eicosanoids

Ketones

Starvation

Fed state

Initial 12–24 hours

24 hours to 4 days

After 4 days

Exercise

The liver

Structure

Metabolic functions

Protein synthesis

Albumin

Globulins

Clotting factors

Protein catabolism

Carbohydrate metabolism

Lipid metabolism

Detoxification

Drug metabolism

Body temperature and thermoregulation

Physiological mechanisms

Thermoregulatory responses

Disturbances of thermoregulation

Fever

Malignant hyperpyrexia

Other causes of hyperpyrexia

Hypothermia

Hypothermic effects of anaesthesia and surgery

References and further reading

Chapter 22 Endocrine physiology

Contents

Classification of hormones

Polypeptides

Glycoproteins

Steroids

Amines

Indole and fatty acid derivatives

Cellular action of hormones

Hormone receptors

Mechanisms of hormonal action

Direct effects on cell membranes

Effects via second messengers

Effects on protein synthesis

Control of hormone production

Hypertrophy and atrophy

Pituitary gland

Anatomy

Embryological development of the pituitary

Anterior lobe of pituitary

Posterior lobe of pituitary

Pituitary hormones

Functions of individual hormones

Thyroid-stimulating hormone (TSH)

Adrenocorticotropic hormone (ACTH)

Growth hormone (GH)

Prolactin

Follicle-stimulating hormone (FSH)

Luteinising hormone (LH)

Vasopressin (antidiuretic hormone, ADH)

Oxytocin

Deficiency and excess of pituitary hormones

Control of pituitary hormones

Thyroid gland

Anatomy

Thyroid hormones

Synthesis of thyroid hormones

Secretion, transport and metabolism of thyroid hormones

Control of thyroid hormone secretion

Mechanism of action of thyroid hormones

Deficiency and excess of thyroid hormones

Deficiency (hypothyroidism)

Excess (hyperthyroidism)

Parathyroid glands

Anatomy

Parathyroid hormone

Action and regulation

Other hormones affecting calcium levels

Vitamin D

Calcitonin

Glucocorticoids and others

Deficiency and excess of parathyroid hormones

Deficiency

Excess

Adrenal glands

Adrenal cortex

Mineralocorticoids

Glucocorticoids

Adrenocortical androgenic hormones

Adrenal medulla

Stimulus and control of medullary hormones

Abnormalities of adrenal gland function

Adrenal insufficiency

Adrenal excess

Pancreas

The islets of Langerhans

Insulin

Glucagon

Somatostatin

Pancreatic polypeptide

Role of the pancreatic hormones in metabolism

Role of other hormones in carbohydrate metabolism

Deficiency and excess

Deficiency of insulin

The effects of diabetes mellitus

Excess of insulin

References and further reading

Chapter 23 Physiology of pregnancy

Contents

Pregnancy

Cardiovascular system

Cardiac output

Heart rate and stroke volume

Systemic vascular resistance and blood flow to organs

Blood pressure

Aortocaval compression

Electrocardiogram (ECG) and echocardiogram

Heart sounds

Venous pressure

Haematology

Blood volume

Immune system

Coagulation

Plasma proteins

Fluid compartments

Respiratory system

Anatomical changes

Lung mechanics and volumes

Minute ventilation (MV)

Diffusing capacity

Blood gases

Dyspnoea during pregnancy

Pulmonary circulation

Oxygen consumption

Gastrointestinal system

Barrier pressure

Gastric secretion

Gastric emptying

Central nervous system

Epidural space

Subarachnoid space

Sympathetic nervous system

Drugs and the nervous system

Endocrine system

Melanocyte-stimulating hormone

Thyroid gland

Adrenal gland

Pituitary gland

Pancreas

Renal function

Liver and biliary system

Musculoskeletal system

Weight gain

The placenta

Embryology and anatomy

Uterine blood flow

Placental transport

Mechanisms of placental transport

Substances crossing the placenta

Oxygen

Carbon dioxide

Glucose

Amino acids

Fatty acids

Electrolytes and water

Proteins

Hormone secretion

Immunological functions of the placenta

Placental transfer of drugs

Measurement of placental drug transfer

Factors affecting placental drug transfer

Lipid solubility

Degree of ionisation

pH of maternal blood

Protein binding

Molecular weight of drug

Materno-fetal concentration gradient

Placental blood flow

Placental transfer of individual drugs

Opioids

Local anaesthetic agents

Inhalational agents

Induction agents

Muscle relaxants

Anticholinergics

Vasopressors

Benzodiazepines

References and further reading

Chapter 24 Fetal and newborn physiology

Contents

Fetal circulation

Newborn circulation

The heart

Pulmonary function

Newborn ventilatory control

Renal function

Hepatic function

Thermoregulation

Nociception

Section 3 Pharmacology

Chapter 25 Physical chemistry

Contents

Intermolecular and interatomic bonds

Atomic structure

Valency

Ionic bonds

Covalent bonds

Dative bonds

Van der Waals forces

Hydrogen bonds

Hydrophobic bonds

Emulsions

Strength of intermolecular bonds

Oxidation and reduction

Diffusion

Simple diffusion

Non-ionic diffusion

Solubility and partition coefficients

Osmosis

Pharmacological aspects of osmosis

Drug isomerism

Structural isomerism

Chain isomerism

Position isomerism

Functional group isomerism

Dynamic isomerism

Stereoisomerism

Optical isomerism

Classification

Physiological stereoisomers

Pharmacological considerations

Cis–trans (geometric) isomerism

Protein binding

Plasma protein binding

Features of plasma proteins

Factors affecting binding

Effects of changes in binding

References and further reading

Chapter 26 Pharmacodynamics

Contents

Concentration–effect relationships

Drug–receptor kinetics

Key equation 1

Key points

Example

Additional terms used

Key equation 2

Key points

Additional terms used

Key equation 3

Key points

Efficacy and drug–receptor interactions

Agonists

Example

Receptors with multiple molecular binding sites

Key equation 4

Partial agonists

Reversible competitive antagonists

Key equation 5

Irreversible competitive antagonists

Key equation 6

Lineweaver–Burk plot

Variations from predictions

Occupancy–response inconsistencies

Hysteresis

General variation

Interactions of drugs with similar effects

Pharmacogenetics

Enzymes

Chapter 27 Pharmacokinetics

Contents

Drug administration

Absorption

Enteral administration

Advantages

Disadvantages

First-pass effect

Bioavailability

Parenteral administration

Advantages

Disadvantages

Intramuscular

Transdermal

Inhaled

Distribution

Blood flow to tissues

Drug uptake by tissues

Active transport

Protein binding

Placental transfer

Elimination

Enterohepatic circulation

Biotransformation

Extraction ratio

Excretion

Pharmacokinetic models

Compartment models

One-compartment model

Two-compartment model

Three-compartment model

Water analogue model

Volume of distribution

Elimination kinetics

Zero-order kinetics

First-order kinetics

Half-lives and time constants

Step 1

Step 2

Step 3

Step 4

Step 5

Clearance

Effective levels

Context-sensitive half-life

Chapter 28 Mechanisms of drug action

Contents

Physicochemical mechanisms

Charge neutralisation

Osmotic effects

Adsorption

Chelation and inclusion complexes

Pharmacodynamic mechanisms

Drug–cell membrane receptors

Ligand-gated ion channels

Cys-loop pentameric receptors

Ionotropic glutamate receptors

Ionotropic purinergic receptors: P2X subtypes

G-protein-coupled receptors (GPCRs)

Other transmembrane messenger systems

Voltage-gated ion channels

Intracellular receptors

Intracellular hormone receptors

Adrenal steroid hormones

Intracellular membrane-bound receptors

Pharmacokinetic actions

Drug interactions with enzymes

Interaction with neurotransmitter metabolism

Acetylcholine: acetylcholinesterase

Catecholamine neurotransmission

GABA metabolism

Immunomodulatory action

Drug interactions with transport proteins

Mechanisms of general anaesthetic action

Anatomical sites of action

Molecular theories

Membrane lipids

Protein site(s) of action

The evidence for a protein site of action

GABAA receptor

Glycine receptor

NMDA receptor

Adverse effects

Physicochemical effects

Pharmacodynamic effects

Regulation of receptor activity and unwanted effects

Pharmacokinetic effects

Idiopathic adverse effects

Hypersensitivity reactions

Pharmacogenetic influences

Mechanisms of drug interactions

Physicochemical

Pharmacokinetic

Pharmacodynamic

Chapter 29 Anaesthetic gases and vapours

Contents

Administration

Uptake of inhaled anaesthetic agents

Delivery phase

Pulmonary phase

Inhaled concentration

Alveolar ventilation

Diffusion

Blood/gas partition coefficient

Partial pressure of volatile agent in the pulmonary artery

Pulmonary blood flow

Ventilation/perfusion distribution

Concentration effect

Second gas effect

Circulatory phase

Cardiac output

Cerebral blood flow (CBF)

Distribution to other tissues

Minimum alveolar concentration (MAC)

The ideal volatile agent

Specific pharmacology

General features

Physical

Clinical

Central nervous system

Relative effects

Respiratory system

Relative effects

Cardiovascular system

Relative effects

Muscle relaxation

Metabolic rate

Toxicity

Soda lime

Immune system

Desflurane

Halothane

Isoflurane

Sevoflurane

Compound A

‘Wet’ and ‘dry’ formulations

Nitric oxide

Nitrous oxide

50% Nitrous oxide in oxygen (Entonox)

Xenon (Xe)

Chapter 30 Hypnotics and intravenous anaesthetic drugs

Contents

General features

Pharmacokinetics

Adverse reactions

The ideal agent

Barbiturates

Chemical structure

Structure–activity relationship

Clinical effects

Complications associated with barbiturate usage

Porphyria

Subcutaneous extravasation

Intra-arterial injection

Thiopental

Physical

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Metabolism

Complications

Steroids

Physical

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Complications

Eltanolone (pregnanolone)

Hydroxydione

Minaxolone

ORG 20599 and ORG 21465

Butyrophenones

Phencyclidine derivatives

Physical

Pharmacodynamics

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Metabolism

Imidazoles

Physical

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Metabolism

Phenols

Physical

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Metabolism

Complications

Benzodiazepines

Chemical

Pharmacokinetics

Clinical

Central nervous system

Cardiovascular system

Respiratory system

Other effects

Metabolism

Diazepam

Midazolam

Lorazepam

Temazepam

Flumazenil

Cautions

Other hypnotic agents

Buspirone

Chloral and related drugs

Clinical effects

Central nervous system

Cardiovascular system

Respiratory system

Metabolism

Cautions

Meprobamate

Zolpidem

Zopiclone

Specific pharmacology

Diazepam

Etomidate

Flumazenil

Ketamine hydrochloride

Midazolam hydrochloride

Propofol

Sodium thiopental

Chapter 31 Analgesic drugs

Contents

Opioids

Classification

Structure–activity relationships

Opioid receptors

Classification

MOP

DOP

KOP

NOP

Sigma receptor

Pharmacodynamics

Clinical effects

CNS effects

Cardiovascular effects

Effects on other organ systems

Side effects

Opioid-specific effects

Opioid metabolites

Pharmacokinetics

Administration

Distribution

Receptor kinetics

Elimination

Morphine

Diamorphine

Codeine

Pethidine

Fentanyl and sufentanil

Remifentanil

Patient factors influencing opioid pharmacokinetics and pharmacodynamics

Opioid drug interactions

Opioid antagonists

Naloxone

Naltrexone

Tramadol

Non-steroidal anti-inflammatory drugs (NSAIDs)

Mechanism of action

Prostaglandin synthesis inhibition

Cyclo-oxygenase isoenzymes

COX-1

COX-2

Efficacy of NSAIDs

Adverse effects

Selective cyclo-oxygenase-2 inhibitors

Paracetamol

Other analgesic drugs

α2-Agonists

Anticonvulsants

Antidepressants

Cannabinoids

Lidocaine

NMDA antagonists

Steroids

Future developments

Nicotinic acetylcholine receptor agonists

Tachykinins

Other centrally mediated contenders

Specific pharmacology

Alfentanil

Codeine

Diclofenac

Fentanyl

Ibuprofen

Ketorolac

Morphine

Naloxone

Paracetamol

Remifentanil

Tramadol

References and further reading

Chapter 32 Neuromuscular blocking agents

Contents

Mechanisms of neuromuscular blockade

Depolarising blockade

Mechanism of action

Clinical features

Plasma cholinesterase abnormalities

Phase I and phase II blockade

Non-depolarising blockade

Mechanism of action

Clinical features

Aminosteroids

Benzylisoquinolinium compounds

Elimination

Anticholinesterases

Mechanism of action

Reversible anticholinesterases

Organophosphorus compounds

Selective binding agent

Specific pharmacology

Atracurium dibesylate

Cis-atracurium dibesylate

Mivacurium chloride

Neostigmine bromide

Pancuronium bromide

Rocuronium bromide

Sugammadex

Suxamethonium chloride (succinylcholine)

Vecuronium bromide

References and further reading

Chapter 33 Local anaesthetic agents

Contents

Structure

Mechanism of action

Factors influencing activity

Molecular weight

Lipid solubility

pKa

pH

Protein binding

Clinical effects and toxicity

Ester-linked agents

Amethocaine

Benzocaine

Cocaine

Amide-linked agents

Bupivacaine

Levobupivacaine

Lidocaine

Prilocaine

Methaemoglobinaemia

Ropivacaine

EMLA

Lidocaine cream

Additives

Glucose

Vasoconstrictors

Adrenaline

Felypressin

Hyaluronidase

pH manipulation

Additives with analgesic activity

Specific pharmacology

Bupivacaine hydrochloride

Levobupivacaine hydrochloride

Lidocaine hydrochloride

Prilocaine hydrochloride

Ropivacaine hydrochloride

Chapter 34 Central nervous system pharmacology

Contents

Antiemetic drugs

Anticholinergic drugs

Phenothiazines

Butyrophenones

Antihistamines

5-Hydroxytryptamine (5-HT3) receptor antagonists

Cannabinoids

Neurokinin receptor antagonists

Steroids

Peripherally acting antiemetic drugs

Miscellaneous antiemetics

Specific pharmacology of antiemetic drugs

Cyclizine hydrochloride and lactate

Dexamethasone

Droperidol

Metoclopramide hydrochloride

Ondansetron hydrochloride

Prochlorperazine

Anticonvulsant drugs

Benzodiazepines

Barbiturates

Phenytoin

Carbamazepine

Gabapentin and pregabalin

Valproate

Lamotrigine

Vigabactrin

Tiagabine

Levetiracetam

Antidepressant agents

Tricyclic antidepressants

Monoamine oxidase inhibitors (MAOIs)

Reversible MAOIs

Selective serotonin reuptake inhibitors (SSRIs)

Serotonin–noradrenaline reuptake inhibitors (SNRIs)

Selective noradrenaline reuptake inhibitors

Noradrenergic and specific serotonergic antidepressants

Lithium

Antipsychotic drugs

Phenothiazines

Thioxanthines

Other antipsychotic drugs

Anti-Parkinsonian drugs

Levodopa

Carbidopa

Domperidone

Selegiline

Dopaminergic drugs

Amantadine

Acetylcholine antagonists

References and further reading

Chapter 35 Autonomic nervous system pharmacology

Contents

Cholinergic system

Muscarinic receptors

Muscarinic agonists

Pharmacological features

Clinical effects

Muscarinic antagonists

Pharmacological features

Clinical effects

Atropine

Glycopyrrolate

Hyoscine

Nicotinic receptors

Nicotinic agonists

Nicotinic antagonists

Clinical effects

Drugs interfering with synthesis, release and metabolism of acetylcholine

Adrenergic system

Adrenoceptors

Agonist responses of adrenoceptors

Clinical effects

Pharmacological features

Adrenoceptor agonists

Clinical uses

Adrenaline

Dobutamine

Dopamine

Dopexamine

Isoprenaline

Noradrenaline

Salbutamol

Clonidine

Metaraminol

α-Adrenoceptor antagonists

Uses

Clinical effects

Phenoxybenzamine

Phentolamine

Labetalol

Tamsulosin and alfuzosin

β-Adrenoceptor antagonists

Mode of action

Uses

Clinical effects

Atenolol

Esmolol

Propranolol

Drugs interfering with synthesis, storage, release and metabolism of catecholamines

Synthesis

Storage

Release

Direct-acting vasodilating agents

Calcium channel antagonists

Organic nitrates, nitrites and related drugs

Uses

Mode of action

Clinical effects

Glyceryl trinitrate

Isosorbide dinitrate

Isosorbide mononitrate

Nitric oxide

Nitroprusside

Potassium channel activators

If current inhibitor

Endothelin receptor antagonists

Prostacyclins

cGMP phosphodiesterase inhibitor

Other agents of importance

Diazoxide

Hydralazine

Specific pharmacology

Adrenaline

Atropine sulphate

Clonidine hydrochloride

Dopamine hydrochloride

Dopexamine hydrochloride

Dobutamine hydrochloride

Ephedrine

Esmolol hydrochloride

Glyceryl trinitrate

Glycopyrrolate

Hyoscine hydrobromide or butylbromide

Isoprenaline

Labetalol hydrochloride

Noradrenaline acid tartrate

Sodium nitroprusside

Chapter 36 Cardiovascular pharmacology

Contents

Antiarrhythmic drugs

Class I

Class II

Class III

Class IV

Adenosine

Cardiac glycosides

Chemistry

Pharmacological effects

Clinical uses

Mechanisms of action

Sodium–potassium adenosine triphosphatase (Na+K+ATPase)

Interference with neuronal catecholamine reuptake

Elimination

Toxicity

Contraindications

Magnesium

Calcium antagonists

Papaverines

Benzothiazepines

Dihydropyridines

Phosphodiesterase inhibitors

Mode of action

Clinical effects

Bipyridines

Imidazolines

Selective imidazoline receptor agonists (SIRAs)

Renin–angiotensin system

Angiotensin-converting enzyme inhibitors

Mechanism of action

Angiotensin-II receptor antagonists

Mechanism of action

Uses

Features

Diuretics

Loop diuretics

Thiazide diuretics

Potassium-sparing diuretics

Osmotic diuretics

Carbonic anhydrase inhibitors

Specific pharmacology

Adenosine

Amiodarone hydrochloride

Digoxin

Diltiazem

Esmolol hydrochloride

Nifedipine

Verapamil

References and further reading

Chapter 37 Respiratory pharmacology

Contents

Administration and modes of action

Control of bronchial calibre

Adrenoceptor agonists

β2-agonists

Other adrenoceptor agonists

Anticholinergic agents

Methylxanthines

Clinical effects

Respiratory system

Cardiovascular system

Central nervous system

Other effects

Steroids

Cromoglicate

Leukotriene receptor antagonists

Respiratory centre stimulants

Mucolytics

Surfactant

Specific pharmacology

Aminophylline

Beclomethasone

Budesonide

Doxapram

Ipratropium bromide

Salbutamol

Sodium cromoglicate

Zafirlukast

Chapter 38 Endocrine pharmacology

Contents

Blood sugar control

Insulin receptor

Glucose

Glucagon

Insulin

Oral hypoglycaemic agents

Sulphonylureas

Biguanides

Thiazolidinediones

Meglitinide analogues

Thyroid hormones and antithyroid drugs

Hypothyroidism

Hyperthyroidism

Thioureylenes

Iodine/iodide mixtures

Radio-iodine

Adrenocortical steroids

Oxytocic drugs

Oxytocin

Ergometrine

Carboprost

Renal hormones

Vasopressin and analogues

Vasopressin

Desmopressin (1-deamino-8-D-arginine vasopressin or DDAVP)

Vasopressin antagonists

Demeclocycline

Vasopressin receptor antagonists

Renin–angiotensin system

Specific pharmacology

Dexamethasone

Hydrocortisone

Insulin (soluble)

Oxytocin

References and further reading

Chapter 39 Gastrointestinal pharmacology

Contents

Reduction of gastric acidity

H2 receptor antagonists

Cimetidine

Famotidine

Nizatidine

Ranitidine

Proton pump inhibitors

Omeprazole

Prostaglandins

Antacids

Mucoprotective drugs

Chelates and complexes

Sucralfate

Tripotassium dicitratobismuthate

Carbenoxolone

Antispasmodics

Anticholinergics

Direct-acting smooth muscle relaxants

Prokinetic agents

Laxatives

Bulking agents

Faecal softeners

Osmotic laxatives

Stimulants

Specific pharmacology

Lansoprazole

Omeprazole

Ranitidine

Chapter 40 Intravenous fluids

Contents

Crystalloids

Water

Electrolytes

Cations

Anions

Solutions

Colloids

Gelatins

Gelofusine (Braun)

Characteristics

Haemaccel (Hoechst)

Characteristics

Dextran 70

Hydroxyethyl starches (HES)

Human albumin solutions (HAS)

Haemoglobin solutions (experimental)

Stroma-free haemoglobin (SFH)

Oxygen affinity

Intravascular persistence

Nephrotoxicity

Nitric oxide scavenging

Microencapsulated haemoglobin

Synthetic oxygen carriers

Chelating agents (experimental)

Perfluorocarbons

References and further reading

Chapter 41 Pharmacology of haemostasis

Contents

Anticoagulants

Oral anticoagulants

Warfarin sodium

Heparins

Structure

Mechanism of action

Low-molecular-weight heparins

Administration

Effects on coagulation studies

Protamine

Activated factor X inhibitors

Thrombin (factor II) inhibitors

Calcium chelating agents

Fibrinolytic agents

Plasminogen activators

Fibrinolytic inhibitors

Antiplatelet drugs

Aspirin

Prostacyclin

P2Y12 inhibitors

Glycoprotein IIb/IIIa inhibitors

Other haemostatic modifiers

Viscosity

Coagulation factors

Platelet action

References and further reading

Chapter 42 Antimicrobial therapy

Contents

Principles of antimicrobial therapy

Antimicrobial therapy in renal failure

Mechanisms of action

Cell wall synthesis

Cell membrane permeability

Protein synthesis

Nucleic acid synthesis

Mechanisms of resistance

Beta-lactams

Mechanism of action

Acquired resistance

Penicillins

Adverse effects

Benzylpenicillin

Amoxicillin

Flucloxacillin

Piperacillin and Tazocin

Clavulanic acid

Temocillin

Cephalosporins

Cephalexin

Cefuroxime

Cefotaxime

Ceftriaxone

Cefixime

Ceftazidime

Cefpirome

Ceftaroline

Carbapenems

Pharmacokinetics

Adverse effects

Imipenem

Meropenem

Monobactams

Pharmacokinetics

Adverse effects

Glycopeptides and lipopeptides

Acquired resistance

Vancomycin

Spectrum of activity

Pharmacokinetics

Adverse effects

Teicoplanin

Daptomycin

Aminoglycosides

Mechanism of action

Acquired resistance

Adverse effects

Gentamicin

Amikacin

Streptomycin

Macrolides

Mechanism of action

Acquired resistance

Erythromycin

Tetracyclines

Mechanism of action

Acquired resistance

Tetracycline

Adverse effects

Doxycycline

Chloramphenicol

Mechanism of action

Acquired resistance

Pharmacokinetics

Adverse effects

Fusidanes

Mechanism of action

Pharmacokinetics

Adverse effects

Quinolones

Mechanism of action

Acquired resistance

Ciprofloxacin

Ofloxacin and levofloxacin

Nitroimidazoles

Mechanism of action

Acquired resistance

Metronidazole

Rifamycins

Mechanism of action

Pharmacokinetics

Adverse effects

Trimethoprim

Mechanism of action

Acquired resistance

Pharmacokinetics

Adverse effects

Sulphonamides

Mechanism of action

Acquired resistance

Pharmacokinetics

Adverse effects

Antimycobacterials

Ethambutol

Isoniazid

Pyrazinamide

Antivirals

Principles of antimicrobial stewardship

Antimicrobial prophylaxis in surgery

References and further reading

Chapter 43 Clinical trials and basic statistics

Contents

Clinical trials

Types of trial

Phased clinical trials

Phase I trials

Phase II trials

Phase III trials

Phase IV trials

Crossover studies

Cohort, cross-sectional and case–control studies

Meta-analyses and systematic reviews

Trial design

Sample size

Variability

Bias

Randomisation

Blinding

Trial implementation

Ethical approval

Data collection

Data analysis

End of trial

Presentation of results

Basic statistics

Data description

Types of data

Numerical data

Categorical data

Displaying data

Frequency distributions

Probability

Probability density curves

Recognised probability density curves

Normal distribution

Describing numerical data

The average value

The spread of values

Sampling

Standard error of the mean (SEM)

Confidence limits

Describing categorical data

Proportions

Contingency tables

Data collection

Experimental studies

Types of hypothesis

Types of error

Power of a study

Data interpretation

P-number

Obtaining P-numbers

Level of significance (α)

Single-tailed and two-tailed testing

Parametric and non-parametric tests

Statistical tests

Comparing numerical data from two groups

Student’s t-test

Ranking tests

Testing categorical data from two groups

Chi-squared test

Comparison of two proportions

Risk

Risk difference (absolute risk reduction, ARR)

Number needed to treat (NNT)

Number needed to harm (NNH)

Relative risk

Odds ratio

Diagnostic or screening tests

Sensitivity

Specificity

Positive predictive value (PPV)

Negative predictive value (NPV)

Likelihood ratio (LR)

Multiple groups

Parametric data

Non-parametric data

Testing relationships

Correlation

Testing for correlation between two variables

Linear regression

Performing linear regression analysis

Systematic reviews

Meta-analysis

Section 4 Physics and clinical measurement

Chapter 44 Applied physics

Contents

Units and derived units

SI units

Fundamental units

Derived units

Named derived units

Unit multiplication factors

Conversion between pressure units

Converting units

Fundamental constants

Mechanics

Mass and weight

Force and pressure

Work done by a force

Work, energy and power

Power

Hydrostatics

Hydrostatic pressure

Barometric pressure

Gauge pressure

Absolute pressure

Work done by a ventilator in compressing inspiratory gases

Work of breathing

Work done by the myocardium

Heat

Units of heat energy

Temperature scales

Specific heat capacity and heat capacity

Gases, liquids and solids

Critical temperature

Variation of physical state with pressure and temperature

Triple point of water

Vapours and gases

Saturated vapour pressure and its relationship to boiling point

Latent heat

Heat loss due to ventilation with cool dry gases

Humidity

Calculation of RH from water vapour pressure and SVP

Heat transfer

Gases

The ideal gas equation

The gas constant (R)

Gas contents in a cylinder

Avogadro’s hypothesis

Dalton’s law of partial pressures

Adiabatic compression or expansion of gases

Hydrodynamics

Gases, liquids and fluid behaviour

Viscosity

Shear stress and shear rate

Coefficient of viscosity

Newtonian fluids

Measurement of viscosity

Viscosity and the damping of fluid flow

Flow through tubes

Hagen–Poiseuille law

Kinematic viscosity

Reynolds number and turbulence

Velocity profiles for laminar and turbulent flow in a tube

Transition between laminar flow and turbulence

Effect of varying cross-section on flow velocity

Pressure and velocity: Bernoulli’s equation

Venturi effect

Injection of gas through a jet

Electricity

Basic quantities and units

Electric charge

Electric current

Magnetic effects of an electric current

Electrical potential

Potential difference (voltage)

Electric circuits

Resistance

Power

Direct current (DC) and alternating current (AC)

RMS value

Phase angle

Phase (angle) difference

Impedance and reactance

Circuit elements

Resistors

Wheatstone bridge circuit

Capacitors

Inductors

Defibrillator circuit

Transformer

Diode

Transistor

Electrical safety

Electric shock (macroshock)

The ‘mains’ supply

How electric shock occurs

Effects of electric shock

Whether the current is AC or DC

The magnitude of the current

The tissues or organs the current passes through

Current density

Duration of current passage

Pre-existing disease in a patient

Prevention of electric shock (macroshock)

Microshock

Some potential sources of microshock

Prevention of microshock

Diathermy hazards

Prevention of diathermy hazards

Electrical burns

Fire and explosion

Prevention of fire and explosion

Ultrasound

Sound

Frequency

Wavelength

Velocity of propagation

Acoustic impedance

Reflection and acoustic impedance

Scatter

Refraction

Power and acoustic intensity

Averaged intensity units

Harmful effects of ultrasound on tissues

Heating effect

Cavitation

Mechanical effect

Ultrasound scanners

Piezoelectric effect

A-mode

B-mode

M-mode

Doppler mode

Doppler effect

B-mode scanning for nerve blocks or vascular access

Interpretation of B-mode scans

Limitations and artefacts of B-mode scans

Special applications of ultrasound in anaesthesia, emergency medicine and critical care

FATE: focus assessed transthoracic echocardiography

FAST: focused assessment with sonography for trauma

TOE: transoesophageal echocardiography

Magnetic resonance imaging

Basic principles of MRI

Changes in the magnetic field caused by the RF pulse

Relaxation phase after RF pulse excitation

Relaxation time constants (T1 and T2)

T1- and T2-weighted images

Pulse sequences

The MRI scanner

MRI scanner coils

Biohazard effects of MRI exposure

Light

Transverse waves, light waves and light rays

Wavelength of light

Refraction of light

Reflection of light

Total internal reflection

Polarised light

Dextro- (d) and laevo- (l) rotatory substances

Luminous intensity and the candela

Light transmission and absorbance (optical density)

Lasers

Stimulated emission

Laser construction

Laser safety

X-rays

Radioactive isotopes and radiation

Radioactive decay

Radiation from radioactive isotopes

Decay half-life

Units of radioactivity

Applications of radioactive isotopes

Measurement of exposure to ionising radiation

Energy absorbed by air

Energy absorbed by body tissue

Biological effect

Biologically significant doses of radiation

Chapter 45 Clinical measurement

Contents

Measurement systems

Characteristics of a measurement system

Static characteristics

Dynamic characteristics

Step response

Damping

Frequency response

Bandwidth

Distortion due to poor frequency response

Natural frequencies or resonances

Phase shift response

Electrical signals

Biological potentials

Characteristics of electrical signals

Frequency spectrum of a signal

Electrical ‘noise’

Signal-to-noise ratio

Signal processing

Amplifiers

Pressure measurement

Aneroid gauge

Manometer

Piezoresistive strain gauge

Blood pressure measurement

Variation due to the site of measurement

Methods of measuring blood pressure

Indirect methods of measuring blood pressure

Manual occlusive cuff methods

Flush method

Automated occlusive cuff methods (oscillometry)

Penaz technique

Continuous arterial wall tonometry

Doppler ultrasound

Sources of error in indirect methods

Direct method: intra-arterial pressure monitoring

Sources of error in arterial pressure monitoring

Gas flow measurement

Benedict Roth spirometer

Vitalograph

Wright respirometer

Dry gas meter

Electronic volume meter

Peak flow meter

Gas flow measurement in anaesthetic machines

Rotameter

Gas flow pattern in a rotameter

Features of the rotameter block

Gas flow measurement in breathing circuits

Pneumotachograph

Screen pneumotachograph

Fleisch pneumotachograph

Hot-wire pneumotachograph

Modified Pitot tube pneumotachograph

Gas and vapour concentrations

Gas analysers

Step response of gas analysers

Types of gas analyser

Discrete analysers

Continuous analysers

Mass spectrometers

Infrared (IR) absorption (in capnographs)

Ultraviolet (UV) absorption

Paramagnetism (in oxygen analysers)

Thermal conductivity

Electrochemical gas analysers

Other methods of gas analysis

Sources of error in gas and vapour measurements

Oxygen measurement

‘In vitro’ measurements of oxygen concentrations

Measurement in fresh gas mixtures

Measurement in blood samples

Clark electrode (polarographic electrode)

Galvanic fuel cell

Sources of error with electrochemical methods

‘In vivo’ measurement of oxygen concentration

Intravascular oxygen electrodes

Transcutaneous oxygen electrodes

Conjuctival oxygen tension electrode

Mass spectrometer

Optodes

Carbon dioxide measurement

‘In vitro’ carbon dioxide measurement

The carbon dioxide electrode

‘In vivo’ measurement of carbon dioxide concentration

Transcutaneous electrodes

Intravascular probes

Optodes

The capnograph: end-tidal CO2 (ETCO2)

Sidestream capnograph

Mainstream capnograph

Clinical uses of the capnograph trace

Infrared absorption spectroscopy

pH measurement

Indirect estimation of pH

The pH electrode

Oximetry

Transmission oximetry

Basic principles

Absorbance curves for HbO2 and Hb

Functional saturation

Fractional oxygen saturation

Co-oximeter

Pulse oximeter

The pulse oximeter signal

Increased response times in pulse oximeters

Reflectance oximetry

Sources of error in oximetry

Neuromuscular monitoring

Methods of neuromuscular monitoring

Electrical stimulation of a peripheral nerve

Assessment of neuromuscular blockade

Vision and touch

Mechanomyography

Accelomyography

Electromyography

Stimulation patterns in neuromuscular monitoring

Single twitch

Train of four (TOF)

Tetanic stimulation

Post-tetanic count (PTC)

Double-burst stimulation (DBS)

Depth of anaesthesia

Historical background

Integrated clinical scores

Lower oesophageal contractility

Frontalis electromyogram (FEMG)

Current methods of assessing anaesthetic depth: electrical activity of the brain

Electroencephalogram (EEG)

Cerebral function analysing monitor (CFAM)

Compressed spectral array

Evoked responses

Bispectral index (BIS) monitoring

Temperature measurement

Temperature scales

Temperature measurement site

Thermometers

Direct-reading thermometers

Liquid expansion thermometers

Chemical thermometers

Dial thermometers

Remote-reading thermometers

Resistance thermometers

Thermistors

Thermocouple

Humidity measurement

Definition of humidity

Measurement of humidity

Pain measurement

Dimensions characterising pain

Acute and chronic pain

Physiological changes associated with pain

Single-dimension pain measurement

Multidimensional pain measurement

Assessment of pain in children

Chapter 46 Anaesthetic equipment

Contents

Medical gas pipeline services

Oxygen supply

Nitrous oxide supply

Medical compressed air

Medical vacuum

Gas cylinders

Cylinder identification

Pin index system (PIS)

Cylinder testing

Estimation of cylinder contents

Gases

Vapours

Pressure regulators

Anaesthetic machines

Metal framework and pipeline circuitry

Medical gas pipeline service (MGPS) connections

Pin index system (PIS) connections for gas cylinders

Safety mechanisms

Back bar

Vaporiser connections

Gas outlets

Anaesthetic machine maintenance

Anaesthetic machine checklist

Vaporisers

Variable bypass vaporiser

Measured flow vaporiser

Plenum variable bypass vaporisers

Flow-splitting ratio

Draw-over variable bypass vaporisers

Measured flow vaporisers

Vaporiser performance

Flow rate

Temperature

Atmospheric pressure

‘Pumping effect’

Carrier gas composition

Mechanical stability

Overfilling

Vaporiser maintenance

Design features of a vaporiser

Breathing systems

Breathing system performance

Breathing system components

Masks and hoses

Hose connectors

Reservoir bags

Mapleson classification for breathing systems

Practical breathing systems

Circle system

Controlled ventilation (CV) with the circle system

Use of volatile agents with the circle

Carbon dioxide absorption

Toxic products due to reaction between volatile agents and soda lime

Oxygen delivery systems

Variable performance

Fixed performance

Low dependency

Medium dependency

High dependency

Resuscitation breathing systems

Endotracheal tubes

Laryngeal mask airway

Scavenging systems

Recommended levels of pollutants

Types of scavenging system

Passive systems

Active systems

Absorbers

Mechanical ventilators

Ideal characteristics of a ventilator

Mapleson classification for ventilators

Inspiratory phase

Ventilator performance and reduced lung compliance

Cycling between inspiration and expiration (inspiratory cycling)

Expiratory phase

Cycling between expiration and inspiration (expiratory cycling)

Ventilator mechanics

Clinical features of ventilators

Humidifiers

Humidifiers for medical gases

Bottle humidifier

Soda lime absorber in the circle breathing system

Heat and moisture exchanger (HME)

Hot water bath

Nebulisers

Intravenous equipment

Intravenous cannulae

Intravenous giving sets

Blood warmers

Regional anaesthesia equipment

Ultrasound needles

Spinal needles

Epidural needles and catheters

Methods of sterilisation

Index

 

An aparitie	1 Dec. 2016
Autor	Ted Lin, Tim Smith, Colin Pinnock Chris Mowatt
Dimensiuni	18.9 x 4.98 x 24.6 cm
Editura	Cambridge University Press
Format	Paperback
ISBN	9781107612389
Limba	Engleza
Nr pag	983