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 Fundamentals of Anaesthesia

Fourth Edition

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 Fundamentals
of Anaesthesia
Fourth Edition

Edited by
Ted Lin
Department of Anaesthesia, Glenfield Hospital,
University Hospitals of Leicester NHS Trust, Leicester, UK

Tim Smith
Department of Anaesthesia, Alexandra Hospital, Worcestershire Acute Hospitals NHS Trust,
Redditch, UK

Colin Pinnock
Formerly of Department of Anaesthesia, Alexandra Hospital, Worcestershire Acute Hospitals
NHS Trust, Redditch, UK

Associate Editor
Chris Mowatt
Department of Anaesthesia, Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital
NHS Trust, Shrewsbury, UK

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 University Printing House, Cambridge CB2 8BS, United Kingdom

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107612389
© Cambridge University Press 2016
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published by Greenwich Medical Media 1999
Second edition published 2003
Third edition published by Cambridge University Press 2009
Fourth edition published 2016
Printed in the United Kingdom by Clays, St Ives plc
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging in Publication data
Names: Lin, Ted, 1945– , editor. | Smith, Tim, 1960 September 1, editor. | Pinnock,
Colin A., editor. | Mowatt, Chris, editor.
Title: Fundamentals of anaesthesia / edited by Ted Lin, Tim Smith, Colin Pinnock,
Chris Mowatt.
Description: Fourth edition. | Cambridge, United Kingdom : Cambridge University
Press, 2016. | Includes bibliographical references and index.
Identifiers: LCCN 2016000988 | ISBN 9781107612389 (pbk. : alk. paper)
Subjects: | MESH: Anesthesia | Analgesia | Analgesics–therapeutic use
Classification: LCC RD81 | NLM WO 200 | DDC 617.9/6–dc23 LC
record available at http://lccn.loc.gov/2016000988
ISBN 978-1-107-61238-9 Paperback

Cambridge University Press has no responsibility for the persistence or accuracy

of URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
Every effort has been made in preparing this book to provide accurate
and up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.

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 To our families, whose support has helped us
overcome the challenges of creating this textbook

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 Contents

List of contributors page ix 11 Body fluids 232

Preface to the first edition xi Mahesh Chaudhari
Preface to the second edition xii 12 Haematology and immunology 247
Preface to the third edition xiii Jeff Neilson and Ted Lin
Preface to the fourth edition xiv 13 Muscle physiology 269
Acknowledgements xv Edwin Mitchell
List of abbreviations xvii 14 Cardiac physiology 282
Justiaan Swanevelder
Section 1: Clinical anaesthesia 1 15 Physiology of the circulation 315
Chris Mowatt Ted Lin
1 Preoperative management 1 16 Renal physiology 344
Gwenda Cavill and Karen Kerr Alexander Ng
2 Conduct of anaesthesia 29 17 Respiratory physiology 371
Chris Mowatt Bal Appadu and Ted Lin
3 Intraoperative management 46 18 Physiology of the nervous system 404
Chris Mowatt Peter Featherstone, Anand Sardesai and
4 Postoperative management 57 Arun Gupta
Tina McLeod 19 Physiology of pain 431
5 Special patient circumstances 79 Ted Lin
Colin Pinnock, Robert Haden and 20 Gastrointestinal physiology 454
Dan Bailey Matthew Faulds and Nick
6 The surgical insult 128 Morgan-Hughes
Colin Pinnock and Robert Haden 21 Metabolism and temperature regulation 466
7 Regional anaesthesia 139 Smita Gohil and Ted Lin
Barrie Fischer and Oscar Domingo 22 Endocrine physiology 491
i Bosch Jo James
8 Principles of resuscitation 170 23 Physiology of pregnancy 512
Anita Stronach Mary Mushambi
9 Major trauma 195 24 Fetal and newborn physiology 531
Jerry Nolan Andrew Wolf

Section 2: Physiology 210 Section 3: Pharmacology 537

Ted Lin Tim Smith
10 Cellular physiology 210 25 Physical chemistry 537
Ted Lin Tim Smith

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 viii Contents

26 Pharmacodynamics 550 38 Endocrine pharmacology 714

Tim Smith Tim Smith
27 Pharmacokinetics 562 39 Gastrointestinal pharmacology 721
Tim Smith Tim Smith
28 Mechanisms of drug action 578 40 Intravenous fluids 727
Sue Hill Tim Smith
29 Anaesthetic gases and vapours 594 41 Pharmacology of haemostasis 733
Tim Smith Tim Smith
30 Hypnotics and intravenous anaesthetic 42 Antimicrobial therapy 739
drugs 606 Jim Stone
Tim Smith 43 Clinical trials and basic statistics 754
31 Analgesic drugs 621 Leon Vries and Ted Lin
Ian Power and Michael Paleologos
32 Neuromuscular blocking agents 647 Section 4: Physics and clinical
Tim Smith measurement 782
33 Local anaesthetic agents 658 Ted Lin
Tim Smith 44 Applied physics 782
34 Central nervous system pharmacology 667 Ted Lin and Rajani Annamaneni
Tim Smith 45 Clinical measurement 845
35 Autonomic nervous system pharmacology 680 Ted Lin and Rajani Annamaneni
Tim Smith 46 Anaesthetic equipment 893
36 Cardiovascular pharmacology 695 Ted Lin and Rajani Annamaneni
Tim Smith
37 Respiratory pharmacology 708 Index 932
Tim Smith

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 Contributors

Rajani Annamaneni Barrie Fischer

Consultant Anaesthetist Consultant Anaesthetist
Glenfield Hospital Alexandra Hospital
Leicester, UK Redditch, UK

Bal Appadu Smita Gohil

Consultant Anaesthetist Consultant Anaesthetist
Peterborough City Hospital Warwick Hospital
Peterborough, UK Warwick, UK

Dan Bailey Arun Gupta

Consultant Anaesthetist Consultant in Anaesthesia and Neurointensive Care
Queen Elizabeth Hospital Addenbrooke’s Hospital,
Birmingham, UK Cambridge, UK

Gwenda Cavill Robert Haden

Consultant Anaesthetist Consultant Anaesthetist
Wansbeck General Hospital Alexandra Hospital
Ashington, Northumberland, UK Redditch, UK

Mahesh Chaudhari Sue Hill

Consultant Anaesthetist Consultant Anaesthetist
Worcestershire Royal Hospital University Hospital Southampton
Worcester, UK Southampton, UK

Oscar Domingo i Bosch Jo James

Consultant Anaesthetist Consultant Anaesthetist
Alexandra Hospital Birmingham Heartlands Hospital,
Redditch, UK Birmingham, UK

Matthew Faulds Karen Kerr

Specialty Registrar in Anaesthetics and Intensive Care Consultant Anaesthetist
Sheffield Teaching Hospitals NHS Foundation Trust Alexandra Hospital
Sheffield, UK Redditch, UK

Peter Featherstone Ted Lin

Specialty Registrar in Anaesthesia Consultant Anaesthetist
Addenbrooke’s Hospital Glenfield Hospital
Cambridge, UK Leicester, UK

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 x List of contributors

Tina McLeod Colin Pinnock

Consultant Anaesthetist Formerly of Department of Anaesthesia
Birmingham Heartlands Hospital Alexandra Hospital
Birmingham, UK Redditch, UK

Edwin Mitchell Ian Power

Consultant in Anaesthesia and intensive Care Professor of Anaesthesia, Critical Care and Pain Medicine
Alexandra Hospital University of Edinburgh
Redditch, UK Royal Infirmary, Edinburgh, UK

Nick Morgan-Hughes Anand Sardesai

Consultant Anaesthetist Consultant Anaesthetist
Sheffield Teaching Hospitals NHS Foundation Trust Addenbrooke’s Hospital
Sheffield, UK Cambridge, UK

Chris Mowatt Tim Smith

Consultant Anaesthetist Consultant Anaesthetist
Royal Shrewsbury Hospital Alexandra Hospital,
Shrewsbury, UK Redditch, UK

Mary Mushambi Jim Stone

Consultant Anaesthetist Consultant Microbiologist
Leicester Royal Infirmary Gloucestershire Royal Hospital
Leicester, UK Gloucester, UK

Jeff Neilson Anita Stronach

Consultant in Haematology Consultant Anaesthetist
Russells Hall Hospital Alexandra Hospital
Dudley, UK Redditch, UK

Alexander Ng Justiaan Swanevelder

Consultant Anaesthetist and Honorary Senior Lecturer Professor and Head of Department of Anaesthesia and
Royal Wolverhampton Hospital NHS Trust and Perioperative Medicine
University of Birmingham Groote Schuur and Red Cross War
West Midlands, UK Memorial Children’s Hospitals
University of Cape Town
Jerry Nolan Cape Town, South Africa
Consultant in Anaesthesia and Intensive Care Medicine
Royal United Hospital Leon Vries
Bath, UK Consultant Anaesthetist
Royal Orthopaedic Hospital NHS Foundation Trust
Michael Paleologos Birmingham, UK
Staff Specialist Anaesthetist
Royal Prince Alfred Hospital Andrew Wolf
Sydney, Australia Professor of Paediatric Anaesthesia and Intensive Care
University Hospitals Bristol NHS Foundation Trust,
Bristol, UK

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 Preface to the first edition

The advent of a syllabus for the FRCA examination, itself this project. I am grateful to all contributing authors for
a requirement of the STA, seemed to me to provide an their tolerance and good humour during alteration of their
ideal opportunity for a dedicated revision textbook. It will golden prose.
therefore be of no surprise to readers that this volume Whilst no single book can cover the entire syllabus as a
mirrors closely the syllabus for the primary FRCA in both ‘one stop’ aid, the majority of material covered in the
structure and content. examination is detailed within these pages. Some items
Having enlisted the willing help of my two co-editors, lately included in the syllabus, after completion of the
Tim Smith and Ted Lin, we set about recruiting authors to manuscript, will be added in future editions (such as the
contribute. Chapter authors have been chosen for their anatomy pertaining to ankle block). Candidates will, how-
ability and known prowess as teachers and a deliberate ever, be well served if this book is used as a general basis
policy of not inviting ‘usual’ contributions from frequently for revision.
seen names was taken. Having said that, several primary I am extremely grateful to Rob Jones, who has been
examiners appear as contributors and within each chapter responsible for generating virtually all the artwork within
coverage of revision topics has been kept as appropriate to this text, the few other diagrams being credited to their
the examination as possible. sources.
To reduce the variability that is the bane of multi- Thanks are also due to both my co-editors for their exten-
author texts I have personally edited every chapter to sive work and dedication. If this volume enables any candi-
ensure consistency of style and it is a reflection of the date to pass the primary examination, who would not have
workload involved that it has taken three years to complete done so otherwise, then our job will have been well done.
Colin Pinnock

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 Preface to the second edition

I am delighted that the success of Fundamentals has Section 3 has been updated comprehensively with the
enabled us to proceed to an early second edition. It will removal of some drugs now lapsed and the incorporation
be apparent to the familiar reader that this edition has of newer agents that have become available. By popular
undergone rather more than a simple facelift. A great deal demand a new chapter on clinical trial design rounds off
of feedback from both examiners and candidates has been the pharmacology section.
used to modify and shape this current volume. New It is, however, Section 4 that has undergone the most
authors have been brought in to Section 1 to revise and radical changes. I am very grateful to Ted Lin for the
modify the clinical chapters where necessary (incorpor- completely new physics and equipment chapters, which
ating several important and new areas of emerging know- provide excellent core revision in these important areas. A
ledge), whilst resuscitation and trauma chapters have been greater number of diagrams (and many revised graphics)
updated by their original writers. Anatomy has been throughout the book and a completely new index com-
extended in scope to reflect subjects that are currently plete the modifications over the first edition.
popular in the Primary FRCA. I thus believe that the second edition of Fundamentals
In Section 2, there are new chapters on neurology and is an even better revision aid to the Primary FRCA exam-
endocrinology, and an extra chapter on neonatal physi- ination and will build on the reputation of its forerunner.
ology has been incorporated to satisfy the demands of the Once again my thanks go to my three co-editors for their
examination syllabus. hard work and determination.
Colin Pinnock

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 Preface to the third edition

I am privileged to have led the creation of the third r Section 3 has a new chapter on analgesic drugs, taking
edition of this popular Primary FRCA text, ably helped account of the substantial developments in this area.
by my three co-editors. Once again, feedback from users The new chapter on mechanisms of drug action puts
of the book has helped enormously in developing FoA3. clear emphasis on the current thinking on the mech-
The Royal College of Anaesthetists’ publication of the anism of anaesthesia.
Primary syllabus within the Competency-based Training r In Section 4, Ted Lin has put together a clear and
Framework has led us to include that knowledge base, concise statistics chapter, which will make preparation
uniquely referenced to Fundamentals, in a new Appendix. for this part of the exam straightforward. The inclusion
A number of new contributors have enhanced the pro- of aspects of ultrasound and MRI scanning here and in
portion of current and past examiners amongst our the clinical section follows its incorporation into the
writers. The greater use of colour allows the reader to syllabus.
navigate more easily, and changes to technique boxes
make that information easier to assimilate. This edition Despite suggestions to expand Fundamentals to cover
contains a number of new chapters in addition to wide- anaesthesia to higher levels and in greater depth, we have
spread updates, and has been thoroughly copy-edited by adhered to our original aim of providing a textbook spe-
Hugh Brazier to an unrivalled standard of consistency cifically designed around the RCA Primary Fellowship. In
over the previous editions. so doing, we have been better able to adapt to changes in
Whilst all chapters have been reviewed, there are a that exam as well as in anaesthetic core knowledge. The
number of significant changes. result is a much more effective exam preparation tool,
r Section 1 contains a significantly updated chapter in which in turn is frequently used as a starting point for
the growing field of preoperative assessment, and a anaesthetists (and indeed others) of all grades including
brand new chapter on resuscitation. The inclusion of consultants, some of whom achieved exam success helped
the DAS algorithms for airway management is a par- by the first edition. Finally, I am particularly grateful to
ticular bonus. Colin for his help and advice during my turn at leading
r In Section 2 Ted Lin has written an additional chapter the editorial process.
specifically covering the physiology of pain, and Colin We were saddened to hear of the death of Dr Andy
Pinnock has edited haematology to bring it more in Ogilvy, author of Section 2, Chapter 11, as this edition was
line with the current syllabus. in preparation.
Tim Smith

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 Preface to the fourth edition

We are greatly pleased to be writing this introduction to In this edition the clinical section (Section 1) has been
our fourth edition of Fundamentals of Anaesthesia. Tech- revised and updated, taking account of the changing
nology, clinical practice and the working environment for guidelines that influence clinical practice and focusing
anaesthetists are continually changing and evolving, and on the explanations behind them. The regional anaesthe-
we have attempted to reflect these trends in this new sia chapter now includes an introduction to ultrasound
edition. techniques.
The curriculum for the FRCA exam is ever-expanding In the physiology section (Section 2) all chapters have
and presents a constant challenge for those in training. been revised and new chapters have been written for
However, the basic principles for our specialty – of care for gastroenterology, neurophysiology, metabolism and tem-
our patients, clinical skills and the application of scientific perature regulation, and renal physiology.
knowledge – remain constant, as they always have been. In the pharmacology section (Section 3), as well as
We have taken care throughout to avoid unnecessary introducing new drugs, the explanations have continued
expansion of the material covered, and to relate material to reflect the changes in expectations for the evolving
to the curriculum for the fellowship exam, as well as Primary FRCA examination.
focusing on the basic principles of anaesthesia. One of The statistics chapter is now combined with the clinical
our priorities has always been to try and make it easier for trials chapter, bringing basic science and clinical research
our readers to identify key facts and concepts in the mass practice together, highlighting the need for basic statistical
of information that they are inevitably presented with – to knowledge in order to interpret and design studies
gain a perspective on the topics contained in this volume. appropriately.
So in this edition we introduce yellow and green It is with great sadness that we mark the passing of our
boxes. Yellow boxes highlight facts or principles which friend and colleague Colin Pinnock with this edition. He
we feel merit emphasis, while green boxes detail examples, was the originator of this project and will always be
calculations or techniques which are of interest but may remembered, not only as a prolific author but also as an
be bypassed without interrupting the flow of the main uncompromising educator.
text. The green boxes can be returned to if so desired and We, the editors, wish our readers an enjoyable and
examined separately. challenging read.
Ted Lin and Tim Smith

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