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This page intentionally left blank
Textbook of
Anaesthesia
Commissioning Editor: Michael Parkinson
Project Development Manager: Sarah Keer-Keer
Project Controller: Frances Affleck
Designer: Erik Bigland
Textbook of
Anaesthesia
EDITED BY

Alan R Aitkenhead BSC MD

Professor of Anaesthesia
University Department of Anaesthesia and Intensive Care
Queen's Medical Centre
Nottingham
UK

David J Rowbotham MDMRCPFRCA

Professor of Anaesthesia and Pain Management
University Department of Anaesthesia, Critical Care and Pain Management
Leicester Royal Infirmary
Leicester
UK

Graham Smith BSc (Rons) MD FRCA

Professor of Anaesthesia
University Department of Anaesthesia, Critical Care and Pain Management
Leicester Royal Infirmary
Leicester
UK

FOURTH EDITION

CHURCHILL
LIVINGSTONE

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2001
Churchill Livingstone
An imprint of Elsevier Science Limited

© Harcourt Publishers Limited 2001

© Elsevier Science Limited 2002. All rights reserved.

No part of this publication may be reproduced, stored in a

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issued by the Copyright Licensing Agency, 90 Tottenham
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'Customer Support' and then 'Obtaining Permissions'.

First published 1985

Second edition 1990
Third edition 1996
Fourth edition 2001

Main edition
ISBN 0443063818
Reprinted 2002, 2003

International edition
ISBN 0443063915
Reprinted 2002, 2003

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British
Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of
Congress

Note
Medical knowledge is constantly changing. As new information
becomes available, changes in treatment, procedures,
equipment and the use of drugs become necessary. The
editors/authors/contributors and the publishers have, as far as
it is possible, taken care to ensure that the information given in
this text is accurate and up to date. However, readers are
strongly advised to confirm that the information, especially
with regard to drug usage, complies with the latest legislation
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 Preface

This fourth edition of Textbook of Anaesthesia has been designed immunology, the kidney, metabolism, and endocrinology. In addi-
with the same objectives as those underlying former editions; the tion, we have rearranged chapters throughout the book in an
aim has been to provide a readable, comprehensive, and concise attempt to produce a more logical structure. In the second section
text to satisfy the needs of new recruits into anaesthesia during the on Practice of Anaesthesia, we have retained much of the content
first two years of training and also present this clinical discipline as of previous editions but following the policy introduced in the
an integrated development from basic sciences. We hoped that this third edition, we have changed approximately one third of the
approach in the first edition would also provide a satisfactory authors. We again emphasise that this is not a reflection of the
primer for trainees in those countries where examinations feature quality of the contributions of the previous authors, to whom we
in the early stages of training. The response to the first edition are extremely grateful; our intentions are simply to ensure that
clearly demonstrated that it did provide suitable reading for anaes- fresh minds are applied to the subject matter and to avoid the risks
thetists studying for the Part I FFARCS (later Part 1 FRCA) which could be associated with asking authors merely to update
examination, the European Diploma of Anaesthesiology, and their contributions. As in past editions, we are grateful to the
equivalent examinations in other parts of the world. The book also authors of all our chapters for the quality of the revisions which
proved to be useful for a wider audience including medical practi- they have made in this edition and we are also indebted to the
tioners giving occasional anaesthetics in rural areas or developing many reviewers and readers of the book who have been sufficiently
countries and non-medical staff involved full-time in anaesthesia interested to provide helpful comments and draw our attention to
such as operating department practitioners, anaesthetic assistants, mistakes and typographical errors.
and nurse anaesthetists. We are grateful to all our contributors for allowing us to under-
In 1990, the Royal College of Anaesthetists changed the syl- take widespread revision of manuscripts in an attempt to achieve
labus for its FRCA examination by reverting to a two-part exami- uniformity of style. In addition we are indebted to the publishers
nation. The Primary, intended to be taken twelve to eighteen who have arranged for redrawing of all figures and incorporation
months after commencing training, has a very broad syllabus of a large number of new additional figures in a standardised for-
encompassing both basic science and clinical practice of anaesthe- mat. Our gratitude must be recorded to Mrs Christine Gethins in
sia, whilst the Final FRCA examination is designed to examine Leicester and Ms Lynne Chapman in Nottingham for substantial
knowledge and practice in clinical measurement and more spe- secretarial assistance. Because of the additional work involved in
cialised aspects of clinical anaesthesia. this larger fourth edition and to provide some youth to the
In order to achieve our basic objective of producing within a editorial team, we have also invited David Rowbotham to join the
single book a text suitable as both an introduction to the clinical editors.
practice of anaesthesia and also one which is appropriate reading We hope that this fourth edition will continue to be as popular
for the Primary FRCA examination, we have made substantial as the previous editions of Textbook, and that it will continue to
changes to this fourth edition of Textbook, most noticeably serve as a useful introductory text for those beginning a career in
by increasing the basic science content. The changes produced, anaesthesia. Our aim has been to try to encompass, as far as is
in comparison with the third edition, are evident most ostensibly possible within a readable text, the syllabus for the new Primary
by a marked increase in size by incorporation of an additional FRCA examination, and hopefully this aim will also have been
19 chapters. For editorial convenience we have divided the book achieved. Previous anaesthetic trainees have also found our book
into two main sections: Principles of Anaesthesia and Practice of useful as a revision manual for the Final FRCA examination;
Anaesthesia. This is not intended to separate or compartmentalise although that is not the primary purpose of this text, nonetheless
basic science and clinical practice; indeed both basic science and it may be helpful in this context. The incorporation of useful
clinical practice are intertwined in most chapters. appendices and practical information on the conduct of anaesthe-
In the section on Principles of Anaesthesia, we have incorpo- sia within most specialist areas of anaesthesia should ensure that it
rated most of the new chapters in order to cover areas which remains useful both as a practical guide in the operating theatre
were not addressed in previous editions and which are now part of and also a foundation of theoretical knowledge.
the syllabus for the Primary FRCA examination. There are new
chapters on statistics, cellular physiology and pharmacology, three Alan R Aitkenhead, Nottingham
additional chapters on the cardiovascular system, three on the Graham Smith and David J Rowbotham, Leicester
nervous system, three on the gastrointestinal tract, and others on 2001

Vll
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 Contributors

Alan R Aitkenhead BSc MD FRCA John Curran PhD FRCA

Professor of Anaesthesia, University Department of Consultant Anaesthetist, Department of Anaesthesia,
Anaesthesia and Intensive Care, Queen's Medical Centre, Nottingham City Hospital, Nottingham, UK
Nottingham, UK
Eric de Melo FRCA
John I Alexander FRCA Consultant Anaesthetist, Department of Anaesthesia,
Consultant Anaesthetist, Department of Anaesthesia, University Hospitals of Leicester NHS Trust,
Bristol Royal Infirmary, Bristol, UK Leicester Royal Infirmary, Leicester, UK
Robert Atcheson MD FRCA David R Derbyshire FRCA
Consultant Anaesthetist, Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Royal Hallamshire Hospital, Sheffield, UK Warwick General Hospital, Warwick, UK
Bryn R Baxendale FRCA Christopher Dodds FRCA
Consultant Anaesthetist, Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Queen's Medical Centre, Nottingham, UK South Cleveland Hospital, Middlesbrough, UK
Jennifer Benton FRCA David J R Duthie MD FRCA
Associate Specialist in Anaesthesia, Department of Consultant Anaesthetist, University Department of
Anaesthesia, Derriford Hospital, Plymouth, UK Anaesthesia, Critical Care and Pain Management,
Glenfield General Hospital, Leicester, UK
Tim Bourne FRCA
Consultant Anaesthetist, Department of Anaesthesia, Neil D Edwards FRCA
University Hospitals of Leicester NHS Trust, Consultant Anaesthetist, Department of Anaesthesia,
Leicester Royal Infirmary, Leicester, UK Royal Hallamshire Hospital, Sheffield, UK
Donal Buggy MSc MRCPI (Dublin) DME FFARCSI Christopher D Elton FRCA
Senior Lecturer, University Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Critical Care & Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust,
Leicester, UK Leicester Royal Infirmary, Leicester. UK
Aiden Byrne FRCA David Fell FRCA
Consultant Anaesthetist, Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Morriston Hospital, Swansea, UK University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary, Leicester, UK
D Paul Cartwright FRCA
Consultant Anaesthetist, Department of Anaesthesia, Helen F Galley PhD
Derby City General Hospital, Derby, UK Senior Lecturer, Academic Unit of Anaesthesia,
University of Aberdeen, Aberdeen, UK
Paul R Clarke MRCP FRCA
Consultant Anaesthetist, Academic Unit of Anaesthesia, Keith J Girling FRCA
St James's University Hospital, Leeds, UK Consultant Anaesthetist, Department of Anaesthesia,
Queen's Medical Centre, Nottingham, UK
Beverley J Collett FRCA
Consultant Anaesthetist, Department of Anaesthesia, Neville W Goodman FRCA
University Hospitals of Leicester NHS Trust, Consultant Anaesthetist, Department of Anaesthesia,
Leicester Royal Infirmary, Leicester, UK Southmead Hospital, Bristol, UK

IX
 CONTRIBUTORS

Ian S Grant FRCP (Edin-Glasg) FRCA Anne E May FRCA

Consultant Anaesthetist and Medical Director, Intensive Consultant Anaesthetist, Department of Anaesthesia,
Therapy Unit, Western General Hospital, Edinburgh, UK University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary, UK
Andrew P Hall MRCP FRCA
Consultant Anaesthetist, Department of Anaesthesia, Rosemary McDonald PhD FRCA
University Hospitals of Leicester NHS Trust, Formerly Consultant Obstetric Anaesthetist, St Jame's
Leicester Royal Infirmary, Leicester, UK University Hospital, Leeds; Postgraduate Dean (Yorkshire),
Department of Postgraduate Medical Education,
Christopher D Harming BSc MD FRCA
Seacroft Hospital, Leeds, UK
Consultant Anaesthetist, Department of Anaesthesia,
University Hospitals of Leicester NHS Trust, Mary C Mushambi FRCA
Leicester General Hospital, Leicester, UK Consultant Anaesthetist, Department of Anaesthesia,
University Hospitals of Leicester NHS Trust,
Anne M Heffernan FFARCSI
Leicester Royal Infirmary, Leicester, UK
Clinical Research Fellow, University Department of
Anaesthesia, Critical Care and Pain Management, Michael H Nathanson FRCA
Leicester Royal Infirmary, Leicester, UK Consultant Anaesthetist, Department of Anaesthesia,
Queen's Medical Centre, Nottingham, UK
Greg Hobbs DipRACOG FRCA
Consultant Anaesthetist, Department of Anaesthesia, Martin Nicol FRCA
Queen's Medical Centre, Nottingham, UK Consultant Anaesthetist, Department of Anaesthesia,
Queen's Medical Centre, Nottingham, UK
Philip M Hopkins MD FRCA
Senior Lecturer, Academic Unit of Anaesthesia, Graham R Nimmo MD MRCP (UK) FFARCSI
St James's University Hospital, Leeds, UK Consultant Physician, Emergency Medicine and Intensive Care,
Western General Hospital, Edinburgh, UK
Jennifer M Hunter MD FRCA
Professor of Anaesthesia, University of Liverpool, Andrew J Ogilvy FRCA
Royal Liverpool University Hospital, Liverpool, UK Consultant Anaesthetist, Department of Anaesthesia,
University Hospitals of Leicester NHS Trust,
Gareth W Jones BSc MRCP FRCA
Leicester General Hospital, Leicester, UK
Consultant Anaesthetist, Department of Anaesthesia,
University Hospitals of Leicester NHS Trust, Susan R Pavord MRCP MRC Path
Leicester Royal Infirmary, Leicester, UK Consultant Haematologist, Department of Haematology,
Leicester Royal Infirmary, Leicester, UK
Michael J Jones BSc MRCP FRCA
Consultant Anaesthetist, Department of Anaesthesia, Ian Power MD FRCA
University Hospitals of Leicester NHS Trust, Professor of Anaesthesia
Glenfield General Hospital, Leicester, UK University Department of Anaesthesia, Critical Care and
Pain Management, Royal Infirmary, Edinburgh, UK
Nisha Kumar MRCP FRCA
Consultant Anaesthetist, Department of Anaesthesia, Charles S Reilly MD FRCA
University Hospitals of Leicester NHS Trust, Professor of Anaesthesia, Department of Surgical and
Leicester Royal Infirmary, Leicester, UK Anaesthetic Sciences, Royal Hallamshire Hospital, Sheffield, UK
Jo M Lamb FRCA Bernard Riley FRCA
Consultant Anaesthetist, Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Queen's Medical Centre, Nottingham, UK Queen's Medical Centre, Nottingham, UK
David G Lambert BSc (Hons) PhD David J Rowbotham MD MRCP FRCA
Senior Lecturer in Anaesthetic Pharmacology, University Professor of Anaesthesia and Pain Management,
Department of Anaesthesia, Critical Care and Pain University Department of Anaesthesia, Critical Care &
Management, Leicester Royal Infirmary, Leicester, UK Pain Management, Leicester Royal Infirmary, Leicester, UK
Jeremy A Langton MD FRCA Colin J Runcie FRCA FRCP (Glas)
Consultant Anaesthetist, Department of Anaesthesia, Consultant Anaesthetist, Department of Anaesthesia,
Derriford Hospital, Plymouth, UK Western Infirmary, Glasgow, UK
Ravi P Mahajan MD FRCA Andrew R A Rushton FRCA
Senior Lecturer, University Department of Anaesthesia and Consultant Anaesthetist, Department of Anaesthesia,
Intensive Care, Nottingham City Hospital, Nottingham, UK Derriford Hospital, Plymouth, UK
 CONTRIBUTORS

Peter J Simpson MD FRCA John Walls FRCP

Consultant Anaesthetist, Department of Anaesthesia, Professor of Nephrology, Department of Nephrology,
Frenchay Hospital, Bristol; Senior Clinical Lecturer in Leicester General Hospital, Leicester, UK
Anaesthetics, University of Bristol, Bristol, UK
Jennifer Warner FRCA
Graham Smith BSc (Hons) MD FRCA Consultant Anaesthetist, Department of Anaesthesia,
Professor of Anaesthesia, University Department of Nottingham City Hospital, Nottingham, UK
Anaesthesia, Critical Care and Pain Management,
Leicester Royal Infirmary, Leicester, UK Nigel Webster PhD FRCA
Professor of Anaesthesia, Institute of Medical Sciences,
Justiaan C Swanevelder FRCA University of Aberdeen, Aberdeen, UK
Consultant Anaesthetist, Department of Anaesthesia,
University Hospitals of Leicester NHS Trust, John A W Wildsmith MD FRCA
Glenfield General Hospital, Leicester, UK Professor of Anaesthesia, Department of Anaesthesia,
Ninewells Hospital and Medical School, Dundee, UK
Jonathan P Thompson FRCA
Senior Lecturer, University Department of Anaesthesia, Sheila M Willatts MD FRCA FRCP
Critical Care & Pain Management, Leicester Royal Infirmary, Clinical Reader in Anaesthesia, University of Bristol,
Leicester, UK Bristol, UK

Douglas A B Turner FRCA J Keith Wood FRCP FRCPE FRCPath

Consultant Anaesthetist, Department of Anaesthesia, Formerly Consultant Haematologist, Leicester Royal Infirmary,
University Hospitals of Leicester NHS Trust, Leicester, UK
Leicester Royal Infirmary, Leicester, UK
David A Zideman BSc FRCA
Peter G M Wallace FRCA Consultant Anaesthetist and Honorary Senior Lecturer,
Consultant Anaesthetist, Division of Anaesthesia, Department of Anaesthesia, Hammersmith Hospital,
Western Infirmary, Glasgow, UK London. UK

XI
This page intentionally left blank
 Contents

PART I PRINCIPLES OF ANAESTHESIA 13. Inhalation anaesthetic agents 152

M. C. Mushambi, G. Smith
Basic considerations
14. Intravenous anaesthetic agents 169
1. Clinical trials and statistics 1 A. R. Aitkenhead
N. W. Goodman
15. Local anaesthetic agents 184
2. Cellular physiology/pharmacology relevant to
/. A. W. WildsmithJ. Kendall
anaesthesia 13
D. G. Lambert 16. Sedative and anticonvulsant drugs 192
3. General principles of pharmacology and /. M. Lamb
pharmacokinetics 21 17. Physiology and measurement of pain 201
D. J. Rowbotham R. Atcheson
Cardiovascular systems 18. Analgesic drugs 211
4. Anatomy of the cardiovascular system 31 /. Alexander
N. Kumar 19. Muscle function and neuromuscular blockade 223
5. The heart 42 /. M. Hunter
N. Edwards
Gastrointestinal tract
6. Peripheral circulation and control of cardiac output
and arterial pressure 54 20. Gastrointestinal physiology 236
K.J. Girling A. M. Heffernan, D. J. Rowbotham
7. Drugs acting on the cardiovascular and autonomic 21. Nausea, vomiting and their treatment 244
nervous systems 65 D. J. Rowbotham
/. P. Thompson
22. The liver 250
Respiratory system A.J. Ogilvy
8. Anatomy of the respiratory tract 101
Haematology and immunology
A. P. Hall
9. Respiratory physiology 109 23. Haematology 259
C. D. Hanning S. R. Pavord, J. K. Wood

10. Drugs acting on the respiratory system 119 24. Immunology and body defences 270
R. P. Mahajan N. R. Webster, H. Galley

Nervous system Kidney

11. Anatomy of the nervous system 130 25. Renal physiology 279
M. H. Nathanson A.J. OgilvyJ. Walls

12. Physiology of the nervous system 136 26. Drugs used in renal disease 289
S. Willatts /. C. Swanevelder

Xlll
 CONTENTS

Metabolism 44. Anaesthesia for gynaecological and genitourinary

surgery 576
27. Metabolism, the stress response to surgery and
/. Warner
perioperative thermoregulation 297
D. Buggy 45. Anaesthesia for orthopaedic surgery 582
/. Cur ran
Endocrinology 46. Anaesthesia for ENT surgery 590
28. Endocrine function 309 G. W.Jones
P. R. Clarke, P. M. Hopkins 47. Anaesthesia for opthalmic surgery 594
M. Nicol
Pregnancy
48. Anaesthesia for radiology and radiotherapy 606
29. Maternal and neonatal physiology 323 T. Bourne
C. D. Elton, R. MacDonald
49. Anaesthesia and psychiatric disease 611
M. J. Jones
Physics and clinical measurement
50. Day-case anaesthesia 614
30. Basic physics for the anaesthetist 336
/. Benton, J. A. Langton
M. C. Mushambi, G. Smith
51. Emergency anaesthesia 619
31. Clinical measurement 353 D. A. B. Turner
A. R. A. Rushton, J. A. Langton
52. Obstetric anaesthesia and analgesia 629
32. Anaesthetic apparatus 373 A. E. May, D. Buggy
G. Smith, A. R. Aitkenhead, M. C. Mushambi
53. Paediatric anaesthesia and intensive care 650
PART II PRACTICE OF ANAESTHESIA E. de Melo
54. Dental anaesthesia 664
33. The operating theatre environment 409 C. S. Reilly
A. R. Aitkenhead
55. Anaesthesia for plastic, endocrine and vascular
34. Preoperative assessment and premedication 417 surgery 672
B. Baxendale, G. Smith /. P. Thompson
35. Intercurrent disease and anaesthesia 429
56. Hypotensive anaesthesia 682
I. S. Grant, G. R. Nimmo
C. Dodds
36. Preoperative checking of equipment and
57. Neurosurgical anaesthesia 688
environment 455
P. J. Simpson
P. Cartwright
58. Anaesthesia for thoracic surgery 699
37. The practical conduct of anaesthesia 460
D. J. R. Duthie
D. Fell
59. Anaesthesia for cardiac surgery 711
38. Monitoring 470
C. /. Runcie, P. G. Wallace
A. Byrne
39. Fluid, electrolyte and acid-base balance 489 60. The intensive care unit 722
D. A. B. Turner B. Riley

40. Complications during anaesthesia 501 61. Management of chronic pain 738
G. Hobbs B. J. Collett

41. Postoperative care 524 62. Cardiopulmonary resuscitation 748

A. R. Ait D.A.

42. Postoperative pain 544

I. Power, G. Smith Appendices 759
D. R. Derbyshire
43. Local anaesthetic techniques 555
A. Lee Index 787

XIV
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