Anaesthesia in Remote Hospitals: A Guide for Anaesthesia Providers (Sustainable Development Goals Series)

This book provides a concise and practical guide for Non-Physician Anaesthesia Providers (NPAPs) such as nurse anaesthetists and Non-Specialist Physicians working in remote settings. In many hospitals in low and even in some middle-income countries, nurse anaesthetists are working without the presence of a specialist anaesthesiologist at their hospital. During their training on the job or at one of the few schools of anaesthesia they have to act as improvising do-it-yourself-teachers for one another. Later in their professional life, NPAPs are often organising their continuous medical education themselves, trying to provide short presentations on topics between attending to patients. This book fills the need for a quick- to-read guide for the everyday work of NPAPs and Non-specialist physician anaesthesia providers, addressing challenges such as electricity failure, lack of technical support, drugs and materials, equipment and support of specialist anaesthesiologists. Anaesthesia in Remote Hospitals: A Guide for Anaesthesia Providers covers the most important fields of anaesthesia in a typical district or referral hospital in a place where resources are limited. It provides many useful tables with doses of drugs, sizes of airway equipment, infusion rate, examples of observation charts and anaesthesia records. Nurse Anaesthetists, Clinical Officers and Resident Physicians will find this book to be an essential guide to Anaesthesia within low resource and remote settings. Notices Preface Acknowledgements Contents List of Abbreviations 1: Introduction Further Reading 2: Basic Physiology for Anaesthesia Providers 2.1 Respiratory Physiology and Ventilation During Anaesthesia 2.2 Oxygen and Carbon Dioxide Transport 2.2.1 Oxygen Transport in the Blood 2.2.2 Carbon Dioxide Transport in the Blood 2.3 The Heart and Circulation 2.3.1 The Heart 2.3.2 Systemic Circulation 2.3.3 The Arterial Part of the Circulation 2.3.4 The Venous Part of the Circulation 2.4 Body Water, Fluid Compartments, and the Role of the Kidneys 2.5 Body Temperature Regulation Further Reading 3: Anaesthesia Equipment and Infrastructure 3.1 Electricity 3.2 Oxygen Supply 3.2.1 How to Assure Continuous Availability of Oxygen 3.2.2 Piped Gas Supply 3.2.3 Oxygen Cylinders 3.2.4 Oxygen Concentrators 3.2.5 How to Assure an Adequate, Uninterrupted Supply of Oxygen During Anaesthesia 3.3 Anaesthetic Machine 3.3.1 Draw-Over System 3.3.2 Draw-Over Vaporiser 3.3.3 Compressed Gas Machines 3.3.4 Breathing Circuit and CO2 Absorption with Soda Lime 3.3.5 Plenum Vaporisers 3.3.6 Catheter Mounts, Angle Pieces, Tube Connectors, T-piece System 3.4 Patient Monitoring Devices 3.4.1 Pulse Oximetry 3.4.2 Non-invasive Blood Pressure Measurement 3.4.3 Electrocardiogram (ECG) 3.4.3.1 Colour Code of ECG Cables 3.4.4 Capnography (CO2 Monitoring) 3.4.4.1 What Can Be Monitored with Capnography? 3.4.4.2 Action to Be Taken If Capnography Is Giving the Following Results 3.4.5 Body Temperature Monitoring 3.4.6 Oxygen Concentration Analysers 3.5 Airway Equipment 3.5.1 Face Masks 3.5.2 Endotracheal Tubes 3.5.3 Laryngeal Mask Airways 3.5.4 Laryngoscopes 3.5.5 Filters and Heat and Moisture Exchangers 3.6 Other Equipment 3.6.1 TOF Monitors and Other Nerve Stimulators 3.6.2 Suction Machine 3.6.3 Soda Lime 3.6.4 Defibrillator 3.7 List of Minimal Equipment for Safe Anaesthesia Further Reading 4: Preparing for Anaesthesia 4.1 Preoperative Evaluation 4.1.1 Anaesthesia Assessment by Preoperative Visit 4.1.2 ASA Risk Classification 4.1.3 Fasting Before Anaesthesia 4.1.4 Patients with Chronic Disease Like Hypertension, Diabetes Mellitus, or COPD 4.2 Anaesthesia Working Place, Trolley, Drugs, and Equipment 4.2.1 Anaesthesia Machine, Oxygen Source 4.2.2 Essential Equipment Per Operating Room 4.2.3 Essential Drugs for Anaesthesia Management 4.3 Preparing the Patient in the Operation Room 4.3.1 The Anaesthesia Record 4.3.2 Patient Preparation, Venous Access, Monitoring, Preloading with Fluid 4.3.3 Prevention of Wound Infection During and After Surgery 4.3.3.1 Patient Hygiene 4.3.3.2 Hand Hygiene 4.3.3.3 Antibiotic Prophylaxis 4.4 Positioning on the Operation Table 4.4.1 Supine Position Flat, with Head Up or Head Down 4.4.2 Lateral Position 4.4.3 Prone Position 4.4.4 Lithotomy Position 4.5 Patient Safety and Checklists Further Reading 5: Post-anaesthesia Care 5.1 Recovery Area, Equipment 5.2 Admission to Recovery Area, ABCDE Assessment, Managing Complications, Discharge 5.2.1 Complications in the Early Post-Anaesthesia Phase 5.3 Postoperative Analgesia 5.4 Intermediate or High-Dependency Care Unit 5.4.1 Criteria for and Management of Delayed Extubation Further Reading 6: Airway Management 6.1 General Considerations 6.2 Guedel Oropharyngeal Airway (OPA) 6.3 Nasopharyngeal Airway (NPA) 6.4 Face Mask 6.5 Endotracheal Intubation 6.5.1 Assessment Before Planned Endotracheal Intubation with Direct Laryngoscopy 6.5.1.1 Mouth Opening 6.5.1.2 Ability to Move the Neck 6.5.1.3 Upper Lip Bite Test 6.5.1.4 Thyromental Distance 6.5.1.5 Neck Circumference 6.5.1.6 Mallampati Classification 6.5.1.7 Pregnancy 6.5.2 Preoxygenation 6.5.3 The Technique for Endotracheal Intubation 6.5.4 Complications of Laryngoscopy/Intubation 6.6 Laryngeal Mask Airway (LMA) 6.6.1 Size of the LMA 6.6.2 Indications 6.6.3 Contraindications 6.6.4 Practical Considerations and Complications 6.7 Difficult Airway Management 6.7.1 Intubation with a Gum Elastic Bougie (Eschmann Stylet) 6.7.1.1 Difficult Airway Algorithm 6.7.2 Emergency Surgical Airway with Front of Neck Access (FONA) 6.8 Rapid Sequence Induction 6.8.1 Indications for RSI 6.8.2 Procedure Further Reading 7: Basic Pharmacology for Anaesthesia Providers 7.1 General Considerations 7.1.1 Storage of Drugs 7.1.2 Drugs for Injection Must Be Kept Sterile 7.1.3 Anaesthesia and Hospital Pharmacy 7.1.4 Variability of Drug Response and Titrating a Drug to Effect 7.1.5 Labelling Syringes 7.2 Anaesthetic Drugs 7.2.1 Ketamine 7.2.2 Thiopentone 7.2.3 Propofol 7.2.4 Etomidate 7.3 Opioid Analgesics 7.3.1 Morphine 7.3.2 Fentanyl 7.3.3 Pethidine 7.3.4 Tramadol 7.3.5 Codeine 7.3.6 Naloxone 7.3.7 Pentazocine 7.3.8 Buprenorphine 7.4 NSAIDs and Other Non-opioid Analgesics 7.4.1 Diclofenac 7.4.2 Ketorolac 7.4.3 Ibuprofen 7.4.4 Paracetamol 7.4.5 Metamizole 7.5 Sedatives 7.5.1 Diazepam 7.5.2 Midazolam 7.5.3 Lorazepam 7.5.4 Chlorpromazine 7.5.5 Promethazine 7.5.6 Clonidine 7.6 Muscle Relaxants and Reversal Agents 7.6.1 Suxamethonium 7.6.2 Pancuronium 7.6.3 Vecuronium 7.6.4 Atracurium 7.6.5 Rocuronium 7.6.6 Reversal Agents for MR (NMBA) 7.6.6.1 Neostigmine 7.6.6.2 Pyridostigmine 7.6.6.3 Sugammadex 7.7 Local Anaesthetics 7.7.1 Lidocaine 7.7.2 Bupivacaine 7.8 Cardiovascular Drugs for Increasing Heart Rate and Treating Hypotension During Anaesthesia and Critical Care 7.8.1 Adrenaline (Epinephrine) 7.8.2 Atropine 7.8.3 Ephedrine 7.8.4 Noradrenaline (Norepinephrine) 7.8.5 Dopamine 7.8.6 Phenylephrine 7.9 Diuretics and Antihypertensive Drugs During Anaesthesia and Critical Care 7.9.1 Furosemide 7.9.2 Glyceryl Trinitrate 7.9.3 Hydralazine 7.9.4 Labetalol 7.9.5 Nifedipine 7.9.6 Mannitol 7.10 Antiemetic Drugs 7.10.1 Ondansetrone 7.10.2 Metoclopramide 7.10.3 Droperidol 7.10.4 Promethazine 7.11 Antibiotic Prophylaxis 7.11.1 Cloxacillin/Flucloxacillin 7.11.2 Ampicillin/Amoxicillin 7.11.3 Clindamycin 7.11.4 Gentamicin 7.11.5 Ceftriaxone 7.11.6 Cefuroxime 7.11.7 Metronidazole 7.12 Hormones: Corticoids, Insulin, Oxytocin 7.12.1 Hydrocortisone 7.12.2 Dexamethasone 7.12.3 Insulin 7.12.4 Oxytocin 7.13 Bronchorelaxation 7.13.1 Salbutamol 7.13.2 Aminophylline 7.14 Pharmacological Treatment of Severe Bleeding 7.14.1 Tranexamic Acid (TXA) 7.14.2 Aminocaproic Acid 7.14.3 FFP Further Reading 8: General Anaesthesia for Major Operations 8.1 General Principles of Inhalation Anaesthesia 8.2 Inhalational Anaesthetic Drugs 8.2.1 Halothane 8.2.2 Isoflurane 8.2.3 Sevoflurane 8.2.4 Other Inhalational Agents 8.2.4.1 Nitrous Oxide 8.2.4.2 Desflurane 8.2.4.3 Diethyl Ether 8.3 Total Intravenous Anaesthesia TIVA 8.4 Balanced Anaesthesia Further Reading 9: Short General Anaesthesia for Minor Procedures 9.1 Indications 9.2 Relative Contraindications 9.3 Drugs for Short GA 9.3.1 Effects 9.3.2 Side Effects 9.3.3 Doses 9.3.4 Short GA Without Available Anaesthesia Staff for Emergency Procedures 9.3.5 Duration of Effect 9.3.6 Short GA for Patients with Hypertension 9.3.7 Short GA for Patients with Respiratory Disease 9.3.8 Short GA for Patients with Kidney Disease 9.3.9 Short GA for Patients with Diabetes 9.3.10 Table of Doses for Short General Anaesthesia “Short GA” 10: Spinal Anaesthesia 10.1 General Considerations and Anatomy 10.1.1 Indications 10.1.2 Contraindications 10.2 Technique 10.3 Local Anaesthetic Drugs for Spinal Anaesthesia 10.3.1 Doses of LA for Spinal Anaesthesia 10.3.2 Duration of Effect 10.3.3 Pethidine for Spinal Anaesthesia 10.4 Side Effects and Complications of Spinal Anaesthesia 10.4.1 Post Dural Puncture Headache 10.4.2 High Spinal 10.4.3 Total Spinal Anaesthesia 10.4.4 Hypotension and Bradycardia 10.4.5 Infection 10.4.6 Spinal or Epidural Haematoma Further Reading 11: Obstetric Anaesthesia 11.1 Physiologic Changes During Pregnancy 11.2 Anaesthesia for Caesarean Section 11.2.1 Spinal Anaesthesia 11.2.2 General Anaesthesia 11.3 Complications of Anaesthesia for Caesarean Section 11.4 Anaesthesia in Preeclampsia and Eclampsia 11.5 Dilatation and Curettage 11.6 Pre- or Postpartum Bleeding, Major Bleeding During Caesarean Section, and Ruptured Ectopic Pregnancy 11.7 Neonatal Resuscitation 11.7.1 Equipment 11.7.2 Procedure: Temperature, Airway, and Breathing 11.7.3 Chest Compressions and Drugs Further Reading 12: Anaesthesia for Major Abdominal Surgery 12.1 General Considerations 12.1.1 Body Temperature 12.1.2 Spinal Anaesthesia 12.1.3 Balanced Anaesthesia 12.1.4 How to Perform Anaesthesia for Abdominal Surgery if Muscle Relaxants Are Out of Stock 12.1.5 Intravenous Induction and Intubation Without Neuromuscular Blocking Agent 12.1.6 Inhalational Induction and Intubation Without Neuromuscular Blocking Agent 12.1.7 Intubation Without Succinylcholine but with a Non-depolarising Muscle Relaxant 12.1.8 Postoperative Care 12.2 Elective Laparotomy 12.3 Emergency Laparotomy 12.3.1 Patients with Acute Abdomen: Presentation and Pathophysiology 12.3.2 Common Causes for Acute Abdomen Requiring Urgent Operation 12.3.3 Management 12.4 Laparoscopy 12.4.1 Anaesthesia Specific Considerations for Laparoscopic Surgery 12.4.2 Potential Complications During Laparoscopy 12.4.3 Postoperative Considerations Further Reading 13: Anaesthesia for Trauma Surgery 13.1 Initial Management 13.1.1 Handover 13.1.2 Primary Survey (c)ABCDE 13.2 Abdominal and Thoracic Trauma 13.2.1 Anaesthesia for Abdominal Trauma 13.2.2 Postoperative Care 13.3 Fractures, ORIF, and Amputation 13.4 Head Injury with Traumatic Brain Injury (TBI) 13.4.1 Prevention of Secondary Brain Injury 13.4.2 Anaesthesia for Burr Hole Evacuation of Epidural or Subdural Haematoma 13.4.3 Anaesthesia for Craniotomy 13.5 Burns Further Reading 14: Paediatric Anaesthesia 14.1 General Considerations 14.2 Physiological Characteristics and Their Implications for Anaesthesia 14.2.1 Respiratory System 14.2.2 Circulatory System 14.2.3 Kidneys and Liver 14.3 Preoperative Assessment and Preparation 14.4 Airway Management and Ventilation 14.4.1 General Considerations 14.4.2 Sizes of Artificial Airways 14.4.3 Appropriate Size of the Laryngeal Mask Airway (LMA) 14.4.4 Artificial Ventilation in Children 14.4.5 Rapid Sequence Induction 14.4.6 Laryngospasm, Bronchospasm, and Post-Extubation Stridor 14.5 Perioperative IV Fluid Management and Blood Transfusion 14.5.1 Venous Access 14.5.2 Fluid Management and Blood Transfusion 14.5.3 Blood Transfusion 14.6 The Conduct of General Anaesthesia 14.6.1 Induction of Anaesthesia for Major Surgery 14.6.2 Maintenance of Anaesthesia 14.6.3 Inhalational Anaesthesia 14.6.4 Recovery from Anaesthesia 14.7 Postanaesthesia Care 14.7.1 Postoperative Observation 14.7.2 Postoperative Analgesia 14.7.2.1 Wound Infiltration with Local Anaesthetic 14.8 Pharmacological Characteristics and Their Implications for Anaesthesia in Paediatric Patients 14.8.1 General Considerations 14.8.2 Dilutions and Doses of Drugs Used During Anaesthesia and Resuscitation 14.9 Anaesthesia for Some Typical Procedures 14.9.1 Hernia Repair 14.9.2 Appendectomy, Intussusception, Ileus 14.9.3 Colostomy in Neonates with Imperforate Anus 14.9.4 Pyloromyotomy 14.9.5 Trauma and Fractures 14.9.6 Burns 14.9.7 Adenotomy and Tonsillectomy 14.9.7.1 Bleeding After Tonsillectomy 14.9.8 Removal of Foreign Body from the Oesophagus or Airways 14.9.8.1 Procedure for Removal of Foreign Bodies From the Airways With Anaesthesia Further Reading 15: Emergencies and Critical Incidents 15.1 Assessment, ABCDE Approach 15.1.1 Working Systematically by ABCDE Approach 15.1.2 The AVPU Method to Assess Level of Consciousness 15.1.3 The Glasgow Coma Scale (GCS) 15.2 Circulatory Shock 15.2.1 Definition, Pathophysiology, and Compensation Mechanisms 15.2.2 Hypovolaemic Shock 15.2.3 Management 15.2.4 Anaphylactic Shock 15.3 Circulatory Arrest and Advanced Life Support (ALS) 15.3.1 Basic and Advanced Life Support 15.3.2 Resuscitating in the Operation Room 15.4 Laryngospasm, Bronchospasm, and Pneumothorax 15.4.1 Laryngospasm 15.4.2 Bronchospasm 15.4.3 Pneumothorax 15.5 Pulmonary Aspiration of Gastric Contents 15.6 Transfusion Reactions 15.7 Malignant Hyperthermia 15.8 Local Anaesthetic Toxicity 15.8.1 Maximum Doses of LA 15.8.2 Early Signs and Management of LA Toxicity 15.9 Prolonged and Severe Adverse Effects of Muscle Relaxants 15.10 Tetanus Further Reading 16: Case Scenarios 16.1 Case Scenarios for Discussion in Groups 16.1.1 Case 1 16.1.2 Case 2 16.1.3 Case 3 16.1.4 Case 4 16.1.5 Case 5 16.1.6 Case 6 16.1.7 Case 7 16.1.8 Case 8 16.2 Points for Discussion and Results of the Case Scenarios 16.2.1 Case 1 16.2.1.1 Expected Discussion Points 16.2.2 Case 2 16.2.2.1 Expected Discussion Points 16.2.3 Case 3 16.2.3.1 Expected Discussion Points 16.2.4 Case 4 16.2.4.1 Expected Discussion Points 16.2.5 Case 5 16.2.5.1 Expected Discussion Points 16.2.6 Case 6 16.2.6.1 Expected Discussion Points 16.2.7 Case 7 16.2.7.1 Expected Discussion Points 16.2.8 Case 8 16.2.8.1 Expected Discussion Points Appendices Pre Anaesthesia Visit Form Anaesthesia Record Observation Chart for Critical Care Patients Epilogue About the Author Index