REVIEW IN

CLINICAL ANESTHESIOLOGY

REVIEW IN

CLINICAL ANESTHESIOLOGY

Saneesh PJ MD DNB (Anesthesiology)

Assistant Professor (Formerly) Department of Anesthesiology and Critical Care Kasturba Medical College Mangalore, India Consultant Anesthesiology and Critical Care Ananthapuri Hospitals and Research Institute Thiruvananthapuram, Kerala, India Email: [email protected]

Forewords Madhusudan Upadya V Mahadevan

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2014, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Review in Clinical Anesthesiology First Edition: 2014 ISBN 978-93-5152-174-7 Printed at Repro India Limited

Dedicated to My father, Sri V Jayachandran who has also been my teacher, friend and mentor, all-in-one

Foreword I have had the pleasure of knowing Dr Saneesh PJ for the last 10 years as an outstanding postgraduate student in Anesthesiology, who was not only the best in his batch but also the most hardworking and systematic. Later, he joined our tertiary medical college teaching department as a faculty member where he trained PG students with the same brilliancy. Having been Saneesh’s teacher and then co-worker, having known his passion for academics and systematic work, and knowing him intimately, it is my privilege to write the Foreword to this book, the fruition of his efforts. The contents of this book have been the crystallization of Saneesh’s success in studies: these are his notes made during his PG course, made and arranged systematically with updated references from standard textbooks and other authentic references; collated systemwise and in a logical order. This book is thus important for the postgraduate students in Anesthesiology, the Anesthesia and OT Technician students, interns learning for their PG Entrance tests, medical undergraduates for their Anesthesia paper, and for any other scholar who wants a good reference at hand to brush up on the science and art of Anesthesiology. This book has been field-tested by generations of PG students in the Kasturba Medical College to whom Saneesh was kind enough to provide copies of his notes for the past decade—over these years, generations of students have found it exactly the resource they need through their course and importantly, just before their examinations—since the book is a concentrated capsule of all you need to know to do well in the examinations, which is also authenticated. These notes have now been updated with references and arranged more systematically into chapters with the theme of ease of use of the subject matter. The immense importance of the book that you are now holding in your hands is that it has already proved to make a significant difference in the performance of Anesthesia PG students, and is a proven tool to provide you the same success. The ‘top-up topics’ are a very new concept and should help the budding anesthesiologists a long way in honing their knowledge. As a postgraduate examiner and a senior teacher, I whole-heartedly recommend this book to all medical students, and assure you it will prove invaluable to you in your quest for success at the examinations. I wish the author and all the users of this wonderful work the success that they so richly deserve in life for their efforts. May this book prove as invaluable to you as it has for many generations of my students! Madhusudan Upadya Professor and Unit Chief Department of Anesthesiology Medical Superintendent Kasturba Medical College Hospital Attavar, Mangalore, India Email: [email protected]

Foreword I am really happy to see that Dr Saneesh PJ has taken all efforts to prepare this elaborate review of the basic and clinical aspects of common problems we encounter in our day-to-day practice. All aspects of the particular selected topics are covered in a simple manner which is very easily understandable with clear definitions of the terms used, scientific explanation on the basic and clinical aspects and anesthetic implications and techniques, stressing on recent developments. I am sure that this unique publication Review in Clinical Anesthesiology will be really useful to postgraduate students, postgraduate teachers and clinicians, and will serve as a ready-reference book. Dr Saneesh is personally known to me as a postgraduate student and later as a colleague. He is an excellent academician, clinician and widely respected as a postgraduate teacher. I firmly believe that the information contained herein will be very useful in the academic and clinical practice of the specialty. V Mahadevan Head of the Department - Anesthesiology Ananthapuri Hospitals & Research Institute Thiruvananthapuram, Kerala, India Email: [email protected] Formerly Director and Professor Department of Anesthesiology Government Medical College Thiruvananthapuram, Kerala, India

Preface Review in Clinical Anesthesiology has been my long-cherished dream ever since I finished my MD in Anesthesiology. My simple intention is to share the study materials I prepared for my examination with my junior colleagues who are pursuing their residency in Anesthesiology and critical care. To create a book which can become a short-cut to the preparation towards the postgraduate examination is not humanly possible, and personally I would describe it as a “crime”. Surely, it is not the intention behind this book. I would stress here that there is no substitute to reading widely accepted standard textbooks in Clinical Anesthesiology. An effort is made here to prepare a comprehensive study material which, I believe, would be very useful during the examination time. Moreover, for the practicing clinicians, this book can be a useful quick reference as well. It all started when I first started to prepare notes on liver disease and anesthesia for a case presentation in a statelevel postgraduate academic forum. Since then, I continued to prepare notes on most of the topics before my University examination for MD. My notes were widely circulated afterwards not only in my parent institution, but also in many colleges via circulation through the friends-circle. The demand for a systematic and organized study materials was on since then. Once I cleared my DNB examination as well, I thought taking up this project would keep me in touch with academics which, I believe, is very important for a professional. I joined back my alma mater as a teaching faculty and my senior colleagues in the department as well as my postgraduate friends helped me to re-organize my approach towards this project. The presentation of each topic is designed in such a way that the first part consists of the clinical discussion from an anesthesiologist’s point of view, with adequate authentic literature-based guidelines and recommendations. The latter part consists of other relevant topics which may be brought into the discussion by the examiner, either as a test of basic science knowledge or as a deviation from the current topic. The latter part, designated as “top-up topics”, improves the coverage of the topic without affecting the topic continuity in the first part of the discussion. Most chapters are further fortified with “Pearls Box” which deals with important topics which may be discussed along with any case scenario. The guidelines, recommendations and management protocols are updated as much as possible and the sources are cited to make it authentic. The tables, charts and other illustrations are provided for crisp depiction of the topic and make it easier to prepare for an examination or academic discussion. Not only postgraduate students, even PG teachers, examiners and practicing anesthesiologists can make use of them as quick-reference material. I am confident that this book will meet its desired goal of providing practical and evidence-based knowledge that can be directly applied to improving performance in examination as well as patient care. Saneesh PJ Email: [email protected] http://facebook.com/saneeshpj

Acknowledgments I would like to put on record my sincere thanks to all my teachers, colleagues and postgraduates I was fortunate to have had, both as a student and in my professional life. I should make special mention of Dr Madhusudan Upadya, Dr V Mahadevan, Dr Ambareesha M, Dr Anand Kulkarni and Dr Anil Asokan for their guidance and blessings during my postgraduation as well as my career afterwards. This book is also a tribute to all my friends/colleagues especially Basant Bhattarai, Nigel Kuriakose and Anoop Kumar AS, who made significant contribution to the literature search to make the contents of this book more authentic. This book is also a mark of regards to my parents and brother who were always encouraging and supporting. It is also a tribute to my wife, Dr Parvathy KS for her unflagging patience, understanding and encouragement during the many hours of work amidst heaps of papers and the glow of the computer screen. I am not sure whether to apologise to my little daughter Anagha and son Karthik who missed me so much during the manuscript preparation and proofreading. I profusely thank Mrs Samina Khan, Mr Amitoj Singh and Mr Rajesh Sharma of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their generous help in bringing out this book. I also thankfully remember my colleagues in Kasturba Medical College (Mangalore), Ananthapuri Hospital (Thiruvananthapuram) and Badr Al Samaa Hospital (Salalah, Oman) for their good wishes and blessings for this project as well as my personal/professional life. Last but not least, I would like to thank the Almighty for having given me the opportunity to bring out this book and pray that it would be useful to all the readers—clinicians and the residents in anesthesiology/critical care.

Contents 1. Difficult Airway Management • • • • • • •

Vocal Cord Palsies 3 Definitions 5 Evaluation of the Airway 6 Difficult Airway Management 12 Fiberoptic Intubation—Technique 24 Approach to the Difficult Extubation 28 Top-Up Topics 28

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2. COPD and Anesthesia

35

3. Bronchial Asthma

69

4. Systemic Hypertension and Anesthesia

87

5. Ischemic Heart Disease and Anesthesia

104

6. Anesthesia for Mitral Stenosis

131

7. Diabetes Mellitus and Anesthesia

145

• • • • • • • • • • • • •

Working Definition 35 Preoperative Evaluation for Patient with Pulmonary Disease 37 Physical Examination 39 Assessment of Pulmonary Function 40 Staging/Classification of Severity of COPD 42 Management of COPD 43 Preoperative Therapy for COPD 48 Management of Anesthesia for COPD Patient 48 Top-Up Topics 52 Smoking and Anesthesia 55 Pulmonary Function Tests 58 Respiratory Failure 64 COPD Assessment Test (CAT) Score 64

• Preoperative Evaluation 76 • Top-up Topics 80 • Cushing Syndrome 84 • General Anesthesia—Broad Outline 91 • Top-up Topics 92 • Treatment of Systemic Hypertension 97

• Preoperative Assessment 104 • Management of Anesthesia in Patients with Known or Suspected Ischemic Heart Disease Undergoing Noncardiac Surgery 114 • Top-up Topics 117 • Diagnosis and Evaluation of the Severity of Ischemic Heart Disease 123 • Anatomy of the Mitral Valve 131 • Pathophysiology and Natural History 131 • Definition and Description of Diabetes Mellitus 145 • Glucotoxicities 147 • Perioperative Approach to Diabetes Mellitus 148