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Dr Podcast Scripts for the Primary FRCA CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao Paulo, Delhi, Tokyo, Mexico City ‘Cambridge University Press ‘The Edinburgh Building, Cambridge CB? 8RU, UK Published in the Us Press, New York «States of America by Cambridge University www.cambridgeorg Information on this tithe: ©R.A Leslie, E, K, Johnson and A. P. L. Goodwin 2011 ‘This publication is in copyright. Subject to statutory exception and (o 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 2011 Printed in the United Kingdom at the University Press, Cambridge A catalogue record for this publication is available from the British Library ISBN 978-1-107-4010 1-3 Paperback ‘Cambridge University Press has no responsibility for the jstence or accuracy of URLs for extemal or third-party internet ites 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 prepating this publication 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. Contents List of contributors page xi Consultant Reviewing Panel xii Proface xiii Acknowledgements xiv 1 — Physiology Respiratory physiology 1 1.1.1 Lung volumes and control of breathing 1 Emily K Johnson 1.12. Respiratory compliance and surface tension 4 Rebecca A Leslie 1.13 Ventilation, perfusion and dead-space 8 Rebecca A Leslie 1.14 Alveolar gas equation and shunt 14 Rebecca A Leslie 1.15 Hypoxic pulmonary vasoconstriction 20 Joy M Sanders 1.1.6 Oxyhaemoglobin dissociation curve 22 Caroline SG Janes 1.17 Altitude physiology 27 Caroline SG Janes 1.2 Cardiovascular physiology 30 1.2.1 Cardiaccycle 30 Rebecca A Leslie 1.22 Coronary circulation 35 Sarah F Bell 1.23 Pacemakercells 39 Natasha A Joshi 1.24 Valsalvamanceuvre 44 Sarah F Bell Es 1.25 Exercise physiology 47 Emily K Johnson Physiology of the central, peripheral and autonomic Nervoussystems 52 1.3.1 Cetebral circulation 52 Emily K Johnson 13.2 CSF 59 Sarah F Bell 1.3.3 Blood-brain bartier 61 Rebecca A Leslie 13.4 Action potentials 64 Rebecca A Leslie 135 Spinalcord 67 Natasha A Joshi 13.6 Reflexarc 71 Emily K Johnson 13.7 The autonomic nervous system and adrenoceptors 74 Rebecca A Leslie Physiology of the neuromuscular junction 79 1.4.1 Neuromuscular junction 79 Emily K Johnson 14.2 Muscle physiology 83 Dana L Kelly Fluids and renal physiology 88 15.1 Fluid balance 88 Rebecca A Leslie Copyrighted material viii Contents, 2. om Q 15.2 Acid-base physiology 93 Emily K Johnson 1.53 Renal physiology 98 Rebecca A Leslie Liver and endocrine physiology 103 1.6.1 Glucose and metabolism Rebecca A Leslie Pituitary and endocrine function 106 Emily K Johnson Thyroid 111 Emily K Johnson Adrenals 115 Caroline V Sampson Starvation and the stress response 119 Emily K Johnson The liver and clotting Matthew C Thomas Proteins and haemoglobin Rebecca A Leslie 103 1.6.2 1.63 1.64 a 1.64 a 123 1.6. QS 128 Immunology 131 1.7.1 Immunology 131 Rebecca A Leslie 2 — Pharmacology Pharmacological principles 2.1.1 Pharmacokinetics 136 Rebecca A Leslie 2.1.2 Pharmacodynamics Rebecca A Leslie 2.1.3 Drug interactions Emily K Johnson 2.1.4 Agonists and antagonists Rebecca A Leslie 2.1.5 Isometism 163 Rebecca A Leslie 136 ISL 155 158 2.2 Intra-venous anaesthetic agents 167 22.1 Propofol and thiopentone Joy M Sanders 22.2 Etomidate and keternine Joy M Sanders 167 172 2: Inhalational anaesthetic agents 175 23.1 Inhalational agents Joy M Sanders 23.2 MAC 183 Joy M Sanders 23.3 Nitrous oxide 185 Emily K Johnson 175 24 Neuromuscular blocking agents and anti-cholinesterases 189 24.1 Neuromuscular blocking drugs 189 Rebecca A Leslie 24.2 Suxamethonium Caroline SG Janes 243 Anti-cholinesterases Rebecca A Leslie 193, 197 2 Local anaesthetics 202 25.1 Local anaesthetics Emily K Johnson 202 2 & Analgesic agents 209 26.1 Analgesic agents Dana Kelly 209 2 Drugs acting on the central nervous system = 216 27.11 Anti-convulsants Rebecca A Leslie 27.2 Benzodiazepines Dana L Kelly 216 219 2s Drugs acting on the cardiovascular system 223 28.1 Antthypertensive agents Caroline V Sampson 223 Copyrighted material Contents ix 282 Antiarrhythmics 227 Emily K Johnson 283 Inottopes 232 Caroline V Sampson 29 Drugs acting on the gastrointestinal tract 236 29.1 Drugs acting on the GI tract 236 Rebecca A Leslie 29.2 Anthemetics 240 Emily K Johnson 29.3 Hypoglycaemics 244 Caroline V Sampson 2.10 Antibiotics 249 2.10.1 Antibiotics 249 Caroline $G Janes 211 Anticoagulants 254 2111 Anticoagulants 254 Archana Panickar 2.12 Statistics 259 2.12.1 Statistical data 259 Rebecca A Leslie 2.12.2 Statistical analysis 263 Rebecca A Leslie 3 — Physics 3.1 Sbunits 268 3.1.1 Sl Units 268 Emily K Johnson 32 iological signals and their measurement 272 3.2.1 Biological signals 272 Adrian Clarke 3.22 Electrocardiogram 275 Adrian Clarke 3.23. Neuromuscular monitoring 279 Dana L Kelly 33 34 35 3.6 Gas flowand its measurement 283 33.1 Gaslaws 283 Rebecca A Leslie 3.3.2 Flow 286 Caroline V Sampson 3.3.3 Measurement of gas volume and flow 291 Rebecca A Leslie Gas supply and delivery 295 34.1 Cylinders and gas supply 295 Rebecca A Leslie 34.2 Breathing systems 300 Dana L. Kelly 343 Vaporisers 304 Rebecca A Leslie 3.4.4 Soda lime and carbon dioxide absorption 309 Emily K Johnson 3455 Scavenging systems 311 Emily K Johnson Measurement of oxygen, carbon dioxide and anaesthetic agents 315 3.5.1 Measurement of anaesthetic agents 315 Caroline V Sampson 35.2 Oxygen measurement 318 Natasha A Joshi 353 Pulse oximetry 322 Emily K Johnson 354 pHand CO: meesurement 324 Rebecca A Leslie 355 Capnography 328 Emily K Johnson Temperature and humidity 332 3.6.1 Heatloss 332 Rebecca A Leslie 3.6.2. Temperature and its measurement 335 Rebecca A Leslie DH rqQuATOVaNaNE Contents. 3. Q 3.6.3 Humidification 339 Rebecca A Leslie Pressure and cardiac output measurement 343 3.7.1 Pressure measurement 343 Archana Panickar 3.7.2 Blood pressure measurement 347 Rebecca A Leslie 3.7.3 Resonance and damping 350 Henry Murdoch 3.7.4 Intra-cranial pressure measurement 353 Caroline SG Janes 3.7.5 Cardiac output measurement 357 Rebecca A Leslie 38 Electricity 363 38.1 Electricity 363 Emily K Johnson 38.2 Electrical safety 367 Joy M Sanders 3.9 Equipment 374 39.1 Defibrillators 374 Natasha A Joshi 39.2 Lasers and diathermy 377 Emily K Johnson 39.3 Ultrasound 382 Emily K Johnson Index 385 asovanana Contributors Sarah F Bell Speciality Registrar in Anaesthesia Wales Deanery, Cardiff, Wales, UK Adrian Clarke Speciality Registrar in Anaesthesia Wales Deanery, Cardiff, Wales, UK Caroline SG Janes Specialist Registrar in Anaesthesia Oxford Deanery, Oxford, UK Emily K Johnson Speciality Registrar in Anaesthesia West Midlands Deanery, Birmingham, UK Natasha A Joshi Speciality Registrar in Anaesth Severn Deanery, Bristol, UK Dana LKelly Speciality Registrar in Anaesthesia Oxford Deanery, Oxford, UK Rebecca A Leslie Speciality Registrar in Anaesthesia Severn Deanery, Bristol, UK Henry Murdoch Speciality Registrar in Anaesthesia Severn Deanery, Bristol, UK Archana Panickar Speciality Registrar in Anaesthesia South Yorkshire and Humber Deanery, UK Caroline V Sampson Speciality Registrar in Anaesthesia East Midlands Deanery, Nottingham, UK Joy M Sanders Speciality Registrar in Anaesthesia Wessex Deanery, Winchester, UK Matthew C Thomas Consultant in Anaesthesia and Intensive Care Medicine Frenchay Hospital, Bristol, UK xi Consultant Reviewing Panel Alexander PL Goodwin Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, Bath, UK Jeffrey Handel Consultant in Anaesthesia and Perioperative Medicine Royal United Hospital, Bath, UK Patrick Magee Consultant in Anaesthesia and Perioperative Medicine, Royal United Hospital, Bath, UK Senior Visiting Lecturer, Dept Mechanical Engineering, University of Bath, Bath, UK Mike Wilkinson Consultant in Anaesthesia and Perioperative Medicine Northampton General Hospital, Northampton, UK Preface Students learn in many different ways, Over the last 2 years Rebecca Leslie and Emily John- son of Dr Podcast have developed a genre of education to assist doctors in training to achieve educational goals. To date, over 200 000 podcasts have been downloaded. Trainees particu- larly use these innovative podcasts to learn and revise prior to examinations where they are assessed in structured oral examinations and where they might be asked to express their understanding verbally. Having examined trainees in the primary FRCA for 10 years, Iam convinced that those candidates who were well prepared and rehearsed fared better in oral examinations. The podcasts for Primary FRCA undoubtedly assist in that preparation and are a great success. Now this book satisfies the demand for the podcast scripts accompanied by relevant diagrams. This book, Dr Podcast Scripis for the Primary FRCA, presents podcasts in the written word as the voices recording the podcasts would have read them. They are enhanced by simple diagrams which illuminate the scriptsin a way not possible in the spoken versions. They have also been reviewed by the original authors. It is hoped that students might use the written yersions with their illustrations to complement the spoken form. Thescripts have been written by those who have recently passed the primary FRCA exam- ination, All the scripts have been reviewed by senior anaesthetists involved in education. The level of knowledge is specifically aimed at those approaching the exam. It must be empha- sised that the scripts should form part of a multifaceted preparation to sit, and be successful in, a Fellowship exam. In themselves they present a different take on each topic, compared to aconventional textbook. Questions are asked, answered, and then tips on understanding or answering a verbal question are given. Those not sitting exams will find them useful for revising topics and help them to prepare teaching material. This book demonstrates the overlap between traditional methods of presenting facts and knowledge with those teaching techniques available in the twenty-first century. The book is an excellent example of how well the old and new complementeach other. It will undoubtedly add another tool to a student's toolbox, allowing them to be best prepared for the daunting hurdles of professional examinations. Dr APL. Goodwin xill Acknowledgements When we first started Dr Podcast it was an untried and untested formula, and we had no idea ifit would be a success. We would like to thank all our authors, voices and especially our consultant reviewers, Alex, Jeff, Patrick and Mike who committed endless time and effort to turn our idea into a popular revision aid. ‘We thank Cambridge University Press for permission to use diagrams from Fundamentals of Anaesthesia 3rd Edition and Physics, Pharmacology and Physiology for Anaesihetists Key Concepts for the FRCA Ist Edition. We also thank the original providers of these diagrams: Tim Smith, Colin Pinnock, Ted Lin, Robert Jones, Matthew Cross and Emma Plunkett. xiv EE rsoe0 aaa Respiratory phys ology 1.1.1. Lung volumes and control of breathing - Emily K Johnson Can you draw and explain the volumes and capacities of the lung? You should be able to draw, label and add values to the spirometer trace. You should practice doing this until you are confident with it and can talk it through as you draw it. Lung volumes. with permission from Cross, M.and Plunkett, 2008 Physics, Pharmacology and Physiology for Anaesthetists: Key Concepts forthe FRCA, Cambridge: Cambridge University Press, © M. Cross and E, Plunkett 2008. 5 & 0 5 10 16 20 25 30 Time (s) Lung volumes can be measured using a spirometer. The tidal volume is the volume of a normal breath and in an adult is around 500 ml (Figure 1.1.1). The functional residual capacity (FRC) is the volume of air in the lungs at the end of normal expiration with the subjectin the standing position and is around 3000 ml in anormal adult. It can be considered as the volume of air in the lungs when the elastic recoil of the lungs is equal to the outward force of the chest wall and diaphragm tone. This is an important volume as itacts asan oxygen reserve, maintaining oxygenation of blood passing through pulmonary capillaries during expiration or breath-holding. FRCincreases with subject height and in males. It isimportant to realise that it decreases approximately 1000 ml in the supine position due to the upward force of the abdominal contents. Dr Podcast Scripts for the Primary FRCA, ed. Rebecca A. Leslie, Emily K. Johnson and Alexander P. L. Goodwin. Published by Cambridge University Press. © R. A. Leslie, E. K, Johnson and A. PL. Goodwin 2011, 2 Chapter 1.1: Respiratory physiology Inspiratory reserve volume is the volume that can be inspired over and above the normal tidal volume and equals approximately 2500 ml. Inspiratory capacity is the total volume that can be inspired above FRC and equals around 3000 ml. Vital capacity is the maximal volume that can be expired after a maximal inspiration and is around 4500 ml. Expiratory reserve volumes the additional volume that can be expired at the end of expi- ration and is approximately 1500 ml. Residual volume is the volume of air remaining in the lungs at the end of maximal expiration and is approximately 1000 to 1500 ml, Which volumes cannot be measured using simple spirometry? ‘The residual volume cannot be measured and therefore any lung capacity which includes this volume can also not be measured, These are the total lung capacity and the functional residual capacity. What is the difference between a volume and a capacity? A capacity is the sum of two or more volumes. Therefore a volume is directly measured whereas a capacity is deduced from the measured volumes. For example the vital capacity is the sum of the expiratory reserve volume, the tidal volume and the inspiratory reserve volume. What is closing capacity? Closing capacity is the lung volume at which airways close, It is equal to the residual volume plus the closing volume. In healthy young subjects the closing capacity is less than the FRC so airway closure does not occur in normal breathing. Closing capacity increases with age, increased intra-thoracic pressure and smoking, In neonates, infants, the supine person aged 40 and the standing person aged 65 the closing capacity is equal to FRC. Once closing capacity exceeds FRC there is airway closure and gas trapping in normal breathing. What is the work of breathing? ‘The work of breathing is the work required to move the lung and chest wall. In normal breath- ing the muscles of inspiration do all the work and expiration is passive. The forces that have to be overcome to expand the lung are divided into elastic forces and non-elastic forces. The non-elastic forces are also called frictional forces and encompass airway and tissue resis- tance. Half of the work of the inspiratory muscles is in overcoming the non-elastic forces. ‘The other half isin overcoming the elastic forces, which is then stored as potential energy in the lung tissue. This potential energy is released on expiration as the elastic tissue returns to its resting state, and it is used to overcome frictional forces. In increased airways resistance or increased respiratory rate the work of expiration may exceed the potential energy stored so expiratory muscles are recruited and expiration becomes active. When the lung isinflated to larger volumes or compliance is low there will be more work required to overcome the elastic forces, and so more energy stored at end inspiration. The work done to overcome the non-elastic forces is lost as heat. This is increased in rapid respiratory rates or high airways resistance. ‘The work of breathing can be demonstrated using pressure-volume curves of the lung on inspiration and expiration (Figure 1.1.1b). Chapter 1.1: Respiratory physiology 3 D Figure 1.1.1b. Work of breathing, Modified with permission from Cross, M.and increased Plunket, E, 2008. Physics, 400 work Pharmacology and Physiology for = Anaesthetists Key Concepts for & ‘300 ‘S the FRCA. Cambridge: Cambridge 2 LE University Press. © M.Cross and E 3 “g Plunkett 2008. 3 ‘es 3 200 B F increased 400 work 05 -1.0 “15 Pressure (kPa) Inspiratory work: ‘ACDA area = work to overcome elastic tissues. ABCA area = work to overcome viscous resistance and friction Expiratory work + CBAG area = work to overcome always resistance (within area ACDA therefore suppliad from stored energy UNLESS increased work causes curve io bow to the let). * Difference between CB’AC and CDAC areas = lost as heat energy. Youshould learn these pressure-volume curves and the areas relevant to the work of breath- ing. Practice drawing and explaining them. How is alveolar ventilation controlled? Alveolar ventilation is controlled by feedback loops. The system of control has three main components: + Acontrol centre, which is the medullary respiratory centre + Effectors, which are the respiratory muscles + Sensors feeding information to the central control, which are chemoreceptors and other types of receptors. ‘The respiratory centre lies in the pons and medulla and consists of three groups of neurones. ‘The medullary centre is in the reticular formation below the floor of the fourth ventricle. It has a dorsal respiratory group, thought to be responsible for inspiration, and a largely dor- mant ventral group, thought to be responsible for expiration. The other two groups of neu- rones make up the apneustic centre in the lower pons and the pneumotaxic centre in the upper pons. Their exact involvement in respiration is not clear, When the respiratory centre is appropriately stimulated it coordinates synchronised activity from the muscles of respiration, which are the diaphragm, the intercostal muscles, the abdominal muscles, and the accessory muscles, such as sternocleidomastoid. These muscle groups increase their work, and ventilation is increased appropriately. 4 Chapter 1.1: Respiratory physiology Tell me more about the chemoreceptors and other sources of input to the respiratory centre ‘The afferent input into the respiratory centre comes from a number of sources, Central chemoreceptors play an important role. They respond mostly to hydrogen ion (H+) con- centration in brain extra-cellular fluid. Thisis influenced by arterial partial pressure of CO. ‘These chemoreceptors are situated near the ventral surface of the medulla. If ventilation is decreased PaCO, will rise and an increased amount of CO) diffuses across the blood-brain barrier. This liberates more H* ions which diffuse into the extra-cellular fluid and stimu- late the chemoreceptors. ‘Ihis process is enhanced by the vasodilatation that accompanies increased arterial pressures of CO. H+ and HCO3 ions are unable to cross the blood-brain barricr, so it is increased PaCO; that affects central chemoreceptors. This is a very sensitive mechanism for increasing ventilation in response to raised CO, because the pH of CSF is usually 7.32 and there is less protein buffering than in plasma, so smaller pH changes are detected. In a chronically raised PaCO; such as in chronic obstructive pulmonary disease (COPD) compensatory changes occur and HCO; ions are actively transported across the blood-brain barrier. Peripheral chemoreceptors are situated in the carotid bodies and the aortic arch. The carotid bodies contain two types of glomus cells. Type 1 cells are rich in dopamine and are close to the end of the carotid sinus nerve. The glomus cells are affected by raised PaCO, and decreased pH, although pH has no effect on the aortic arch chemoreceptors. Peripheral chemoreceptors also mount a response to low PaO, and are the only receptors responsible for this response, Overall the peripheral chemoreceptors are only responsible for 20% of the body's response to a raised PaCO;, with the rest being due to the central chemoreceptors; however, it is the peripheral chemoreceptors that act fastest. Other receptors that feed information to the respiratory centre include lung stretch recep- tors in bronchial smooth muscle, which transmit signals in the vagus with large amounts of distension causing an increased expiratory time and reduced respiratory rate. This is the Hering-Breuer reflex. Irritant receptors lie between airway epithelial cells and cause bron- choconstriction and hyperventilation in response to noxious gases. J, orjuxtacapillary, recep- tors are non-myelinated C fibres in the alveolar walls that respond to circulatory changes and can cause shallow fast breathing and apnoea. There are other receptors in the nose and upper airways that respond to mechanical and chemical stimuli. Joint and muscle receptors are also thought to influence ventilation by stimulation of the respiratory centre when limbs move, such as in exercise. Arterial baroreceptors decrease ventilation when they increase blood pressure, and pain and temperature receptors can also influence ventilation. To acer- tain degree ventilation is under voluntary control from higher centres and cortical input can override brainstem control centres. The limbic system and hypothalamus also have input in extreme emotional states. 1.1.2. Respiratory compliance and surface tension - Rebecca A Leslie Whats the normal intra-pleural pressure? ‘The intra-pleural pressure is normally negative due to the lungs natural tendency to collapse inwards and the chest walls tendency to spring outwards. When standing and at normal | Chapter 1.1: Respiratory physiology 5 Figure 1.1.2. Whole lung pressure-volume loop, Modified with permission from Cross, Mand Plunkett, E. 2008. Physics, Pharmacology and Physiology for Anesthetists Key Concepts for the FRCA, Cambridge: Cambridge Unive'sity Press. © M, Cross and E. Plunkett Lung} 5908 Lung volume ° 5 10 5 Pressure (cmH,0) resting volume the intra-pleural pressure at the apex is —10 cmH,O and at the base it is -2.5 cmH20. Theintra-pleural pressure becomes more negative during normal ventilation. It normally changes by 3-4 cmH,O unless the inspiration is particularly forceful or the airway resistance increases. During expiration the intra-pleural pressure returns back to normal unless expi- ration is forced or resistance increased. During forced expiration the intra-pleural pressure may even exceed zero, and hence airway pressure, What is compliance? To answer this question you should draw a pressure-volume curve. You should practice drawing this curve so you can draw it quickly and casily when answering any question on respiratory compliance. Compliance is the change in volume for a pressure change across the lung (Figure 1.1.2). ‘Therefore compliance is how easily the lungs expand, and it represents the slope of the pressure-volume curve. The normal expanding pressures of the lung are between —5 and —10 cmH]30. At these pressures the slope of the pressure-volume curve is steep, so for a small change in pressure there is a large change in volume. Therefore it can be said at these pressures that the lung is remarkably compliant. The compliance of the normal lung is approximately 200 ml/emH,0. At higher expanding pressures, the lung is stiffer, and much less compliant, as demon- strated by the flatter part of the curve. What are the components that influence respiratory compliance? ‘The two main components to respiratory compliance are lung compliance and thoracic wall compliance. The lung compliance is determined by the elastic recoil properties of the pulmonary con- nective interface within the alveoli. The lungs expand in response to the pressure gradient across their surface. This is called the transpul- monary pressure, and itis produced by the respiratory muscles. Transpulmonary pressure is the difference between alveolar pressure and intra-pleural pressure. Alveolar pressures dur- ing quiet ventilation can be approximated to atmospheric pressure, so transpulmonary pres- sure equates to intra-pleural pressure. ‘Ihe lung compliance at ERC is 200 ml/cmH 0. At high transmural pressures the lung compliance drops. This is because the elastic fibres are fully stretched close to their elastic limit. ue and the surface tension at the fluid/ai