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Essential Anesthesia
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 (ISBN-13: 9780511261602)

Essential Anesthesia

This is a concise, accessible introduction to the essentials of anesthesia, suitable for medical students, junior doctors and all operating theater staff. It provides a brief, broad overview of the science and practice of anesthesia without overwhelming the reader with intimidating detail. The first section of the book describes the evaluation of the patient, the different approaches to anesthesia, and the post-operative care of the patient in pain. The next section introduces the essentials of physiology and pharmacology and their role in understanding the principles of anesthesia. The final section presents a step-by-step description of clinical cases, ranging from the simplest to the most complex. These clinical vignettes give a very real introduction to the practicalities of anesthesia and will give the non-anesthetist physician an idea of how to prepare a patient for a surgical procedure.

DR. TAMMY EULIANO, Associate Professor of Anesthesiology, received her M.D. from the University of Florida and continued there throughout residency and fellowship. She has received numerous awards for her dedication to teaching including the International Anesthesia Research Society Teaching Recognition Award (finalist), the University of Florida College of Medicine Exemplary Teacher, and is a member of the Society of Teaching Scholars. Her research in simulator technology and patient safety has also been recognized by the American Society of Anesthesiologists.

DR. J. S. GRAVENSTEIN is Graduate Research Professor of Anesthesiology, Emeritus, University of Florida College of Medicine. Dr. Gravenstein received his Dr. med. from the University of Bonn in Germany and his M.D. from Harvard University School of Medicine. Dr. Gravenstein is known worldwide for his work in patient monitoring, patient safety, and simulation technology. His numerous awards include the Massachusetts General Hospital Trustees’ Medal, and an honorary doctorate in medicine from the University of Graz, Austria.

Essential Anesthesia

From Science to Practice

T. Y. Euliano and J. S. Gravenstein

University of Florida College of Medicine, Gainesville, Florida, USA

The Pitt Building, Trumpington Street, Cambridge, United Kingdom

The Edinburgh Building, Cambridge, CB2 2RU, UK
40 West 20th Street, New York, NY 10011-- 4211, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
Ruiz de Alarcón 13, 28014 Madrid, Spain
Dock House, The Waterfront, Cape Town 8001, South Africa

http:/ /

© T. Y. Euliano & J. S. Gravenstein 2004

This book 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 2004

Printed in the United Kingdom at the University Press, Cambridge

Typefaces Utopia 9/13 pt. and Dax System LATEX 2e [TB]

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

Library of Congress Cataloging in Publication data
Euliano, Tammy, 1966–
Essential anesthesia / Tammy Euliano, J. S. Gravenstein.
p. cm.
Includes bibliographical references and index.
ISBN 0 521 53600 6 (paperback)
1. Anesthesiology. 2. Anesthesia. I. Gravenstein, J. S. II. Title.
RD81.E83 2004
617.9′6–dc22 2004051801

ISBN 0 521 53600 6 paperback

The publisher has used its best endeavors to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
   Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors and publisher 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 publisher 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.

For Alix and Neil


  Foreword page ix
  Preface xi
  Acknowledgements xii

  Introduction A very short history of anesthesia 1
PART I Clinical management
1   Pre-operative evaluation 5
2   Airway management 24
3   Vascular access and fluid management 38
4   Regional anesthesia 54
5   General anesthesia 69
6   Post-operative care 76
7   Monitoring 89
8   The anesthesia machine 110
PART II Applied physiology and pharmacology
9   Anesthesia and the cardiovascular system 119
10   Anesthesia and the lung 132
11   Anesthesia and other systems 153
12   A brief pharmacology related to anesthesia 165
PART III Clinical cases
1   Breast biopsy under conscious sedation 209
2   Carpal tunnel release under Bier block 212
3   Cataract removal under MAC 215
4   Cesarean section under regional anesthesia 217
5   Gastric bypass under general anesthesia 221
6   AV shunt placement under peripheral nerve block 226
7   Open repair of an abdominal aortic aneurysm in a patient with coronary artery disease 229
8   Trauma patient under general anesthesia 233

  Index 241
  Index of select tables and figures 249


The most recognizable part of the anesthesiologist’s work consists of maintaining the stability of the patient’s multiple and complex organ systems during surgical operations while providing freedom from pain. To accomplish these sometimes opposing goals, the anesthesiologist must have detailed knowledge of the diseases affecting the patient and must be able to base all therapeutic decisions on an astute understanding of physiology and pharmacology. Emphasizing the serious nature of the anesthetic state, anesthesia has been described as “a controlled overdose of drugs requiring continuous intensive care of the patient.” Understandably then, many founders of critical care medicine were anesthesiologists and, by the same token, much material in this book is immediately applicable to the intensive care of critically ill patients.

   The authors had set out to write a book to introduce medical students to the complexities of anesthetic practice including compassionate pre- and post-operative care. However, this little book rapidly grew beyond that early goal. Physicians and nurses outside of anesthesia will discover in these pages wonderful reviews of physiology and pharmacology and clinical pearls helpful in preparing a patient for anesthesia and surgery. That Drs. Euliano and Gravenstein have a wealth of teaching experience shows on every page. They successfully present very complex subjects in a lively manner and in relatively simple terms. I am confident that the reader will find this text not only thorough but also – how rare for a medical text – pleasant to read. This book offers answers to many questions, while simultaneously stimulating the reader to consult one of the many voluminous specialty texts that provide details, requiring much more space than available in a volume of this size.

Jerome H. Modell, M.D.

In Greek mythology, the night has twin sons, Thanatos (death) and Hypnos (sleep), who carry flaming torches pointing toward the floor, to light a path through the dark. Juan Marín, a Latin American anesthesia pioneer, designed this image to represent anesthesia. He placed a small light between Thanatos and Hypnos indicating the flame of life the anesthesiologist must guard. The upper half of the emblem shows the rising or setting sun of consciousness. The Confederación Latinoamericana de Anestesiología and the Revista Colombiana de Anestesiología have adopted this beautiful emblem, which in the past had been used by the World Federation of Societies of Anaesthesiologists.


“What should I read in preparation for a rotation through the anesthesia service?” – so have asked not only students, but also other medical and non-medical visitors to the operating room. In response to this often posed question, we could recommend several wonderful and exhaustive texts, but such tomes demand an investment of time and effort only the dedicated specialist could muster. An introductory text should be easy to read, and it should be short enough to be completed in a few hours. It has to be a sketch instead of a full painting, yet it must clearly show the features of the subject. This we have striven to accomplish but, occasionally, we succumbed and included a bit of trivia. We hope the reader will forgive us for that.

   We have divided the little book into three parts. The first part presents the equivalent of a miniature operating manual covering pre-, intra- and post-anesthesia tasks and the tools of the profession. In the second part, we give a synopsis of cardiovascular and respiratory physiology and pharmacology of importance to peri-operative clinical practice. The third part places the reader into the operating room looking over the shoulder of a busy anesthesiologist taking care of patients with special problems. Here, we have chosen common clinical situations, and we have incorporated difficulties – some of them avoidable – in order to highlight challenges faced in daily practice. A reader who had started at the beginning of the book and now looks at the clinical examples should be able to apply much of the information presented in the first and second sections of the book to the problems arising in the clinical cases. Of course, some might prefer to read about the cases first – perhaps in preparation for a visit to the operating room – in order to get a preview of the extraordinary world of clinical anesthesia and surgery. Such an approach should raise many questions in the reader’s mind, topics we hope to have touched on in the first two sections of the book.

   Our hope is that this little text will intrigue some into further investigation of the fascinating field of anesthesiology, provide insight into the subspecialty for our colleagues in other areas, and improve the understanding of physiology, pharmacology, and peri-operative medicine for all our readers.

T. Y. Euliano, J.S. Gravenstein
July, 2004


We are grateful to the many people who helped in the preparation of this text. In particular we thank Dr. Dietrich Gravenstein, Kendra Kuck, Kelly Spaulding, and Frederike Gravenstein for lending their expertise, as well as Peter Silver and Cambridge University Press for providing direction in completing this (first) edition. And finally, we are grateful to the medical students, who prompted the project in the first place, and continue to keep us on our toes

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