Title Page



List of Contributors



List of Abbreviations

Chapter 1: Anaesthetic Assessment and Preparation for Surgery

The Preoperative Assessment Clinic

The Anaesthetic Assessment


Risk Associated with Anaesthesia and Surgery

Obtaining Informed Consent

Further Useful Information

Chapter 2: Anaesthetic Equipment and Monitoring

Airway Equipment

The Safe Delivery of Anaesthesia

Measurement and Monitoring

Further Useful Information

Chapter 3: Drugs and Fluids Used During Anaesthesia


Intravenous Anaesthetic Drugs

Inhaled Anaesthetic Drugs

Total Intravenous Anaesthesia

Neuromuscular Blocking Drugs

Analgesic Drugs

The Regulation of Opioid Drugs

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)


Local Anaesthetic Drugs

Calculation of Doses

Intravenous Fluids

Risks of Blood and Blood-Product Transfusions

Further Useful Information

Chapter 4: The Practice of General Anaesthesia

Preoperative Checks

Preparation for Anaesthesia

Induction of Anaesthesia

Maintaining the Airway

Maintenance of Anaesthesia

Transfer Into the Operating Theatre

Emergence from Anaesthesia

Further Useful Information

Chapter 5: Local and Regional Anaesthesia

The Role of Local and Regional Anaesthesia

Local and Regional Anaesthetic Techniques

Monitoring During Local and Regional Anaesthesia

Complications of Central Neural Blockade

Local Anaesthetic Toxicity

Regional Anaesthesia: In Awake or Anaesthetised Patients?

Further Useful Information

Chapter 6: Special Circumstances

Anaesthesia for Emergency Surgery

Reducing the Risks of Aspiration

Anaesthesia for Obstetric Patients

Anaesthesia for Thoracotomy

Aspiration of Gastric Contents


Malignant Hyperpyrexia (Hyperthermia) (MH)

Difficult Intubation

Failed Intubation

Needle Cricothyroidotomy

Further Useful Information

Chapter 7: Post-Anaesthesia Care

The Post-Anaesthesia Care Unit

Postoperative Complications and their Management

Postoperative Intravenous Fluid Therapy

Major Surgery

Postoperative Analgesia

Further Useful Information

Chapter 8: The Acutely Ill Adult Patient on the Ward

Section 1: Recognition and Assessment

Clinical Scoring Systems (Track and Trigger Systems)

Critical Care Outreach Teams

Receiving a Call

The Principles of Assessment

Initial Approach to the Patient

Primary Assessment and Resuscitation

What to Do Next?

Section 2: Management of Common Emergencies

Acute Shortness of Breath


Low Urine Output

Chest Pain

Cardiac Arrhythmias

Cardiac Arrest

Reduced Conscious Level

Further Useful Information

Answers to Short-Answer Questions

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Answers to True/False Questions

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8



Title Page

To a wonderful wife and marvellous, uncomplaining mother.


Anthony McCluskey

Consultant in Anaesthesia and Critical Care

Stockport NHS Foundation Trust

Stepping Hill Hospital

Stockport, UK


It is now over 15 years since I embarked upon the first edition of this book, and with each subsequent edition I have tried to respond to the demands of the readers and the changes within the specialty of anaesthesia itself. In recent years the anaesthetist's role has expanded dramatically from simply ‘providing the conditions under which surgery can be performed safely’ and now involves contact with the majority of patients admitted to hospital. This includes playing a major role in preoperative assessment and postoperative care, acute and chronic pain management, as well as the recognition, resuscitation and management of the critically ill. This edition sees many changes to reflect this.

The first major change to this edition is the loss of the chapter giving an overview of critical care. During my career in anaesthesia I have been privileged to see this specialty grow from the efforts of groups of enthusiasts to its recent formal recognition and the formation of the Faculty of Intensive Care Medicine within the Royal College of Anaesthestists. Consequently, I would encourage students to turn to the many excellent texts available on this fascinating and evolving specialty.

The next change in this edition is a reorganization of the way anaesthesia is presented. Firstly, information on equipment, monitoring and the drugs and fluids you will see anaesthetists use in their everyday practice. This is followed by an overview of ‘giving an anaesthetic’, which describes the processes and procedures used to ensure the patient's safety. Also included is a small chapter covering some of the specialist branches of anaesthesia that students may encounter; it has not been possible to cover every one and I hope those whose specialties are not included will understand.

Trainees from many specialties now work as part of the ‘Hospital at Night’ team, and one of their roles is to respond to requests for help with acutely ill patients that they may not be familiar with. Following on from the success of the chapter in the previous edition on the recognition and management of the acutely ill patient on the ward, this has now been expanded into two sections; the first on recognition and assessment of these challenging patients, followed by advice on how initially to manage commonly encountered problems.

But perhaps the greatest change for this edition is that I now welcome my son, as he embarks on a career in anaesthesia, as co-author. He has provided a fresh insight into the specialty as seen by an anaesthetist in training, and is more aware of what medical students need to know, rather than what I think they ought to know. He has worked tirelessly on the manuscript and provided new photographic illustrations; for that I owe him enormously – thank you!

I close by reiterating what I said at the end of the preface of the previous edition, but this time the message comes from both of us; we hope you enjoy this book, but even more we hope it helps you care for your patients. If it has, tell your friends; if it hasn't, tell us why and we'll try to ensure that the next edition is even better!


I would like to thank Intersurgical for Figures 2.3 and 2.5, Aircraft Medical for Figure 2.7(d), and Tanya Lachlan, Deltex Medical for Figures 2.18 and 2.19. Figure 2.10 is from McGuire and Younger, 2010 (see useful information section in Chapter 2), with permission of Oxford University Press on behalf of the British Journal of Anaesthesia.

Figures 8.6, 8.7, 8.8 and 8.9 are reproduced with kind permission from Michael Scott and the Resuscitation Council (UK).

Figure 4.12 is reproduced with permission of Dr. P. Ross and I am grateful to Dr J. Corcoran for his help and advice with transversus abdominis plane blocks and Figure 5.2.

Thanks are due to the Difficult Airway Society for Figure 6.3 and the National Tracheostomy Safety Project for Figures 8.1 and 8.2.

I would also like to express my sincere gratitude to Dr Richard Morgan, Professor Gary Smith and Dr Jas Soar for their contributions to the previous edition, some of which by necessity have been included in this edition.


AAGBI Association of Anaesthetists of Great Britain and Ireland
ABG arterial blood gas
ACE-I angiotensin converting enzyme inhibitors
ACS acute coronary syndrome
ADH antidiuretic hormone
AKI acute kidney injury
ALS advanced life support
AMI acute myocardial infarction
ANTT antiseptic no-touch technique
ARDS acute respiratory distress syndrome
ASA American Society of Anesthesiologists
AT anaerobic threshold
ATN acute tubular necrosis
BIS bispectral index
BMI body mass index
BNF British National Formulary
BiPAP bilevel positive airway pressure
BP blood pressure
BTS British Thoracic Society
CAP community-acquired pneumonia
CCU coronary care unit
CEPOD Confidential Enquiry into Perioperative Death
CNS central nervous system
CO2 carbon dioxide
COPD chronic obstructive pulmonary disease
COX cyclo-oxygenase enzyme
CPAP continuous positive airway pressure
CPR cardiopulmonary resuscitation
CPX cardiopulmonary exercise
CRP c-reactive protein
CRT capillary refill time
CSF cerebrospinal fluid
CT computerised tomography
CTPA computerised tomography pulmonary angiography
CVC central venous catheter
CVP central venous pressure
CVS cardiovascular system
CXR chest X-ray
DAS Difficult Airway Society
DBP diastolic blood pressure
DBS double-burst simulation
DNAR do not attempt resuscitation
DS degrees of substitution
DVT deep vein thrombosis
ECF extracellular fluid
ECG electrocardiograph
EEG electroencephalograph
EMLA eutectic mixture of local anaesthetic
ENT ear, nose, and throat
ETT exercise tolerance test
EWS early warning score
FAST focused assessment with sonography in trauma
FBC full blood count
FEV1 forced expiratory volume in 1 second
FFP fresh frozen plasma
FiO2 fractional inspired oxygen concentration
FRC functional residual capacity
FVC forced vital capacity
GCS Glasgow Coma Scale
GFR glomerular filtration rate
GI gastrointestinal
GIFTASUP guidelines on IV fluid therapy for adult surgical patients
GTN glyceryl trinitrate
HAFOE high airflow oxygen enrichment
HAP hospital acquited pneumonia
Hb haemoglobin
HbA1c glycosylated haemoglobin
HDU high dependency unit
HIV human immunodeficiency virus
HR heart rate
HRT hormone replacement therapy
5-HT 5-hydroxytryptamine
HTLV human T-cell lymphotrophic virus
ICF intracellular fluid
ICP intracranial pressure
I:E ratio inspiratory:expiratory ratio
ILM intubating LMA
INR international normalized ratio
IPPV intermittent positive pressure ventilation
IR immediate release
IV intravenous
IVC inferior vena cava
IVRA intravenous regional anaesthesia
JVP jugular venous pressure
K+ potassium ions
kPa kilopascals
LBBB left bundle branch block
LED light-emitting diode
LFT liver function test
LMA laryngeal mask airway
LP lumbar puncture
LSD lysergic acid diethylamide
MAC minimum alveolar concentration
MAP mean arterial pressure
MET metabolic equivalent
MH malignant hyperpyrexia
MI myocardial infarction
MR modified release
MRI magnetic resonance imaging
Na+ sodium ions
NCEPOD National Confidential Enquiry into Patient Outcome and Death
NIBP non-invasive blood pressure
NICE National Institute for Health and Clinical Excellence
N2O nitrous oxide
NSAID non-steroidal anti-inflammatory drug
NSTEMI non-ST-segment elevation myocardial infarction
NYHA New York Heart Association
OCP oral contraceptive pill
OLV one lung ventilation
OSAHS obstructive sleep apnoea and hypopnoea syndrome
OTC over the counter
PaCO2 arterial partial pressure of carbon dioxide
PACU post-anaesthesia care unit
PCA patient-controlled anaesthesia
PCI percutaneous coronary intervention
PCV pressure-controlled ventilation
PE pulmonary embolism
PEA pulseless electrical activity
PEEP positive end expiratory pressure
PEFR peak expiratory flow rate
PMGV piped medical gas and vacuum system
PaO2 arterial partial pressure of oxygen
POCT point of care testing
PONV postoperative nausea and vomiting
psi pounds per square inch
PT prothrombin time
ROSC return of spontaneous circulation
RRT renal replacement therapy
RSI rapid-sequence induction
SBP systolic blood pressure
SpO2 peripheral oxygen saturation
STEMI ST-segment elevation myocardial infarction
SVC superior vena cava
TAP transversus abdominis plane
TCI target-controlled infusion
TIVA total intravenous anaesthesia
TOF train-of-four
TTE transthroacic echocardiography
U&E urea and electrolytes
VCO2 carbon dioxide production
VF ventricular fibrillation
VIE vacuum-insulated evaporator
VO2 oxygen consumption
V/Q ventilation/perfusion ratio
VT ventricular tachycardia
VTE venous thromboembolism
WHO World Health Organisation