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“If you can’t explain it simply, you don’t
understand it well enough.”
Albert Einstein
Second Edition
Physics in
Anaesthesia
Ben Middleton, Justin Phillips and Simon Stacey
With contributions from Rik Thomas
Second edition © Scion Publishing Ltd, 2021
ISBN 978 1 911510 80 2
First edition published in 2012 (978 1 904842 98 9)
All rights reserved. No part of this book may be reproduced or transmitted, in any form
or by any means, without permission.
A CIP catalogue record for this book is available from the British Library.
Scion Publishing Limited
The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury OX16 9UX, UK
www.scionpublishing.com
Important Note from the Publisher
The information contained within this book was obtained by Scion Publishing Ltd from sources believed by us to be
reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury
whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can
be accepted by the authors or publishers.
Readers are reminded that medicine is a constantly evolving science and while the authors and publishers have
ensured that all dosages, applications and practices are based on current indications, there may be specific practices
which differ between communities. You should always follow the guidelines laid down by the manufacturers of
specific products and the relevant authorities in the country in which you are practising.
Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this
publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our
attention.
Registered names, trademarks, etc. used in this book, even when not marked as such, are not to be considered
unprotected by law.
Cover design by AM Graphic Design Ltd
Cover wave image supplied by Dr Mark Salmon
Typeset by Evolution Design & Digital Ltd (Kent), UK
Printed in the UK
Last digit is the print number: 10 9 8 7 6 5 4 3 2 1
Contents
Foreword
Preface
Acknowledgements
About the authors
Abbreviations
1 Atoms and matter
1.1 The atom
1.2 States of matter
1.3 Phase diagrams
2 Simple mechanics
2.1 Force, velocity and acceleration
2.2 Force, weight and pressure
2.3 Viscosity
2.4 Surface tension and wall tension
2.5 Surfactant and surface tension
3 Energy and power
3.1 Work and energy
3.2 Efficiency and power
3.3 Work of respiration
3.4 Compliance
3.5 Work done during spontaneous breathing
3.6 Flow characteristics during breathing
3.7 Work done by the heart
4 Temperature and heat
4.1 Heat
4.2 Temperature
4.3 Transfer of heat
4.4 Black-body radiation
4.5 Regulation of body temperature
4.6 Measuring temperature
4.7 Laws of thermodynamics
5 Waves
5.1 Properties of waves
5.2 Sound waves
5.3 Electromagnetic waves
5.4 Simple harmonic motion
5.5 Resonance and damping
5.6 Harmonic series and Fourier analysis
5.7 The Doppler effect
5.8 Flux, intensity and luminance
6 Pressure measurement
6.1 Absolute and relative pressure
6.2 Simple pressure-measuring devices
6.3 Pressure relief valves
6.4 Pressure regulator valves
6.5 The siphon effect and air entrainment
6.6 Blood pressure
6.7 Non-invasive blood pressure measurement
6.8 Invasive blood pressure monitoring
7 Humidity
7.1 Water vapour content of air
7.2 Absolute and relative humidity
7.3 Measuring humidity
7.4 Humidity and human physiology
7.5 Humidification of inhaled air
7.6 Nebulizers
7.7 Aerosol generating procedures
8 Measurement of gas flow
8.1 Flow
8.2 Laminar flow
8.3 Turbulent flow
8.4 Bernoulli’s principle
8.5 The Venturi effect
8.6 The Coanda effect
8.7 Volume and flow measurement
9 The gas laws
9.1 The ideal gas
9.2 Avogadro’s law and Avogadro’s constant
9.3 Partial pressure
9.4 Boyle’s law
9.5 Charles’s law
9.6 The pressure law: Gay-Lussac’s law
9.7 The combined gas laws
9.8 The universal gas law
10 Diffusion, osmosis and solubility
10.1 Diffusion
10.2 Diffusion of respiratory and anaesthetic gases
10.3 Lung function test of pulmonary diffusing capacity
10.4 Osmosis
10.5 Solubility
10.6 Partition coefficient
10.7 Colligative properties of solutions
11 Measuring gas and vapour concentrations
11.1 Respiratory gas monitoring
11.2 Infrared absorption spectroscopy for gases
11.3 Capnography
11.4 Paramagnetic oxygen analysers
11.5 Electrochemical cells
11.6 Electrodes used in arterial blood gas analysis
11.7 Other gas monitoring techniques
12 Vaporizers
12.1 Introduction to vaporizers
12.2 The draw-over vaporizer
12.3 Variable bypass vaporizers
12.4 Factors affecting delivered concentration of anaesthetic agent
12.5 Direct injection vaporizers
12.6 The dual circuit vaporizer: a vaporizer to deliver desflurane
12.7 Vaporizers functioning at altered atmospheric pressures
13 Medical gas supplies
13.1 General principles of compressed gas cylinders
13.2 Gas that liquefies in a cylinder
13.3 Piped medical gas
13.4 Vacuum and suction
13.5 Combustion risk
14 Breathing systems and ventilation
14.1 Key components in breathing systems
14.2 The circle system
14.3 The Mapleson classification
14.4 Mapleson A, B and C systems
14.5 Mapleson D, E and F systems
14.6 Minimizing pollutants in the theatre environment
14.7 Ventilators
14.8 Ventilator designs
14.9 Modes of ventilation
14.10 Non-invasive ventilation
14.11 Negative pressure ventilation
15 Optics
15.1 Refraction
15.2 Optical fibres
15.3 Fibreoptic endoscopes
15.4 Absorption of light: Beer’s law
15.5 Haemoglobin absorption spectra
15.6 Pulse oximetry
15.7 Trans-cranial near-infrared spectroscopy
15.8 CO-oximetry
16 Blood flow measurement
16.1 Measurement of liquid flow
16.2 Dye dilution and washout curves
16.3 Thermodilution – pulmonary artery catheter
16.4 Lithium chloride dilution
16.5 Doppler velocity and flow measurement
17 Equipment management
17.1 Equipment management principles
17.2 Safety critical systems
17.3 Calibration
17.4 Cleaning and disinfection
17.5 Sterilization
18 Basics of electricity
18.1 Electric current
18.2 Electric potential
18.3 Electrical resistance
18.4 Rules of electrical circuits
18.5 Electrical power and energy
18.6 Resistor combinations
18.7 Measuring small physiological changes: the Wheatstone bridge
19 Electromagnetism and alternating current
19.1 Magnetic fields
19.2 Electromagnetism
19.3 Alternating current and power
19.4 Transformers
19.5 High voltage power transmission
20 Electrical shocks and safety
20.1 Electrocution
20.2 Earthing
20.3 Electrical safety devices
20.4 Micro-shock
20.5 Electrical safety standards
20.6 Static electricity
20.7 Current density and electro-surgery
21 Electrocardiography, pacing and defibrillation
21.1 Capacitance
21.2 Defibrillators
21.3 Biological potentials
21.4 Electrocardiography
21.5 Potentials in skeletal muscle: electromyography
21.6 Potentials in the brain: electroencephalogram
21.7 Cardiac pacemakers
22 Processing, storage and display
22.1 The ‘black box’
22.2 Transducers and signal pick-up
22.3 Signal conditioning
22.4 Analogue-to-digital conversion
22.5 Hardware, software and operating systems
22.6 Displays
22.7 Networking and electronic records
23 Ultrasound
23.1 Ultrasound waves
23.2 Imaging modes
23.3 Attenuation
23.4 Reflection and acoustic impedance
23.5 Resolution
23.6 Cardiac ultrasound: TOE and TTE
23.7 Therapeutic ultrasound
24 Lasers
24.1 The principle of the laser
24.2 Types of medical laser
24.3 Precautions with laser treatment
25 Magnetic resonance imaging
25.1 Principles of magnetic resonance imaging
25.2 Safety considerations
26 Nuclear physics and radiation
26.1 Radioactivity
26.2 Radiation
26.3 Radioactive decay and half-life
26.4 Ionizing radiation
26.5 Radiotherapy
26.6 X-rays: transmission, production and imaging
26.7 Scintigraphy and SPECT scans
26.8 Positron emission tomography
26.9 X-ray computed tomography
27 Basic mathematical concepts
27.1 Basics
27.2 Very large and very small numbers
27.3 Functions
27.4 Trigonometry
27.5 Calculus
27.6 Exponential growth
27.7 Exponential decay
28 Physical quantities and SI units
28.1 Physical constants
28.2 Fundamental and derived SI units
28.3 Standard prefixes for SI units
28.4 Respiratory and gas quantities
29 Statistics
29.1 Errors, uncertainty and averages
29.2 Study design
29.3 Outcome measures and the uncertainty of their definition
29.4 The basis of meta-analysis and evidence-based medicine (EBM)
29.5 Types of data and their representation
29.6 Parametric and non-parametric distributions
29.7 Indices of central tendency and variability
29.8 Common statistical tests
Index
Foreword
Taking the first step towards preparing for the exam can be daunting and finding the
right resources equally so. Those resources that ultimately become invaluable act not
only as complete guides to the subject at hand, but as quick-fire aids as the exam draws
closer.
The FRCA syllabus is comprehensively covered, and the relationship between physics
and anaesthesia is consistently articulated throughout the book. Traditionally dense
topics are presented with clarity, logic and care and, as a result, everything is not only
easy to follow, but also easy to digest and understand. The use of ‘real life’ examples
adds extra meaning to the content and accelerates the process of learning. Each chapter
is rounded off with a straightforward summary, and the web-based, exam-style, MCQ
and SBA questions now include helpful pointers and references back to the text.
Each of these attributes is welcomed for anyone deep in the revision process.
Combined, they are what continues to make this book an indispensable text for the
primary FRCA examinations. Of course, there is work still to be done by the candidate,
but in the midst of my own exam preparation, I’m fortunate to have been exposed to this
book to such a degree.
Dr Zara Al-Faham, MBChB BSc
Core Trainee 1
East of England School of Anaesthesia
Preface
Ten years ago, we were convinced there was a need for a book that really helped the
clinician to reacquaint themselves with the basic principles of physics. Our challenge
was to write a book that takes the reader from the level of dual science GCSE to
success at FRCA exams. We did our level best to deliver such a book, and thankfully
the feedback we received has been such that a second edition is now here. This time we
have put a lot of effort into the SBAs and MCQs: they are separate to the book so you
can look at the book whilst answering the questions. We have added pointers, clues and
tips beneath the questions so as to maximise your learning whilst going through the
questions. We really believe this has added extra breadth to the book.
As in the first edition, the topics have been carefully selected to ensure that they are all
relevant for those tackling the FRCA – if you go to www.scionpublishing.com/pia2 and
click on “Resources” you will find:
• the latest FRCA syllabus indexed against sections in the book
• a copy of the contents list annotated to let you know which topics it is essential that
you learn, and which are only for those looking to excel
These updates make for a comprehensive text suitable not only for doctors but also for
nurses, operating department practitioners and students. Short, snappy chapters include
worked examples to help understanding of tricky areas, along with clinical examples to
highlight the relevance to anaesthetic practice. All the key terms are highlighted in bold
at their first mention and defined. Links to self-assessment questions (MCQs and SBAs
in an FRCA style) can be found at the end of each chapter – a QR code will take you
straight to them.
The result, we hope, is a book that brings an understanding of physics to those who have
long since given up on it, with the minimum of pain and frustration.
Ben, Justin and Simon
Comments, errors and omissions
We welcome feedback and so if you have any questions or comments regarding the book or the SAQs, please email
[email protected].
• Errors in the SAQs will be corrected immediately on the website.
• Errors in the book will be corrected at the next printing and an alert noted on the
website.
Acknowledgements
This second edition was greatly helped by the energy and insight of Dr Zara Al-Faham.
Her hard work has resulted in the SBAs and MCQs being greatly improved. She also
meticulously went through every line, table and diagram in the first edition, and this has
helped create a sharper second edition.
Rik Thomas helped us to write the first edition but was unable to assist with this new
edition; we remain grateful for his contributions.
We also would like to thank Gary Corderey for his generous help with the Equipment
management chapter. Thank you also to Dr Raghu Nalgirkar for his help and support
with the improvements to the Ultrasound chapter.
We would like to thank our publisher, Jonathan Ray, for his patience in waiting for the
planets to align in order for a second edition to be born. Our families have had to
endure the peaks and troughs during this project, and we would like to dedicate this
book to them: Elwira, Oliver & Jeremy; Deborah; Ese, Luke, Harry & Hannah.
