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 GLOBAL
RECONSTRUCTIVE
SURGERY
 GLOBAL
RECONSTRUCTIVE
SURGERY

James Chang, MD
Chief of Plastic & Reconstructive Surgery
Johnson & Johnson Distinguished Professor of Surgery
Stanford University Medical Center
Stanford, CA, USA

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Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

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Preface, vii SECTION 3: Cleft and Craniofacial Surgery
Foreword, vi ii
List of Contributors, x 3.1 Primary Unilateral Cleft Lip Repair, 137
Acknowledgments, xiv Elbert E. Vaca and Arun K. Gosain
Dedication, xv 3.2 Primary Bilateral Cleft Lip Repair, 151
John Paro and William J McClure
3.3 Secondary Cleft Lip Reconstruction, 160
SECTION 1: Peri operative Management Jonathan T. Xu and June K. Wu
3.4 Primary Cleft Palate Repair, 166
1.1 Pre-Operative Screening, 1 Joseph E. Losee and Jonathan Y Lee
Katherine D. Gallagher 3.5 Alveolar Bone Grafting, 176
1.2 Operating Room Requirements and Setup, 6 Helena 0. Taylor and Stephen R. Sullivan
Frances L. Snyder and Fran Fisher 3.6 Scalp Reconstruction, 182
1.3 General Anesthesia, 13 Derrick C. Wan and Danielle H. Rochlin
Deborah A. Rusy 3.7 Ptosis Rep air, 190
1.4 Regional Anesthesia, 23 Lisa Moody, Tarek El-Savvy, and Rohit K. Khosla
Rachel C. Steckelberg, Frederick Mihm, 3.8 Nasal Reconstruction, 198
and Ryan Derby Danielle H. Rochlin and Richard J Redell Ill
1.5 WHO Safety Protocols and Process Excellence, 34 3.9 Microtia, 211
Richard G. Gillerman Charles H. Thome
1.6 lntraoperative Emergencies, 39 3.10 Jaw Surgery, 218
Michael L. Beach and George A. Gregory Robert M. Menard and Nikhil K. Desai
1.7 PACU Setup and Requirements, 45
Susan R. Fossum, Wendell C. Alderson, and Maria A. Pedersen
1.8 Post-Operative Pain Control, 50 SECTION 4: Burns
James T. Nguyen
1.9 Post-Operative Anesthetic Complications, 56 4.1 Acute Burn Management. 228
Robin Gray Cox Yvonne Karanas
4.2 Burn Wound Management, 233
Katie Osborn
SECTION 2: Key Techniques 4.3 Eyelid Burn Reconstruction. 241
Branko Bojovic and Matthias B. Donelan
2 .1 Skin Grafting, 60 4.4 Face Burn Reconstruction (Cheek, Nose, and Lip). 248
Paul J Therattil and Richard L. Agag Joshua Peterson, Benjamin Levi, and Jeffrey L. Lisiecki
2 .2 Nerve Repair, 66 4.5 Neck Burn Reconstruction, 255
Shelley Noland Shafquat Hussain Khundkar
2 .3 Tendon Repair, 70 4.6 Shoulder and Axilla Burn Reconstruction, 263
Gloria R. Sue and James Chang Roger L. Simpson and Thomas A. Davenport
2.4 Bone Fixation, 77 4. 7 Elbow and Wrist Burn Reconstruction. 270
Scott H. Kazin Lauren Hewell Fischer and Shankar Man Rai
2 .5 Local Skin Flaps. 86 4.8 Hand Burn Reconstruction, 276
Arash Momeni and Kimberly E. Souza Michael G. Galvez and James Chang
2 .6 Common Regional Flaps, 100 4.9 Leg Burn Reconstruction, 281
David M. Tsai, Amanda Norwich, Ean Saberski, and Deepak Narayan Michael Mirmanesh and Pirko Maguiiia
2 .7 Microsurgery Essentials, 117 4.10 Foot Burn Reconstruction, 285
Rudolf F Buntic Grace Jane Chiou, Vinita Puri, and Drew J Davis
2 .8 Common Free Flaps. 126 4.11 Post-Operative Burn Therapy, 298
Gordon K. Lee and Rebecca M. Garza Nancy 8. Chee

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 CONTENTS

SECTION 5: Hand Surgery 5.8 Replantation, 369

Shilu Shrestha and James Chang
5.1 Syndactyly Reconstruction. 307 5.9 Cerebral Palsy Surgery, 377
Steve J. Kempton. Brett F. Michelotti, A. Neil Salyapongse, and Tokoya Williams and Paige M. Fox
Michael L. Bentz 5.10 Splinting and Hand Therapy Principles. 382
5.2 Polydactyly Reconstruction, 312 Jennifer Miye Chan
Saoussen Sa/hi and Aaron J. Berger
5.3 Thumb Hypoplasia Reconstruction, 321
Vincent R. Hentz SECTION 6: Trauma
5.4 Transverse Deficiency, 334
Angelo B. Lipira and Jeffrey B. Friedrich 6.1 Compartment Syndrome Treatment, 390
5.5 Cleft Hand, 341 Fernando Ovalle, Jr. and David M. Megee
Benjamin Chia and Jeffrey B. Friedrich 6.2 Lower-Extremity Trauma Reconstruction, 396
5.6 Common Tendon Transfers, 348 Damon S. Cooney and Adekunle Elegbede
Kate E Elzinga, Alexandra A. von Guionneau, and Kevin C. Chung
5. 7 Hand Fracture Treatment: Acute and Delayed, 360 Index, 404
Matthew Cavo and Warren C. Hammert

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 P R E FA C E

As you will read in the forewords written by three visionaries in the field, there is currently a tremendous
need for Global Reconstructive Surgery. The goal of this textbook is to teach perioperative principles and
surgical techniques for optimal reconstruction throughout the body—from head to toe. The outstanding
contributors—surgeons, anesthesiologists, nurses, and therapists—all have first-hand medical experience
in working in austere environments, with basic equipment and limited supplies. We hope this textbook can
be used across the developing world to help deliver and teach reconstructive surgery to the overwhelming
number of patients in need.

vii
F O R E WO R D
CHIRURGIA PRO OMNIBUS
Five billion people on the planet today do not have access to safe, timely,
and affordable surgical and anesthesia care. How can this be so, in a
world that entertains curing cancer, artificial intelligence, Bitcoin, and
Uber flying taxis? For starters, half of the world lives on less than $3.50
per day, so out-of-pocket expenses for surgery can easily equal a year
of household income in low- and middle-income countries, leading to
impoverishment for patients and often entire families. However, this
is only half the picture; surgical workforce is critically low and often
completely absent in resource-limited settings. Many countries have 20
times fewer surgeons, anesthesiologists, and obstetricians than are needed
based on the work of the Lancet Commission on Global Surgery (LCoGS),
and 100 times less than we have in the United States.
Workforce deficits leading to surgical access disparities are stagger-
ing, and looking ahead, the world will not achieve universal health care
(UHC) or the sustainable development goals (SDGs) without integrating
surgery. So as we approach the SDGs and the role of surgery, it is
important to understand what laid the foundation for global surgery
over the last four decades. In 1980 Halfdan Mahler, the Director General
of the WHO at the time, said in his address to the 12th biennial World
Congress of the International College of Surgeons: “The vast majority
of the world’s population has no access whatsoever to skilled surgical
care, and little is being done to find a solution … I beg of you to give
serious consideration to this most serious manifestation of social ineq-
uity in health care.” From a policy standpoint, little progress was made
until 2008, when Paul Farmer and Jim Kim penned an op-ed piece in
the World Journal of Surgery in which they called surgery “the neglected
stepchild of global health.” These words resonated with the global health
world, maybe because they were the words of Paul Farmer and Jim
Kim, or possibly the time had come and the ground was fertile for an
awakening to the role of surgery in health system strengthening. A few
years later, Jim Kim—now the president of the World Bank—in his
address to the Lancet Commission on Global Surgery in January 2014
called out surgical care for what it is when he said that “surgery is an
indivisible, indispensable part of health care.” Then he challenged us
to do better, to craft a vision for surgery with time-bound targets to
hold ourselves accountable. By 2015 Disease Control Priorities 3 (DCP3)
and the Lancet Commission on Global Surgery were published, just in
time to usher in the landmark resolution from the World Health
Assembly—WHA 68.15—a resolution that for the first time formally
recognized the role of surgery in global public health and welfare.
The world took heed, and the last 3 years have seen an awakening
in the global surgery, anesthesia, and obstetrics communities to respond
to Jim Kim’s challenge. This global surgery awakening has led to a
realization that the dearth of health care workforce in low- and middle-
income countries may in fact be the most important limiting factor in
surgery, anesthesia, and obstetrical scale up. Further, with the rise of
non-communicable diseases (NCDs) like cancer, trauma, cardiovascular
disease, and obesity, surgery is integral to the solution. Cancer and
trauma both include diagnosis and treatment that may require surgery,
and then both often require reconstructive surgery for advanced or
viii
extensive disease. Reconstructive surgery therefore is necessary for suc-
cessful cancer, trauma, and other aspects of NCD management. In other
words, surgical extirpation is often insufficient. For example, manage-
ment of the external fixator for open fractures with extensive soft tissue
loss is often not enough and may require local, regional, or free flap
reconstruction to successfully salvage a limb. If we ignore the full spec-
trum of surgery—including reconstructive surgery—we are not providing
true access to cancer, trauma and surgery for a range of NCDs. This
fact is often lost when public health experts talk about “essential surgery.”
Why then is this textbook so important? Dr. Ephrem Lemango from
the Ministry of Health in Ethiopia and a fellow commissioner on the
Lancet Global Health Commission on High Quality Health Care Systems
in the SDG Era, said at that Commission’s first meeting in Boston that
in global health, “We often try to copy things we can’t paste.” All too
often clinicians from high-income countries bring treatment pathways
and principles from high-income settings only to find out that they are
ill- equipped to address the nuances and realities of resource-limited
settings. This textbook takes a different approach and offers a practical
guide for clinicians in district hospitals, by surgeons who have lived
and worked in those settings. It has a clear, organized format based on
the way clinicians examine, prepare for, and then treat patients in
resource-limited settings.
Each chapter elegantly matches form and function; the structure of
each chapter matches the clinical pathway and thought processes of
care delivery. Patients come to us with a clinical problem; there is a
pre-operative assessment phase, operative intervention, and then post-
operative care. If there are complications, clinicians must have an under-
standing of the options for management. And supporting this whole
treatment algorithm from beginning to end, the surgeon and surgical
team must be guided by core principles for management. Each chapter
then has key references for more in-depth study.
Halfdan Mahler closed his famous 1980 Mexico City speech by saying,
“Your decisions today will be crucial in determining whether surgery
will play its proper role in bringing the people of the world nearer to
the goal of health for all.” This textbook takes us a step closer to our
goal of eliminating health care disparities in resource-limited settings
by educating the next generation of surgeons in the art and science of
reconstructive surgery. As we surgeons all know, surgery for all requires
reconstructive surgery for all.
John G. Meara, MD, DMD, MBA
Kletjian Professor of Global Surgery
Harvard Medical School

Psychic Income is a distinctive feature in reconstructive plastic surgery:
It is the rich feeling associated with helping another in a dramatic,
successful, and sustainable fashion. In addition, reconstructive surgery
is known and respected in its use of fine surgical technique, and we are
known for skill and knowledge for problem solving for other specialties.
It was mandated by Hippocrates, founder of medicine: “Perfect your
own skill and knowledge for the benefit of the other person.”
Once focused only on multiplication of our efforts, we now think
globally. In other words, the expansion of reconstructive surgery has
been in a linear growth track, but with global thinking it has become
logarithmic. Reconstructive surgery has become internationalized. From
the medically high-resourced countries, it now includes medium- to
low-resourced countries.
This development is the result of reconstructive surgery becoming
worldwide. Its multiplication has resulted in a bona fide component
of surgery and medicine, and the word global has become part of our
everyday thinking and vocabulary. Additionally, these programs also
provide substantial benefit both to the doers and the recipients. The
multiplication is the result of six factors:
(1) Residents’ popularity and requests.
(2) The many international projects of medical schools and independent
foundations.
(3) The medium-resource countries that have developed expertise and
resources and now help other midlevel places.
(4) The more than 58 organizations are now doing Foreign Medical
Programs (FMPs).
(5) The happiness and satisfaction of participants in the service and
teaching trips.
(6) The national plastic surgery societies who have begun to engage
many of the FMPs, embracing them into organized plastic surgery,
showing that the movement is becoming more mainstream.
This new textbook, Global Reconstructive Surgery, a monumental
work, is the essential fund of knowledge that will serve practicing recon-
structive surgeons around the world. Each chapter was authored by a
distinguished, experienced, dedicated expert and humanitarian. Because
of this work, the future is clear and has good compass bearing. We are
now pointed straight up to the benefit of our patients, ourselves, and
humanity.
Dr. Donald Rudolf Laub
Founder – Interplast
FOREWORD ix
In the 1960s, plastic surgery was still evolving. For the first time ever,
it was believed that plastic surgery could rehabilitate and reintegrate
those who were outcasts because of deformities and disabilities. One
man, Dr. Donald Laub of Stanford University, pioneered the idea that
reconstructive plastic surgery could renew lives and restore hope. With
that vision, Interplast (now ReSurge International) was born in 1969.
It was the first organization of its kind.
Thousands of volunteers traveled overseas to help children. By 1979,
4000 surgeries had been provided. Medical volunteers transformed lives
by dedicating their time to ReSurge, providing surgeries and training
local doctors so that they could perform the surgeries on their own.
As the developing world changed with the Internet and better infra-
structure, ReSurge forged a bold new course. In 1999 we established
the first permanent Surgical Outreach Program, where local surgeons
provide year-round care. By building surgical capacity and supporting
local surgeons, the program now enables twice as many patients to
receive care annually.
Now more than 80% of our surgeries are performed by developing
world surgeons with ReSurge oversight, training, and support; it is our
most efficient and cost-effective way to provide life-changing surgery.
ReSurge also continually improves the quality of health care through
education programs. We have provided more than 100,000 surgeries
and look forward to pioneering the way for generations to come.
For example, we are exploring our success in identifying, cultivating,
and supporting humanitarian surgical leaders, seeking to understand the
elements of our success and to replicate that elsewhere. And we are looking
at ways to scale up our training practices to have a greater effect.
Training the next generation of reconstructive surgeons and allied
professionals has moved to the center of ReSurge’s work in Africa, Latin
America, and Asia. By partnering with respected academic faculty and
practitioners, ReSurge has developed curricula in reconstructive surgery,
anesthesia, nursing, and occupational therapy. These faculty and prac-
titioners, or Visiting Educators, teach current techniques in each of the
specialties. ReSurge follows up on those trainings by reviewing and
providing feedback on subsequent surgeries performed by the trainees.
By engaging this next generation, ReSurge hopes to expand the number
of Surgical Outreach Partners who provide reconstructive surgery
worldwide.
This textbook is a key contribution to the training of surgical pro-
fessionals in the global workforce. We are pleased to support the leader-
ship of our Dr. James Chang, our Consulting Medical Officer, the editor,
and driving vision of this resource.
Jeff Whisenant
CEO, ReSurge International
LIST OF CONTRIBUTORS

Richard L. Agag, MD Matthew Cavo, MD Ryan Derby, MD

Associate Professor Clinical Assistant Professor Clinical Assistant Professor
Chief, Division of Plastic Surgery Department of Orthopaedic Surgery Department of Anesthesiology,
Rutgers Robert Wood Johnson Medical School Wright State University Perioperative, and Pain Medicine
New Brunswick, NJ, USA Boonshoft School of Medicine Stanford University
Hand and Reconstructive Surgeons and Stanford, CA, USA
Wendell C. Alderson, AA, RN Associates
UC Davis Medical Center Employee Centerville, OH, USA Robin Gray Cox, MB, BS, FRCA, FRCPC
1978–2017 Professor
ICU Life Flight Jennifer Miye Chan, OTR, CHT Department of Anesthesia
Recovery Room Volunteer Occupational Therapist University of Calgary
ReSurge International, Rotaplast Certified Hand Therapist Calgary, AB, Canada
Alliance for Smiles Rehabilitation Therapy
Sacramento, CA, USA Lucile Packard Children’s Hospital Stanford Thomas A. Davenport, MD
Menlo Park, CA, USA Long Island Plastic Surgical Group
Michael L. Beach, MD, PhD Chief Division of Plastic Surgery
Professor of Anesthesiology, of Biomedical Nancy B. Chee, OTD, OTR/L, CHT NYU Winthrop University Hospital
Data Science, and of Pediatrics Hand Therapist IV Mineola, NY, USA
Geisel School of Medicine at Dartmouth Hand Therapy Department
Hanover, NH, USA California Pacific Medical Center Drew J. Davis, MD
San Francisco, CA, USA; Assistant Chief
Michael L. Bentz, MD, FAAP, FACS Adjunct Assistant Professor Plastic & Reconstructive Surgery
Chairman, Division of Plastic Surgery Department of Occupational Therapy Santa Clara Valley Medical Center
Vice Chairman for Clinical Affairs, Samuel Merritt University San Jose, CA, USA;
Department of Surgery Oakland, CA, USA Clinical Instructor (Affiliated)
Professor of Surgery, Pediatrics and Stanford Hospital and Clinics
Neurosurgery Benjamin Chia, MD Palo Alto, CA, USA
Layton F. Rikkers Professor of Surgical Hand and Microvascular Surgery Fellow
Leadership University of Washington Orthopaedics and Nikhil K. Desai, DMD, MD
University of Wisconsin Sports Medicine Regional Chair of Maxillofacial Surgery
Madison, WI, USA Seattle, WA, USA Kaiser Permanente Medical Center
Santa Clara, CA, USA
Aaron J. Berger, MD, PhD Grace Jane Chiou, MD
Attending Surgeon Resident Physician Matthias B. Donelan, MD
Division of Plastic Surgery Division of Plastic and Reconstructive Surgery Chief of Staff
Nicklaus Children’s Hospital Stanford University Shriners Hospitals for Children—Boston
Miami, FL, USA Stanford, CA, USA Visiting Surgeon
Department of Surgery
Branko Bojovic, MD, FACS Kevin C. Chung, MD, MS Division of Plastic and Reconstructive
Chief of Plastic, Reconstructive and Laser Charles B. G. de Nancrede Professor of Surgery Surgery
Surgery Chief of Hand Surgery, Michigan Medicine Massachusetts General Hospital
Shriners Hospitals for Children—Boston Professor, Plastic Surgery and Orthopaedic Associate Professor of Surgery
Assistant Surgeon Surgery Harvard Medical School
Department of Surgery Assistant Dean for Faculty Affairs Boston, MA, USA
Division of Plastic and Reconstructive Surgery Associate Director of Global REACH
Massachusetts General Hospital University of Michigan Medical School Adekunle Elegbede, MD, PhD
Assistant Professor of Surgery Ann Arbor, MI, USA Resident Physician
Harvard Medical School Plastic and Reconstructive Surgery
Boston, MA, USA Damon S. Cooney, MD, PhD Johns Hopkins/University of Maryland
Assistant Professor Baltimore, MD, USA
Rudolf F. Buntic, MD Associate Program Director, Johns Hopkins/
Chief, Division of Microsurgery University of Maryland Plastic Surgery Tarek El-Sawy, MD, PhD
California Pacific Medical Center Residency Training Program Adjunct Clinical Assistant Professor
The Buncke Clinic Department of Plastic and Reconstructive Department of Ophthalmology
San Francisco, CA, USA; Surgery Stanford University School of Medicine
Clinical Associate Professor (Affiliated) Johns Hopkins University School of Medicine Palo Alto, CA, USA
Stanford Medical School Baltimore, MD, USA
Stanford, CA, USA

x
 LIST OF CONTRIBUTORS xi

Kate E. Elzinga, MD, FRCSC Arun K. Gosain, MD Scott H. Kozin, MD

Plastic Surgeon Children’s Service Board Professor Chief of Staff, Shriners Hospitals for
Section of Plastic Surgery Chief, Division of Pediatric Plasticc Surgery Children
University of Calgary Lurie Children’s Hospital of Chicago Team Leader, Touching Hands Project
Calgary, AB, Canada Northwestern University Feinberg School of Clinical Professor, Orthopaedic Surgery
Medicine Lewis Katz School of Medicine at Temple
Lauren Hewell Fischer, MD Chicago, IL, USA University
Todd S. Hewell, III, MD, FACS, Ltd Clinical Professor, Orthopaedic Surgery
Aesthetic & Reconstructive Plastic Surgery George A. Gregory, MD Sidney Kimmel Medical College at Thomas
St. Charles, IL, USA Professor Jefferson University
Anesthesia and Pediatrics Philadelphia, PA, USA
Fran Fisher, RN, PhD University of California, San Francisco
Outpatient Surgery San Francisco, CA, USA Gordon K. Lee, MD, FACS
Sutter Roseville Medical Center Professor of Plastic Surgery
Roseville, CA, USA Warren C. Hammert, MD Associate Chief of Clinical Affairs
Professor of Orthopaedic and Plastic Residency Program Director
Susan R. Fossum, BSN, RN, CPAN Surgery Director of Microsurgery
PACU Staff Nurse Chief, Division of Hand Surgery Stanford Plastic and Reconstructive Surgery
ReSurge International Department of Orthopaedics and Palo Alto, CA, USA
AHA ACLS, PALS Instructor Rehabilitation
Sacramento, CA, USA University of Rochester Jonathan Y. Lee, MD, MPH
Rochester, NY, USA Assistant Professor of Surgery
Paige M. Fox, MD, PhD Division of Plastic and Reconstructive
Assistant Professor Vincent R. Hentz, MD Surgery
Division of Plastic and Reconstructive Professor of Surgery (Emeritus) Baystate Health System - University of
Surgery Stanford University Massachusetts Medical School
Stanford University School of Medicine Stanford, CA, USA Springfield, MA, USA
Stanford, CA, USA
Yvonne Karanas, MD Benjamin Levi, MD
Jeffrey B. Friedrich, MD, MC Chief, Division of Plastic Surgery Director, Burn/Wound and Regenerative
Professor of Surgery and Orthopedics Director, Burn Center Medicine Laboratory
Division of Plastic Surgery Santa Clara Valley Medical Center Assistant Professor in Surgery
University of Washington Associate Clinical Professor (Affiliated) University of Michigan
Seattle, WA, USA Stanford University School of Medicine Ann Arbor, MI, USA
Stanford, CA, USA
Katherine D. Gallagher, MD Angelo B. Lipira, MD
Retired Steve J. Kempton, MD Assistant Professor
Inpatient Pediatrics Chief Resident Plastic and Reconstructive Surgery
Kaiser Permanente Medical Center Division of Plastic Surgery Oregon Health and Science University
Walnut Creek, CA, USA University of Wisconsin—Hospital and Portland, OR, USA
Clinics
Michael G. Galvez, MD Madison, WI, USA Jeffrey L. Lisiecki, MD
Division of Plastic and Reconstructive Resident
Surgery Shafquat Hussain Khundkar, MBBS, Section of Plastic Surgery
Stanford Hospital and Clinics FCPS Department of Surgery
Stanford, CA, USA Professor of Plastic Surgery University of Michigan
Department of Plastic Surgery Ann Arbor, MI, USA
Rebecca M. Garza, MD Popular Medical College
Assistant Professor Former Professor and Head of Plastic Surgery Joseph E. Losee, MD
Department of Surgery Dhaka Medical College and Hospital Ross H. Musgrave Professor of Pediatric
Section of Plastic and Reconstructive Dhaka, Bangladesh Plastic Surgery
Surgery Vice Chair, Department of Plastic Surgery
The University of Chicago Rohit K. Khosla, MD Division Chief, Pediatric Plastic Surgery
Chicago, IL, USA Assistant Professor Children’s Hospital of Pittsburgh of UPMC
Division of Plastic & Reconstructive Surgery Pittsburgh, PA, USA
Richard G. Gillerman, MD, PhD Stanford University Medical Center
Clinical Assistant Professor Surgical Director, Cleft & Craniofacial Center Pirko Maguiña, MD, FACS
Department of Surgery (Anesthesia) Lucile Packard Children’s Hospital at Associate Professor of Surgery
Warren Alpert School of Medicine Stanford Department of Surgery
Brown University Palo Alto, CA, USA University of California, Davis
Providence, RI, USA Sacramento, CA, USA
xii LIST OF CONTRIBUTORS

William J. McClure, MD Amanda Norwich, MD Richard J. Redett III, MD

Chief of Surgical Services Section of Plastic and Reconstructive Professor
ReSurge International Surgery Director, Pediatric Plastic Surgery
Sunnyvale, CA, USA Department of Surgery Department of Plastic and Reconstructive
Yale University School of Medicine Surgery
David M. Megee, MD New Haven, CT, USA Bloomberg Children’s Center
Assistant Professor of Surgery Johns Hopkins School of Medicine
Division of Plastic Surgery James T. Nguyen, MD Baltimore, MD, USA
University of Cincinnati Anesthesia & Perioperative Care
College of Medicine Premier Anesthesia Consulting Danielle H. Rochlin, MD
Cincinnati, OH, USA Orange County, CA, USA Resident Physician
Division of Plastic and Reconstructive
Robert M. Menard, MD, FACS Shelley Noland, MD Surgery
Surgical Director Assistant Professor Stanford University
Northern California Kaiser Permanente Plastic & Orthopedic Surgery Stanford, CA, USA
Craniofacial Clinic Mayo Clinic Arizona
The Permanente Medical Group Phoenix, AZ, USA Deborah A. Rusy, MD, MBA, FASA
Santa Clara, CA, USA Professor
Katie Osborn, RN, MSN, EdD Department of Anesthesiology
Brett F. Michelotti, MD Nursing Education and Development Perioperative Director, American Family
Assistant Professor of Surgery Consultant Children’s Hospital/UWHealth
Division of Plastic Surgery Vizient, Inc. University of Wisconsin
University of Wisconsin—Hospital and Irving, TX, USA; School of Medicine and Public Health
Clinics Professor Emeritus, Division of Nursing Madison, WI, USA
Madison, WI, USA California State University, Sacramento
Sacramento, CA, USA Ean Saberski, MD
Frederick Mihm, MD Section of Plastic and Reconstructive
Professor and Chief, Division of Critical Fernando Ovalle, Jr., MD Surgery
Care Medicine Chief Resident Department of Surgery
Department of Anesthesiology, Division of Plastic and Reconstructive Yale University School of Medicine
Perioperative, and Pain Medicine Surgery New Haven, CT, USA
Stanford University University of Cincinnati Medical Center
Stanford, CA, USA Cincinnati, OH, USA Saoussen Salhi, MD
Attending Surgeon
Michael Mirmanesh, MD John Paro, MD Division of Plastic Surgery
Resident Physician Plastic Surgery Nicklaus Children’s Hospital
Division of Plastic Surgery Palo Alto Medical Foundation Miami, FL, USA
University of California, Davis Pleasanton, CA, USA
Sacramento, CA, USA A. Neil Salyapongse, MD
Maria A. Pedersen, BA, RN, CAPA Clinical Professor
Arash Momeni, MD Perioperative Nurse Plastic and Orthopedic Surgery
Assistant Professor of Surgery Sutter Davis Hospital Surgery Center University of Wisconsin—Hospital and
Director, Clinical Outcomes Research Davis, CA, USA Clinics
Division of Plastic and Reconstructive Madison, WI, USA
Surgery Joshua Peterson, BS
Stanford University Medical Center Medical Student Shilu Shrestha, MD
Stanford, CA, USA University of Michigan Medical School Consultant Orthopedic and Hand &
Ann Arbor, MI, USA Reconstructive Microsurgeon
Lisa Moody, MD Department of Orthopedics
Plastic & Reconstructive Surgeon Vinita Puri, MS (General Surgery), MCh Hospital and Rehabilitation for Disabled
Moody Surgical Associates (Plastic Surgery) Children
Founder/Owner Professor and Head B&B Hospital
Duluth, GA, USA Department of Plastic Surgery Kathmandu, Nepal
Seth G S Medical College and KEM
Deepak Narayan, MD Hospital Roger L. Simpson, MD, MBA
Section of Plastic and Reconstructive Mumbai, India Long Island Plastic Surgical Group
Surgery Director of the Burn Center
Department of Surgery Shankar Man Rai, MD Nassau University Medical Center
Yale University School of Medicine Professor and Chairman East Meadow, NY, USA;
New Haven, CT, USA Department of Plastic Surgery Assistant Professor of Surgery
Kirtipur Hospital State University of New York
Kirtipur, Nepal Stony Brook, NY, USA
 LIST OF CONTRIBUTORS xiii

Frances L. Snyder, BSN, RN, CNOR Paul J. Therattil, MD Derrick C. Wan, MD

Perioperative Registered Nurse Resident Physician Associate Professor
Bellingham Ambulatory Surgery Center Division of Plastic and Reconstructive Department of Surgery
Bellingham, WA, USA Surgery Stanford University
Department of Surgery Stanford, CA, USA
Kimberly E. Souza, MD Rutgers New Jersey Medical School
Resident Physician Newark, NJ, USA Tokoya Williams, MD
Department of Orthopaedic Surgery Postdoctoral Fellow
University of Utah Charles H. Thorne, MD Stanford University
Salt Lake City, UT, USA Chairman Stanford, CA, USA
Department of Plastic Surgery
Rachel C. Steckelberg, MD, MPH Lenox Hill Hospital June K. Wu, MD
Regional Anesthesia Fellow New York, NY, USA Assistant Professor
Department of Anesthesiology, Surgery
Perioperative, and Pain Medicine David M. Tsai, MD Columbia University
Stanford University Section of Plastic and Reconstructive New York, NY, USA
Stanford, CA, USA Surgery
Department of Surgery Jonathan T. Xu, BA
Gloria R. Sue, MD Yale University School of Medicine Medical Student
Resident Physician New Haven, CT, USA Columbia University
Division of Plastic and Reconstructive College of Physicians and Surgeons
Surgery Elbert E. Vaca, MD New York, NY, USA
Stanford University Resident Physician
Stanford, CA, USA Division of Plastic Surgery
Northwestern University Feinberg School of
Stephen R. Sullivan, MD, MPH Medicine
Associate Professor Chicago, IL, USA
Harvard Medical School
Mt Auburn Hospital Alexandra A. von Guionneau, MBBS
Cambridge, MA, USA Candidate
Medical Student
Helena O. Taylor, MD, PhD Faculty of Life Sciences and Medicine
Assistant Professor King’s College London
Harvard Medical School London, UK
Mt Auburn Hospital
Cambridge, MA, USA
AC K N OW L E D G M E N T S

I offer special thanks to Angela Sotelo, Kathleen Roeder Chang, and Julia Roeder Chang for their copyediting
and proofreading assistance, and to my talented editors at Elsevier, Trinity Hutton, Belinda Kuhn, and Joanna
Souch. Their guidance and encouragement have been essential.

xiv
 D E D I C AT I O N

This textbook is dedicated to the staff, board, and volunteers of the non-profit organization, ReSurge Inter-
national. Their collective goal for 50 years has been to deliver and teach reconstructive surgery to those in
need, regardless of religion, politics, or social standing. Their generosity of time, money, expertise, and spirit
is inspirational to me.

xv
VIDEO CONTENTS
1.2 Operating Room Requirements and Setup
Video 1 Operating Room Requirements and Setup
1.7 PACU Setup and Requirements
Video 1 PACU Setup
2.1 Skin Grafting
Video 1 Split-Thickness Skin Graft Harvest
2.3 Tendon Repair
Video 1 Extrinsic Flexors and Surrounding Vasculonervous
Elements, From Superficial to Deep
Reproduced from Chang J, Legrand A, Valero-Cuevas
F, Hentz VR, Chase RA. Anatomy and biomechanics
of the hand. In: Neligan P, Chang J, eds. Plastic
Surgery, 4th ed, vol 6. London: Elsevier Saunders;
2018. Video 6.1.3
Video 2 The Extensor Tendon Compartments
Reproduced from Chang J, Legrand A, Valero-Cuevas
F, Hentz VR, Chase RA. Anatomy and biomechanics
of the hand. In: Neligan P, Chang J, eds. Plastic
Surgery, 4th ed, vol 6. London: Elsevier Saunders;
2018. Video 6.1.1
2.4 Bone Fixation
Video 1 Humeral Osteotomy for Cubitus Valgus Using Staples
for Internal Fixation
2.7 Microsurgery Essentials
Video 1 Key Steps in Arterial Microsurgical Anastomosis
2.8 Common Free Flaps
Video 1 Microvascular Technique
3.1 Primary Unilateral Cleft Lip Repair
Video 1 Explanation of Unilateral Cleft Lip Repair Markings
xvi
3.4 Primary Cleft Palate Repair
Video 1 Furlow Palatoplasty in Veau II Cleft
3.6 Scalp Reconstruction
Video 1 Scalp Reconstruction With Galeal Scoring
3.7 Ptosis Repair
Video 1 Conjunctival-Mullerectomy
Video 2 Levator Advancement
Video 3 Frontalis Sling With Palmaris Longus Tendon
4.1 Acute Burn Management
Video 1 Setting the Depth on the Watson Knife
Video 2 Tangential Excision of a Burn Wound Using a
Watson Knife
Video 3 Tangential Excision of a Burn Wound Using a
Weck Knife
Video 4 Demonstration of Dermatome Assembly and Setting
Video 5 Skin Graft Harvest Using a Dermatome
4.4 Face Burn Reconstruction (Cheek, Nose, and Lip)
Video 1 Examination of a 30-Year-Old Male With Facial Burn
Scarring
4.6 Shoulder and Axilla Burn Reconstruction
Video 1 Anterior Axillary Fold Contracture Restricting
Abduction
5.10 Splinting and Hand Therapy Principles
Video 1 Fabrication of Orthoses Using Alternative Materials
6.1 Compartment Syndrome Treatment
Video 1 Forearm Compartment Syndrome Fasciotomy

SYNOPSIS
Elective surgery in resource-limited countries is often performed by
mobile surgical teams, either as an outreach within the country itself,
or as a volunteer group from another country. These teams provide a
needed service; however, they are often operating in unfamiliar settings
and with limited ancillary support. Careful screening of the patients
with respect to overall health and post-operative requirements is neces-
sary to ensure maximum benefit from the surgery, with minimum risk
to the patient. This chapter offers guidelines for pre-operative screening,
including a targeted medical history, the medical examination, and
appropriate laboratory testing. Specific concerns are outlined. Sample
medical history checklist and an immediate pre-operative checklist are
included.
INTRODUCTION
You are planning to do surgery in a resource-limited country. The need
is great. The surgical team is willing. Your goal is to help as many people
as possible. In this setting, how can you ensure the maximum benefit
for your patients with the least risk? Appropriate evaluation of the site
and careful screening of the prospective patients are vital to ensure
patient safety and to produce good outcomes. Site requirements and
patient selection will vary according to area, team expertise, and the
types of surgeries planned. The following are some general guidelines
and considerations to aid in the process.
SCREENING OF THE SITE
When planning surgery in a new and unfamiliar venue, the site should
be evaluated. The more complex the surgery and the longer the recovery,
the more important are the physical environment and the services avail-
able. Guidelines for the operating room (OR) and post-anesthesia care
unit (PACU) needs are discussed in their respective chapters. The fol-
lowing are considerations for optimal post-operative care.
Ward Needs
• Adequate number of beds for anticipated patient days (number of
patients × length of stay per patient).
• Hygiene: adequate bathroom and handwashing facilities.
• Ability to keep surgical sites clean post-operatively.
• Ability to ensure patient comfort (which in turn facilitates pain
control). This includes temperature conditioning (AC units, fans,
heaters) and positioning.
1.1
Pre-Operative Screening
Katherine D. Gallagher
• Reasonable proximity to OR and PACU to allow monitoring and
ease of transport. Ramps or elevators to move between levels may
be needed.
Nursing Support
• Adequate trained nurses to carry out any patient care and medica-
tion administration that exceed the family’s capabilities (e.g., IV
medications).
• Staff comfortable with monitoring patients for post-operative com-
plications (bleeding, poor circulation, poor intake, uncontrolled pain).
Ancillary Support
• Availability of an intensive care unit (ICU) and arrangements for
transfer of care, if needed.
• A laboratory able to perform blood counts, routine chemistries and,
when appropriate, HIV tests, sickle cell anemia screens, and malaria
screens.
• Access to a blood bank with the ability to obtain screened blood
and to perform a type and cross-match in a reasonable length of
time (1–2 hours).
• A pharmacy in-house or within a reasonable distance that can supply
medications that are needed and that were not brought into the
country by the team.
Follow-Up Care
• A designated, willing, and available practitioner is needed for the care
needs during the time period when the team is no longer present (dress-
ing changes, graft monitoring, pins, catheters, etc.). This individual should
be identified before surgery and must realistically have time available.
Optimally this person will be able to work with the operating surgeons
while they are on-site and communicate with them after they leave, to
discuss care concerns and to provide follow-up information.
• Physical/occupational therapy may be needed to monitor patients
and provide splinting and exercises to preserve surgical improve-
ments. Speech therapy is ideal after the correction of a cleft palate.
These follow-up care requirements are ideal. If certain requirements
cannot be met, it does not necessarily mean that surgery is not possible.
It does, however, limit the types of surgery that can be safely performed
at the targeted venue and in the time allotted.
PATIENT SELECTION
Initial patient selection is made taking into account the expertise of
the team and the time and facilities available. Patients can then be
1
2 SECTION 1 Perioperative Management
prioritized according to need and urgency. Generally, functional cor-
rections take precedence over cosmetic improvements; however, the
adverse effect of some cosmetic defects on a patient’s life may increase
the urgency of repair.
Consideration is given to timing “windows” such as early repair of
cleft lips, timing of cleft palate repair for development of clear speech,
and correction of strabismus or ptosis to prevent amblyopia. Expecta-
tions of the patient and the family should be explored. Families often
expect the surgery to produce a “normal” appearance and function and
need to understand the limitations of a procedure. In the case of mul-
tiple anticipated surgeries, the family and the surgical team together
should establish priorities and the order of surgical interventions.
Finally, the ability of the patient and the environment to sustain
improvements achieved by surgery should be considered. How vital is
ongoing care (speech therapy, physical therapy, splinting) to the final
success of the surgery, and is it available to the patient? This is a difficult
judgment to make, because there are countless variables. It is, however,
worth some thought. All surgery carries some risk, and the long-term
benefits need to justify this risk.
Once a patient is selected for surgery, a more detailed history and
examination is necessary to identify and evaluate any surgical or anes-
thetic risk factors. This screening is best accomplished by involving the
surgeon, the anesthesiologist, and the pediatrician or internist. Each
brings specific expertise and concerns to the screening process.1
PATIENT SCREENING: HISTORY
A targeted patient history is the most important part of the pre-operative
screening and has been shown to be the best tool for assessing anesthesia
risk. Standard questionnaires have been validated as reliable tools in
adults, and these can be modified for use with children.2 Areas covered
include current health, past medical history, family history, and presence
of any chronic conditions. In adults, exercise capacity has been proven
to be a reliable indicator of cardiovascular status, and the threshold level
for elective surgery is at least 4 METs (metabolic equivalents; 4 MET =
climbing a flight of stairs or rapidly walking one block). Personal and
family histories of bleeding problems are more predictive of clotting
disorders than standard “screening” blood tests. Likewise, a personal or
family history of anesthesia problems is a strong predictor for malig-
nant hyperthermia or other anesthesia issues. Sample questionnaires for
adults and children are included in this chapter (Boxes 1.1.1 and 1.1.2).
If the provider taking the screening history is not fluent in the local
language, accurate translation is vital. It is best to go over the screening
questions with the translators in advance, so that they know what con-
cerns are being addressed by each question and what answers constitute
“red flags” that need further clarification. Translation of the questions
into the local language/dialect may facilitate the process. The translator
must be able to ask questions correctly in the patient’s language and
to explain what is being asked, and must also have enough fluency in
English (or the language of the surgical team) to explain the answers. A
good translator can also help interpret cultural biases and local practices.
Be aware that some parents/patients may be reluctant to mention
medical problems for fear that surgery will be denied. Families need
to be assured that a medical condition will not automatically preclude
surgery, and that accurate information is necessary to provide the best
care possible.
PATIENT SCREENING: PHYSICAL EXAMINATION
A full physical examination is optimal but not always possible, particu-
larly in a busy, crowded clinic. At a minimum, vital signs and evaluation
of general appearance, airway, and heart and lungs are necessary.
BOX 1.1.1 Sample Child History
1. Is your child well today? Have they had a fever, cough, or runny nose in
the last 2 weeks?
2. Is the child taking any medications (including herbal medications and
supplements)?
3. Does the child have an allergy to any medications?
4. Does the child have any chronic medical problems? Are they seeing a
doctor regularly for a condition?
5. Has the child had previous surgeries? When and by whom? Were there
any problems?
6. Has the child or anyone in the family had problems with anesthesia (requir-
ing special treatment or a long hospital stay)? Did anyone have trouble
awakening after anesthesia?
7. Was the child born early? How many weeks early?
8. Is the child developing normally? For school aged children: How is the
child doing in school?
9. Can the child run, jump, and play as actively as other children?
10. Infants: Does the baby turn blue or get out of breath when nursing?
11. Any heart problems? Does the child get blue lips or badly out of breath
with exercise?
12. Any lung problems? Asthma, bronchitis, or other trouble breathing?
13. Does the child snore at night, and if so, does it awaken him?
14. Has the child had seizures (convulsions) or fainting spells?
15. Does the child or any family member have trouble stopping bleeding from
small cuts? Do they get bruising on the face or around joints?
BOX 1.1.2 Sample Adult History
1. Are you well today? Have you had a cold, cough, or fever in the past 2
weeks?
2. Are you taking any medications (including herbal medications and
supplements)?
3. Are you allergic to any medications?
4. Are you seeing a doctor regularly for any health problem?
5. Are you a smoker? Do you use any drugs, or plants such as betel?
6. Do you have any heart problems?
• Have you ever had a heart attack, a stroke, or chest pain?
• Have you ever been told that you have an irregular heartbeat or heart
failure?
• Can you climb two flights of stairs without chest pain or breathing
trouble?
7. Do you have any lung trouble like asthma, bronchitis or tuberculosis?
8. Do you snore at night? Does it interrupt your sleep? Are you very sleepy
during the day?
9. Do you have high blood pressure? Is it being treated?
10. Do you have diabetes? Is it controlled by diet, pills, or insulin?
11. Do you have heartburn or stomach problems?
12. Do you have kidney disease?
13. Do you have thyroid problems? Are you taking medicine for it?
14. Do you have pain, stiffness, or arthritis in your neck or jaw?
15. Have you had surgery before? Were there any complications with the
surgery?
16. Have you or anyone in your family had complications with anesthesia?
17. Have you or anyone in the family had trouble with bleeding that did not
stop normally?
18. Could you be pregnant?

TABLE 1.1.1 Pediatric Vital Sign Normal Ranges
Age Group Heart Rate Awake
Infant (1–12 months) 100–180
Toddler (1–3 years) 98–140
Preschooler (3–5 years) 80–120
School Age (6–12 years) 75–118
Adolescent (13+ years) 60–100
BP, blood pressure.
• Vital signs (normal values for age are found in Table 1.1.1):
• Weight: For accurate calculation of fluids and medication doses
and as part of the evaluation of nutritional status. Infants and
small children must be undressed to avoid overestimating weight.
• Pulse, respirations, and pulse oximetry: As screening for unrec-
ognized cardiac or pulmonary issues.
• Blood pressure: Required for ages 3 years and above to rule out
hypertension.
• Temperature: As a screen for acute illness. Temperature >100.4°F
or >38°C is considered a fever.
• General appearance:
• Note and categorize any syndromic features.
• Assess general developmental level.
• Assess tone: Hypotonia increases the risk of functional airway
obstruction and of post-operative atelectasis. Additionally, some
types of hypotonia (mitochondrial defects) are at risk for malig-
nant hyperthermia.
• Assess nutritional status. Mid-upper-arm circumference is the
standard measure. Wasting of the buttocks (gluteals) is an easily
noted sign suggestive of malnutrition.
• Airway:
• Assess mouth opening and adequacy of the airway (Mallampati
score).
• Look carefully for micrognathia/Pierre Robin sequence because
intubation and maintenance of the airway can be very difficult.
• Evaluate neck extension for intubation (and while checking the
neck, in adults, also look for jugular venous distention).
• Check for loose teeth because they are a potential aspiration risk.
• Lungs:
• Note tachypnea with or without retractions (“quiet tachypnea”
may point to cardiac issues).
• Listen for wheezes, cough, rales, or lower airway rhonchi indicat-
ing active pulmonary involvement.
• Note frequency and quality of any cough during the interview
and examination. A significant cough can be provoked by using
a tongue blade to produce a gag reflex.
• Heart:
• Note rate, rhythm, and abnormal murmurs. Many children have
an exaggerated “sinus arrhythmia” (variation in heart rate with
respiration), and up to one-third will have a short systolic flow
murmur at the left sternal border. Any other abnormalities or
any murmurs that the examiner cannot confidently identify as
benign warrant further investigation before surgery.
• Abdomen:
• Palpation of the abdomen can identify organomegaly or masses
requiring further investigation.
• Skin and nails:
• Abnormalities may suggest nutritional issues. Clubbing of fingers
is a sign of underlying chronic illness, usually pulmonary. Pete-
chiae and excess bruising suggest platelet or clotting problems,
respectively.
CHAPTER 1.1 Pre-Operative Screening 3
Respirations Systolic BP Diastolic BP
30–53 72–104 37–56
22–37 86–106 42–63
20–28 89–112 46–72
18–25 97–120 57–80
12–20 110–131 64–83
PATIENT SCREENING: LABORATORY EVALUATION
• Hemoglobin: Visual assessment of pallor for anemia lacks
sensitivity.
• Platelet count is needed only if petechiae suggest thrombocytopenia.
• White count is rarely useful.
• Pregnancy test in females between puberty and age 55: This needs
to be requested and done discreetly and in private. Patients are
assured that it is standard testing for ALL female patients, regardless
of history.
• Additional considerations:
• HIV testing in areas of high prevalence
• Malaria screen, sickle cell screen in areas of high prevalence
• Chest x-ray and electrocardiogram (ECG) in patients 65 years
and older
• There is no evidence that other “routine” tests such as urinalysis or
electrolytes are useful. Clotting studies do not reliably predict intra-
operative or post-operative bleeding in the absence of “red flags” in
the individual and family history.
PATIENT SCREENING: SPECIFIC CONCERNS
Age
Infants (age 1 month to 1 year) are at increased risk for adverse events
(estimated 4 times that of older children), and neonates are at particu-
larly great risk (up to 40 times that of older children). The absolute
lowest age limit for surgery is 10 weeks, and infants under 1 year should
be considered only if the surgery is time sensitive (cleft lip repair).
Additionally, prematurity (gestational age under 37 weeks) independently
increases anesthetic risk up to 60 weeks post-conception; in premature
infants who had bronchopulmonary dysplasia, the risk is present through-
out life. Older adults (age 65 years and above) are also at increased risk,
largely due to atherosclerosis and lung damage from smoking and
environmental exposure.
Weight
Weight is a function of age and nutrition, both of which are independent
risk factors. The absolute minimum weight for elective surgery is 10
pounds (4.6 kg). Certain surgeries are best performed after a patient
reaches a size that allows a clear operative field and sufficient tissue for
repair.
Malnutrition
A malnourished child presents an increased anesthesia risk, but is par-
ticularly at risk for poor wound healing and post-operative infections
due to suppressed immune function. Additionally, malnutrition may
be a marker of chronic illness, malabsorption, or feeding difficulties.
Malnourishment may be evaluated using the World Health Organiza-
tion (WHO) weight for height charts (Table 1.1.2). A child is considered
malnourished if it is below 2 standard deviations (SD) and severely
malnourished if below 3 SD from the mean. A malnourished child is
4 SECTION 1 Perioperative Management

TABLE 1.1.2 WHO Weight for Height

BOYS GIRLS
−3 SD −2 SD −1 SD Median Length (cm) Median −1 SD −2 SD −3 SD
2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6
3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5
4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5
5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5
6.6 7.2 7.8 8.3 70 8.2 7.5 6.9 6.3
7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7,1
8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8
9.2 10.0 10.8 11.7 85 11.4 10.4 9.6 8.8
10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8
11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8
12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7
13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9
14.4 15.6 17.0 18.5 110 18.6 16.8 15.4 14.1
15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7
17.1 18.6 20.4 22.4 1209 22.8 20.7 18.9 17.3

not a candidate for elective surgery and requires nutritional
rehabilitation.
Syndromes and Developmental Delay
A genetic syndrome does not automatically preclude surgery; however,
caution and additional workup are advised. Certain syndromes may
have associated cardiac defects, airway anomalies and, particularly,
hypotonia, all of which independently increase anesthesia risks. A child
with Down’s syndrome, in addition to hypotonia and a challenging
airway, may have atlanto-occipital instability. Children with Holt-Oram
syndrome, sometimes seen for hand surgery, may have arrhythmias or
pulmonary hypertension. Discussion of all syndromes and their impli-
cations is beyond the scope of this chapter. An excellent reference is
Smith’s Recognizable Patterns of Human Malformation, now available in
a digital version.3
Developmental delay also does not automatically preclude surgery;
however, the presence of delay should alert the examiner to look for
underlying syndromes. Additionally, the level of function should be
considered when planning repairs. Cleft palate repair/revision to improve
speech is not reasonable in a child who will remain non-verbal.
Anemia
This presents a twofold risk. There is a greater risk of tissue hypoxia
during periods of compromised airway or relative hypotension, and
there is a smaller margin of tolerance for blood loss during a procedure.
A minimum hemoglobin of 10 g/dL is generally recommended. At high
altitude (>8000 feet), the minimum should be higher (11–12 g/dL),
although exact values have not been defined.
Acute Respiratory Illness
This is one of the more difficult situations to assess.4 It is of particular
concern in children, because they are subject to frequent respiratory
illnesses, and their smaller airways render them more susceptible to
obstruction. An acute respiratory illness is known to increase airway
irritability and the risk of laryngospasm or bronchospasm during anes-
thesia. The airway remains hyperreactive for at least 2 weeks after an
illness. A child with a recent onset of runny nose, cough, and particularly
fever, and any child with wheezing, rales, or lower airway rhonchi should
not be scheduled for surgery and should not be considered for surgery
in the following 2 weeks. A child should NOT be given antibiotics or
“cold medications” and scheduled soon after because neither alters the
course of the illness or changes the airway hyperreactivity.
A more difficult situation is the afebrile child with a history of
cough only, or with clear rhinorrhea and a negative chest examination.
Changes in weather and travel may trigger an irritant cough. Children
with cleft palates often have chronic irritant rhinorrhea and cough,
and judgment must be made on examination, general appearance,
and parental report of baseline symptoms.5 Parental assessment has
been shown to be quite accurate in determining illness. If the parent
feels that the child is acting ill, this must be taken seriously. Any child
with a family member who is experiencing a significant illness should
be evaluated with care. Up to half of the children who have respi-
ratory syncytial virus (RSV) or influenza may be asymptomatic on
examination, yet are at increased risk for intra- and post-operative
complications.
Chronic Medical Conditions
These need to be evaluated on a case-by-case basis. Asthma, for example,
increases anesthesia risk even if it is well controlled. The risk can be
minimized with pre-operative bronchodilators. Many anesthesiologists
are comfortable handling a patient who is currently asymptomatic from
mild asthma. Controlled type 2 diabetes and controlled hypertension
do not preclude elective surgery. Some conditions, on the other hand,
require specialized monitoring and expertise, which may not be avail-
able. Examples would be sickle cell disease and insulin-dependent dia-
betes. An exhaustive list of chronic conditions and their requirements
and risks are beyond the scope of this chapter. If there is any question
about the effect of a chronic condition, surgery should be deferred.
Patient safety is paramount.6
PATIENT SCREENING: DAY OF SURGERY
All patients should be reevaluated on the day of their surgery to ensure
that the child is fasting and free of acute illness and that all screening
steps have been completed. A stamp, or a separate form attached to the
front of the patient’s chart, should be filled out to document the process.
 CHAPTER 1.1 Pre-Operative Screening 5

BOX 1.1.3

Presurgical Checklist: Date_______________

Name__________________________________
Medical Record Number___________________ Weight_______________
New Signs of Illness Yes No
Fever Yes No
Runny Nose Yes No
Cough Yes No
Anemia Yes No Hgb_______
Pregnancy Test Pos Neg N/A
NPO
Last meal _________ AM/PM
Last milk _________ AM/PM formula breast
Last water _________ AM/PM
Patient ID number on arm or armband? Yes No
Surgery/site _____________________ L R both N/A
Post-operative appearance discussed with family? Yes No
Post-operative care discussed with family? Yes No
____________________________________________
Practitioner’s Signature

This is complementary to the surgical “time out” and is of equal impor- KEY REFERENCES
tance. A sample form is included in this chapter (Box 1.1.3).
1. The Pediatrician’s Role in the Evaluation and Preparation of Pediatric
Patients Undergoing Anesthesia. Policy Statement from the American
CONCLUSION Academy of Pediatrics. Pediatrics. 2014;134(5):634–641.
2. Hilditch WG, Ashbury AJ, Jack E, McGrane S. Validation of a
Each patient, each family, and each site is unique. The earlier “require-
pre-anesthetic screening questionnaire. Anaesthesia. 2003;58:874–877.
ments” are meant as guidelines; they are issues to be considered when 3. Jones KL, Jones MC, Del Campo M. Smith’s Recognizable Patterns of
planning surgery in any environment, but they are especially important Human Malformation. Philadelphia, PA: Elsevier/Saunders; 2013.
in resource-limited settings. The simple fact that we CAN perform 4. Houck P. Anesthesia for the child with a recent upper respiratory infection.
surgery does not necessarily mean that we SHOULD. Careful screening http://www.uptodate.com/contents/anesthesia-for-the-child-with-a-recent-
of both the site and the individual patients will allow teams to serve upper-respiratory-infection; Up To Date. Accessed October, 2016.
patients with maximum benefit and minimum risk and to remain true 5. Kulkarni K, Patil M, Shirke A, Jadhav S. Perioperative respiratory
to the medical dictum, primum non nocere. complications in cleft lip and palate repairs. Indian J Anaesth.
2013;57(6):562–568.
6. World Health Organization. Pocket Book of Hospital Care for Children:
KEY PRINCIPLES Guidelines for the Management of Common Childhood Illnesses. 2nd ed.
Geneva: WHO; 2013.
• In a resource-limited setting, pre-operative screening is particularly important,
because there may not be equipment and expertise available to handle
unanticipated complications. Resources at the site will dictate the type and
extent of surgery that can reasonably be offered.
• Patient screening is most effective as a team effort, with collaboration
between the surgeon, the anesthesiologist, and the medical provider.
• A careful medical history including family history is the most useful tool
for assessing anesthesia and operative risk. The medical examination then
concentrates on overall health, the airway, and the cardiopulmonary system.
Minimal laboratory workup is required if the history and examination are
normal.
• Acute respiratory illness increases the risk of peri-operative adverse events
and precludes elective surgery. Many chronic medical conditions require
specialized equipment and monitoring and also preclude elective surgery
in a resource-limited setting.
• With respect to children, the common minimum requirements for surgery
are 10 weeks of age, 10 pounds of weight (4.6 kg), 10 g/dL hemoglobin,
and no acute illness.
1.2
Operating Room Requirements and Setup
Frances L. Snyder, Fran Fisher
SYNOPSIS
The purpose of this chapter is to help experienced perioperative reg-
istered nurses prepare for their first international surgical trip by famil-
iarizing them with the process of establishing and running a successful
operating room (OR) in an unfamiliar facility in a foreign country.
This will be accomplished through discussions of pre-trip preparations,
setting up the OR with limited supplies and resources, establishing
professional working relationships with local staff members, planning
ahead, conservation of supplies, and emergency preparedness.
INTRODUCTION
First-time participants on a surgical team trip may feel a measure of
pre-trip apprehension. This is a normal reaction to an upcoming
unknown experience with unfamiliar team members. Be assured
that there are resources available to prepare you for your work.
This chapter is one such tool. As an experienced OR nurse, you
already possess a solid foundation in the basics of perioperative stan-
dards of practice. With a willingness to be flexible, an openness to
becoming engaged in problem solving, and a desire to experience new
people, places, and cultures, you will be well prepared to meet any
challenge.
PRE-TRIP PREPARATION
Your role is integral to the success of the trip. In addition to providing
intraoperative patient care, the OR nurse establishes the OR and ensures
that all equipment, instruments, and supplies are available and func-
tioning properly during the entire trip. The responsibilities begin before
departure.
• If you will be traveling to the site with an organization, contact
organizing personnel pre-trip to learn as much information as pos-
sible about the facility.
• Contact previous trip participants to glean valuable information
about the local staff and site resources.
• Review packing lists to familiarize yourself with the equipment and
supplies being sent.
• On occasion, the bulk of the supplies will be purchased when the
team arrives at the hospital. Inquire about the details of that process
(e.g., Who is the local contact person? What supplies will be
available?)
• If possible, visit the organization’s medical supply warehouse to
learn the proper operation and care of the equipment.
6
• Explore opportunities at your own work site to learn how to clean,
sterilize, and troubleshoot instruments and equipment.
During travel, it is imperative to keep track of all equipment and
supplies. The containers should be counted as they are checked in to
the airlines and every time they are back in your possession at a new
destination. If applicable, arrange for safe overnight storage of the con-
tainers (Fig. 1.2.1).
ESTABLISH THE SURGICAL SUITE
Upon arrival in the host country, the team travels to the facility where
the surgeries will be performed during the duration of the trip. Work
begins as soon as the accompanying boxes of equipment and supplies
have been unloaded. The first task is to determine the perioperative
space. This will be established within the limitations of the facility and
in collaboration with the local staff. The team members discuss and
envision the surgical suite setup as they tour the space provided (Fig.
1.2.2). Patient flow patterns need to be considered. Ideally, the physical
layout will enable an easy flow from pre-operative (PREOP) to OR to
post-anesthesia care unit (PACU) to ward. For patient safety, the OR
and PACU must be in close proximity. A small, quiet, calm space can
usually be made available near the OR for patients to await their surgery.
The wards are often in a more distant part of the facility.
Once the perioperative space is finalized, the OR nurse will need to
assess available local resources and processes that the team may need
to utilize.
1. Key local staff members need to be identified (e.g., OR supervisor or
head nurse, technician support staff). These colleagues will quickly
become valued team members. This can be challenging if commu-
nication requires interpreter assistance. During the initial setup day,
interpreters are extremely busy assisting with patient evaluations.
2. Sterile saline for irrigation will be needed for all surgeries. Distilled
water for the autoclave may be required. It takes time to obtain these
fluids, so this should be a priority.
3. Determine local facility instrument sterilization processes. Locate
the hospital’s sterile processing department (SPD) or central ster-
ilization area. Which local staff members will be responsible for
sterilization of the instrument sets? What is their availability, and
what are hours of operation? Negotiate the process for having the
team’s instrument sets sterilized at the end of each day and retrieved
the next morning (Fig. 1.2.3).
4. Locate an area to securely store team supplies. If the OR is large
enough and not used by local staff during off hours, supplies may
be kept in the OR itself. Often supplies will be stored in an anteroom
 CHAPTER 1.2 Operating Room Requirements and Setup
FIG. 1.2.1 Hard Pelican cases and cardboard boxes containing equip-
ment and supplies, labeled and ready for transport.
FIG. 1.2.2 Upon arrival at the hospital, the team gets a tour of the
surgical suite.
or a room located near the OR. If necessary, obtain locks and keys
for the OR and storage room.
5. Determine how to locally procure needed supplies. Team supplies
are limited, and some items may run out before the trip is over.
Certain items may be easily obtained within the facility (e.g., gauze,
syringes, disposable gloves). If sterile gowns and drapes run out,
local sterile cloth gowns and drapes may be available for team use
(Fig. 1.2.4). Identify key local staff members who are authorized to
obtain these supplies should they be required.
6. Inquire about facility environmental services processes.
• How are clean linen for the OR bed and positioning aids
procured?
• What are the trash and soiled linen removal processes?
• What is the local system for sharps disposal?
7
FIG. 1.2.3 Local staff ready to assist with instrument sterilization.
FIG. 1.2.4 If team supplies run out, locally supplied sterile cloth gowns
and drapes are utilized.
• What is the procedure for room cleanup between cases and/or
terminally at end of the surgical day?
CREATING A FUNCTIONAL OPERATING ROOM
The next major activity centers on setting up the OR. The first task is
to determine the layout of the OR. This is accomplished in collabora-
tion with the team anesthesia providers. The arrangement of the room
and final OR bed placement will be based on the most appropriate
space for setting up the anesthesia machines.
Assess Available OR Furniture and Equipment
1. Beds/stretchers
• Familiarize yourself with the OR beds provided. In general, these
beds are operated manually (Fig. 1.2.5). Practice using the controls
because some functions may not be fully operable. Critical func-
tions for successful surgery include locking/unlocking, Trendelen-
burg, raising/lowering, side tilting.
• Be aware that transport stretchers may not raise/lower and may
have no brakes or side rails.
2. Lighting
• Most facilities will have at least one ceiling-mounted light. Deter-
mine whether these lights are fully functional and adequate for
OR bed placement. Often additional portable lights may be
required for surgeries involving multiple procedures (e.g., burn
scar excision and simultaneous skin graft harvesting).
8 SECTION 1 Perioperative Management
FIG. 1.2.5 An example of a manually operated surgical bed.
FIG. 1.2.6 An example of the circulator’s work space, including all
supplies required for daily cases.
• Be prepared for power outages by having alternate light sources
ready (e.g., flashlights, headlamps, or mobile phone flashlights).
3. Tables
• Obtain tables as appropriate for anticipated procedures. A flat
surface is required for a sterile procedural back table. A small
cart with functioning wheels is ideal. Mayo stands are not always
readily available.
• A larger table can be used as the OR nurse’s work space (Fig.
1.2.6). The supplies used on every case can be placed here for
quick access (e.g., non-sterile examination gloves, prep solutions,
local medications, dressing supplies, positioning aids, tape).
4. Positioning equipment
• Arm boards may be variations of standard arm boards or simple
pieces of wood that are pushed under the OR mattress to secure
in place. If no arm boards are available, patients’ arms can be
tucked at their sides and secured when applying the safety straps.
FIG. 1.2.7 Positioning aids such as donuts and shoulder rolls are made
and covered with plastic for ease of reuse.
• Donuts for head support and shoulder rolls are usually not obtain-
able. These will have to be made with available materials (e.g.,
packing material, bed linen). For ease of cleaning and reuse, once
a positioning aid is fashioned, cover it in plastic (e.g., ziplock
bag, clean trash bag) (Fig. 1.2.7). Both pediatric and adult-sized
donuts and shoulder rolls will be required.
• A hand table will be necessary if upper-extremity procedures are
planned. If no hand table is available, one can be made by secur-
ing two arm boards together. A layer of cardboard can be taped
over the top of the arm boards and padded to provide a level
working surface. Cover with plastic for ease of cleaning and reuse.
5. Sitting stools and stepstools
• Surgeons will need sitting stools during hand procedures.
• Stepstools are useful in assisting ambulatory patients in getting
up onto the OR bed.
Equipment
Equipment essential for surgery may be sent with the team. Check
room outlets for safety and compatibility with this equipment. Save all
original packing materials to repack equipment for return transport at
end of the trip. If local facility equipment is to be used by the team,
check each item and determine that it functions properly and safely.
1. Electrosurgery unit (ESU)
• All perioperative nurses have experience with and understand
the safe use of electrosurgical equipment and accessories. On
surgical trips an ESU is used for most surgeries, and its proper
operation is essential to prevent patient injury. If using a facility-
provided ESU, thoroughly familiarize yourself with how it operates
before the first case. A large assortment of patient grounding
pads (i.e., dispersive electrodes) can be encountered, and you
may be unfamiliar with the options that are available. Disposable
grounding pads come in a variety of sizes and are designed for
single use. Reusable grounding pads/plates (e.g., Megadyne pads,
metal plates with conductive gel) are convenient and reduce waste
(Fig. 1.2.8). Every type of dispersive electrode has risks and
 CHAPTER 1.2 Operating Room Requirements and Setup
FIG. 1.2.8 Metal electrosurgery unit (ESU) grounding plate with conduc-
tive jelly.
FIG. 1.2.9 An example of a compact, portable autoclave that may be
sent on team trips.
benefits for patients. To ensure patient safety, you must fully
understand the proper use of the specific type of grounding
option available to you. Pay particular attention to weight limits
and the manufacturer’s instructions and safety suggestions.
2. Suction
• A functioning suction machine is critical. Often there is a single
suction that is shared between the surgeon and the anesthesia
provider. The machine is best placed near the head of the OR
bed for ease of joint access. Every day, before proceeding with
surgery, test the machine to ensure that there is adequate suction.
3. Autoclave
• An autoclave may be sent with the team (Fig. 1.2.9). The autoclave
should be located near the OR, preferably in an adjoining room.
This close proximity provides easy access and ensures that
unwrapped sterile instruments aren’t carried long distances down
busy hallways.
• It is imperative to read the accompanying operating instructions
before use. If operation of the autoclave requires distilled or
9
FIG. 1.2.10 An example of the contents of a basic tissue set.
demineralized water, it must be obtained locally. If distilled water
is not readily available in the facility, “battery water” may be
procured from a local car shop. Be very careful to check every
bottle label before putting it in the autoclave reservoir to ensure
that it isn’t “battery acid.”
Instrument Sets
Instrument sets appropriate for expected types of procedures are usually
sent on each trip (Fig. 1.2.10). At least two basic sets are required. Three
sets are desirable if the cases will be in quick succession (e.g., multiple
cleft lip procedures). These sets will be alternated between cases. While
one is in use, another can be cleaned and sterilized. At the end of each
day of surgery, an appropriate set will need to be sterile and available
in the event of a nighttime emergency. If necessary, this set can be
flash-sterilized and left in the team’s autoclave with the door closed.
All other sets should be wrapped, labeled, and sent to the hospital’s
central processing for sterilization. All instrument sets will then be
sterile and available for the next day’s surgeries. Count these packs
when dropping them off and picking them up again the next morning.
Ensuring sterilization of wrapped instruments may be a challenge.
Most sites use steam sterilization indicator tape, known as autoclave
tape. This tape’s color change provides visual assurance that the package
has been exposed to the steam sterilization process. However, autoclave
tape does not prove that steam has actually penetrated the package and
that the internal contents are sterile. To confirm the sterility of wrapped
instruments, place an internal indicator, such as a chemical indicator
strip, within each package that is to be sterilized. These internal indica-
tor strips are usually not available on-site and will have to be brought
with the team.
Instrument packs sent out for local sterilization are sometimes
returned in a wet or damp condition (Fig. 1.2.11). These sets cannot
be considered sterile. It is necessary and educational to engage in a dis-
cussion with the local team emphasizing the importance of the drying
component of the sterilization process. With collaboration a solution
can be agreed upon that will benefit the patients. For example, when a
wrapped instrument set has finished the sterilization cycle, allow it to sit
in the hot autoclave, door ajar, to dry for half an hour before removing.
An alternative solution is to process the team’s sets late in the day and
leave them in the autoclave until they are picked up in the morning.
Instrument sets sent on trips usually include just the bare minimum
to perform successful surgery. Any lost or broken instruments may
compromise the following procedures. Check surgical drapes carefully
10 SECTION 1 Perioperative Management
FIG. 1.2.11 A wrapped instrument that was sent out for sterilization
and returned in a wet condition. This instrument cannot be considered
sterile.
FIG. 1.2.12 Extra supplies are stored in the packing boxes. Highly
visible labels identify the box contents.
at the end of each case to avoid discarding small items. Carefully clean
the instruments to avoid any damage. Post a list of the contents of each
set in the decontamination area. As a set is reassembled, inventory the
instruments and compare to the list. This ensures that the set is complete
and that no instruments have been inadvertently lost.
Supplies (Video 1.2.1)
Supplies are usually sent with the team. When unpacking the supplies,
save all wrappers for reuse as bed sheets, sheet protectors, donuts, shoul-
der or chest rolls, etc. Supplies to be used for daily surgeries will be
brought into the OR. Surplus items will be stored in the packing boxes
(Fig. 1.2.12). Group items together in a box according to their use (i.e.,
all draping items in one box and all dressings together in another box).
FIG. 1.2.13 A day’s supply of sterile gauze. The gauze is sterilized in
a dressing drum that is delivered to the OR.
List the contents of each box on colorful, highly visible labels. Place
these labels on or above each box. This enables all team members to
easily locate items. The storage area needs to be secured at night.
If the team will be procuring supplies upon arrival, the first few
days will be challenging. The type and quantity of supplies needed will
be based on the surgeries scheduled. Planning ahead for future needs
is essential. The team will be relying heavily on the local supply chain,
and requested items may take time to obtain. Some items, such as gauze,
may be received in bulk and need to be sterilized before use (Fig. 1.2.13).
Other items may not be available, or the team may not be accustomed
to the local equivalent. The challenge is to obtain adequate supplies to
provide the best patient care possible. As team members learn the options
and limitations of the local system of procurement and sterilization,
the following days evolve into an easier rhythm.
One of the most significant challenges for the perioperative nurse
on a surgical trip begins with the first surgery and continues until the
final procedure. This involves a thorough familiarity with the limitations
and possibilities of the instrumentation, equipment, and supplies. Most
large/complicated surgeries will be scheduled early in the trip to allow
time for appropriate post-operative care. Toward the end of the trip,
there may a sizable number of shorter surgeries. Dressing changes may
also be performed in the OR. If possible, look at the tentative cases
scheduled for the entire trip. Based on this plan, identify instrument,
equipment, and supply needs. Understand that this is only a preliminary
plan and that cases will be canceled and surgeries will be added. This
requires clear communication and collaboration with team members.
The order of planned surgeries may need to be adjusted to prevent
instrument or equipment conflicts. This ensures that there are no delays
and that surgical time is maximized. It is recommended that brief team
meetings are convened at the end of each surgical day. These issues can
be brought up and handled before they become full-blown problems.
Both careful planning and conservation of supplies are critical from
day one.
• Do not open any sterile supplies unless you are certain that they
will be used.
 CHAPTER 1.2 Operating Room Requirements and Setup
• Remember that other team members have access to and will use the
general supplies.
• Check the inventory daily. Cross-check frequently with scheduled
cases and communicate with team members regarding any limita-
tions or shortages.
EMERGENCY PREPAREDNESS
All emergency equipment, medication, and supplies should be assigned
specific, permanent locations. Every member of the team must know
these locations to provide appropriate care in the event of an emergency
(Fig. 1.2.14).
1. Before the first surgery all team members, including the local staff,
should gather to review the location and function of emergency
supplies, medications, and equipment (e.g., automated external
defibrillator [AED], fire extinguishers). Plans for safe emergency
egress from the surgical suite should be discussed.
2. Names of emergency supplies and medications may be unfamiliar.
The team must agree on terminology.
3. Practice using the equipment and supplies because they may differ
from what you are accustomed to.
4. Familiarize yourself with the local oxygen delivery system. Locate
the central source and the process for quickly obtaining a backup
supply.
5. A formal call team must be in place at the end of each day’s surgery.
This team must have the keys to access the OR and supply room to
quickly retrieve sterile instruments and surgical supplies. As previ-
ously stated, members of the call team must know the location of
emergency medications and understand the operation of all critical
supplies and equipment.
OTHER CONSIDERATIONS
Setup day in the host facility is a long and busy one. Many activities
are happening simultaneously. While the OR is being organized, other
FIG. 1.2.14 Emergency medications, equipment, and supplies set up
in a permanent, accessible location. Note the easily available Broselow
Pediatric Emergency Tape.
11
team members will be setting up their specialties. A clinic to evaluate
patients for surgery may be concurrently under way. The perioperative
nurse will need to collaborate with and provide assistance to other team
members as required.
• The clinic may need supplies or extra assistance with patient intake
(e.g., vital signs, weights, pregnancy tests).
• Often the local oxygen delivery system involves large portable cyl-
inders. These freestanding O2 tanks create a potentially hazardous
situation because they can easily fall over. The anesthesia providers
may need assistance in safely securing these cylinders (i.e., put the
tanks into a corner of the room and push heavy objects against
them) (Fig. 1.2.15).
• Orient yourself to the final anesthesia and PACU setups so you can
assist as required during the trip.
To provide safe patient care and to keep cases moving forward, the
perioperative nurse must be flexible. Be cognizant of where your skills
may be needed.
• Assist with anesthesia induction.
• Set up the sterile back table or scrub in to assist in the event that
the local scrub tech process breaks down.
• Provide backup support to the PACU RN recovering patients.
• Wash/decontaminate instruments and anesthesia equipment.
• Assist with dressing changes.
• Facilitate turnovers between cases and terminal room cleaning at
day’s end.
EDUCATIONAL COMPONENT
On surgical trips, education is a key piece of the perioperative RN’s
work. Use every opportunity to educate and support the profes-
sional development of local nursing colleagues. Equally important,
be open to learning what they have to teach you. Be aware that you
are also a role model. Always maintain the highest standards of
practice. Be willing to interact as peers and collaborate with local
staff. The example you give by your attitude, professionalism, and
FIG. 1.2.15 Freestanding O2 tanks secured with duct tape and heavy
objects in front.
12 SECTION 1 Perioperative Management

compassionate care of patients and their family members has a profound

impact.

CONCLUSION
Participating in an international surgical trip may be challenging, but
it is also deeply fulfilling both personally and professionally. You will
very quickly become an enthusiastic “veteran.” Sharing your experiences
and knowledge with other nurses will help encourage and motivate
them to enter this very specialized track of perioperative nursing. Patients
all over the world deserve the safe surgical care that our professional
practice offers.

KEY PRINCIPLES
• Maintain rigorous perioperative standards of practice within the structure
of what you find on-site.
• To ensure that all essential pre-operative patient assessment parameters
have been met, create and consistently use a pre-operative assessment
checklist.
• Perform a “time out” or “surgical pause” before each surgical procedure.
Follow recommended processes to verify correct patient, surgery, site, and
side.
• For cleft palate surgery, adhere to safety protocols. FIG. 1.2.16 Pediatric patient in PACU post cleft palate surgery. Note
the tongue stitch taped to the cheek and “no-no’s” on the arms to
• Count and account for the throat pack on every palate procedure.
prevent disruption of the fresh surgical repair.
• Ensure a suture is secured to the throat pack and that the suture is
visibly hanging out of the patient’s mouth.
• Before the patient is transferred to PACU, verify with the anesthesiologist
and surgeon that the throat pack has been removed.
• A tongue stitch is required for each palate patient. It is to be securely taped
to the patient’s cheek before transferring to PACU.
• Ensure that “no-no’s” (padded cylindrical restraints to limit elbow bending)
are placed on the arms of all pediatric patients before transferring to the
PACU. This prevents disruption of a fresh surgical site or premature removal
FURTHER READING
of an IV (Fig. 1.2.16). AORN. Guidelines for perioperative practice 2016. 1st ed. Denver: AORN;
• Be mindful of and take preventative measures against perioperative 2016.
hypothermia. Rothrock JC. Alexander’s Care of the Patient in Surgery. 15th ed. St. Louis,
• Minimize exposed bare skin. MO: Elsevier; 2015.
• Use passive insulation on all patients (e.g., blankets, plastic bags, mayo Osborn K, Wraa C, Watson A, Holleran R. Medical-Surgical Nursing:
stand covers, space blankets). Preparation for Practice. 2nd ed. Upper Saddle River, NJ: Pearson
Publishing; 2014.

SYNOPSIS
Delivery of general anesthesia requires a trained anesthesia provider;
the availability of functioning, safe anesthetic equipment and patient
monitors; and the essential anesthetic and resuscitative medications.
Anesthesia is an essential component of surgery, and when anesthesia
services are inadequate, difficulties are experienced. Maintaining the
safety of patients while treating them in areas with limited resources
is a continuing challenge.
Minimum requirements for general anesthesia in developed countries
include a source of pressurized oxygen; an effective suction device;
standard American Society of Anesthesiologists (ASA) monitors, includ-
ing heart rate, blood pressure, electrocardiogram (ECG), pulse oximetry,
capnography, and temperature; and inspired and exhaled concentrations
of oxygen and applicable anesthetic agents.1
In low- to middle-income countries (LMICs), due to large economic
inequities, extreme variations exist in the availability of both anesthesia
providers and the necessary equipment and drugs. The provision of
general anesthesia relies heavily on technology and sophisticated equip-
ment and supplies. Often in LMICs, there are shortages of needed drugs
and essential equipment (anesthesia delivery machines, monitors, laryn-
goscopes, and disposables such as airway devices), and for much of the
anesthesia equipment donated, there are no hospital personnel capable
of providing maintenance.2 Current practice for provision of anesthesia
for reconstructive surgical procedures must be adapted to the availability
of supplies and experienced anesthesia providers on-site.
GENERAL ANESTHESIA IN LMICS
Currently, in developing countries, general anesthesia with spontaneous
ventilation is the most common technique used to facilitate surgical
procedures, with regional anesthesia (spinal, peripheral nerve block, or
local infiltration) with or without sedation being a close second method.
Provision of general anesthesia without intubation or deep sedation is
often used to accommodate minor surgical procedures and wound
closures.2,3 Successful training of anesthesia providers (either physicians
or nurses) requires a hospital setting that has sufficient volume and
diversity of operations, non-obsolete anesthesia equipment, and a struc-
tured and comprehensive training program that is recognized by the
national ministry of health or other relevant professional bodies.4
ANESTHESIA DELIVERY SYSTEMS (MACHINES,
VAPORIZERS, AND MONITORS)
The most common type of anesthetic machine in use in developed
countries is the continuous-flow anesthetic machine, which is designed
1.3
General Anesthesia
Deborah A. Rusy
to provide an accurate and continuous supply of medical gases (oxygen,
air, nitrous oxide), mixed with an accurate concentration of anesthetic
vapor that is delivered to the patient at a set pressure and flow. Avail-
ability of functional anesthesia equipment is problematic in the LMICs,
with variation seen within and between hospitals. Donated equipment is
often outdated and obsolete, the local providers are often not properly
trained to use or repair it, and they are unable to acquire replacement
parts when needed.5 Many anesthesia machines currently encountered
in LMICs have been modified by the local providers using the only parts
available, which may be non-standard and often do not meet biomedical
standards. Caution must be taken when using this equipment.6
Of the anesthesia machines available in LMICs, many are considered
obsolete because they lack certain safety features such as oxygen moni-
tors that display O2 concentration, and oxygen supply pressure failure
alarms or fail-safe delivery devices that would shut off gas flow and
sound an alarm if a hypoxic gas mixture were inadvertently being deliv-
ered. Many also lack calibrated anesthetic vaporizers for safer volatile
anesthetic agents such as isoflurane and sevoflurane, a vaporizer Pin
Index Safety System and interlock device (an interlock mechanism that
prevents gases from more than one vaporizer being put to use at the
same time, thus causing an accidental overdose), or Diameter Index
Safety System (DISS); this system consists of non-interchangeable gas
line connectors that provide a standard for non-interchangeable, remov-
able connections for use with medical gases (Fig. 1.3.1).
Draw-over anesthesia machines are currently the most prevalent
machines used in LMICs. They are generally portable and easy to
assemble, consist of a low-resistance breathing circuit with a one-way
valve to prevent rebreathing, a method to ventilate the patient such as
a bellows or self-inflating bag, and a draw-over (low resistance) variable
bypass vaporizer. With this type of system, the carrier gas (room air or
supplemental oxygen) is drawn over the vaporizer either by ventilation
supplied by the anesthesia provider (via self-inflating bag or bellows)
or by the patient’s spontaneous breathing. With a draw-over vaporizer,
the final oxygen concentration delivered to the patient is dependent on
both the added flow of oxygen and the minute ventilation volume
(respiratory rate and tidal volume) as well as on the pattern of ventila-
tion. These vaporizers are at high risk for delivery of a hypoxic mixture.7
Plenum variable bypass vaporizers, which have a much higher internal
resistance and require fresh gas flow above atmospheric pressure. They
are unidirectional, agent specific, and more accurate in delivery of set
anesthetic concentration than draw-over type. They have become more
prevalent in the major LMIC cities. These vaporizers, which can produce
a more accurate concentration of agent at very low gas flows, are similar
to those seen in industrialized countries. Most vaporizers encountered
in LMICs, when available, are often not properly calibrated, risking
potential for the delivery of erroneous concentrations of an inhalational
13
14 SECTION 1 Perioperative Management

/D&HLED+RQGXUDV .XPDVL*KDQD %OXHILHOGV1LFDUDJXD

/HRQ1LFDUDJXD 8ODDQ%DDWDU0RQJROLD 8ODDQ%DDWDU0RQJROLD

0EDOH8JDQGD 'HKUDGXQ,QGLD .KRQ.DHQ7KDLODQG

FIG. 1.3.1 Examples of anesthesia machines found in developing countries (with permissions from Dräger-
werk AG & Co. KgaA).

FIG. 1.3.2 Vaporizer selection: Harare, Zimbabwe.
FIG. 1.3.3 Boyle Bottle ether vaporizer: Dehradun, India.
anesthetic agent. Recently more LMIC hospitals have been able to acquire
sevoflurane vaporizers; however, the majority of sites in the rural areas
still make use of halothane, isoflurane, enflurane, and ether vaporizers
(Fig. 1.3.2).
Measured-flow vaporizers are obsolete in the United States; however,
they may still be encountered in the form of the Copper Kettle, Verni-
trol, Metomatic, and Boyle Bottle and Goldman vaporizers in LMICs
(Figs. 1.3.3 and 1.3.4).
The concentration of anesthetic delivered with these devices is
dependent on the vapor pressure of the anesthetic liquid, the gas flow
through the device, and total gas flow in the system. When delivering
halothane via a measured-flow vaporizer, the typical flow rate to the
vaporizer is set at 100 mL/min and the fresh gas flow at 5 L/min, which
gives a concentration of approximately 1%. With these delivery systems,
it is critical to ensure sufficient diluent gas to prevent a lethal dose of
halothane being delivered to the patient.8 Halothane and, to a lesser
extent, ether are volatile anesthetics commonly used in developing
countries. Ether is an excellent analgesic that is still used in LMICs due
to its low cost and its relative safety, because it does not depress respira-
tion or the cardiovascular system. Disadvantages seen with this anesthetic
agent are that it has extremely high lipid solubility, leading to very slow
onset and slow emergence, and it is very pungent, making it difficult
to use for induction. It is also associated with a high incidence of post-
operative nausea and vomiting (PONV) and is extremely flammable
and occasionally explosive in oxygen.9 Ether use is now limited due to
decreased availability and flammability.
Halothane has been replaced by sevoflurane in the operating rooms
of most developed countries and is no longer available in the United
States. As a result of this lack of demand and absence of profit, phar-
maceutical companies selling this product are threatening to stop
CHAPTER 1.3 General Anesthesia 15
FIG. 1.3.4 Goldman vaporizer: Dehradun, India.
production, which could be a threat to the hundreds of thousands of
patients in LMICs who are dependent on this anesthetic for surgical
procedures.10 Halothane, like ether, is inexpensive and is still used for
both mask induction and maintenance anesthesia. This agent, in com-
parison with newer agents such as isoflurane and sevoflurane, has an
increased risk of sensitizing the myocardium to exogenous epinephrine,
which commonly results in dysrhythmias such as junctional rhythm,
bradycardia, pre-ventricular contractions, or ventricular tachycardia.
Complications when using halothane frequently arise during mask
induction of anesthesia or during surgical infiltration of tissues with
local anesthetic containing epinephrine.
Halothane may be delivered from an isoflurane vaporizer and vice
versa because the two agents have very similar vapor pressures. If doing
so, care must be taken to completely empty vaporizers before filling to
avoid delivery of a gas admixture. One must be extremely cautious if
delivering halothane via an isoflurane vaporizer because it has the
potential to deliver up to a 5% concentration of halothane.11
Soda lime carbon dioxide scrubbers present in local LMIC hospital
anesthesia systems may be old or exhausted and may not change color
to signal when patients develop hypercarbia.12 If soda lime is unavail-
able, a patient’s Paco2 may be better controlled with a non-rebreathing
circuit, such as a Mapleson D or Bain circuit. Rebreathing with these
circuits can be avoided and normocarbia maintained by keeping the
fresh gas flow high at 1.5 to 2 times per minute ventilation. Suggested
fresh gas flow with the use of a Mapleson D system or Bain circuit is
200 to 300 mL/kg with spontaneous ventilation, 2 L/min fresh gas flow
in patients <10 kg, 3.5 L/min fresh gas flow in patients 10 to 50 kg, and
70 mL/kg fresh gas flow in patients >60 kg during controlled ventila-
tion.13 The disadvantage of non-rebreathing systems is that they require
large fresh gas flows that may rapidly deplete available oxygen supplies.14
Anesthetic ventilators, taken for granted in developed countries,
may be available in some LMIC centers; however, they often are not
serviced, leading to delivery of inappropriate tidal volumes and present-
ing risk of barotrauma.15
Volunteer surgical service organizations often transport the equip-
ment, monitors, and supplies needed to provide general anesthesia for
short-term surgical missions; however, they still must rely on in-country
16 SECTION 1 Perioperative Management
electricity, water, and oxygen supplies, which are often intermittently
unavailable at most sites, or permanently unavailable at some of the
rural LMIC sites. In hospitals in developed countries, the primary gas
source for the anesthesia machine is a pipeline supply source delivered
through wall outlets at a pressure of 50 to 55 psig. In most LMIC
hospitals, the oxygen source is typically supplied in tanks. When oxygen
is available from a wall outlet, it is likely that the line is connected to
large oxygen tanks outside the hospital and not the typical liquid oxygen
reservoirs used in developed countries. Oxygen tank size and color code
also vary according to location. US standards require oxygen tanks to
be green, whereas the World Health Organization (WHO) specifies that
they be white. The most common tank cylinders available are type E,
G, or H. The E cylinders contain 625 L of oxygen, corresponding to a
pressure of 2200 psi. The G and H cylinders are much larger and can
hold 5300 L and 6900 L of oxygen, respectively, when completely full.11
When oxygen supply to an anesthesia machine is by tank, one should
always have a backup tank on-site and immediately available. Due to
the cost and limited availability of the oxygen supply, whenever possible,
the fresh gas flow used to deliver an anesthetic should be minimal
(1–2 L/min), and providers should turn off flows when not in use.
In some rural hospitals, there is no available source of oxygen, and
providers are dependent on oxygen concentrators.6 These machines
run atmospheric air through zeolite, which absorbs nitrogen, to produce
an admixture that is 95% oxygen concentration.
Other gases such as nitrous oxide are often not available. However,
when they are being used, one must be vigilant to frequently check the
oxygen supply source and to continuously monitor patient oxygen
saturation, because delivery of a hypoxic gas mixture can easily occur
if the oxygen source is empty. This is especially true if safety devices
such as proportioning systems and the measurement of inspired oxygen
concentration are not present.
Waste gases emitted from the anesthesia machine can be detrimental
to operating room personnel when inhaled. In developed countries,
these gases are scavenged to a central vacuum system or to a passive
duct system that safely transports the waste gases into the atmosphere.
Often in LMIC operating rooms, these gases are not scavenged, and
they are released directly into the operating room. They can easily be
scavenged from anesthesia machines by running corrugated tubing from
the exhaust valve of the breathing system to an outside window or a
suction device.
The WHO recommends that the minimum standard of care for
patient monitoring while receiving anesthesia consists of pulse oximetry,
heart rate monitoring, non-invasive blood pressure recording, and
temperature monitoring. It also suggests monitoring the capability for
inspired and exhaled concentrations of oxygen and applicable anesthetic
agents and also monitoring the availability of additional equipment
such as bag valve masks, laryngoscopes, oral airways, precordial stetho-
scopes, and cricothyrotomy kits.16
The patient monitors encountered in LMICs are often suboptimal,
with missing or broken parts and cables, or none at all. In most facili-
ties, there are no volatile anesthetic or EtCO2 gas analyzers, and the
ability to monitor ECG and pulse oximetry is also sporadic. Often,
anesthesia providers must rely on obtaining blood pressure via blood
pressure cuff and sphygmomanometer and auscultation of breath and
heart sounds with a precordial stethoscope. In some rural areas, moni-
toring may consist only of a precordial stethoscope and the vigilance
of an anesthesia provider with a “finger on the pulse.”
Pulse oximetry was recognized as an international standard in anes-
thetic care in 2009, and it is the only piece of technological equipment
required by the WHO Surgical Safety Checklist.
Temperature monitoring is often not available in LMICs. Temperature
monitoring should be utilized for cases in which the patient is at risk
for significant hypothermia, which may be seen during procedures
requiring large body portions to be exposed, or where blood loss with
repletion may be necessary. Temperature monitoring may also be needed
for patients having procedures in warmer climates where operating
rooms have no air conditioning systems, because these patients are at
risk for hyperthermia.
A continuous source of electricity is needed to power most anesthesia
equipment including monitors and ventilators. Anesthesia providers
in LMICs must be prepared for frequent power outages. If possible, a
backup generator should be available. The anesthesiologist, surgeon,
and nurses should have backup plans for how to monitor the patient’s
vital signs and how to provide light, suction, and hemostasis during
power failure. Equipment brought by teams should have a backup
rechargeable battery source. Because the electric power source current
may differ from that in the United States, current converters, plug adapt-
ers, and grounding devices may be needed.
Volunteer surgical teams may consider transporting portable anes-
thesia machines; however this requires knowledge of how to set up and
troubleshoot them. Machines that are brought must have gas connection
hoses with connected fittings that have the capacity to attach to the
oxygen gas cylinder valve outlets and pressure regulators at the host
sites, and the machines will also need appropriate tubing that enables
waste gases to be disposed into the atmosphere. Figs. 1.3.5A and 1.3.5B
depict a portable anesthesia machine utilized by ReSurge International.
This system contains a stand that holds oxygen tubing with connectors
from tank pressure regulators to a flow meter; to temperature-
compensated, concentration-calibrated, dial-controlled sevoflurane and
isoflurane vaporizers; and to a portable baralyme circle system (“King
System”) (Figs. 1.3.5A and 1.3.5B).
ANESTHETIC DISPOSABLE SUPPLIES AND
MEDICATIONS IN LMICS
Most anesthetic supplies that are considered “single-use disposables”
in the United States are cleaned and reused in LMICs. Sterilization
practices are varied, and often inadequate, with increased risk of iat-
rogenic infections. Pediatric-size endotracheal tubes (ETTs) are extremely
limited and often unavailable. Available supplies are recycled numerous
times, which puts them at risk for weakening, kinking, and balloon
cuff rupture.10 Pediatric anesthesia circuits, masks, oral airways, laryngeal
mask airways (LMAs), and intravenous catheters are a rare commodity.
When reusing supplies, careful cleaning and disinfecting processes
should be followed. Laryngoscopes, ETTs, suction catheters, oral airways,
LMAs, masks, and other equipment exposed to mucous membranes
and bodily fluids should first be thoroughly washed with soap and
water to remove particulate organic matter. After initial cleaning, it is
then advisable to soak the equipment in a high-level chemical disin-
fectant or use a sterilization process. Examples of high-level disinfectants
include glutaraldehyde 2% to 3.5% (Cidex®), ortho-pthalaldehyde
(Cidex-OPA®), sodium hypochlorite 1000 to 2500 ppm (bleach), hydro-
gen peroxide 6%, iodine at a concentration of 450 ppm, and 70% to
90% ethyl and isopropyl alcohol. These disinfectants are bactericidal,
tuberculocidal, fungicidal, and virucidal with 10- to 40-min exposure.14
Steam sterilization, if available, can also be used on plastic disposables
once washed, but repeated treatments tend to discolor and weaken the
plastic. Any equipment that has been washed should be completely dry
before reuse.
Hospitals in LMICs frequently have poorly organized storage and
distribution of health care–related disposable products and drugs. Often
stock supply levels are unknown, and a continuous supply of disposables
and essential drugs is not reliable. Many anesthetic and resuscitation
medications that are standardly stocked in operating room pharmacies

A B
FIG. 1.3.5 (A and B) Portable anesthesia machines.
in the developed countries may be unavailable in LMICs. It is vitally
important to check all drug labels for the concentration before admin-
istering, because drug concentrations found abroad may differ from
the standard concentrations seen in the United States. When diluting
medications to a certain concentration, a standard dilution should be
chosen and used for every case as a measure to avoid drug-dosing error.
Surgical teams should create a list of the names and amounts of
medications required to provide anesthesia for the number of expected
cases, and specific to the procedures being performed. When general
anesthesia is being performed, this usually consists of premedications,
induction agents, analgesics, volatile anesthetics, muscle relaxants, local
anesthetics, antibiotics, anti-nausea medications, and drugs required
for resuscitation.
When preparing and packing medications and disposable supplies
for a surgical trip, it is wise to consider bringing anything thought to
be essential for providing safe general anesthesia. Packing lists will vary
depending on the number and type of surgical procedures being per-
formed. Box 1.3.1 is an example of an anesthesia supply list of items
necessary for a plastic reconstructive surgical mission.
PREPARATION FOR GENERAL ANESTHESIA
Preliminary Site Visit/Report
A preliminary site visit is crucial to allow for the assessment of the
anesthesia equipment (machine, monitors, suction equipment, and other
anesthesia equipment and disposables), physical operating room space,
and PACU availability on-site. It also allows for an introductory visit
with the host physicians, sponsors, and hospital administration before
provision of team care. Review of the host hospital site should also
include the accessibility of a clinical laboratory, blood bank and access
to blood products, pharmacy, and radiology services. Certain more
complex reconstructive surgical procedures cannot be performed safely
if the hospital is lacking these. Also included in the assessment, and
critical to provision of general anesthesia, is the availability of electric
power, oxygen, running water, and sterilization processes.
Transportation of Anesthesia Supplies and Equipment
Supplies may be shipped in advance or transported with the team. In
past years, airlines were very generous in allowing for free transport of
equipment and supplies used for volunteer medical and surgical mis-
sions. This generosity has long disappeared, and many groups now
CHAPTER 1.3 General Anesthesia 17
must check in equipment and supply boxes with personal luggage,
paying for any excess baggage charges. Drugs and supplies traveling
with the teams require government agency permission before travel,
and are usually subject to extra fees. Transportation through customs
can be facilitated with government agency approval letters, obtained
once the drugs and equipment have been guaranteed to meet govern-
ment requirements. This may require that certain drugs and supplies
not be transported (i.e., flammable explosive volatile anesthetics, outdated
or illegal drugs).17 Often supplies may be confiscated if pre-approval
has not occurred. Narcotics and schedule II drugs may be restricted
from transport to certain countries, or may require an official letter
from the host country’s government agency. Transported equipment
and drugs should be of the same quality that would be standard use
in the United States. Outdated medications are wasted in the United
States due to possible sub-therapeutic potency. It is inappropriate, and
in some countries illegal, to transport in outdated medications.
PREPARATION OF THE OPERATING ROOM AND
PATIENT FOR GENERAL ANESTHESIA
Team Anesthesia Providers
Surgical team anesthesia providers should have previous experience
caring for the patients having the planned surgical procedures, with
knowledge of all perioperative issues specific to these procedures and
of methods to deal with them. Those providing general and regional
anesthesia (anesthesiologists or anesthetists) who anticipate caring for
young children should have extensive pediatric experience and be com-
petent in the care of this group of patients.14 Teams should perform
practice emergency scenarios and should conduct brief training sessions
to familiarize both themselves and the local staff with safety protocols
before performing the first surgical procedure.
Universal precautions should be followed at all times. The use of
personal and protective equipment should abide by the same standards
as in the United States. Sufficient supplies of sterile gloves, gowns, masks,
and protective eyewear should be available for the entire team. Safety
devices such as blunt needle and sharps dispensers are also recom-
mended to help decrease the risk of inadvertent needlestick.18 Providers
should take precautions to prevent the spread of infectious diseases
that have a high prevalence in many of the LMICs, such as HIV and
hepatitis, by using a syringe and needle only once, as suggested by the
Centers for Disease Control and Prevention.19 When drawing up
18 SECTION 1 Perioperative Management

BOX 1.3.1 Anesthesia Supplies Checklist

Portable Anesthesia Machine (optional): IV Administration Sets:
Anesthesia Monitors (ECG, BP, O2 sat, EtCO2): Pediatric drip IV set w/ injection port
Manometer and tubing w/ FEMALE connector Adult IV set w/ injection port
BP cuffs w/ MALE connector Extension set
Neonate, infant, child, adult Burettes
Pulse oximeter, portable 1-ft IV tubing for blocks
Adult pulse oximetry probes
Pediatric pulse oximetry probes IV Catheters:
CO2 detector, disposable 18g
ECG lead pkg, adult 20g, 22g, 24g
ECG lead pkg, pediatric
CO2 sampling lines Needles:
Electrical converters 18g, 20g, 22g
Defibrillator 26g 1.25”
Spinal needle 22g, 25g
Hardware/Laryngoscopes/Airway Equipment: Stimulating block needles
AA, C, D, 9V batteries
Syringe pump Syringes:
Portable suction 1 cc TB/with needle
Portable GlideScope 3 cc
Laryngoscope handle, adult 5 cc, 10 cc
Laryngoscope handle, pediatric 20 cc
Laryngoscope blades: Macintosh #1, #2, and #3
Tape/Tourniquet:
Laryngoscope blades: Miller #0, #1, and #2
1/2” pink tape
Laryngoscope blades: Phillips #1, #2
1”, 2” Transpore plastic tape
Eschmann Stylet:
Coban
ET tube stylets: adult/peds
Tegaderm/Band-Aid/Steri-Strip
Magill forceps: adult/peds
Tourniquets
Oral airways: 40, 50, 60, 70, 80, 90, 100 mm
Nasal airway: 14, 18, 22, 26, and 30 Other Supplies:
Head strap OR scrub wear
Precordial chest piece/adhesive discs Disposable gloves
Tongue blades OR caps, masks, shoe covers
Scissors Alcohol wipes
Towel clamps Gauze
Flashlight Sanitary Cavi wipes
Nerve stimulator ETT Cleaning Brushes
Stethoscope Disinfectant solution
Heavy cleaning gloves
LMA: #1, #2, #2.5, #3, and #4 Endotracheal Tubes:
Clipboard
RAE cuffed: 3.0–7.0
Anesthesia records
Straight cuffed: 3.0–7.0
Pens/pencils/marking pen
Breathing Circuits: Pediatric drug dosing chart
Pediatric expandable circles Anesthesia textbooks/e-books
Adult expandable circles Foreign language dictionary
O2 tubing Plastic bags: 1/2–2 gallon, trash
Nasal cannula Duct tape
Scavenge tubing
Emergency Medications:
15-mm connectors
Adenosine inj. 6 mg (3 mg/mL)
Ambu bag: pediatric/adult
Albuterol inhaler
Face Masks: Atropine sulfate (0.2 mg/cc)
Infant, toddler, child, adult Calcium chloride 10% 1 g (100 mg/mL)
Dexamethasone phosphate inj. (4 mg/mL)
Suction Catheters: Dextrose inj. 50% 25 g
6-Fr, 8-Fr, 10-Fr, 12-Fr, 14-Fr Dopamine HCl inj. 200 mg (40 mg/mL)
Yankauer suctions Ephedrine sulfate (50 mg/mL)
 CHAPTER 1.3 General Anesthesia 19

BOX 1.3.1 Anesthesia Supplies Checklist—cont’d

Epinephrine inj. 1:10,000 1 mg (0.1 mg/mL) Anti-Emetics/Antihistamines:
Epinephrine inj. 1:1000 1 mg (1 mg/mL) Diphenhydramine HCl (Benadryl) (50 mg/mL)
Furosemide (Lasix) 20 mg (10 mg/mL) Droperidol inj. (2.5 mg/mL)
Glycopyrrolate inj. (0.2 mg/mL) Metoclopramide HCl (10 mg/2 mL)
Hydralazine HCl (20 mg/mL) Ondansetron
Lidocaine HCl 1%
Lidocaine HCl 4% Anesthetic Agents:
Phenylephrine HCl inj. 1% (10 mg/mL) Sevoflurane
Labetalol inj. (5 mg/mL) Isoflurane
Metoprolol inj. (1 mg/mL) Propofol (10 mg/mL)
Naloxone HCl (Narcan) inj. (0.4 mg/mL)
Sodium bicarbonate inj. 8.4% 50 mEq (1 meq/mL) Local Anesthetics
Verapamil HCl inj. (2.5 mg/mL) Bupivacaine HCl 0.25%
Bupivacaine HCl 0.5%
Neuromuscular Blockers/Reversal Agents: Lidocaine HCl 2%
Succinylcholine chloride inj. 200 mg (20 mg/mL) Bupivacaine HCl 0.25%/EPI 1:200,000
Rocuronium/cisatracurium Lidocaine HCl 1%/EPI 0.001%
or Vecuronium bromide
Neostigmine methylsulfate (0.5 mg/mL) Antibiotics:
Cefazolin IV (1 g)
Analgesics: Clindamycin IV
Ketamine HCl (100 mg/mL) Antibiotic ointment packet
Fentanyl (50 mcg/mL) Amoxicillin (250 mg)
Tylenol suppository (350 mg)
Tylenol tab (350 mg/tab) Ointments:
Butorphanol Jelly/ointment
Nalbuphine (Nubain) Lidocaine jelly
Lacri-Lube ophth. ointment

medications from multi-dose vials, the use of clean needles with no
previous patient exposure should be adhered to.
Anesthesia Documentation
At a minimum, anesthetic records should consist of documentation of
a pre-operative health and physical examination, consent to receive
anesthesia after explanation of benefits and risks, and an intra-operative
anesthetic record containing anesthetic type, interval between patient
vital signs, estimated blood loss and fluids given, medications given,
and documentation of procedures performed by the anesthesia team
(i.e., intubation, invasive line placement, axial or peripheral nerve blocks).
Post-operative orders for patient monitoring and pain control and a
post-operative assessment note are also essential.
NPO Guidelines
The ASA guidelines for nil per os (NPO) times should be observed
before general anesthesia for elective cases. These include 2 hours for
clear liquids, 4 hours for breast milk, and 6 hours for formula, milk,
and light solid meals. Younger children should be encouraged to drink
clear liquids up to 2 hours before anesthesia induction to prevent dehy-
dration, hypotension, and difficult intravenous access, particularly in
hot climates where air conditioning is not available.
procedures should be taken into account. It would be prudent to provide
initial oral doses in smaller amounts than those given in the United
States, such as for midazolam (0.1–0.25 mg/kg) and ketamine (2–3 mg/
kg), because it has been shown that these lower doses can still provide
decreased separation anxiety yet offer earlier recovery.20 Intravenous
premedication dosing for older children and adults is also acceptable.
INDUCTION OF ANESTHESIA
Intravenous ketamine alone has often been successfully used to provide
general anesthesia or deep sedation for surgical procedures in LMIC
rural areas where complex monitoring, anesthesia equipment, electricity,
and oxygen may all be in short supply or unavailable.21,22 Advantages
include allowing for maintenance of spontaneous ventilation, avoidance
of airway manipulation, and maintenance of blood pressure. Disad-
vantages are that when used alone, it may not be sufficient for surgeries
on the head and neck, which may require a secured, protected airway,
or for cases requiring ventilatory control, muscle relaxation, or the
prevention of movement during the procedure. In these cases, induction
of anesthesia may be accomplished by mask induction with volatile
anesthetic agents or, if an IV is present, with an induction agent such
as propofol.

Premedication
The use of pre-operative sedative and anxiolytic medications may provide
for comfort to patients when both they and, if they are children, their
parents have a decreased understanding of the procedures and process
due to limited medical knowledge or language barriers. Oral midazolam
or ketamine may be utilized for pediatric patients; however, consider-
ation for increased risk of prolonged post-operative sedation after short
Airway
For most procedures, the airway is secured after induction. Choice of
airway is dependent on the procedure. It is generally the preference of
the surgeon to have an oral RAE ETT in place for cleft lip, palate, and
nose surgery. This allows for insertion of the Dingman retractor and
allows for a symmetrical view of the face without traction on one side
of the lip. Often RAE tubes are not available in LMICs, so if they are
20 SECTION 1 Perioperative Management

desired, one should consider transporting these items. Straight ETTs

may be adapted for use in cleft cases when needed. Procedures on the
head not involving the lip or palate may be performed with a regular
straight ETT or an LMA. Reconstructive plastic procedures on the upper
and lower extremities are often performed with the use of an LMA
during general anesthesia. After intubation, it is extremely important
to auscultate bilateral breath sounds, and if EtCO2 monitoring is unavail-
able, one should consider the use of a disposable CO2 detector, which
can demonstrate the presence of CO2 based on indicator paper color
changes.

Unanticipated Difficult Airways

Airway issues are the most common complications in pediatric anes-
thesia and are also prevalent in adults. Specialized equipment for difficult
airways such as a fiber-optic bronchoscope or a video laryngoscope,
part of the difficult airway rescue algorithm in developed countries, is
rarely available in underdeveloped countries.
If a difficult airway is identified before anesthesia, it is important
to determine that the necessity and benefits of the procedure outweigh
the risk for airway complications. Careful pre-operative examination
should be performed on children who have syndromes with associated
abnormal airway, such as Pierre Robin, Treacher Collins, Goldenhar,
Klippel-Feil, and Down’s syndrome, and on patients with tumors or
restrictive burn contractures of the neck and mouth. If mask ventilation FIG. 1.3.6 Training local providers to use the C-MAC video laryngoscope
or LMA placement appears feasible, anesthesia may be induced with in Harare, Zimbabwe (with permission from Karl Storz Endoscopy-America,
inhalation agents and spontaneous breathing. After successful mask Inc.).
induction and IV placement, if positive pressure ventilation is possible,
anesthesia may be deepened and laryngoscopy attempted, preferably
without muscle paralysis; or, if needed, anesthesia may be deepened
with the use of a short-acting relaxant.23
Surgical teams may bring compact, portable difficult airway devices
such as a C-MAC laryngoscope™ (Fig. 1.3.6), GlideScope™ (Fig. 1.3.7),
or Airtraq™. These devices increase visibility of the glottis when standard
laryngoscopy fails; however, no device guarantees successful intubation,
particularly if there is limited mouth opening or extreme micrognathia.
Blind nasal intubation and the use of a gum elastic bougie are techniques
that are frequently utilized when more advanced difficult airway equip-
ment is not available.24 In patients who have limited mouth opening
(neck and facial contractures from burns) or micrognathia with difficult
intubation, an LMA can often be placed as an airway conduit.
The ASA difficult airway algorithm should be followed when the
inability to intubate, ventilate, and oxygenate occurs. Anesthesia person-
nel providing care in LMICs should have knowledge of this algorithm
and of the equipment necessary to follow suggested protocols (Figs.
1.3.6 and 1.3.7).

MAINTENANCE ANESTHESIA
A simple anesthetic with as few drugs as possible is the safest choice
when monitoring or post-operative recovery may be minimal or
absent. Typically, most anesthetics in underdeveloped countries consist
of an induction agent (propofol or mask induction with volatile
anesthetic), maintenance anesthesia with a volatile anesthetic (sevoflu-
rane, isoflurane, halothane), and scant amounts of narcotic. It is best
to avoid muscle relaxants if not needed for the surgery. Often the anes-
thetic is supplemented with regional anesthesia blocks or wound infil-
tration by the surgeon to allow for a decrease in narcotic analgesics
and other general anesthetics the patient is receiving. The use of smaller
amounts or no narcotic or muscle relaxants will decrease the risk of
post-operative apnea, airway compromise, and hypoxia; however, one
should be aware that increased incidence of emergence delirium may
be seen.
FIG. 1.3.7 Training local providers to use the GlideScope video laryn-
goscope in Leon, Nicaragua.
EMERGENCE FROM ANESTHESIA
Emergence from anesthesia involves the discontinuation of administra-
tion of general anesthesia and adjuvant agents at the end of the surgical
procedure and the return of consciousness afterward.
Most patients transition smoothly within a short period of time
from a surgical anesthetic state to the awake state. Before anesthetic
emergence and removal of the ETT or LMA, the anesthesiologist should
ensure that the patient has adequate hemodynamic stability, oxygenation,
ventilation, and temperature. Reversal of any neuromuscular blockade
given (typically assessed with a peripheral nerve stimulator) and veri-
fication of spontaneous ventilation with adequate tidal volume, minute
 CHAPTER 1.3 General Anesthesia 21

ventilation, and oxygenation must occur. The airway should be suctioned

and clear of secretions, which, if present, could evoke laryngospasm.
Adequacy of analgesia and prophylaxis against PONV should also be
taken into consideration.
Emergence from anesthesia and patient consciousness may occur
either before (“awake extubation”) or after extubation (“deep extuba-
tion”). The level of wakefulness may be assessed with the ability to
follow commands such as eye opening or hand squeeze, and the ability
to protect the airway with cough or gag reflex. It is probably safer to
extubate the trachea in most patients when they are awake. Awake
extubation is necessary for patients with delayed gastric emptying (due
to drugs, trauma, or systemic illness), a difficult tracheal intubation,
or respiratory problems.
However, in some cases it may be desirable to avoid stimulation of
airway reflexes and to minimize coughing, straining, and hypertension, A
which is sometimes seen during awake extubation. In these situations,
if there is no contraindication, an extubation while the patient is still
deeply anesthetized may be performed. This method may also be desir-
able for children with reactive airway disease. For “deep extubation,”
the anesthetic depth must be sufficient to avoid reflex responses to
airway stimulation, which could lead to laryngospasm or bronchospasm.
It is preferable during deep extubation to have the airway adequately
suctioned and the patient breathing spontaneously.

COMPLICATIONS DURING EMERGENCE

AND RECOVERY
PONV are common complications during recovery from anesthesia,
and can be exacerbated with pain and dehydration. Symptoms may be
reduced with prophylactic anti-emetics, such as ondansetron (0.1 mg/
kg) and dexamethasone (4–10 mg).
Emergence delirium may be common in toddlers and preschool-
aged children whose anesthetic consists of a volatile anesthetic and a
local anesthetic block, with few or no other adjuncts such as narcotics
or benzodiazepines. Many times the symptoms are self-limited, but if
symptoms persist, pharmacological intervention such as small intrave-
nous doses of propofol 0.5 to 1 mg/kg, midazolam 0.02 to 0.1 mg/kg,
or fentanyl 1 to 2 mcg/kg may be needed. B
Post-extubation stridor is common if tracheal, laryngeal, or vocal
cord edema develops during surgery. Treatment of the edema includes FIG. 1.3.8 (A and B) Anesthesia education in Quang Ngai on a ReSurge
humidified oxygen, dexamethasone, and nebulized racemic epineph- International trip.
rine (0.25 mL of racemic epinephrine diluted in 2.5 mL of normal
saline).
Negative pressure pulmonary edema (NPPE) is a rare problem that KEY PRINCIPLES
can occur when a patient has a partially or totally obstructed upper • Delivery of general anesthesia requires a trained anesthesia provider, the
airway, and it generates large negative pressures during attempts to availability of functioning, safe anesthetic equipment and patient monitors,
draw in air. This is treated with supportive measures consisting of and the essential anesthetic and resuscitative medications.
administration of 100% oxygen and application of 5 to 10 cm H2O • Minimum requirements for general anesthesia in developed countries include
positive end-expiratory pressure (PEEP). In cases where pulmonary a source of pressurized oxygen, an effective suction device, standard ASA
edema does not subside in a timely manner, a diuretic may also be monitors (including heart rate, blood pressure, ECG, pulse oximetry, cap-
needed. nography, temperature, and inspired and exhaled concentrations of oxygen),
and applicable anesthetic agents.
CONCLUSIONS • Anesthesia perioperative mortality in LMICs is two to three times that in
developed countries, substantially due to preventable risk factors such as
Although the incidence of anesthesia complications has decreased over lack of qualified anesthesia providers and lack of necessary equipment and
the past 50 years, those receiving surgical care in LMICs are still at two supplies.
to three times the risk of mortality compared with those having surgery • Careful pre-operative examination should be performed in children who have
with anesthesia in developed countries. Anesthesia providers participat- syndromes with associated abnormal airways and in patients with tumors or
ing in surgery abroad must be committed to providing local care teams restrictive burn contractures of the neck and mouth. Difficult airway equip-
with education for the provision of evidence-based best practices, and ment should be available, and the ASA difficult airway algorithm should be
for the development of protocols and perioperative checklists for safe followed when inability to intubate, ventilate, and oxygenate occurs.
anesthesia care (Figs. 1.3.8A and 1.3.8B).
22 SECTION 1 Perioperative Management
KEY REFERENCES
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April 29, 2018.
9. Simpson S, Wilson IH. Draw-over anaesthesia review. Update in
Anaesthesia. 1992;2:3–4.
10. Bosenberg AT. Pediatric anesthesia in developing countries. Curr Opin
Anesthesiol. 2007;20:204–210.
11. Tobias JD, Kim Y, Davis J. Anesthetic care in developing countries:
equipment and techniques. South Med J. 2002;95(2):239–247.
12. Kampalath L. Induction and maintenance of anesthesia. In: Gregory G,
ed. Anesthesia Care of Pediatric Patients in Developing Countries.
https://storage.googleapis.com/global-help-publications/books/help
_anesthesiapediatricsbw.pdf. p. 189. Accessed April 29, 2018.
13. Kaul TJ, Mittal G. Mapleson’s breathing systems. Indian J Anaesth.
2013;57(5):507–515.
14. Fischer QA, Politis GD, Tobias JD, Proctor LT. Pediatric anesthesia for
voluntary services abroad. Anesth Analg. 2002;95:336–350.
15. Dubowitz G, Detlefs S, McQueen K. Global anesthesia workforce crisis: a
preliminary survey revealing shortages contributing to undesirable
outcomes and unsafe practices. World J Surg. 2010;34(3):438–444.
16. World Health Organization. WHO guidelines for safe surgery. 2009: Safe
Surgery; SavesLives. http://apps.who.int/iris/bitstream/handle/10665/
44185/9789241598552_eng.pdf. pp. 15–18. Accessed April 29, 2018.
17. Sherman J, Gaal D. Materials management and pollution prevention. In:
Roth R, ed. The Role of Anesthesiology in Global Health. New York:
Springer; 2015:97.
18. Chackungal S, Nickerson JW, Knowlton LM, et al. Best practice guidelines
on surgical response in disasters and humanitarian emergencies: report
of the 2011 Humanitarian Action Summit Working Group on Surgical
Issues within the Humanitarian Space. Prehosp Disaster Med.
2011;26(6):1–8.
19. Centers for Disease Control and Prevention. Injection safety; the one and
only campaign. https://www.cdc.gov/injectionsafety/1anonly.html.
Accessed April 29, 2018.
20. Darlong V, Shende D, Subramanyum MS, Sundar R. Oral ketamine or
midazolam or low dose combination for premedication in children.
Anaesth Intensive Care. 2004;32(2):246–249.
21. Craven R. Ketamine. Anesthesia. 2007;62(suppl 1):48–53.
22. Bonanno FG. Ketamine in war/tropical surgery (a final tribute to the
racemic mixture). Injury. 2002;33:323–327.
23. Jerome EH. The Pediatric Airway. In: Gregory G, ed. Anesthesia Care of
Pediatric Patients in Developing Countries. https://storage.googleapis.com/
global-help-publications/books/help_anesthesiapediatricsbw.pdf. p. 159.
Accessed April 29, 2018.
24. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic bougie to
facilitate blind nasotracheal intubation in children: a series of three cases.
Anaesthesia. 2006;61:291–294.

Rachel C. Steckelberg, Frederick Mihm, Ryan Derby
SYNOPSIS
The use of ultrasound (US) has revolutionized regional anesthesia and
become an important component of surgical anesthesia and acute pain
management.1–4 Its relative safety and ease of performance make it a
perfect option for surgeries in resource-poor settings. Specifically, regional
anesthesia is used to desensitize a precise body part to painful stimulus.
Research suggests that acute post-operative pain continues to be under-
treated.5,6 US-guided regional anesthesia (UGRA) may be used to address
acute post-operative pain and improve outcomes as well as provide
surgical anesthesia for specific procedures. There are several applications
for UGRA that are beyond the scope of this text. This chapter will focus
on upper- and lower-extremity blocks. The overall purpose of this
chapter is to provide step-by-step instruction on how to perform the
most commonly used nerve blocks and to highlight their contribution
in the context of reconstructive surgery in resource-poor settings.
CLINICAL ISSUES
Presentation
Acute post-operative pain is a recognized and challenging problem.
UGRA is appropriate whenever post-operative pain control is a concern
and can sometimes be used as the sole anesthetic, avoiding a general
anesthesia altogether.
General Risks
The most worrisome risks for all peripheral nerve blocks include:
1. Nerve injury
2. Bleeding
3. Infection
Associated Conditions
Patients with an existing nerve injury, or with skin or systemic infection
(i.e., sepsis), or who have a coagulopathy of any etiology may not be
good candidates for UGRA. The risks and benefits of a nerve block
must always be considered.
Additional Considerations
Although this guide describes single-injection techniques, it is possible
to place perineural catheters at the nerve targets to provide longer
analgesia. Special equipment and pumps to provide continuous infu-
sions are necessary and beyond the scope of this chapter.
MANAGEMENT
1. Choice of local anesthetic (LA): There are many acceptable LAs that
can be used to meet specific patient needs. In general, LA can be
classified by duration and depth of block. The most commonly used
LAs and their concentrations are listed in Table 1.4.1.
1.4
Regional Anesthesia
2. Equipment:
1. US probe: High-frequency linear probe (10–15 MHz)
2. Needle: 100-mm insulated needle
a. There are several regional anesthesia needles commercially
available that all share these qualities
3. An extension tube to attach a syringe of LA
4. Blunt tip to minimize risk of nerve or vascular injury
5. Skin preparation: chlorhexidine, Betadine, or alcohol
6. Probe cover: helpful to maintain strict aseptic technique. When
using a probe cover, limit air bubbles from gel because they will
distort the US image.
7. Monitors: pulse oximeter (audible heart rate tone), continuous
ECG, and non-invasive blood pressure
8. Sedation: titrate to the needs of your patient. Nerve blocks can
be performed with little or no sedation. Midazolam 2 mg, fentanyl
100 mcg, or propofol 20 to 50 mg are commonly used dosages.
3. Preparation:
1. Position: ensure proper and comfortable patient positioning as
well as ergonomic positioning of the US machine.
2. US image: obtain best US image of the target by adjusting depth,
gain, focus, and frequency of the probe.
3. Skin preparation: strict aseptic technique is important at needle
insertion site to minimize risk of infection.
4. Safety pause: immediately before performing block, confirm:
a. Correct patient
b. Correct surgery and side
c. Correct block and side
d. No contraindications to nerve block
e. All equipment including resuscitation equipment is available,
including 20% lipid emulsion.
5. Injection technique:
a. An in-plane needle technique is described for all blocks included
in this chapter, except for the ankle block.
b. Incremental injection of 5 mL with frequent aspiration for
blood is important to minimize risk of complications.
c. High injection pressures may signify an intraneural injection,
and redirection of the needle may be necessary.
d. Use slow injection of LA.
TECHNIQUES
I. Facial Block
Infra-Orbital Block2
Intro: The infra-orbital block anesthetizes the infra-orbital nerve, a
branch of the maxillary division (V2) of the trigeminal nerve, and
provides sensory innervation to the upper lip, lower eyelid, and nasal
vestibule area in between. It is easy to perform and can provide sub-
stantial analgesia for cleft lip surgeries in children.
Indications: Cleft lip surgery
23
24 SECTION 1 Perioperative Management

TABLE 1.4.1 Local Anesthetics and Their

Concentrations
CONCENTRATION
Local Anesthetic Analgesic Block Surgical Block
Short-Acting
Lidocaine n/a 1.5%–2%
Mepivacaine n/a 1.5%

Long-Acting
Ropivacaine 0.25% 0.5%
Bupivacaine 0.25% 0.5%

Technique
1. Patient Positioning:
a. Supine, anesthetized patient
2. Technique:
a. Draw an imaginary line parallel to midline at mid-pupillary
location.
b. Palpate the infra-orbital foramen just below the infra-orbital
margin on the mid-pupillary line. This is your target.
c. Rest the index finger of your other hand on the infra-orbital
ridge during injection to prevent inadvertent needle entry into
the globe.
d. Injection: using a 30-gauge needle, start needle at mid-pupillary
line even with the lateral border of nares and angle upward toward
the infra-orbital foramen. Walk off bone into foramen; then
deposit 0.5 to 1 mL of LA just outside foramen.
See Fig. 1.4.1: Infra-Orbital Block.
KEY PRINCIPLES
• Injection near the infra-orbital foramen allows sensory block of all branches
of the infra-orbital nerve, which branches quickly after exiting the foramen.
• A finger on the orbital ridge protects against globe injury.
• Avoid injection inside the foramen to protect against compartment pressure
and ischemic injury to the nerve. Be sure to pull out of the foramen before
injection.
• Bilateral blocks are recommended even for unilateral cleft lip, because
surgery often crosses the midline.
• For routine cleft lip repair, this block can enable avoidance of any opioids
in small infants.
• This block may not be completely effective if significant nasal reconstruction
is required.
FIG. 1.4.1 Infra-Orbital Block.
2. Home Base:
a. Supraclavicular fossa. The nerve plexus and relevant vasculature
are easily identifiable here by US. This is the same position as
with a supraclavicular nerve block. Identify the subclavian artery
and surrounding plexus, which appears as a “bunch of grapes.”
3. Scanning:
a. Slide the probe in the cephalad direction while keeping the nerve
plexus in the center of the screen, holding the probe perpendicular
to the skin.
b. The nerve plexus will begin to appear as discrete hypoechoic or
dark circles between the scalene muscles.
4. Target:
a. Scan cephalad until the three distinct nerve roots are viewed
stacked on top of one another within the interscalene groove.
These are typically the C5 nerve root and two fascicles of C6.
5. Needling:
a. Advance the needle anteriorly toward the target. For safety, it is
recommended to deposit the LA posteriorly to the plexus. It is
not necessary to puncture between the dark circles.
b. The needle may be redirected above or below the target to obtain
adequate spread.
6. Injection:
a. 15 to 20 mL.
See Fig. 1.4.2: Interscalene Block.

II. Upper Extremity (Brachial Plexus)

Interscalene Block1,3
Intro: The interscalene block is performed at the level of the nerve
roots, between the anterior and middle scalene muscles of the neck
within the interscalene groove. Blockade of the brachial plexus at the
interscalene level reliably blocks C5 to C7 nerve roots but frequently
spares the ulnar nerve distribution, resulting in failure to block the ring
and small fingers.
Indications: surgery involving the shoulder, distal clavicle, and proxi-
mal humerus.
Technique
1. Patient Positioning:
a. Supine, back elevated 30 to 45 degrees with patient’s head turned
away from block site. Consider positioning a pillow under the
ipsilateral shoulder if needling area is limited.
KEY PRINCIPLES
• Unique side effects include Horner’s syndrome, hoarse voice from recurrent
laryngeal nerve blockade, and ipsilateral hemi-diaphragmatic paresis from
phrenic nerve palsy.
• Lower volumes of LA and/or injecting posteriorly may reduce the incidence
of phrenic nerve palsy.
• Occasionally, the nerve roots may course through the scalene muscle (<5%).
Target individual nerve roots if this is the case.
• Be wary of neck vasculature traversing through the plexus. Use a Doppler
if indicated to identify blood vessels.
• The interscalene block spares the ulnar nerve distribution and proximal
(above elbow) medial portion of arm near the axilla (intercostal-brachial
nerve).

Middle scalene m.
A C
FIG. 1.4.2 Interscalene Brachial Plexus Block. (A) Needle/probe/patient position for block on right shoul-
der. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow).
Supraclavicular Block
Intro: The supraclavicular block is performed just above the clavicle at
the level of the first rib where the trunks and divisions of the brachial
plexus course. This block has grown in utility with the increase in
utilization of US, because it allows the practitioner to view vital struc-
tures such as the pleura and arterial branches of the thyrocervical trunk,
which traverse the plexus at this level.
Indications: Surgery below the shoulder, including the hand
Technique:
1. Patient Positioning: Supine with head elevated approximately 45
degrees, turned away from surgical side.
2. Home Base: Place the probe in the supraclavicular fossa with the
beam aimed into the thorax as if to image “behind” the clavicle.
3. Scanning:
a. Slide the probe medially until the subclavian artery is visualized
as a pulsatile black circle.
b. The nerves can be seen at this level as a “cluster of grapes,” or
round hypoechoic structures lateral to the artery.
c. Identify the first rib and pleura. There should be near complete
dropout, or shadowing, deep to the first rib, whereas the image
will appear hazy or shimmering deep to the pleura.
d. Tilt and slight rotation of the probe can improve the image of
the nerves if they do not appear crisp.
e. Occasionally the first rib is not seen directly below the artery,
depending on probe position. Care must be taken to avoid advanc-
ing the needle beyond the first rib or edge of the pleura.
4. Target:
a. The trunks and divisions typically are found immediately lateral
to the artery but can also extend far laterally and medial to the
artery.
b. Doppler can be used to identify blood vessels that course through
the plexus at this level.
5. Needling:
a. Direct the needle from lateral to medial toward the “corner pocket”
formed by the artery and first rib.
CHAPTER 1.4 Regional Anesthesia 25
C5 nerve root
Anterior scalene m.
C6 nerve root
Carotid
artery
Vertebral
artery
b. A single injection at the “corner pocket” is usually sufficient.
c. Other injection techniques have been described, including a
second injection above the plexus and an “intra-cluster” injection.
We recommend using the single-injection technique unless the
spread is deemed inadequate.
6. Injection:
a. 20 to 30 mL.
See Fig. 1.4.3: Supraclavicular Block.
KEY PRINCIPLES
• Phrenic nerve palsy occurs in 1/3 of patients.
• The carotid artery can be confused for the subclavian artery. Care should
be taken to identify the first rib and pleura to help locate the appropriate
target. The subclavian artery lies lateral to the carotid artery.
• Ulnar nerve sparing is possible, and the block should be monitored as it
sets up if the ulnar nerve distribution is important for surgery. Supplementa-
tion for the ulnar nerve can easily be done at or above the elbow if needed.
Infra-Clavicular Block
Intro: The infra-clavicular block is performed below the clavicle at the
level of the cords. It covers a territory similar to that of the supraclavicular
block. However, unlike the supraclavicular block, it has a much lower
rate of phrenic nerve palsy (3%) and is a good alternative in patients
with severe lung disease. Additionally, evidence suggests that the infra-
clavicular block provides better analgesia than the supraclavicular block
when a continuous perineural catheter technique is used due to better
spread of LA to the nerves within the sheath at this location.
Indications: Surgery below the shoulder including the entire hand
Technique:
1. Patient Positioning:
a. Supine with patient’s arm abducted 90 degrees and elbow flexed
90 degrees. This position creates more space between the clavicle
and probe for the needle.
26 SECTION 1 Perioperative Management
A C
FIG. 1.4.3 Supraclavicular Brachial Plexus Block. (A) Needle/probe/patient position for block on right
arm. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow).
b. Not all patients will be able to comfortably position their arm
in this way. Abduct the arm as much as is comfortable for the
patient. The block can still be done if no abduction is
possible.
2. Home Base:
a. Place probe in sagittal plane in the delto-pectoral groove and
locate the pulsatile axillary artery. The axillary vein should be
adjacent medially.
b. If artery is not visible, translate the probe in the medial-lateral
and cephalad-caudad directions until it is in view.
3. Scanning:
a. The three cords of the brachial plexus can be seen surrounding
the artery at this point.
b. Scan medially until the rib or lung is identified deep and caudad
to targets.
c. Identify the neurovascular cluster between the pectoralis major
and minor. These blood vessels are branches of the thoraco-
acromial trunk and care must be taken to avoid them.
4. Target:
a. The lateral, posterior, and medial cords surround the axillary
artery. The lateral cord is often the most visible, whereas the
medial may be difficult to appreciate.
b. Although it is safe to perform the block with pleura in view as
long as meticulous needle imaging is observed, it is often possible
to find a preferred image in which pleura is not visible.
5. Needling:
a. Direct the needle from cephalad to caudad, aiming for the 6
o’clock position to the artery.
b. Small amounts of hydro-dissection once the needle pierces the
pectoralis minor can help to float the lateral and posterior cords
out of the needle’s path.
c. A single injection creating a large pocket of LA immediately
posterior to the artery is adequate.
6. Injection:
a. 20 to 40 mL.
See Fig. 1.4.4: Infra-Clavicular Block.
Axillary Block7
Intro: The axillary nerve block is performed at the level of the terminal
branches of the brachial plexus via injection around the axillary artery.
Brachial plexus
Subclavian
artery
1st rib
KEY PRINCIPLES
• Abducting the arm and flexing the elbow help to rotate the clavicle poste-
riorly, allowing space for the needle. Performing the block with the arm
adducted is possible but may require a steeper needle trajectory.
• To improve needle imaging, insert the needle as parallel to the probe as
possible, taking advantage of the space created by abducting the arm. If
the needle image is still poor, translating the probe along the curvature of
the chest wall may improve the image.
• The hyperechoic area immediately posterior to the artery may represent a
US artifact (posterior acoustic enhancement) but may also hide the posterior
cord. Alternatively, the posterior cord may lie more laterally than this
hyperechoic area.
It specifically targets the four main branches of the brachial plexus: the
median, ulnar, radial, and musculocutaneous nerves.
Indications: Surgery involving the distal forearm and hand
Technique:
1. Patient Positioning:
a. Supine with arm abducted 90 degrees with external rotation
2. Home Base:
a. Place transducer in the axilla and identify the pulsatile axillary
artery.
3. Scanning:
a. If the artery is not easily visible, scan cephalad and caudad until
it is in view.
b. Another useful landmark is the “conjoint tendon” of the teres
major and latissimus dorsi muscles. The terminal branches of
the brachial plexus are often easily visualized and blocked at this
level.
4. Target:
a. Three of the four principal branches of the brachial plexus sur-
round the axillary artery: median (superficial and lateral to the
artery), ulnar (superficial and medial to the artery), and radial
(posterior to the artery).
b. The 4th branch of the brachial plexus, the musculocutaneous
nerve, is located between the coracobrachialis and biceps brachii
muscles. It is often described as a “pod of peas” in between the
two muscles, but it has great anatomical variability and may be
located closer to the artery.
 CHAPTER 1.4 Regional Anesthesia 27

Pectoralis major m.

Laterial cord

Pectoralis minor m.
Medial cord

Art
Vein

Posterior cord
A C Pleura
FIG. 1.4.4 Infra-Clavicular Brachial Plexus Block. (A) Needle/probe/patient position for block on right
arm. (B) Ultrasound image. (C) Ultrasound anatomy labeled with needle path (dashed black arrow). Art,
subclavian artery; Vein, subclavian vein.

5. Needling: III. Lower Extremity

a. Direct needle toward the posterior aspect of the axillary artery.
b. Inject roughly half of the LA posteriorly to the axillary artery.
c. Redirect the needle to the anterior aspect of the artery. Another
10 to 15 mL of LA should be administered to complete the spread
around the axillary artery.
d. Lastly, redirect the needle toward the musculocutaneous nerve,
where another 5 to 7 mL of LA should be administered to com-
plete the block.
6. Injection:
a. 20 to 40 mL.
See Fig. 1.4.5: Axillary Block.
KEY PRINCIPLES
• This block is applicable in patients at risk of morbidity from phrenic nerve
palsy or vascular puncture (e.g., significant pulmonary disease or on
anticoagulation).
• There are several axillary veins that surround the axillary artery; these
should be identified before needling.
• Aspiration should be performed during injection every 5 to 10 mL, and slow
injection should be utilized to minimize the risk of intravascular injection.
• There is considerable patient-to-patient variation of the plexus at this level.
The terminal branches should be traced distally to confirm their location.
• The vasculature is easily compressed, making the block suitable for patients
with coagulopathies.
• This technique is identical to previous transarterial approaches but allows
for more accurate deposition of LA without arterial puncture and resultant
bleeding within the sheath, which will dilute LA concentration.
Femoral Nerve Block1,3
Intro: The femoral nerve block is performed at the level of the common
femoral nerve of the lumbar plexus at the inguinal crease. It covers the
anterior thigh, femur, and knee. The saphenous nerve, a terminal branch
of the femoral nerve, is also blocked and courses down the medial
aspect of the lower leg and foot. This block’s ease of performance and
reliability have made it a commonly used block.
Indications: Surgery involving anterior thigh, femur, knee, medial
lower leg, and foot or ankle.
Technique:
1. Patient Positioning: Supine with the leg extended and abducted
2. Home Base:
a. Place the probe on the inguinal crease.
b. Scan medially until pulsatile femoral artery can be seen.
3. Scanning:
a. Scan cranially-caudally looking for the common femoral artery
to branch into femoral profundus and lateral circumflex arteries.
b. The femoral nerve has many fine branches near the bifurcation
of the common femoral artery and becomes difficult to visualize.
c. Scan cephalad until you see one artery and look for the oblong
femoral nerve lateral to the nerve that may appear adherent to
the iliopsoas muscle.
d. Identify the femoral vein medial to the artery.
e. Identify the fascia iliaca, which invests the iliopsoas muscle and
femoral nerve. Importantly, this fascia does NOT include the
femoral artery.
4. Target:
a. The nerve lies lateral to the artery and superior to the iliopsoas
muscle.
b. Tilt the probe until the nerve image is optimal.
28 SECTION 1 Perioperative Management

Median n.
Vein Vein
Art Vein
Coracobrachialis
muscle Ulnar n.
Vein

Radial n.
Musculocutaneous n.
A C

FIG. 1.4.5 Axillary Brachial Plexus Block. (A) Needle/probe/patient position for block on right arm. (B)
Ultrasound image. (C) Ultrasound anatomy labeled with needle paths (dashed black arrow). Note: multiple
needle passes indicated to obtain optimum local anesthetic spread.

5. Needling:
a. Advance the needle from lateral to medial, aiming to pierce the
fascia iliaca at the lateral-most aspect of the nerve.
b. Continue to advance the needle either deep or superficial to the
nerve, depending on which direction the injectate courses.
c. Injecting deep to the nerve ensures that you have pierced the
fascia iliaca.
6. Injection:
a. 15 to 30 mL.
See Fig. 1.4.6: Femoral Nerve Block.
KEY PRINCIPLES
• The block’s reliability rests on injecting deep to the fascia iliaca. In the
event that the nerve is difficult to see, injecting deep to the fascia iliaca
is a good end point.
• An important consideration of this block is that it results in quadriceps
weakness, and patients are at risk of falling.
• The hyperechoic area lateral to the femoral artery is often mistaken for the
femoral nerve. The femoral nerve lies deep to the fascia iliaca.
• Remember the orientation of the important structures using the mnemonic
NAVL (nerve, artery, vein, lymphatics, from lateral to medial).
Popliteal Sciatic Nerve Block
Intro: A sciatic nerve block performed at the popliteal fossa provides
near-complete coverage of the lower leg. The sciatic nerve courses down
the posterior aspect of the leg and is easily visible as a superficial struc-
ture at the popliteal crease. The sciatic nerve is composed of two distinct
nerves (common peroneal and tibial nerves). These distinct nerves are
surrounded by a common fascial envelope until they branch near the
fossa. A saphenous or femoral nerve block must be performed to provide
complete coverage of the lower leg.
Indications: Surgery below the knee
Technique:
1. Patient Positioning:
a. Lateral or supine with patient’s leg flexed and propped on pillows.
b. The lateral position is preferred when the patient has a large leg
circumference, difficult-to-visualize anatomy, or limited room
for the probe when in the supine position.
2. Home Base:
a. Place the probe in the popliteal fossa and identify the pulsatile
popliteal artery.
3. Scanning:
a. The tibial nerve should be visible superficial to the popliteal
artery. If the nerve is not clearly visible, tilting the probe caudad
(i.e., direct the US beam toward the feet) should assist in bring-
ing the nerve in view.
b. Once the tibial nerve is in view, translate the probe cephalad
looking for the common peroneal nerve to enter laterally and
join the tibial nerve.
4. Target:
a. There are two well-established locations to perform this block.
i. Scan until you reach the point where the common peroneal
and tibial components of the sciatic nerve just bifurcate. The
ideal spot is where the two components are adjacent and still
surrounded in a common fascial envelope.
ii. An alternative is to scan more proximally until there is one
distinct nerve, referred to as the sciatic nerve.
5. Needling:
a. Direct the needle from lateral to medial trying to achieve a parallel
needle-to-probe orientation by entering the skin approximately
the same distance from the probe as the depth of the target on
the US image.
b. To block at the sciatic nerve bifurcation:
i. Advance the needle between the common peroneal and
tibial components, being careful not to damage either
nerve.
ii. If it is difficult to advance between the two components, target
each nerve separately or direct the needle to the medial aspect
of the tibial nerve.
Another random document with
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marked touches, and it ends in vapid flippancy and impertinence.
Among our neighbours on the Continent, Moliere and Rabelais
carried the freedom of wit and humour to an almost incredible
height; but they rather belonged to the old French school, and even
approach and exceed the English licence and extravagance of
conception. I do not consider Congreve’s wit (though it belongs to
us) as coming under the article here spoken of; for his genius is any
thing but merry. Lord Byron was in the habit of railing at the spirit
of our good old comedy, and of abusing Shakspeare’s Clowns and
Fools, which he said the refinement of the French and Italian stage
would not endure, and which only our grossness and puerile taste
could tolerate. In this I agree with him; and it is pat to my purpose. I
flatter myself that we are almost the only people left who understand
and relish nonsense. We are not ‘merry and wise,’ but indulge our
mirth to excess and folly. When we trifle, we trifle in good earnest;
and having once relaxed our hold of the helm, drift idly down the
stream, and delighted with the change are tossed about ‘by every
little breath’ of whim or caprice,
‘That under Heaven is blown.’

All we then want is to proclaim a truce with reason, and to be pleased

with as little expense of thought or pretension to wisdom as possible.
This licensed fooling is carried to its very utmost length in
Shakspeare, and in some other of our elder dramatists, without,
perhaps, sufficient warrant or the same excuse. Nothing can justify
this extreme relaxation but extreme tension. Shakspeare’s trifling
does indeed tread upon the very borders of vacancy: his meaning
often hangs by the very slenderest threads. For this he might be
blamed if it did not take away our breath to follow his eagle flights, or
if he did not at other times make the cordage of our hearts crack.
After our heads ache with thinking, it is fair to play the fool. The
clowns were as proper an appendage to the gravity of our antique
literature, as fools and dwarfs were to the stately dignity of courts
and noble houses in former days. Of all people, they have the best
right to claim a total exemption from rules and rigid formality, who,
when they have any thing of importance to do, set about it with the
greatest earnestness and perseverance, and are generally grave and
sober to a proverb.[7] Poor Swift, who wrote more idle or nonsense
verses than any man, was the severest of moralists; and his feelings
and observations morbidly acute. Did not Lord Byron himself follow
up his Childe Harold with his Don Juan?—not that I insist on what
he did as an illustration of the English character. He was one of the
English Nobility, not one of the English People; and his occasional
ease and familiarity were in my mind equally constrained and
affected, whether in relation to the pretensions of his rank or the
efforts of his genius.
They ask you in France, how you pass your time in England
without amusements; and can with difficulty believe that there are
theatres in London, still less that they are larger and handsomer than
those in Paris. That we should have comic actors, ‘they own,
surprises them.’ They judge of the English character in the lump as
one great jolter-head, containing all the stupidity of the country, as
the large ball at the top of the Dispensary in Warwick-lane, from its
resemblance to a gilded pill, has been made to represent the whole
pharmacopœia and professional quackery of the kingdom. They have
no more notion, for instance, how we should have such an actor as
Liston on our stage, than if we were to tell them we have parts
performed by a sea-otter; nor if they were to see him, would they be
much the wiser, or know what to think of his unaccountable twitches
of countenance or nondescript gestures, of his teeth chattering in his
head, his eyes that seem dropping from their sockets, his nose that is
tickled by a jest as by a feather and shining with self-complacency as
if oiled, his ignorant conceit, his gaping stupor, his lumpish vivacity
in Lubin Log or Tony Lumpkin; for as our rivals do not wind up the
machine to such a determined intensity of purpose, neither have they
any idea of its running down to such degrees of imbecility and folly,
or coming to an absolute stand still and lack of meaning, nor can
they enter into or be amused with the contrast. No people ever laugh
heartily who can give a reason for their doing so: and I believe the
English in general are not yet in this predicament. They are not
metaphysical, but very much in a state of nature; and this is one
main ground why I give them credit for being merry,
notwithstanding appearances. Their mirth is not the mirth of vice or
desperation, but of innocence and a native wildness. They do not
cavil or boggle at niceties, and not merely come to the edge of a joke,
but break their necks over it with a wanton ‘Here goes,’ where others
make a pirouette and stand upon decorum. The French cannot,
however, be persuaded of the excellence of our comic stage, nor of
the store we set by it. When they ask what amusements we have, it is
plain they can never have heard of Mrs. Jordan, nor King, nor
Bannister, nor Suett, nor Munden, nor Lewis, nor little Simmons,
nor Dodd, and Parsons, and Emery, and Miss Pope, and Miss Farren,
and all those who even in my time have gladdened a nation and
‘made life’s business like a summer’s dream.’ Can I think of them,
and of their names that glittered in the playbills when I was young,
exciting all the flutter of hope and expectation of seeing them in their
favourite parts of Nell, or Little Pickle, or Touchstone, or Sir Peter
Teazle, or Lenitive in the Prize, or Lingo, or Crabtree, or Nipperkin,
or old Dornton, or Ranger, or the Copper Captain, or Lord Sands, or
Filch, or Moses, or Sir Andrew Aguecheek, or Acres, or Elbow, or
Hodge, or Flora, or the Duenna, or Lady Teazle, or Lady Grace, or of
the gaiety that sparkled in all eyes, and the delight that overflowed all
hearts, as they glanced before us in these parts,
‘Throwing a gaudy shadow upon life,’—

and not feel my heart yearn within me, or couple the thoughts of
England and the spleen together? Our cloud has at least its rainbow
tints; ours is not one long polar night of cold and dulness, but we
have the gleaming lights of fancy to amuse us, the household fires of
truth and genius to warm us. We can go to a play and see Liston; or
stay at home and read Roderick Random; or have Hogarth’s prints of
Marriage à la Mode hanging round our room. ‘Tut! there’s livers
even in England,’ as well as ‘out of it.’ We are not quite the forlorn
hope of humanity, the last of nations. The French look at us across
the Channel, and seeing nothing but water and a cloudy mist, think
that this is England.
——‘What’s our Britain
In the world’s volume? In a great pool a swan’s nest.’

If they have any farther idea of us, it is of George III. and our Jack
tars, the House of Lords and House of Commons, and this is no great
addition to us. To go beyond this, to talk of arts and elegances as
having taken up their abode here, or to say that Mrs. Abington was
equal to Mademoiselle Mars, and that we at one time got up the
‘School for Scandal,’ as they do the ‘Misanthrope,’ is to persuade
them that Iceland is a pleasant summer-retreat, or to recommend the
whale-fishery as a classical amusement. The French are the cockneys
of Europe, and have no idea how any one can exist out of Paris, or be
alive without incessant grimace and jabber. Yet what imports it?
What! though the joyous train I have just enumerated were, perhaps,
never heard of in the precincts of the Palais-Royal, is it not enough
that they gave pleasure where they were, to those who saw and heard
them? Must our laugh, to be sincere, have its echo on the other side
of the water? Had not the French their favourites and their
enjoyments at the time, that we knew nothing of? Why then should
we not have ours (and boast of them too) without their leave? A
monopoly of self-conceit is not a monopoly of all other advantages.
The English, when they go abroad, do not take away the prejudice
against them by their looks. We seem duller and sadder than we are.
As I write this, I am sitting in the open air in a beautiful valley, near
Vevey: Clarens is on my left, the Dent de Jamant is behind me, the
rocks of Meillerie opposite: under my feet is a green bank, enamelled
with white and purple flowers, in which a dew-drop here and there
still glitters with pearly light—
‘And gaudy butterflies flutter around.’

Intent upon the scene and upon the thoughts that stir within me, I
conjure up the cheerful passages of my life, and a crowd of happy
images appear before me. No one would see it in my looks—my eyes
grow dull and fixed, and I seem rooted to the spot, as all this
phantasmagoria passes in review before me, glancing a reflex lustre
on the face of the world and nature. But the traces of pleasure, in my
case, sink into an absorbent ground of thoughtful melancholy, and
require to be brought out by time and circumstances, or (as the
critics tell you) by the varnish of style!
The comfort, on which the English lay so much stress, is of the
same character, and arises from the same source as their mirth. Both
exist by contrast and a sort of contradiction. The English are
certainly the most uncomfortable of all people in themselves, and
therefore it is that they stand in need of every kind of comfort and
accommodation. The least thing puts them out of their way, and
therefore every thing must be in its place. They are mightily offended
at disagreeable tastes and smells, and therefore they exact the utmost
neatness and nicety. They are sensible of heat and cold, and
therefore they cannot exist, unless every thing is snug and warm, or
else open and airy, where they are. They must have ‘all appliances
and means to boot.’ They are afraid of interruption and intrusion,
and therefore they shut themselves up in in-door enjoyments and by
their own firesides. It is not that they require luxuries (for that
implies a high degree of epicurean indulgence and gratification), but
they cannot do without their comforts; that is, whatever tends to
supply their physical wants, and ward off physical pain and
annoyance. As they have not a fund of animal spirits and enjoyments
in themselves, they cling to external objects for support, and derive
solid satisfaction from the ideas of order, cleanliness, plenty,
property, and domestic quiet, as they seek for diversion from odd
accidents and grotesque surprises, and have the highest possible
relish not of voluptuous softness, but of hard knocks and dry blows,
as one means of ascertaining their personal identity.
 OF PERSONS ONE WOULD WISH TO HAVE
SEEN

The New Monthly Magazine.]

[January, 1826.
‘Come like shadows—so depart.’

B—— it was, I think, who suggested this subject, as well as the

defence of Guy Faux, which I urged him to execute. As, however, he
would undertake neither, I suppose I must do both—a task for which
he would have been much fitter, no less from the temerity than the
felicity of his pen—
‘Never so sure our rapture to create
As when it touch’d the brink of all we hate.’

Compared with him I shall, I fear, make but a common-place piece of

business of it; but I should be loth the idea was entirely lost, and
besides I may avail myself of some hints of his in the progress of it. I
am sometimes, I suspect, a better reporter of the ideas of other
people than expounder of my own. I pursue the one too far into
paradox or mysticism; the others I am not bound to follow farther
than I like, or than seems fair and reasonable.
On the question being started, A—— said, ‘I suppose the two first
persons you would choose to see would be the two greatest names in
English literature, Sir Isaac Newton and Mr. Locke?’ In this A——, as
usual, reckoned without his host. Every one burst out a laughing at
the expression of B——’s face, in which impatience was restrained by
courtesy. ‘Yes, the greatest names,’ he stammered out hastily, ‘but
they were not persons—not persons.’—‘Not persons?’ said A——,
looking wise and foolish at the same time, afraid his triumph might
be premature. ‘That is,’ rejoined B——, ‘not characters, you know. By
Mr. Locke and Sir Isaac Newton, you mean the Essay on the Human
Understanding, and the Principia, which we have to this day. Beyond
their contents there is nothing personally interesting in the men. But
what we want to see any one bodily for, is when there is something
peculiar, striking in the individuals, more than we can learn from
their writings, and yet are curious to know. I dare say Locke and
Newton were very like Kneller’s portraits of them. But who could
paint Shakspeare?’—‘Ay,’ retorted A——, ‘there it is; then I suppose
you would prefer seeing him and Milton instead?’—‘No,’ said B——,
‘neither. I have seen so much of Shakspeare on the stage and on
book-stalls, in frontispieces and on mantle-pieces, that I am quite
tired of the everlasting repetition: and as to Milton’s face, the
impressions that have come down to us of it I do not like; it is too
starched and puritanical; and I should be afraid of losing some of the
manna of his poetry in the leaven of his countenance and the
precisian’s band and gown.’—‘I shall guess no more,’ said A——.
‘Who is it, then, you would like to see “in his habit as he lived,” if you
had your choice of the whole range of English literature?’ B—— then
named Sir Thomas Brown and Fulke Greville, the friend of Sir Philip
Sidney, as the two worthies whom he should feel the greatest
pleasure to encounter on the floor of his apartment in their
nightgown and slippers, and to exchange friendly greeting with
them. At this A—— laughed outright, and conceived B—— was jesting
with him; but as no one followed his example, he thought there
might be something in it, and waited for an explanation in a state of
whimsical suspense. B—— then (as well as I can remember a
conversation that passed twenty years ago—how time slips!) went on
as follows. ‘The reason why I pitch upon these two authors is, that
their writings are riddles, and they themselves the most mysterious
of personages. They resemble the soothsayers of old, who dealt in
dark hints and doubtful oracles; and I should like to ask them the
meaning of what no mortal but themselves, I should suppose, can
fathom. There is Dr. Johnson, I have no curiosity, no strange
uncertainty about him: he and Boswell together have pretty well let
me into the secret of what passed through his mind. He and other
writers like him are sufficiently explicit: my friends, whose repose I
should be tempted to disturb, (were it in my power) are implicit,
inextricable, inscrutable.
“And call up him who left half-told
The story of Cambuscan bold.”

‘When I look at that obscure but gorgeous prose-composition (the

Urn-burial) I seem to myself to look into a deep abyss, at the bottom
of which are hid pearls and rich treasure; or it is like a stately
labyrinth of doubt and withering speculation, and I would invoke the
spirit of the author to lead me through it. Besides, who would not be
curious to see the lineaments of a man who, having himself been
twice married, wished that mankind were propagated like trees! As
to Fulke Greville, he is like nothing but one of his own “Prologues
spoken by the ghost of an old king of Ormus,” a truly formidable and
inviting personage: his style is apocalyptical, cabalistical, a knot
worthy of such an apparition to untie; and for the unravelling a
passage or two, I would stand the brunt of an encounter with so
portentous a commentator!’—‘I am afraid in that case,’ said A——,
‘that if the mystery were once cleared up, the merit might be lost;‘—
and turning to me, whispered a friendly apprehension, that while B
—— continued to admire these old crabbed authors, he would never
become a popular writer. Dr. Donne was mentioned as a writer of the
same period, with a very interesting countenance, whose history was
singular, and whose meaning was often quite as uncomeatable,
without a personal citation from the dead, as that of any of his
contemporaries. The volume was produced; and while some one was
expatiating on the exquisite simplicity and beauty of the portrait
prefixed to the old edition, A—— got hold of the poetry, and
exclaiming ‘What have we here?’ read the following:—
‘Here lies a She-Sun and a He-Moon there,
She gives the best light to his sphere,
Or each is both and all, and so
They unto one another nothing owe.’

There was no resisting this, till B——, seizing the volume, turned to
the beautiful ‘Lines to his Mistress,’ dissuading her from
accompanying him abroad, and read them with suffused features and
a faltering tongue.
‘By our first strange and fatal interview,
By all desires which thereof did ensue,
By our long starving hopes, by that remorse
Which my words’ masculine persuasive force
Begot in thee, and by the memory
Of hurts, which spies and rivals threaten’d me,
I calmly beg. But by thy father’s wrath,
By all pains which want and divorcement hath,
I conjure thee; and all the oaths which I
And thou have sworn to seal joint constancy
Here I unswear, and overswear them thus,
Thou shalt not love by ways so dangerous.
Temper, oh fair Love! love’s impetuous rage,
Be my true mistress still, not my feign’d Page;
I’ll go, and, by thy kind leave, leave behind
Thee, only worthy to nurse in my mind.
Thirst to come back; oh, if thou die before,
My soul from other lands to thee shall soar.
Thy (else Almighty) beauty cannot move
Rage from the seas, nor thy love teach them love,
Nor tame wild Boreas’ harshness; thou hast read
How roughly he in pieces shiver’d
Fair Orithea, whom he swore he lov’d.
Fall ill or good, ’tis madness to have prov’d
Dangers unurg’d: Feed on this flattery,
That absent lovers one with th’ other be.
Dissemble nothing, not a boy; nor change
Thy body’s habit, nor mind; be not strange
To thyself only. All will spy in thy face
A blushing, womanly, discovering grace.
Richly cloth’d apes are called apes, and as soon
Eclips’d as bright we call the moon the moon.
Men of France, changeable cameleons,
Spittles of diseases, shops of fashions,
Love’s fuellers, and the rightest company
Of players, which upon the world’s stage be,
Will quickly know thee.... O stay here! for thee
England is only a worthy gallery,
To walk in expectation; till from thence
Our greatest King call thee to his presence.
When I am gone, dream me some happiness,
Nor let thy looks our long hid love confess,
Nor praise, nor dispraise me; nor bless, nor curse
Openly love’s force, nor in bed fright thy nurse
With midnight startings, crying out, Oh, oh,
 Nurse, oh, my love is slain, I saw him go
O’er the white Alps alone; I saw him, I,
Assail’d, fight, taken, stabb’d, bleed, fall, and die.
Augur me better chance, except dread Jove
Think it enough for me to have had thy love.’

Some one then inquired of B—— if we could not see from the
window the Temple-walk in which Chaucer used to take his exercise;
and on his name being put to the vote, I was pleased to find that
there was a general sensation in his favour in all but A——, who said
something about the ruggedness of the metre, and even objected to
the quaintness of the orthography. I was vexed at this superficial
gloss, pertinaciously reducing every thing to its own trite level, and
asked ‘if he did not think it would be worth while to scan the eye that
had first greeted the Muse in that dim twilight and early dawn of
English literature; to see the head, round which the visions of fancy
must have played like gleams of inspiration or a sudden glory; to
watch those lips that “lisped in numbers, for the numbers came”—as
by a miracle, or as if the dumb should speak? Nor was it alone that he
had been the first to tune his native tongue (however imperfectly to
modern ears); but he was himself a noble, manly character, standing
before his age and striving to advance it; a pleasant humourist
withal, who has not only handed down to us the living manners of his
time, but had, no doubt, store of curious and quaint devices, and
would make as hearty a companion as Mine Host of Tabard. His
interview with Petrarch is fraught with interest. Yet I would rather
have seen Chaucer in company with the author of the Decameron,
and have heard them exchange their best stories together, the
Squire’s Tale against the Story of the Falcon, the Wife of Bath’s
Prologue against the Adventures of Friar Albert. How fine to see the
high mysterious brow which learning then wore, relieved by the gay,
familiar tone of men of the world, and by the courtesies of genius.
Surely, the thoughts and feelings which passed through the minds of
these great revivers of learning, these Cadmuses who sowed the teeth
of letters, must have stamped an expression on their features, as
different from the moderns as their books, and well worth the
perusal. Dante,’ I continued, ‘is as interesting a person as his own
Ugolino, one whose lineaments curiosity would as eagerly devour in
order to penetrate his spirit, and the only one of the Italian poets I
should care much to see. There is a fine portrait of Ariosto by no less
a hand than Titian’s; light, Moorish, spirited, but not answering our
idea. The same artist’s large colossal profile of Peter Aretine is the
only likeness of the kind that has the effect of conversing with “the
mighty dead,” and this is truly spectral, ghastly, necromantic.’ B——
put it to me if I should like to see Spenser as well as Chaucer; and I
answered without hesitation, ‘No; for that his beauties were ideal,
visionary, not palpable or personal, and therefore connected with
less curiosity about the man. His poetry was the essence of romance,
a very halo round the bright orb of fancy; and the bringing in the
individual might dissolve the charm. No tones of voice could come
up to the mellifluous cadence of his verse; no form but of a winged
angel could vie with the airy shapes he has described. He was (to our
apprehensions) rather “a creature of the element, that lived in the
rainbow and played in the plighted clouds,” than an ordinary mortal.
Or if he did appear, I should wish it to be as a mere vision, like one of
his own pageants, and that he should pass by unquestioned like a
dream or sound—
——“That was Arion crown’d:
So went he playing on the wat’ry plain!”’

Captain C. muttered something about Columbus, and M. C. hinted

at the Wandering Jew; but the last was set aside as spurious, and the
first made over to the New World.
‘I should like,’ said Miss D——, ‘to have seen Pope talking with
Patty Blount; and I have seen Goldsmith.’ Every one turned round to
look at Miss D——, as if by so doing they too could get a sight of
Goldsmith.
‘Where,’ asked a harsh croaking voice, ‘was Dr. Johnson in the
years 1745–6? He did not write any thing that we know of, nor is
there any account of him in Boswell during those two years. Was he
in Scotland with the Pretender? He seems to have passed through
the scenes in the Highlands in company with Boswell many years
after “with lack-lustre eye,” yet as if they were familiar to him, or
associated in his mind with interests that he durst not explain. If so,
it would be an additional reason for my liking him; and I would give
something to have seen him seated in the tent with the youthful
Majesty of Britain, and penning the Proclamation to all true subjects
and adherents of the legitimate Government.’
 ‘I thought,’ said A——, turning short round upon B——, ‘that you of
the Lake School did not like Pope?’—‘Not like Pope! My dear sir, you
must be under a mistake—I can read him over and over for
ever!’—‘Why certainly, the “Essay on Man” must be masterpiece.’—‘It
may be so, but I seldom look into it.’—‘Oh! then it’s his Satires you
admire?’—‘No, not his Satires, but his friendly Epistles and his
compliments.’—‘Compliments! I did not know he ever made
any.’—‘The finest,’ said B——, ‘that were ever paid by the wit of man.
Each of them is worth an estate for life—nay, is an immortality.
There is that superb one to Lord Cornbury:
“Despise low joys, low gains;
Disdain whatever Cornbury disdains;
Be virtuous, and be happy for your pains.”

‘Was there ever more artful insinuation of idolatrous praise? And

then that noble apotheosis of his friend Lord Mansfield (however
little deserved), when, speaking of the House of Lords, he adds—
“Conspicuous scene! another yet is nigh,
(More silent far) where kings and poets lie;
Where Murray (long enough his country’s pride)
Shall be no more than Tully or than Hyde!”

‘And with what a fine turn of indignant flattery he addresses Lord

Bolingbroke—
“Why rail they then, if but one wreath of mine,
Oh! all accomplish’d St. John, deck thy shrine?”

‘Or turn,’ continued B——, with a slight hectic on his cheek and his
eye glistening, ‘to his list of early friends:
“But why then publish? Granville the polite,
And knowing Walsh, would tell me I could write;
Well-natured Garth inflamed with early praise,
And Congreve loved and Swift endured my lays:
The courtly Talbot, Somers, Sheffield read,
Ev’n mitred Rochester would nod the head;
And St. John’s self (great Dryden’s friend before)
Received with open arms one poet more.
Happy my studies, if by these approved!
Happier their author, if by these beloved!
 From these the world will judge of men and books,
Not from the Burnets, Oldmixons, and Cooks.”’

Here his voice totally failed him, and throwing down the book, he
said, ‘Do you think I would not wish to have been friends with such a
man as this?’
‘What say you to Dryden?’—‘He rather made a show of himself,
and courted popularity in that lowest temple of Fame, a coffee-
house, so as in some measure to vulgarize one’s idea of him. Pope, on
the contrary, reached the very beau-ideal of what a poet’s life should
be; and his fame while living seemed to be an emanation from that
which was to circle his name after death. He was so far enviable (and
one would feel proud to have witnessed the rare spectacle in him)
that he was almost the only poet and man of genius who met with his
reward on this side of the tomb, who realized in friends, fortune, the
esteem of the world, the most sanguine hopes of a youthful ambition,
and who found that sort of patronage from the great during his
lifetime which they would be thought anxious to bestow upon him
after his death. Read Gay’s verses to him on his supposed return
from Greece, after his translation of Homer was finished, and say if
you would not gladly join the bright procession that welcomed him
home, or see it once more land at Whitehall-stairs.’—‘Still,’ said Miss
D——, ‘I would rather have seen him talking with Patty Blount, or
riding by in a coronet-coach with Lady Mary Wortley Montagu!’
E——, who was deep in a game of piquet at the other end of the
room, whispered to M. C. to ask if Junius would not be a fit person to
invoke from the dead. ‘Yes,’ said B——, ‘provided he would agree to
lay aside his mask.’
We were now at a stand for a short time, when Fielding was
mentioned as a candidate: only one, however, seconded the
proposition. ‘Richardson?’—‘By all means, but only to look at him
through the glass-door of his back-shop, hard at work upon one of
his novels (the most extraordinary contrast that ever was presented
between an author and his works), but not to let him come behind
his counter lest he should want you to turn customer, nor to go
upstairs with him, lest he should offer to read the first manuscript of
Sir Charles Grandison, which was originally written in eight and
twenty volumes octavo, or get out the letters of his female
correspondents, to prove that Joseph Andrews was low.’
 There was but one statesman in the whole of English history that
any one expressed the least desire to see—Oliver Cromwell, with his
fine, frank, rough, pimply face, and wily policy;—and one enthusiast,
John Bunyan, the immortal author of the Pilgrim’s Progress. It
seemed that if he came into the room, dreams would follow him, and
that each person would nod under his golden cloud, ‘nigh-sphered in
Heaven,’ a canopy as strange and stately as any in Homer.
Of all persons near our own time, Garrick’s name was received
with the greatest enthusiasm, who was proposed by J. F——. He
presently superseded both Hogarth and Handel, who had been
talked of, but then it was on condition that he should act in tragedy
and comedy, in the play and the farce, Lear and Wildair and Abel
Drugger. What a sight for sore eyes that would be! Who would not
part with a year’s income at least, almost with a year of his natural
life, to be present at it? Besides, as he could not act alone, and
recitations are unsatisfactory things, what a troop he must bring with
him—the silver-tongued Barry, and Quin, and Shuter and Weston,
and Mrs. Clive and Mrs. Pritchard, of whom I have heard my father
speak as so great a favourite when he was young! This would indeed
be a revival of the dead, the restoring of art; and so much the more
desirable, as such is the lurking scepticism mingled with our
overstrained admiration of past excellence, that though we have the
speeches of Burke, the portraits of Reynolds, the writings of
Goldsmith, and the conversation of Johnson, to show what people
could do at that period, and to confirm the universal testimony to the
merits of Garrick; yet, as it was before our time, we have our
misgivings, as if he was probably after all little better than a
Bartlemy-fair actor, dressed out to play Macbeth in a scarlet coat and
laced cocked-hat. For one, I should like to have seen and heard with
my own eyes and ears. Certainly, by all accounts, if any one was ever
moved by the true histrionic æstus, it was Garrick. When he followed
the Ghost in Hamlet, he did not drop the sword, as most actors do
behind the scenes, but kept the point raised the whole way round, so
fully was he possessed with the idea, or so anxious not to lose sight of
his part for a moment. Once at a splendid dinner-party at Lord ——’s,
they suddenly missed Garrick, and could not imagine what was
become of him, till they were drawn to the window by the convulsive
screams and peals of laughter of a young negro boy, who was rolling
on the ground in an ecstasy of delight to see Garrick mimicking a
turkey-cock in the court-yard, with his coat-tail stuck out behind,
and in a seeming flutter of feathered rage and pride. Of our party
only two persons present had seen the British Roscius; and they
seemed as willing as the rest to renew their acquaintance with their
old favourite.
We were interrupted in the hey-day and mid-career of this fanciful
speculation, by a grumbler in a corner, who declared it was a shame
to make all this rout about a mere player and farce-writer, to the
neglect and exclusion of the fine old dramatists, the contemporaries
and rivals of Shakspeare. B—— said he had anticipated this objection
when he had named the author of Mustapha and Alaham; and out of
caprice insisted upon keeping him to represent the set, in preference
to the wild hair-brained enthusiast Kit Marlowe; to the sexton of St.
Ann’s, Webster, with his melancholy yew-trees and death’s-heads; to
Deckar, who was but a garrulous proser; to the voluminous
Heywood; and even to Beaumont and Fletcher, whom we might
offend by complimenting the wrong author on their joint
productions. Lord Brook, on the contrary, stood quite by himself, or
in Cowley’s words, was ‘a vast species alone.’ Some one hinted at the
circumstance of his being a lord, which rather startled B——, but he
said a ghost would perhaps dispense with strict etiquette, on being
regularly addressed by his title. Ben Jonson divided our suffrages
pretty equally. Some were afraid he would begin to traduce
Shakspeare, who was not present to defend himself. ‘If he grows
disagreeable,’ it was whispered aloud, ‘there is G—— can match him.’
At length, his romantic visit to Drummond of Hawthornden was
mentioned, and turned the scale in his favour.
B—— inquired if there was any one that was hanged that I would
choose to mention? And I answered, Eugene Aram.[8] The name of
the ‘Admirable Crichton’ was suddenly started as a splendid example
of waste talents, so different from the generality of his countrymen.
This choice was mightily approved by a North-Briton present, who
declared himself descended from that prodigy of learning and
accomplishment, and said he had family-plate in his possession as
vouchers for the fact, with the initials A. C.—Admirable Crichton! H
—— laughed or rather roared as heartily at this as I should think he
has done for many years.
 The last-named Mitre-courtier[9] then wished to know whether
there were any metaphysicians to whom one might be tempted to
apply the wizard spell? I replied, there were only six in modern times
deserving the name—Hobbes, Berkeley, Butler, Hartley, Hume,
Leibnitz; and perhaps Jonathan Edwards, a Massachusets man.[10] As
to the French, who talked fluently of having created this science,
there was not a title in any of their writings, that was not to be found
literally in the authors I had mentioned. [Horne Tooke, who might
have a claim to come in under the head of Grammar, was still living.]
None of these names seemed to excite much interest, and I did not
plead for the re-appearance of those who might be thought best fitted
by the abstracted nature of their studies for their present spiritual
and disembodied state, and who, even while on this living stage, were
nearly divested of common flesh and blood. As A—— with an uneasy
fidgetty face was about to put some question about Mr. Locke and
Dugald Stewart, he was prevented by M. C. who observed, ‘If J——
was here, he would undoubtedly be for having up those profound
and redoubted scholiasts, Thomas Aquinas and Duns Scotus.’ I said
this might be fair enough in him who had read or fancied he had read
the original works, but I did not see how we could have any right to
call up these authors to give an account of themselves in person, till
we had looked into their writings.
By this time it should seem that some rumour of our whimsical
deliberation had got wind, and had disturbed the irritabile genus in
their shadowy abodes, for we received messages from several
candidates that we had just been thinking of. Gray declined our
invitation, though he had not yet been asked: Gay offered to come
and bring in his hand the Duchess of Bolton, the original Polly:
Steele and Addison left their cards as Captain Sentry and Sir Roger
de Coverley: Swift came in and sat down without speaking a word,
and quitted the room as abruptly: Otway and Chatterton were seen
lingering on the opposite side of the Styx, but could not muster
enough between them to pay Charon his fare: Thomson fell asleep in
the boat, and was rowed back again—and Burns sent a low fellow,
one John Barleycorn, an old companion of his who had conducted
him to the other world, to say that he had during his lifetime been
drawn out of his retirement as a show, only to be made an exciseman
of, and that he would rather remain where he was. He desired,
however, to shake hands by his representative—the hand, thus held
out, was in a burning fever, and shook prodigiously.
The room was hung round with several portraits of eminent
painters. While we were debating whether we should demand speech
with these masters of mute eloquence, whose features were so
familiar to us, it seemed that all at once they glided from their
frames, and seated themselves at some little distance from us. There
was Leonardo with his majestic beard and watchful eye, having a
bust of Archimedes before him; next him was Raphael’s graceful
head turned round to the Fornarina; and on his other side was
Lucretia Borgia, with calm, golden locks; Michael Angelo had placed
the model of St. Peter’s on the table before him; Corregio had an
angel at his side; Titian was seated with his Mistress between himself
and Giorgioni; Guido was accompanied by his own Aurora, who took
a dice-box from him; Claude held a mirror in his hand; Rubens
patted a beautiful panther (led in by a satyr) on the head; Vandyke
appeared as his own Paris, and Rembrandt was hid under furs, gold
chains and jewels, which Sir Joshua eyed closely, holding his hand so
as to shade his forehead. Not a word was spoken; and as we rose to
do them homage, they still presented the same surface to the view.
Not being bonâ-fide representations of living people, we got rid of
the splendid apparitions by signs and dumb show. As soon as they
had melted into thin air, there was a loud noise at the outer door,
and we found it was Giotto, Cimabue, and Ghirlandaio, who had
been raised from the dead by their earnest desire to see their
illustrious successors—
‘Whose names on earth
In Fame’s eternal records live for aye!’

Finding them gone, they had no ambition to be seen after them,

and mournfully withdrew. ‘Egad!’ said B——, ‘those are the very
fellows I should like to have had some talk with, to know how they
could see to paint when all was dark around them?’
‘But shall we have nothing to say,’ interrogated G. J——, ‘to the
Legend of Good Women?’—‘Name, name, Mr. J——,’ cried H—— in a
boisterous tone of friendly exultation, ‘name as many as you please,
without reserve or fear of molestation!’ J—— was perplexed between
so many amiable recollections, that the name of the lady of his choice
expired in a pensive whiff of his pipe; and B—— impatiently declared
for the Duchess of Newcastle. Mrs. Hutchinson was no sooner
mentioned, than she carried the day from the Duchess. We were the
less solicitous on this subject of filling up the posthumous lists of
Good Women, as there was already one in the room as good, as
sensible, and in all respects as exemplary, as the best of them could
be for their lives! ‘I should like vastly to have seen Ninon de l’Enclos,’
said that incomparable person; and this immediately put us in mind
that we had neglected to pay honour due to our friends on the other
side of the Channel: Voltaire, the patriarch of levity, and Rousseau,
the father of sentiment, Montaigne and Rabelais (great in wisdom
and in wit), Moliere and that illustrious group that are collected
round him (in the print of that subject) to hear him read his comedy
of the Tartuffe at the house of Ninon; Racine, La Fontaine,
Rochefoucault, St. Evremont, &c.
‘There is one person,’ said a shrill, querulous voice, ‘I would rather
see than all these—Don Quixote!’
‘Come, come!’ said H——; ‘I thought we should have no heroes,
real or fabulous. What say you, Mr. B——? Are you for eking out your
shadowy list with such names as Alexander, Julius Cæsar,
Tamerlane, or Ghengis Khan?’—‘Excuse me,’ said B——, ‘on the
subject of characters in active life, plotters and disturbers of the
world, I have a crotchet of my own, which I beg leave to
reserve.’—‘No, no! come, out with your worthies!’—‘What do you
think of Guy Faux and Judas Iscariot?’ H—— turned an eye upon him
like a wild Indian, but cordial and full of smothered glee. ‘Your most
exquisite reason!’ was echoed on all sides; and A—— thought that B
—— had now fairly entangled himself. ‘Why, I cannot but think,’
retorted he of the wistful countenance, ‘that Guy Faux, that poor
fluttering annual scare-crow of straw and rags, is an ill-used
gentleman. I would give something to see him sitting pale and
emaciated, surrounded by his matches and his barrels of gunpowder,
and expecting the moment that was to transport him to Paradise for
his heroic self-devotion; but if I say any more, there is that fellow G
—— will make something of it. And as to Judas Iscariot, my reason is
different. I would fain see the face of him, who, having dipped his
hand in the same dish with the Son of Man, could afterwards betray
him. I have no conception of such a thing; nor have I ever seen any
picture (not even Leonardo’s very fine one) that gave me the least
idea of it.’—‘You have said enough, Mr. B——, to justify your choice.’
‘Oh! ever right, Menenius,—ever right!’
‘There is only one other person I can ever think of after this,’
continued H——; but without mentioning a name that once put on a
semblance of mortality. ‘If Shakspeare was to come into the room, we
should all rise up to meet him; but if that person was to come into it,
we should all fall down and try to kiss the hem of his garment!’
As a lady present seemed now to get uneasy at the turn the
conversation had taken, we rose up to go. The morning broke with
that dim, dubious light by which Giotto, Cimabue, and Ghirlandaio
must have seen to paint their earliest works; and we parted to meet
again and renew similar topics at night, the next night, and the night
after that, till that night overspread Europe which saw no dawn. The
same event, in truth, broke up our little Congress that broke up the
great one. But that was to meet again: our deliberations have never
been resumed.
 ON THE CONVERSATION OF LORDS

The New Monthly Magazine.]

[April, 1826.
‘An infinite deal of nothing,’—Shakspeare.

The conversation of Lords is very different from that of authors.

Mounted on horseback, they stick at nothing in the chace, and clear
every obstacle with flying leaps, while we poor devils have no chance
of keeping up with them with our clouten shoes and long hunting-
poles. They have all the benefit of education, society, confidence,
they read books, purchase pictures, breed horses, learn to ride,
dance, and fence, look after their estates, travel abroad:—authors
have none of these advantages, or inlets of knowledge, to assist them,
except one, reading; and this is still more impoverished and clouded
by the painful exercise of their own thoughts. The knowledge of the
Great has a character of wealth and property in it, like the stores of
the rich merchant or manufacturer, who lays his hands on all within
his reach: the understanding of the student is like the workshop of
the mechanic, who has nothing but what he himself creates. How
difficult is the production, how small the display in the one case
compared to the other! Most of Correggio’s designs are contained in
one small room at Parma: how different from the extent and variety
of some hereditary and princely collections!
The human mind has a trick (probably a very natural and
consoling one) of striking a balance between the favours of wisdom
and of fortune, and of making one thing a gratuitous and convenient
foil to another. Whether this is owing to envy or to a love of justice, I
will not say: but whichever it is owing to, I must own I do not think it
well founded. A scholar is without money: therefore (to make the