LAP- 2 ANESTHESIA CRASH
COURSE
PRE-ANESTHETIC EVALUATION
American society of Anesthesiologists (ASA)
classification. (E- Emergency surgery )
ASA physical status Description
I Normal, healthy patients. No comorbidities
II Mild systemic disease
III Severe systemic disease
IV Severe systemic disease which is a constant threat to life
V Moribund patient who will die without surgery
VI Brain dead patient posted for organ transplant
FASTING GUIDELINES
• Full meal – 8 hours
• Cows milk / Light meal – 6 hours
• Breastmilk – 4 hours
• Clear liquids- 2 hours
MALLAMPATTI CLASSIFICATION – for assessment
of airway prior to surgery
DIFFICULT AIRWAY
EASY AIRWAY
DRUGS TO BE CONTINUED / OMITTED ON DAY OF SURGERY
ANTIHYPERTENSIVES Can continue on day of surgery except ACE-I and ARB
OHAs and Insulin Omit on day of surgery
All psychiatric medications Can continue on day of surgery except Lithium and TCAs
Thyroid medications (for Hyper and Hypothyroidism) Can continue on day of surgery
Anti- TB drugs (AKT) Can continue on day of surgery , check LFTs
Clopidogrel Omit 7 days before surgery
Warfarin Omit 5 days before surgery
Low molecular weight heparin Last dose – 12 (OD dose ) - 24 hrs( BD- dose) before surgery
Unfractionated heparin Last dose - 4 hours before surgery
DRUGS TO BE CONTINUED / OMITTED ON DAY OF SURGERY
Steroids Can continue on day of surgery
OC pills Can continue on day of surgery if low risk of DVT
Diuretics Omit on morning of surgery and check S. Electrolytes
Smoking STOP 6-8 WEEKS prior to surgery
Pre-Medication :
• Anxiolytics - Midazolam
• Antacids – PPIs, H2 blockers
• Analgesics – PSM, NSAIDS
• Anti-sialagogues – Glycopyrrolate /Atropine
• Anti-emetics – Porkinetics, 5-HT3 blockers
• Antibiotics- 60 min prior to surgery
MONITORING IN ANESTHESIA
PULSE OXIMETRY BEER LMABERT LAW
NIBP OSCILLOMETRY
CENTRAL VENOUS MC SITE – RIGHT IJV
CANNULA
MONITORING IN ANESTHESIA
INVASIVE BLOOD PRESSURE MC SITE- RADIAL ARTERY
MONITORING
CAPNOGRAPHY GOLD STD. METHOD OF
CONFIRMING INTUBATION
BISPECTRAL INDEX DEPTH OF ANESTHESIA
MONITORING
MONITORING IN ANESTHESIA
ECG ARRYTHMIAS- LEAD II
MI- LEAD V5
TEMPERATURE MOST ACCURATE SITE FOR
MONITORING -
PULMONARY ARTERY
PULMINARY ARTERY MEASURES:
CATHETER • Pulmonary artery pressure
• Pulmonary capillary wedge
pressure
• Left ventricular failure
MONITORING IN ANESTHESIA
NEUROMUSCULAR ULNAR NERVE
MONITORING ADDUCTOR POLLICIS MUSCLE
TYPES OF CAPNOGRAPHS
MH and
NORMAL rebreathing
‘SHARK FIN’
Asthma, Spontaneous breathing
bronchospasm
etc
Hypoventilation CPR
ROSC
Hyperventilation
DRUGS IN ANESTHESIA
QUESTION INTRAVENOUS INDUCTION AGENT
Barbiturate used as an IV anesthetic Thiopentone
Preferred IV induction agent for neurosurgery Thiopentone
Accidental intra-arterial injection causes intense vasospasm Thiopentone
Not used in patients with egg allergy Propofol
Should be discarded if kept open for more than 6 hours Propofol
MC used in Day care anesthesia Propofol
Contraindicated in Porphyrias Thiopentone
Causes adrenal suppression Etomidate
Most cardiostable IV induction agent Etomidate
QUESTION INTRAVENOUS INDUCTION AGENT
Causes hallucinations, post operative delirium Ketamine
Most painful on IV injection Propofol
Increases intracranial and intraocular pressure Ketamine
Bets bronchodilator Ketamine
Best in hypotension, bleeding, shock Ketamine
QUESTION INHALATIONAL AGENT
SECOND GAS EFFECT, DIFFUSION HYPOXIA Nitrous oxide
CONTRAINDICATED IN CLOSED CAVITY SURGERIES Nitrous oxide
PREFERRED FOR INHALATIONAL INDUCTION IN CHILDREN Sevoflurane
PREFERRED IN OBESE PATIENTS Desflurane
LOWEST BLOOD: GAS PARTITION COEFFICIENT Desflurane
PREFERRED FOR INDUCTION IN ASTHMA Halothane >> Sevoflurane
CAUSES LIVER DAMAGE Halothane
PREFERRED FOR INDUCTION IN NEUROSURGERY, CARDIAC Sevoflurane
SURGERY AND LIVER SURGERY
PREFERRED FOR INDUCTION IN DAY CARE SURGERY Sevoflurane
AGENT MAC
HALOTHANE 0.75
SEVOFLURANE 2
DESFLURANE 6
ISOFLURANE 1.4
NITROUS OXIDE 104
QUESTION NMBA
Shortest acting NMB Succinylcholine
Fastest acting NMB Succinylcholine
NMB that causes fasciculations and should be avoided in burns, Succinylcholine
muscular dystrophy, malignant hyperthermia
Electrolyte abnormality in which Scoline is C/I Hyperkalemia
Longest acting NMB Pancuronium
NMB undergoing Hoffmans elimination Atracurium/ Cisatracurium
IMMEDIATE reversal of Rocuronium and Vecuronium Suggamadex
Reversal of Non – depolarizing NMB at end of surgery with Neostigme (+glycol)
NMB preferred in day care surgery Rocuronium / Suggamadex
MC used nerve for clinical monitoring of NM blockade – Ulnar nerve
QUESTION LOCAL ANESTHETIC
First local anesthetic used Cocaine
Only naturally derived LA having a sympathomimetic Cocaine
effect
Most commonly used LA and its safe dose Lignocaine
EMLA cream contains Lignocaine and Prilocaine
How to remember ‘Esters’ and ‘Amides’ AMIDES have an extra ‘I’
Cardiac arrest Local anesthetic
Seizures
LOCAL ANESTHETIC SYSTEMIC TOXICITY
MALIGNANT HYPERTHERMIA
VENOUS AIR EMBOLISM
INSTRUMENTS IN ANESTHESIA
1ST GENERATION LMA LMA CLASSIC
2nd GENERATION LMA LMA SUPREME
SPECIAL LMA LMA FASTRACH
INTUBATING LMA
INSTRUMENTS IN ANESTHESIA
2ND GENERATION LMA LMA PROSEAL
I-GEL LMA MADE OF THERMOELASTIC
POLYMER
THERE IS NO CUFF
STANDARD PVC ETT
INSTRUMENTS IN ANESTHESIA
NORTH POLE TUBE USED IN HEAD AND NECK
SURGERIES
SOUTH POLE TUBE USED IN HEAD AND NECK
SURGERIES
UNCUFFED TUBE USED IN CHILDREN
INSTRUMENTS IN ANESTHESIA
DOUBLE LUMEN TUBE ONE LUNG VENTILATION
FOR THORACIC SURGERY
FLEXOMETALLIC /
ARMORED TUBE
MCCOY LARYNGOSCOPE DIFFICULT INTUBATION
INSTRUMENTS IN ANESTHESIA
MILLER LARYNGOSCOPE USED IN CHILDREN
MACINTOSH USED IN ADULTS
LARYNGOSCOPE
VIDEOLARYNGOSCOPE USED IN DIFFICULT
INTUBATION
INSTRUMENTS IN ANESTHESIA
TRACHEOSTOMY TUBE
VENTURI MASK FIXED PERFOMANCE
DEVICE
BLUE – 24%
GREEN- 66 %
HIGH FLOW NASAL MAX. FIO2- 100%
CANNULA
INSTRUMENTS IN ANESTHESIA
NRBM MAX. FIO2- 80%
NASAL PRONGS / NASAL MAX. FIO2- 40%
CANNULA
SIMPLE FACE MASK / MAX. FIO2- 60%
HUDSON MASK
INSTRUMENTS IN ANESTHESIA
NIV MASK MAX. FIO2- 100%
NASOPHARYNGEAL
AIRWAY
OROPHARYNGEAL /
GUEDEL’S AIRWAY
INSTRUMENTS IN ANESTHESIA
NITROUS OXIDE PIN INDEX – 3,5
BLUE BODY AND BLUE
SHOULDER
OXYGEN PIN INDEX – 2,5
BLACK BODY AND WHITE
SHOULDER
OXYGEN – WHITE
NITROUS OXIDE – BLUE
AIR - BLACK
VACUUM- YELLOW
CO2 ABSORBER
OPEN CIRCUIT
CIRCLE SYSTEM / CLOSED CIRCUIT
SEMICLOSED CIRCUIT / MAPLESON SYSTEMS
MAPLESON CIRCUIT OF CHOICE IN ADULTS FOR
SPONTAENOUS VENTILATION – MAPLESON A (MAGILL
CIRCUIT)
MAPLESON CIRCUIT OF CHOICE IN ADULTS FOR CONTROLLED
VENTILATION – MAPLESON D ( BAIN’S CIRCUIT)
MAPLESON CIRCUIT OF CHOICE IN CHILDREN FOR
SPONTANEOUS / CONTROLLED VENTILATION – MAPLESON F (
JACKSON REEVE CIRCUIT )
RSI Modified RSI
Preoxygenation No mask ventilation Gentle mask ventilation
Induction agent Thiopentone sodium Propofol
Muscle relaxant Succinylcholine (Sch) Sch / Rocuronium
Pre-ox Cricoid pressure → Drugs Pre-ox-Cricoid pressure →Drugs
ET tube placement → Inflate the Gentle ventilation ET tube
Method
cuff → Release the cricoid placement → Inflate the cuff →
pressure. Release the cricoid pressure.
REVERSE TRENDELENBURG
TRENDELENBURG
RAMP
POSITION
ROSE
RECOVERY
POSITION
POSITION
CHIN LIFT- HEAD TILT JAW THRUST
SNIFFING MILS
ONE LINERS IN CARDIOPULMONARY RESUSCITATION
QUESTION ANSWER
Adults : 30: 2 , Child (single rescuer- 30:2), 2 rescuer-
CHEST COMPRESSION : VENTILATION RATIO
15:2 , Neonates – 3:1
100-120 / minute 30 :2
DEPTH OF CHEST COMPRESSIONS 5-6 cm
AED PAD POSITIONS Apex, left parasternal
MANOUVRES TO OPEN THE OBSTRUCTED IRWAY Chin lift, head tilt, jaw thrust
BREATHS AFTER INTUBATION 10 breaths / min(adult) and 20-30 breaths / min ( child)
DRUG USED IN CPR IV Adrenaline – 1 mg every 3-5 minutes
TTM Targeted temperature management
ONE LINERS IN CARDIOPULMONARY RESUSCITATION
QUESTION ANSWER
AMIODARONE DOSE 1st dose – 300 mg , 2nd dose – 150 mg
SHOCK ENERGY FOR DEFIBRILLATION Monophasic – 360 J , Biphasic – 120-200 J
HIGH QUALITY CPR
• Push hard at least 2 inches (5 cm) and fast (100-
120/min)
• Allow complete chest recoil.
• Minimize interruptions in compressions.
• Avoid excessive ventilation.
• Change compressor every 2 minutes, or sooner if
fatigued.
• If no advanced airway, 30 : 2 compression-
ventilation ratio.
LUNG PROTECTIVE VENTILATION
Criteria Goal/Range
Tidal Volume (VT) 4-6 mL/kg PBW
Positive End-Expiratory Pressure (PEEP) Titrated based on oxygenation needs
Plateau Pressure (Pplat) < 30 cm H2O
Driving Pressure (ΔP) ≤ 15 cm H2O
Respiratory Rate (RR) Adjusted to maintain minute ventilation
Lowest possible to maintain PaO2 55-80 mmHg or
Fraction of Inspired Oxygen (FiO2)
SpO2 88-95%
REGIONAL ANESTHESIA – REVISION
QUESTION ANSWER
Spinal anesthesia / Lumbar puncture given in
L4 – L5 , SUBARACHNOID SPACE (CSF)
which intervertebral space
Pt. refusal, bleeding, raised ICP, infection at injection
C/I to Spinal and Epidural anesthesia
site, severe hypotension
Last structure to pierce for spinal anesthesia Arachnoid mater
Last structure to pierce for epidural anesthesia Ligamentum flavum
PDPH Gold std. treatment – Epidural blood patch
High spinal anesthesia
Total spinal anesthesia
CAUDAL ANESTHESIA – given in children < 8 years of age
IV REGIONAL ANESTHESIA / BIER’S BLOCK
Quincke spinal needle
Tuohy epidural needle
Combined spinal epidural Epidural catheter
needle
Brachial Plexus Block - approaches
Interscalene approach Supraclavicular approach Axillary approach
Day care anesthesia
• Induction agent of choice – Propofol
• Opioid of choice – Remifentanil
• Muscle relaxant of choice – Rocuronium / Suggamadex
• Airway management – LMA
• Inhalational agent of choice – Sevoflurane
• Preferred agent for TIVA – Propofol
• Recovery score- Aldrete score
• PONV Score- Apfel score
EXTRA POINTS
• MC allergen in OT - Antibiotics, latex, Muscle relaxants, local
anaesthetics.
• For Surgery : Minimum acceptable Hb : 8 gm/dl.
• Platelet count :For surgery : 80,000 - 1,00,000.
• What is Train-of-Four (TOF)?
• TOF is a way to test muscle relaxation by sending 4 quick electrical
pulses (at 0.5 seconds apart) to a peripheral nerve — most commonly
the ulnar nerve at the wrist.
• TOF Ratio = Amplitude of 4th twitch ÷ Amplitude of 1st twitch
• A patient is considered ready for extubation only when TOF ratio ≥
0.9 (i.e., no fade).
• Fade in the 4th twitch means residual neuromuscular blockade.
