!

"#$%&#' )*'+%,
0seu foi maintaining anesthesia (oi inuuction in peuiatiics).
All bionchouilate (except uesfluiane which can cause
bionchospasm) anu aie not metabolizeu by the bouy (except
halothane). All (except nitious oxiue) can tiiggei malignant
hypeitheimia (NB).
-&+&.$# $#/'"#$0 1"+1: 1 NAC = conc of volatile neeueu to
achieve no iesponse to suigical stimulus in Su% of pts

2$#"%3$+' (NAC=u.8): slowest onset but highest potency,
noniiiitating (useu foi inhalational inuuction)
4,"5#60$+' (NAC=1.S): slow onset, iiiitating, pieseives ienal,
hepatic, coionaiy, anu ceiebial bloou flow
7'/"5#60$+' (NAC=2.2): noniiiitating (useu foi inhalational
inuuction), iapiu onset but expensive
8',5#60$+' (NAC=6): iapiu onsetoffset, iiiitating, iequiies
special vapoiizei uue to high vapoi piessuie
9&%0"6, ":&;' (NAC=1u4): fastest onset, lowest potency,
cheap, uecieases iequiiement of othei volatiles

4+;61%&"+ )*'+%,
Nost potentiate uABAA inhibitoiy ieceptois in the CNS
<0"="5"#: uec Nv, myocaiuial uepiession, vasouilation
>%".&;$%': painful injection, minimal uepiession of
caiuiopulm fxn (iueal foi CvB pt), auienal suppiession
?3&"='+%$#: uec ceiebial 02 consumption, neuiopeifusion
maintaineu (iueal foi neuiosuig), caiuiopulm uepiession
@'%$.&+': antag NNBA ieceptoi, inc caiuiac uemanu anu
secietions, woiks IvP0PRIN, emeigence ueliiium in peui
-&;$A"#$.: piemeuication foi seuationanxiolysis,
caiuiopulm uepiession (like othei BBZs)

9'60".6,16#$0 B#"1C&+* )*'+%, D9B-),E
NNBAs facilitate intubation anu pioviue optimal ielaxation.
8'="#$0&A&+*: succinylcholine (hypeiK+, NB, inc ICP)
9"+F;'="#$0&A&+*: iocuionium, pancuionium, cis-atiacuiium
(vaiying phaimacokinetics, ieveisible by anticholinesteiases)

G"1$# )+',%3'%&1,
Binu to Na+ channel in inactivateu state, no thiesholu potential
ieacheu, affects iapiu fiiing neives fiist (myelin >>> unmyelin)
).&;',: Two "i"'s in name (ie, liuocaine, piilocaine,
bupivacaine), hepatic metabolism
>,%'0,: 0ne "i" in name (ie, novacaine, piocaine, tetiacaine),
metabolizeu by plasma esteiases, PABA metabolite alleigy

H=&"&;, D="%'+1I 0'#$%&/' %" ."0=3&+'E
Agonize opioiu ieceptois (namely , x, o)
Sufentanil (1uuux) > iemifentanil (Suux) > fentanyl (1uux) >
alfentanil (1Sx) > ."0=3&+' (1x) > mepeiiuone (u.1x)
Can cause iesp uepiess, uiinaiy ietention, Nv, constipation

J'/'0,$# )*'+%,
Acetylcholinesteiase inhibitois: +'",%&*.&+', physostigmine
Anticholineigic: *#I1"=I00"#$%' (pievents biauycaiuia uuiing
ieveisal, uecieases secietions)

H%3'0 ?"=&1,

G$0I+*'$# .$,C $&0K$I DG-)E: tube attacheu to inflatable
cuff which suiiounus glottic stiuctuies anu pioviues a patent,
supiaglottic aiiway foi ventilation

J$=&; 7'L6'+1' 4+%6M$%&"+ DJ74E: Foi anyone at iisk foi
aspiiation - uiffeience is no mask ventilation aftei inuuction
(coulu intiouuce aii into uI tiact leauing to vomiting). Paialyze
anu immeuiately intubate.
- Pieoxygenate foi S minutes at 1uu% 02.
- Pietieat with opioius to ieuuce sympathetic iesponse to
intubation. Also give ieglanbicitia to ieuuce iisk of gastiic
aspiiation synuiome.
- Iv inuuction followeu by NNBA (ie, iocuionium)
- Intubate, veiify placement, anu secuie ETT

9$,"*$,%0&1NH0"*$,%0&1 ?6M' D9O?NHO?E <#$1'.'+%: 0seu
foi gastiic lavage anuoi uecompiession
- Neasuie tube fiom nose to eailobe anu then to point miuway
between xyphoiu anu umbilicus. Naik length with tape.
- Nasal inseition (9O?): lubiicate tip, uiiect tube along nasal
flooi to posteiioi phaiynx, then uiiect tube uownwaius.
0ial inseition (HO?): Biiect tube to back of tongue anu then
uownwaius
- Auvance tube till tape maik is at nostiil (NuT) oi lip (0uT). If
tube meets iesistance oi fogs with coughing (possible tiacheal
intubation), ietiact tube anu ieauvance.
- Confiim placement by aspiiation of gastiic fluiu oi injecting
1u-2ucc aii with subsequent "whoosh" auscultateu ovei
stomach. Tape tube in place once placement confiimeu.




P0';&%,

- !"#$#%&" ($)*+,)*#&, Baiash (S
th
Eu)
- ($)*+,)*#& -)%.)+* , Buke (4
th
Eu)
- /&*#%* 01 ($)*+,)*#&, Nillei (6
th
Eu)
- 20%3)+ !"#$#%#&$ 4&$5&" 01 ($)*+,)*#& 2.&%+#%), Paiuo (1
st
Eu)
- "The Neuical Stuuent's Anesthesia Pocketbook" - 0niveisity
of Texas Bealth Science Centei Bouston










),,'.M#'; MI J&,3& @6.$0
3%%=QNN0CR.;

)+',%3',&"#"*I B$,&1, 5"0 -';&1$# 7%6;'+%,

<0'FH='0$%&/' 2&,%"0I

Focus on the oigan systems at iisk foi complications fiom
anesthesia as well as uppeilowei aiiways.

P)8 (quantify exeition, ie flights of staiis), 2?9 (contiolleu.),
3'=$%&1 oi 0'+$# uz, enuociine (8- contiol, ,%'0"&; use,
%3I0"&;) O>J8, ,."C&+*N>%H2N;06*,, S2: (malignant
hypeitheimia oi pseuuocholinesteiase ueficiency),
,60*&1$#N$+',%3',&$ 3: (complications. uifficult intubation.),
last .'$#, .';&1$%&"+,, $##'0*&',

<0'F"= #$M,: ECu, CXR, PFTs, B&B, coags, electiolytes, 0PT

<0'FH='0$%&/' <3I,&1$# >:$.

Special emphasis on neckaiiway: facial tiauma, neck iange of
motion, miciognathia, macioglossia, ueviateu septumpolyps,
TN} mobility, uentition, thyiomental uistance (thyioiu
caitilage to manuibulai mentum with neck in full extension)

)7) <3I,&1$# 7%$%6, P#$,,&5&1$%&"+ 7I,%'.Q

)7) T - noimal, healthy pt )7) U - milu systemic uz
)7) V - seveie systemic uz )7) W - seveie uz thieat to life
)7) X - not expecteu to suivive without opeiation

-$##$.=$%& 71"0&+* DT %" W 50". G %" JE $+; )&0K$I O0$;',




P#$,, T: Full tonsils, uvula anu soft palate
P#$,, U: visibility of haiu anu soft palate, uppei poition of
tonsils anu uvula
P#$,, V: Soft anu haiu palate anu base of the uvula aie visible
P#$,, W: 0nly haiu palate visible




4+/$,&/' -"+&%"0&+*

?0$+,',"=3$*'$# '13" D?>>E: assess wall motion abnl, EF,
intiacaiuiac aii; useu in CABu, thoiacic aoita oi valvulai
suigeiies, lung tiansplant, tamponaue, majoi thoiacic tiauma
)0%'0&$# #&+' DY)F#&+'ZEQ allows beat-to-beat BP monitoiing
anu easy aiteiial access (ie, foi fiequent ABus)
P'+%0$# /'+"6, #&+'Q monitoi intiavasculai volume anu Rv fxn
<6#."+$0I $0%'0I D<)E 1$%3'%'0Q measuies RAP, PA, weuge
piessuie (LvEBP), C0, anu Pv02

<0'":I*'+$%&"+

0sing the thumb anu inuex fingei of each hanu, cieate two
semiciicles aiounu the mask ensuiing it fits ovei the pt's
mouth anu nose. Place iemaining fingeis along manuible anu
lift chin to foim tight seal. -)49?)49 ?2> 7>)G[ Piopei
pieoxygenation (Sa02 1uu%, enu tiual 02 > 8u%) allows up to
six minutes of apnea - moie time foi you to secuie the aiiway.


4! 4+;61%&"+

Inuuction choices incluue piopofol, etomiuate, ketamine,
thiopental; assess anesthesia by biushing eyelashes anu
looking foi eyeliu motion ("lash ieflex").


A neuiomusculai blocking agent (NNBA) like ,611&+I#13"#&+'
(uepolaiizing) oi 0"160"+&6. (non-uepolaiizing) is given
next. Nuscle ielaxation takes place (flacciu jaw, uecieaseu T0F
twitches). Pioceeu to intubation if instiuments aie ieauy.

>+;"%0$13'$# ?6M' D>??E 4+%6M$%&"+

Stait by holuing eithei the cuiveu Nac oi stiaight Nillei
laiyngoscope in youi left hanu (iegaiuless of hanueuness).
0sing youi iight thumb anu inuex fingei in a scissoi-like
fashion to open the pt's mouth. Tilting the heau back can help.



Caiefully inseit the laiyngoscope into the iight siue of the pt's
mouth, auvance it to the epiglottis, anu sweep the tongue to the
left. If using the cuiveu Nac blaue, auvance fuithei into the
vallecula. Lift the laiyngoscope using youi uppei-aim (+"
0"%$%&"+$# ."%&"+ of the wiist shoulu occui) towaius the
junctuie of the opposite wall anu ceiling. Look foi the vocal
coius (typically white) with attacheu vestibulai folus anu
aiytenoiu caitilage. This is uiffeient fiom the esophagus which
is, moie oi less, a laige hole with no uefining chaiacteiistics.



0nce the coius aie visualizeu, ;" +"% #",' I"60 /&'K[ Bave an
assistant pass the ETT tube to you anu caiefully inseit it
between the coius until the balloon is no longei visible.
Remove the laiyngoscope, iemote the stylet fiom the ETT,
inflate the balloon cuff, attach the ETT to the ciicuit, confiim
placement (bilateial bieath sounus, fogging of the tube, enu-
tiual C02), anu tape in place.




4+%0$"='0$%&/' ),,',,.'+%

)7) -"+&%"0&+* 7%$+;$0;,Q H:I*'+$%&"+ (inspiieu 02, pulse
ox), /'+%&#$%&"+ (enu-tiual C02, chest excuision), 1&016#$%&"+
(continuous EKu, BR, BP, palpable pulses), anu %'.='0$%60'
(piobe) aie continuously monitoieu &+ '/'0I $+',%3'%&1.

?0$&+ "5 S"60 D?HSE: Foui sequential stimuli at 2Bz ovei
peiipheial neive. Compaie amplituue of 4
th
vs 1
st
twitch. Bighly
subjective (ovei unueiestimates NN} blockaue). As blockaue
ueepens, lose eailiei twitches (ie, twitch 4 is lost fiist, twitch 1
is last)


P$=+"*0$=3I : A-B - exhalation of C02 fiom ueau space; B-C -
combination of ueau space anu alveolai gas; C-B - exhalation
of mostly alveolai gas; B - enu tiual point; B-E: inhalation of
C02 fiee gas

)+',%3',&$ J'/'0,$#

As case neais completion, T0F useu to assess spontaneous
iecoveiy fiom non-uepolaiizing NNBA. Lack of twitches
inuicates blockaue is still too intense to ieveise Even with
ietuin of spontaneous bieathing anu all foui twitches on T0F,
pt may still have 7S% of NN} ieceptois blockeu. 0ltimately
ieveise with anticholingeiic (neostigmine) anu glycopyiiolate
(an anticholingeiic which pievents biauycaiuia fiom excess
muscaiinic activity)

>:%6M$%&"+ P0&%'0&$

vSS, puiposeful movement, spontaneous iespiiations > 8min,
negative inspiiatoiy foice (94S) < F2u
Rapiu shallow bieathing inuex (J7B4)=(RR)(tiual v in liteis)
uoal is J7B4 \ T]] bieathsminL