The Medical Students Anesthesia Pocketbook

University of Texas Health Science Center Houston

Table of Contents
MOST SEDATIVE HYPNOTICS WORK THROUGH THE INHIBITORY GAMMAAMINOBUTYRIC ACID (GABA) NEUROTRANSMITTER SYSTEM IN WHICH INCREASED CHLORIDE CONDUCTANCE LEADS TO NEURONAL INHIBITION. MOST IV INDUCTION AGENTS BIND TO A SPECIFIC SITE CALLED GABAA FOR THIS INHIBITORY EFFECT, AND THEY HAVE A RAPID ONSET DUE TO LIPOPHILIC PROPERTIES WHICH ALLOW THEM TO QUICKLY PARTITION INTO THE HIGHLY PERFUSED LIPOPHILIC BRAIN AND SPINAL CORD. THEY ALSO HAVE SHORT DURATION OF ACTION, WITH THEIR TERMINATION OF EFFECT DUE TO REDISTRIBUTION INTO LESS PERFUSED TISSUES SUCH AS MUSCLE AND FAT..................................................................................................................14 FENTANYL ALFENTANIL SUFENTANIL REMIFENTANIL - MORE POTENT THAN MORPHINE, WITH SUFENTANIL BEING THE MOST POTENT (UP TO 1,!!!" AS POTENT). IN ADDITION, ALL ARE SHORTER ACTING THAN MORPHINE, WITH REMIFENTANIL BEING THE SHORTEST. OFTEN USED TO ATTENUATE THE STRESS RESPONSE TO SURGICAL STIMULATION. LOW DOSES PRODUCE BRIEF EFFECT, BUT LARGER DOSES ARE LONG ACTING, INCREASED INCIDENCE OF CHEST WALL RIGIDITY VS. OTHER OPIATES, NO ACTIVE METABOLITES, USUALLY SAFE IN PATIENTS WITH MORPHINE ALLERGIES. ...............................................................................................................................................1#

C$%&'()*&$'+: Trent Bryson MS4, Tanner Baker MS4, Claudia Moreno MS4,
Darrell Wilcox MS3, and Allison DeGreeff MS3

Acknowled e!ents
"e the contributors would first and fore!ost like to thank the faculty at the University of Texas at Houston for their su##ort$ uidance$ and teachin s in hel#in us create this #ocket book% "e would also like to thank the residents for their contributions to our learnin and skill develo#!ent as well as in hel#in us revise the content to be as detailed$ succinct$ and accurate as #ossible%

Anesthesia &verview
Ada#ted fro! 'A Medical Students Anesthesia Pri!er( by )oy *% Soto$ M+ ,roysoto-ucla%edu.

I%&'$,*-&($% /n !any #ro ra!s across the country$ !edical students are only ex#osed to two weeks of anesthesiolo y durin their third or fourth year% The student often attends daily lectures and !i ht be told to 0read Miller1s 2asics of Anesthesia0$ but often by the ti!e the student has finally fi ured out why we are doin what we1re doin $ the rotation is over$ and he or she leaves with only a !ini!u! of anesthesia knowled e% This #ri!er is intended to ive a brief overview of what we do$ when we do it$ and why we do it for standard$ unco!#licated cases %%% the ty#es that you are bound to see durin your rotation% 2y no !eans is the infor!ation contained co!#rehensive$ or intended to allow you to #ractice anesthesia solo$ but it is intended to ive an overview of the 0bi #icture0 in a for!at that can be 3uickly read in one sittin $ and then referred to as needed% 4ee# in !ind that there are !any ways to acco!#lish the sa!e thin in anesthesia$ and you will undoubtedly see techni3ues that differ fro! what we1ve written here$ but our oal a ain is to #resent you with a si!#le overview% Anesthesia is a challen in and excitin s#ecialty$ but can also be extre!ely frustratin if not tau ht clearly durin the short ex#osure that !any !edical students et to the field% P'.$/.'0&(1. H(+&$'2 0%, P32+(-04 Unlike the standard internal !edicine H5P$ ours is !uch !ore focused$ with s#ecific attention bein #aid to the airway and to or an syste!s at #otential risk for anesthetic co!#lications% The ty#e of o#eration and the ty#e of anesthetic will also hel# to focus the evaluation% &f #articular interest in the history #ortion of the evaluation are6 Coronary Artery Disease 7 "hat is the #atient1s exercise tolerance8 How well will his or her heart sustain the stress of the o#eration and anesthetic8 Askin a #atient how he feels ,i%e% S&2$ CP. after cli!bin two or three fli hts of stairs can be very useful as a 0#oor !an1s stress test0% Hypertension 7 How well controlled is it8 /ntrao#erative blood #ressure !ana e!ent is affected by #reo#erative blood #ressure control% Ast !a 7 How well controlled is it8 "hat tri ers it8 Many of the stressors of sur ery as well as intubation and ventilation can sti!ulate bronchos#as!% /s there any history of bein hos#itali9ed$ intubated$ or #rescribed steroids for asth!a8 This can hel# assess the severity of disease% "idney or #i$er disease 7 +ifferent anesthetic dru s have different !odes of clearance and or an function can affect our choice of dru s%

%eflux Disease 7 Present or not8 Anestheti9ed and relaxed #atients are #rone to re ur itation and as#iration$ #articularly if a history of reflux is #resent% This is usually an indication for ra#id se3uence intubation ,succinylcholine ; cricoid #ressure.% S!okin& 7 Currently s!okin 8 Airway and secretion !ana e!ent can beco!e !ore difficult in s!okers% Alco ol Consu!ption or Dru& A'use8 7 +rinkers have an increased tolerance to !any sedative dru s ,conversely they have a decreased re3uire!ent if drunk.$ and are at an increased risk of he#atic disease$ which can i!#act the choice of anesthetic a ents% <ndocrine6 Steroids = #atients with recent steroid use !ay re3uire #reo#erative steroids to cover secondary adrenal su##ression% Dia'etes 7 "ell controlled8 The stress res#onse to sur ery and anesthesia can !arkedly increase blood lucose concentrations$ es#ecially in diabetics% T yroid = Hy#o>Hy#er !etabolic states affect the cardiovascular syste!$ renal clearance$ and ther!ore ulation% Medications 7 Many !edications interact with anesthetic a ents$ and so!e should be taken on the !ornin of sur ery ,blood #ressure !edications. while others should #robably not ,diuretics$ diabetes !edications.% Aller&ies 7 "e routinely ive narcotics and antibiotics #erio#eratively$ and it is i!#ortant to know the ty#es of reactions that a #atient has had to !edications in the #ast% The ?@ anesthesia aller en is the non7de#olari9in #aralytics% The ?2 class is antibiotics% (a!ily History 7 There is a rare$ but serious disorder known as 504(6%0%& 32/.'&3.'5(0 that affects susce#tible #atients under anesthesia$ and is heritable% Another heritable disorder is /+.*,$-3$4(%.+&.'0+. ,.7(-(.%-2 which affects succinylcholine duration and !ay re3uire extended #osto#erative ventilation% Anest esia istory 7 Has the #atient ever had anesthesia and sur ery before8 +id anythin o wron 8 #ast Meal 7 "hether the #atient has an e!#ty sto!ach or not i!#acts the choice of induction techni3ue ,another indication for ra#id se3uence intubation.% "hile a history of a difficult intubation !ay be the !ost reliable #redictor of future difficult intubations$ the #hysical exa! is also i!#ortant to hel# #redict #otential #roble!s% Aor the #hysical exa!$ the s#ecific areas which are of #articular i!#ortance to the anesthesiolo ist include the cardiovascular syste!$ lun s$ head>neck>u##er airway$ si ns of #reexistin neurolo ical dysfunction$ and si ns of coa ulation dysfunction% Many tests have been #ro#osed to hel# #redict difficulty with intubation$ but no sin le factor$ taken inde#endently$ has been able to acco!#lish this oal% However$ when

!ulti#le factors are taken to ether$ the #redictive value is increased% The followin so!e s#ecific as#ects of the head>neck>u##er airway exa! which can be used to hel# #redict difficulties that !ay be encountered% Head>Ceck>U##er Airway exa! (acial trau!a or defor!ities7 !ay !ake it difficult to #erfor! laryn osco#y% De$iated septu! or nasal polyps7 can #ose difficulty with nasal intubation or with insertin a naso astric tube$ #ossibly resultin in bleedin % )eck ran&e of !otion7 the #atient needs to be able to assu!e the sniffin #osition ,cervical flexion and atlanto7occi#ital extension. so that the oral$ #haryn eal$ and laryn eal axes are ali ned which will facilitate viewin the lottic o#enin % Cor!al #atients should achieve :D de rees or !ore of atlanto7occi#ital extension$ which can assessed by observin the an le traversed by the occlusal surface of the !axillary teeth when the head is fully extended fro! the neutral #osition% +ifficulty with intubation !ay be #redicted by a si nificant reduction in the ability to achieve this de ree of extension or if the #atient ex#eriences any #ain$ tin lin $ or nu!bness durin this !ove!ent% TM* !o'ility and de&ree of !out openin& 7 this is i!#ortant for deter!inin the ade3uacy of s#ace for !ani#ulatin the laryn osco#e and endotracheal tube% Measure the inter7incisor distance% An o#enin of E : c! or 2 fin er breadths will likely not #rovide ade3uate s#ace and !ay result in a difficult intubation% /n addition$ ask the #atient to !ove the lower incisors as hi h on the u##er li# as #ossible ,u##er li# bite test.% /f the lower incisors do not reach the ver!ilion border of the u##er li#$ this !ay be a si n of inade3uate translational !ove!ent of the TMF$ which is also necessary for successful laryn osco#y% Dentition7 /t is i!#ortant to note the #resence of dentures$ #oor dentition$ loose teeth$ or ca#s$ which !ay not tolerate di ital !ani#ulation or !ay be at risk of da!a e when the laryn osco#ic blade is inserted into the !outh% +entures should be re!oved before sur ery% /n addition$ the #resence of #ro!inent !axillary incisors !ay result in obstruction of the view of the lottis% Conversely$ edentulous #atients are enerally easy to intubate$ but !ay #ose difficulty with !ask ventilation% Ton&ue+,rop arynx7 +irect laryn osco#y allows visuali9ation of the larynx by dis#lacin the ton ue anteriorly into the !andibular s#ace$ which !oves the ton ue out of the line of si ht% A nor!al si9ed ton ue will enerally fit easily into the s#ace between the two !andibular ra!i% However$ if the ton ue is too lar e ,!acro lossia. or the !andible is too s!all ,!icro nathia.$ there will likely be difficulty with #ro#er visuali9ation of the lottis% The Malla!#ati classification is a !ethod to assess the ton ue si9e in relation to the si9e of the oro#harynx% The test is #erfor!ed by havin the #atient sit with their head in the neutral #osition$ and then o#en their !outh as wide as #ossible and #rotrude the ton ue as far as #ossible% They should not #honate$ as this can elevate the soft #alate and alter the view% A Class : or B view !ay be associated with difficult laryn osco#y%

The si9e of the !andible can be assessed by !easurin the thyro!ental distance% This is the distance fro! the !entu! of the !andible to the thyroid cartila e% A thyro!ental distance of G c! ,a##roxi!ately : fin er breadths. or less$ as often seen in #atients with a recedin !andible or a short neck$ !ay indicate a #ossible difficult intubation% Alternatively$ the sterno!ental distance ,fro! !entu! to sternal notch. can also be used$ which assesses the si9e of the !andible and neck% A sterno!ental distance of E @: c! !ay also #oint to difficulty with intubation% Ainally$ a #hysical status classification is assi ned$ based on the criteria of the A!erican Society of Anesthesiolo ists ,ASA@7D.$ with ASA7@ bein assi ned to a healthy #erson without !edical #roble!s other than the current sur ical concern$ and ASA7D bein a !oribund #atient$ not ex#ected to survive for !ore than twenty four hours without sur ical intervention% An 0<0 is added if the case is e!er ent% The full details of the classification scale are also detailed later% IV8+ 0%, P'.5.,(-0&($% The two skills you should take the o##ortunity to #ractice while on your rotation are /H insertion and airway !ana e!ent>intubation% <very #atient ,with the exce#tion of so!e children that can have their /H1s inserted followin inhalation induction. will re3uire /H access #rior to bein brou ht to the o#eratin roo!% The key to success with /H #lace!ent is #re#aration and #atience% All of us have successfully found and cannulated a vein$ only to find that we left the ba of /H fluid or the ta#e across the roo!% Cor!al saline$ Iactated )in er1s solution$ or other balanced electrolyte solutions ,Plas!alyte$ /solyte. are all co!!only used solutions intrao#eratively% Many #atients are understandably nervous #reo#eratively$ and we often #re!edicate the!$ usually with a ra#id actin ben9odia9e#ine such as intravenous !ida9ola! ,which is also fabulously effective in children orally or rectally.% Metoclo#ra!ide$ 2icitra$ and>or an H2 blocker are also often used if there is a concern that the #atient has a full sto!ach$ and anticholiner ics such as lyco#yrrolate can be used to decrease secretions% R$$5 S.&*/ 0%, M$%(&$'+ 2efore brin in the #atient to the roo!$ the anesthesia !achine$ ventilator$ !onitors$ and cart !ust be checked and set u#% The anesthesia !achine !ust be tested to ensure that the au es and !onitors are functionin #ro#erly$ that there are no leaks in the as delivery syste!$ and that the backu# syste!s and fail7safes are functionin #ro#erly%

The !onitors that we use on !ost #atients include the #ulse oxi!eter$ blood #ressure !onitor$ and electrocardio ra!$ all of which are ASA re3uire!ents for #atient safety% <ach are checked and #re#ared to allow for easy #lace!ent when the #atient enters the roo!% Jou !ay see so!e !ore co!#licated cases that re3uire !ore invasive !onitorin such as arterial or central lines% /n the o#eratin roo!$ the anesthesia !achine can su##ort non7invasive and invasive !onitors% "hile in the !aKority of cases$ non7invasive !onitorin is sufficient$ exa!#les and indications of invasive !onitors include6 Arterial lines for continuous blood #ressure !onitorin = usually radial$ but can be brachial$ fe!oral$ etc% o Used in any case where wide swin s in blood #ressure are ex#ected$ where ti ht control of blood #ressure is needed$ in cardio#ul!onary by#ass cases$ or when there will be the need for !ulti#le blood as analyses% Central venous lines for !easurin CHP7 ty#ically /F or subclavian o Used in any case when there is the need to closely !onitor the intravascular volu!e status or there is a need to evaluate ri ht ventricular function% Pul!onary artery catheter for !easurin "ed e #ressure ,IH<+P. o Used to deter!ine )AP$ PA$ IH<+P$ C&$ and Pv& 2% These !easure!ents are hel#ful when faced with #oor left ventricular function$ valvular disease$ recent M/$ A)+S$ !assive trau!a$ !aKor vascular sur eries$ or when there is a critical need to accurately assess the intravascular fluid volu!e or the res#onse to blood #ressure interventions% Transeso#ha eal echo ,T<<. = used in !any CH cases o Used to evaluate re ional wall !otion abnor!alities indicative of !yocardial ische!ia$ to evaluate stroke volu!e>eKection fraction$ to evaluate cardiac valvular function$ to look for intracardiac air$ to !onitor chan es in cardiac function$ or to evaluate ade3uacy of intravascular fluid volu!e% The anesthesia cart is set u# to allow easy access to intubation e3ui#!ent includin endotracheal tubes$ laryn osco#es$ stylets$ oral>nasal airways and the !yriad of dru s that we use daily% A #ro#erly functionin suction syste! is also vital durin any ty#e of anesthetic%

"hen it co!es to drawin u# the initial dru s$ there are B cate ories of dru s that should be ready for each case6 induction a ents$ sedation>anal esia dru s$ reversal a ents$ and e!er ency dru s% At ti!es$ the s#ecific dru s !ay vary de#endin on the case$ but the followin are !ost co!!only used% The first : cate ories should be drawn u# in #re#aration for the case$ but the e!er ency dru s are often already #re#ared% -nduction A&ents Iidocaine ,@M. ,@N! >!I. = +raw u# in a Dcc syrin e Pro#ofol ,@N! >!I. = +raw u# in a 2Ncc syrin e )ocuroniu! ,@N! >!I. = +raw u# in a Dcc syrin e Sedation+Anal&esia Dru&s Hersed ,@! >!I. = +raw u# in :cc syrin e Aentanyl ,DN!c >!I. = +raw u# in Dcc syrin e %e$ersal A&ents Ceosti !ine ,@! >!I. = +raw u# in Dcc syrin e *lyco#yrrolate ,N%2! >!I. = +raw u# in Dcc syrin e .!er&ency Dru&s ,OAt Her!ann$ these dru s are already #re#ared and should be found in #lastic ba . OPhenyle#hrine ,@NN!c >!I. = /n @Ncc syrin e O<#hedrine ,D! >!I. = /n @Ncc syrin e OSuccinylcholine ,2N! >!I. = /n @Ncc syrin e Atro#ine @! >!I = /n :cc syrin e &ther #re#arations that can be done before the case focus on #atient #ositionin and co!fort$ since anesthesiolo ists ulti!ately are res#onsible for intrao#erative #ositionin and resultant neurolo ic or skin inKuries% Heel and ulnar #rotectors should be available$ as should axillary rolls and other #ads de#endin on the #osition of the #atient%

I%,*-&($% 0%, I%&*)0&($% Jou now have your sedated #atient in the roo! with his /H , ender selected at rando! %%% you enerally anestheti9e !en and wo!en the sa!e.$ and he1s co!fortably lyin on the o#eratin table with all of the afore!entioned !onitors in #lace and functionin % /t is now ti!e to stow your tray tables and brin your seats to the full u#ri ht #osition$ because it1s ti!e for take7off% /ndeed$ !any #eo#le co!#are anesthesia with flyin an aircraft since the take7off and landin can be 3uite rocky at ti!es whereas the actual flyin can see! like s!ooth sailin % The first #art of induction of anesthesia should be #re7oxy enation with @NNM oxy en delivered via a face !ask% The oal should be an end7tidal oxy en concentration of !ore than PNM$ a SaN2 of @NNM$ or lackin end tidal as !onitorin $ at least four full tidal volu!e breaths with a ti ht fittin !ask% Perfor!in a 'Kaw thrust( or 'chin lift( will o#ti!i9e the #atients airway for ba !ask ventilation%

The reason we #re7oxy enate #rior to induction and intubation is to !axi!i9e the a!ount of ti!e a #erson can tolerate a#nea without desaturatin % This translates to !ore ti!e available to secure the airway$ which is very i!#ortant if the #atient turns out to have an unantici#ated difficult airway% "hen breathin sto#s$ the bodys oxy en stores are li!ited to the oxy en in the blood and the oxy en in the lun s% A nor!al #erson uses a##roxi!ately 2DN7:NN !I of oxy en each !inute and can desaturate in as little as :N = GN seconds of a#nea% "ithin the lun s$ the functional residual ca#acity ,A)C. is a##roxi!ately : liters in a nor!al #erson% "hen breathin roo! air ,2@M & 2.$ the A)C contains !ostly nitro en and a relatively s!all a!ount of oxy en% However$ when breathin @NNM &2$ this effectively re#laces the nitro en with oxy en within the A)C and creates a tre!endous additional reserve of oxy en that can be used by the body% This #re7oxy enation can #rovide : = G additional !inutes of a#nea before si nificant & 2 desaturation occurs% A ain$ usin the exa!#le of a nor!al s!ooth induction in a healthy #atient with an e!#ty sto!ach$ the next ste# is to ad!inister an /H$ anesthetic until the #atient is unconscious% A useful uide to anesthetic induction is the loss of the lash reflex$ which can be elicited by ently brushin the eyelashes and lookin for eyelid !otion% Patients fre3uently beco!e a#neic after induction and you !ay have to assist ventilation% The !ost co!!on choices used for /H induction$ #robably in order of fre3uency$ are Pro#ofol$ Thio#ental$ <to!idate$ and 4eta!ine% Assu!in that you are now able to !ask ventilate the #atient$ the next ste# is usually to ad!inister a neuro!uscular blockin a ent such as succinylcholine ,a de#olari9in Q

relaxer. or vecuroniu! ,or any of the other 7oniu!s or 7uriu!s$ which are all non de#olari9in relaxers.% A twitch !onitor is usually used to ascertain de#th of relaxation$ and when the twitch has sufficiently di!inished$ intubation can be atte!#ted% Cote that the above induction a ents usually last for less than ten !inutes$ so !any of us will turn on a volatile anesthetic a ent while we are !ask ventilatin and waitin for the !uscle relaxant to take effect% Try to kee# a ood !ask seal so you don1t anestheti9e yourself %%% &nce the #atient is ade3uately anestheti9ed and relaxed$ it1s ti!e to intubate$ assu!in you have all necessary su##lies at the ready% Hold the laryn osco#e in your left hand ,whether you1re ri ht or left handed. then o#en the #atient1s !outh with your ri ht hand$ either with a head tilt$ usin your fin ers in a scissors !otion$ or both% /nsert the laryn osco#e carefully and advance it until you can see the e#i lottis$ swee#in the ton ue to the left% Advance the laryn osco#e further into the vallecula ,assu!in you1re usin a curved Macintosh blade.$ then usin your u##er ar! and C&T your wrist$ lift the laryn osco#e toward the Kuncture of the o##osite wall and ceilin % There should be no rotational !ove!ent with your wrist$ as this can cause dental da!a e% "hen #ro#erly done$ the blade should never contact the u##er teeth% &nce you see the vocal cords$ insert the endotracheal tube until the balloon is no lon er visible$ then re!ove the laryn osco#e$ hold the tube ti htly$ re!ove the stylet$ inflate the cuff balloon$ attach the tube to your circuit and listen for bilateral breath% /f you have chest rise with ventilation$ !istin of the endotracheal tube$ bilateral breath sounds and end tidal CN2$ you1re in the ri ht #lace and all is wellR Ta#e the tube securely in #lace$ #lace the #atient on the ventilator$ and set your as flows a##ro#riately%

M0(%&.%0%-. As with flyin an air#lane$ the !aintenance #ortion of anesthesia can be very s!ooth$ but when thin s o wron $ they can o very wron very 3uickly% Therefore it is vital to continually !onitor blood #ressure$ #ulse$ <4*$ N2 saturation$ te!#erature$ end7tidal N2$ CN2$ C2N$ and volatile a ent levels$ #resence or absence of twitch$ and #atient #osition$ as #ositionin chan es can occur with table !ove!ent>tilt ,or sur eon in#ut.% /t is also vital to #ay attention to the case itself$ since blood loss can occur very ra#idly$ and certain #arts of the #rocedure can threaten the #atient1s airway$ es#ecially durin oral sur ery or <CT cases% /t is also i!#ortant to kee# track of the #ro ress of the case% /t is a co!!on be inner1s !istake to ive #atients a !uscle relaxant that lasts for an hour when the case only has @N !inutes to o% A ood anesthesiolo ist has a 0sixth sense%0 He or she

@N

is always #ayin attention to the tone of the #ulse oxi!eter or the slur#in of blood into the suction canister% Hi ilance is key to a ood anesthetic% &ne can also #re#are for #otential #ost7o#erative #roble!s durin the case$ by treatin the #atient intrao#eratively with lon 7actin anti7e!etics and #ain !edications% E5.'6.%-. Usin our analo y of flyin an air#lane$ a #oor landin >e!er ence can be disastrous% 4nowin when to turn down> off your anesthetic a ents co!es with ex#erience and attention to the #ro ress of the sur ical case% <!er ence isn1t as easy as it !i ht at first see!$ since very i!#ortant ste#s have to take #lace before a #atient can be safely extubated% "hen usin nonde#olari9in neuro!uscular blockin a ents such as )ocuroniu! or Cisatracuriu!$ a #eri#heral nerve sti!ulator is used to !onitor the #har!acolo ical effects of these dru s$ and the dosa e can be titrated to effect% Cear the end of the case$ the nerve sti!ulator is used to assess the de ree of s#ontaneous recovery fro! these dru s% Ceosti !ine$ an anticholinesterase dru $ is ty#ically used as a reversal a ent when the s#ontaneous recovery is occurrin $ as deter!ined by the #resence of twitches induced by the nerve sti!ulator% "hen utili9in a train7of7four sti!ulation$ the reater the nu!ber of visible !uscle twitches$ the reater the de ree of s#ontaneous recovery that has occurred% A lack of !uscle twitches indicates the blockade at the neuro!uscular Kunction is still too intense and the ad!inistration of neosti !ine is not likely to facilitate reversal% /t is also i!#ortant to note that even with B twitches and the return of s#ontaneous breathin $ the #atient !ay still have u# to LDM of the CMF rece#tors occu#ied by the blockin a ent% The ade3uacy of recovery fro! the neuro!uscular blockin dru s can be tested clinically by the ability of the #atient to !aintain a head lift$ le lift or hand ri# stren th for S D seconds% &nce a #atient has ade3uately recovered fro! the effects of the neuro!uscular blockin a ents$ is able to breathe on his own$ is able to follow co!!ands$ de!onstrates #ur#oseful !ove!ents$ and can #rotect his airway$ he is !ost likely ready to be extubated% /n addition$ the followin #hysiolo ical #ara!eters are also used to assess readiness for extubation%
RR > 8 & < 30/min TV > 5 cc/kg TV/RR > 10 PaO2 > 65-70 mmHg on FiO2 < 40% Pa O2 < 50 mmHg H!mo"#namic $%a&i'i%# T!m(!)a%*)! a% '!a$% 35 +,F > -20

Suction !ust always be close at hand$ since !any #atients can beco!e nauseous after extubation$ or si!#ly have co#ious oro#haryn eal secretions% &nce the #atient is @@

reversed$ awake$ suctioned$ and extubated$ care !ust be taken in transferrin hi! to the urney and oxy en !ust be readily available for trans#ortation to the recovery roo!>Post7Anesthesia Care Unit ,PACU.% Ainally$ re!e!ber that whenever extubatin a #atient$ you !ust be fully #re#ared to reintubate if necessary$ which !eans havin dru s and e3ui#!ent handy PACU -$%-.'%+ The anesthesiolo ist1s Kob isn1t over once the #atient leaves the o#eratin roo!% Concerns that are directly the res#onsibility of the anesthesiolo ist in the i!!ediate #osto#erative #eriod include nausea>vo!itin $ he!odyna!ic stability$ and #ain% &ther concerns include continuin awareness of the #atient1s airway and level of consciousness$ as well as follow7u# of intrao#erative #rocedures such as central line #lace!ent and #osto#erative T7rays to rule out #neu!othorax% /n su!!ary$ anesthesia is a s#ecialty in which an extensive knowled e of #hysiolo y and #har!acolo y can be a##lied to the care of #atients in a uni3ue one7on7one intensive care settin % Challen e us to teach you what you don1t understand$ and et as !uch #ractice with airway !ana e!ent as #ossible% Also$ re!e!ber that at the heart of anesthesiolo y are the A2C1s 7 airway$ breathin and circulation% Co !atter what field you !ay enter$ basic knowled e of the A2C1s is #art$ of any co!#lete #hysician1s re#ertoire% <nKoyR

@2

Co!!only Used Medications

V$40&(4. A%.+&3.&(-+ All are 'ronc odilators, except for desflurane / ic is irritatin& and !ay cause 'ronc ospas!0 Ad!inistered alone 1i0e0, /it out narcotics2, in aled anest etics increase respiratory rate 'ut decrease tidal $olu!e0 .xcept for alot ane, in aled anest etics are not !eta'oli3ed 'y t e 'ody and are eli!inated 'y $entilation0 All $olatile anest etics 1'ut not nitrous oxide2 are capa'le of tri&&erin& !ali&nant ypert er!ia 1MH20 W ile in !any cases $olatile anest etics are used for !aintenance of anest esia, in so!e circu!stances t ese dru&s !ay 'e c osen to induce anest esia suc as in pediatrics cases in / ic t e c ild !ay not tolerate -4 place!ent a/ake0 Halot ane Pro6 Chea#$ nonirritatin so can be used for inhalation induction Con6 Ion ti!e to onset>offset$ Si nificant Myocardial +e#ression$ Sensiti9es !yocardiu! to catechola!ines$ Association with He#atitis -soflurane Pro6 Chea#$ excellent renal$ he#atic$ coronary$ and cerebral blood flow #reservation Con6 Ion ti!e to onset>offset$ irritatin so cannot be used for inhalation induction Desflurane Pro6 <xtre!ely ra#id onset>offset Con6 <x#ensive$ Sti!ulates catechola!ine release$ Possibly increases #osto#erative nausea and vo!itin $ )e3uires s#ecial active7te!#erature controlled va#ori9er due to hi h va#or #ressure$ /rritatin so cannot be used for inhalation induction Se$oflurane Pro6 nonirritatin so can be used for inhalation induction% <xtre!ely ra#id onset>offset% Con6 <x#ensive% +ue to risk of 'co!#ound A( ex#osure !ust be used at flows S 2 I>!in% Theoretical #otential for renal toxicity fro! inor anic fluoride !etabolites% )itrous ,xide Pro6 +ecreases volatile anesthetic re3uire!ent$ +irt chea#$ Iess !yocardial de#ression than volatile a ents Con6 +iffuses freely into as filled s#aces ,bowel$ #neu!othorax$ !iddle ear$ eye$ +ecreases AiN2$ /ncreases #ul!onary vascular resistance

@:

IV A%.+&3.&(-+ Most sedati$e ypnotics /ork t rou& t e in i'itory &a!!a5a!ino'utyric acid 1GABA2 neurotrans!itter syste! in / ic increased c loride conductance leads to neuronal in i'ition0 Most -4 induction a&ents 'ind to a specific site called GABAA for t is in i'itory effect, and t ey a$e a rapid onset due to lipop ilic properties / ic allo/ t e! to 6uickly partition into t e i& ly perfused lipop ilic 'rain and spinal cord0 T ey also a$e s ort duration of action, /it t eir ter!ination of effect due to redistri'ution into less perfused tissues suc as !uscle and fat0 Bar'iturates 1e0&0, t iopental2 +ecrease /CP by decrease in cerebral oxy en consu!#tion% Since cerebral #erfusion is #reserved$ desirable dru for neurosur ery cases% Causes res#iratory and cardiac de#ression% Pro6 <xcellent brain #rotection$ Sto#s sei9ures$ Chea# Con6 Myocardial de#ression$ Hasodilation$ Hista!ine release$ Can #reci#itate #or#hyria in susce#tible #atients 7ropofol /n adults$ induction dose @%D to 2%D ! >k while continuous infusion of @NN to 2NN !icro ra!s>k >!in !aintains unconsciousness% These values differ for children and for the elderly% Pro6 Prevents nausea>vo!itin $ Uuick recovery if used as solo anesthetic a ent Con6 Pain on inKection$ <x#ensive$ Su##orts bacterial rowth$ Myocardial de#ression ,the !ost of the four.$ Hasodilation$ cross reactivity in #atients with e aller y% .to!idate Mini!al de#ression of cardiovascular and #ul!onary function% /deal for #atients with CH+ or he!odyna!ic instability% /nduction dose of N%2 to N%B ! >k that causes #ain on inKection and !yoclonus% Su ested that it !ay su##ress cortisol synthesis% Pro6 Ieast !yocardial effect of /H anesthetics Con6 Pain on inKection$ Adrenal su##ression ,8 si nificance if used only for induction.$ Myoclonus$ Causea>Ho!itin "eta!ine "orks via anta onis! of the C7!ethyl7+7as#artate rece#tor channel co!#lex% Mini!ally de#resses the cardiores#iratory syste!% /nduction dose of @ to 2 ! >k in adults% +irectly sti!ulates SCS and increases 2P and heart rate% /ncreasin de!and on the heart and is not a ood choice for CA+ #atients% Pro6 "orks /H$ P&$ P)$ /M 7 ood choice in uncoo#erative #atient without /H$ Sti!ulation of SCS ood for hy#ovole!ic trau!a #atients$ often #reserves airway reflexes Con6 +issociative anesthesia with #osto# dys#horia and hallucinations$ /ncreases /CP>/&P and CM)N2$ Sti!ulation of SCS bad for #atients with co!#ro!ised cardiac function$ increases airway secretions

@B

Dex!edeto!idine Selective al#ha72 adrener ic a onist$ which is used in the o#eratin roo! as an adKunct to eneral anesthesia$ or to #rovide sedation for awake fibero#tic intubation or for re ional anesthesia% /t is enerally iven as a loadin dose of N%D7@ !c >k over @N !inutes$ followed by an infusion of N%2 to N%L !c >k >hr% /t #roduces sedative7hy#notic and anal esic effects without causin res#iratory de#ression% Ben3odia3epines 1BD82 Usually #rovided as #re!edication for sedation and anxiolysis before eneral anesthesia% Pro#erties include anxiolytic effects to sedation and unconsciousness at hi her doses% Mida9ola! ,Hersed. induction dose of N%@ to N%2 ! >k and infusion rates of N%2D to @ !icro ra!>k #er !inute% 2+Vs #roduce res#iratory$ cardiovascular$ and u##er airway reflex de#ression and in the #resence of hy#ovole!ia$ !ay cause si nificant hy#otension% )eversal of the sedative action of these co!#ounds with the co!#etitive anta onist$ flu!a9enil% L$-04 A%.+&3.&(-+ .sters 7 Metaboli9ed by #las!a esterases 7 one !etabolite is PA2A$ which can cause aller ic reactions% Patients with 0aller y to novacaine0 usually do well with a!ides for this reason% All have only one 0i0 in their na!e$ e % Procaine$ Tetracaine$ Chlor#rocaine% A!ides 7 Metaboli9ed by he#atic en9y!es% All have at least two 0i0s in their na!e$ e % Iidocaine$ )o#ivicaine$ 2u#ivicaine O/($(,+ Morp ine = de#resses breathin #rinci#ally by i!#airin the !edullary res#onse to C&2% Also tri er the che!orece#tor tri er 9one ,CTV. which !ay lead to nausea$ and !ay in turn sti!ulate the vo!itin center and #roduce e!esis% Also$ !or#hine decreases */ !otility and #ro#ulsion$ #roduces urinary retention$ and releases hista!ine by sti!ulatin baso#hils in the lun s and !ast cells in the skin% /n the CHS$ !or#hine !ay #roduce vascular dilation$ decrease SH)$ and overall hy#otension% /t is lon actin 5 renally excreted active !etabolite has o#iate #ro#erties$ therefore beware in renal failure De!erol 7 eu#horia$ sti!ulates catechola!ine release$ so beware in #atients usin MA&/1s$ renally active !etabolite associated with sei9ure activity$ therefore beware in renal failure

@D

(entanyl+Alfentanil+Sufentanil+%e!ifentanil 7 More #otent than !or#hine$ with Sufentanil bein the !ost #otent ,u# to @$NNNx as #otent.% /n addition$ all are shorter actin than !or#hine$ with )e!ifentanil bein the shortest% &ften used to attenuate the stress res#onse to sur ical sti!ulation% Iow doses #roduce brief effect$ but lar er doses are lon actin $ increased incidence of chest wall ri idity vs% other o#iates$ no active !etabolites$ usually safe in #atients with !or#hine aller ies% M*+-4. R.4090%&+ D./$40'(:(%6 Succinylc oline 7 inhibits the #ost7Kunctional rece#tor and #assively diffuses off with increased /CP>/&P$ !uscle fasciculations and #osto# !uscle aches$ tri ers MH$ increases seru! #otassiu! es#ecially in #atients with burns$ crush inKury$ s#inal cord inKury$ !uscular dystro#hy or disuse syndro!es% )a#id and short actin % N$%,./$40'(:(%6 Many different kinds$ all endin in 'oniu!( or 'uriu!(% <ach has a different !etabolis!$ onset$ and duration !akin choice de#end on s#ecific #atient and case% So!e exa!#les6 7ancuroniu! 7 Slow onset$ lon duration$ tachycardia due to va olytic effect0 Cisatracuriu!7 Slow onset$ inter!ediate duration$ Hoff!an ,nonen9y!atic. eli!ination so attractive choice in liver>renal disease% %ocuroniu! 7 Aastest onset of nonde#olari9ers !akin it useful for ra#id se3uence induction$ inter!ediate duration% R.1.'+04 A6.%&+ A%&(-3$4(%.'6(-+ R.1.'+04 A6.%&+ All are acetylcholinesterase inhibitors$ thereby allowin !ore acetylcholine to be available to overco!e the neuro!uscular blocker effect at the nicotinic rece#tor$ but also causin !uscarinic sti!ulation% ,Choliner ic Crisis SLUD CB;6 Salivation$ Lacri!ation$ Urination$ Diarrhea$ Ciliary constriction,!iosis.$ Bronchos#as!$ Bradycardia%. )eosti&!ine 7 shares duration of action with lyco#yrrolate ,see below. .drop oniu! 7 shares duration of action with atro#ine ,see below. 7 ysosti&!ine 7 crosses the 222$ therefore useful for atro#ine overdose A%&(-3$4(%.'6(-+ *iven with reversal a ents to block the !uscarinic effects of choliner ic sti!ulation$ also excellent for treatin bradycardia and excess secretions

@G

Atropine 7 used in conKunction with <dro#honiu!$ crosses the 222 causin drowsiness$ so !aybe bad at end of sur ery for reversal$ so!e use as #re!ed for all children since they tend to beco!e bradycardic with intubation and #roduce co#ious drool Glycopyrrolate 7 used in conKunction with neosti !ine$ does not cross 222 Central Anticholiner ic Syndro!e6 2lind as a bat ,2lurred vision. )ed as a beet ,Alushin . +ry as a bone ,Anhydrosis. Aast as a hare ,Tachycardia. Mad as a hatter ,+eleriu!.

@L

Phar! Charts
I%3040&($%04 A%.+&3.&(-+ I%3040&($% A%.+&3.&(-+ N(&'$*+ O9(,. M0<$' A,10%&06.+
Co odor Aast induction and recovery Mini!al cardio#ul!onary de#ression *ood anal esic Pleasant odor Slower induction and recovery

P'(50'2 U+.
Minor sur ery Used in co!bination with eneral anesthetics for eneral anesthesia Most widely used #edi anesthetic world wide% Asth!a #atients ,no bronchoconstriction. Adults Most widely used anesthetic in adults%

T$9(-(&2 -$%-.'%+
Acute7C>H Chronic7inhibition of 2@2 !etabolis! and induction of 2@2 +<A/C/<CCJ Slow induction>recovery Sensiti9es !yocardiu! to catechola!inesHent% Arryth!ias He#atotoxicity Hy#otension Sei9ures - hi h W X Ce#hrotoxicity Pun ent odor ,not reat for kids. 2roncho7irritant Hery #un ent /rritatin to airways IA)JC*&SPASM <x#ensiveYYY

H04$&30%.

E%74*'0%. I+$74*'0%.

Pleasant odor Iess S%<% than Halothane Stable cardiac rhyth! )a#id onset>recovery Mini!al !etabolis!low tox #otential <xcellent Muscle relaxant )a#id onset>recovery Hi h #otency ,least soluble. <ven less !etabolis! Aast induction>recovery Hi h #otency ,least soluble. Conirritatin va#or

D.+74*'0%. S.1$74*'0%. M.&3$9274*'0%.

A!bulatory sur ery ,for ra#id recovery. &ut#atient anesthesia /nhalation /nduction ,es#ecially children.

)enal Toxicity

Citrous &xide +esflurane$ Sevoflurane$ <nflurane AAST<ST S#eed of &nset I&"<ST Hi h MAC

/soflurane Halothane

Methylfurane SI&"<ST H/*H<ST Iow MAC

Potency ,G. ,2%2. ,@%D. ,N%P.

,@NB.

MAC Mini!u! Alveolar Concentration = defines the a!ount of anesthetic necessary to achieve no res#onse to sur ical sti!ulus% The nu!bers listed above are the concentrations necessary to achieve @ MAC$ or no res#onse in DNM of the #o#ulation% A MAC of @%: is 2 standard deviations u#$ or where QDM dont res#ond% A MAC of @%D is the MAC 2A)$ where sy!#athetic outflow is co!#letely blocked% "hen usin !ulti#le a ents$ MACs are additive$ i%e% Z MAC of nitrous ,D2M. ; Z MAC of Sevo ,@%@M. is e3ual to 2%2M sevo alone%

@P

I%&'01.%$*+ A%.+&3.&(-+ I%&'01.%$*+ A%.+&3.&(-+

B0')(&*0&.+ ,H5A. 7Thio#ental 7Methohexital 7Thia!ylal B.%:$,(0:./(% .+ ,H5A. 7+ia9e#a! 7Mida9ola! 7Iora9e#a! D(++$-(0&(1. ,H5A. 74eta!ine

O%+.&
:N7BN sec

E4(5(%0&($%

P30'50-$=(%.&(-+
)edistribution

A,10%&06.+ U+.
)a#id onset Aast recovery Anesthesia for short #rocedures% )elative ra#id onset Mini!al res# and CH de#ression Preanesthetic /ntense anal esia and a!nesia )adiolo ical #rocedures in children$ 2ronchodilato r

D(+0,10%&06.+
Co anal esia Alkaline>Tissue /rritant% )es# 5 CH de#ression Iow T/ &+ risk Cot a ood anal esic Cant #roduce sur ical anal esia

7@N7@2 hrs 7 :7G hrs :7D !in 72N7BN hrs 727G hrs +e!ethelated in the Iiver% ,#rolon ed t@>2 with cirrosis$ etc.

727: hrs

+issociative anesthesia ,//. un#leasant recovery w> hallucinations and ni ht!ares

M(+-.440%.$*+ ,H5A. 7<to!idate 7Pro#ofol

[@ !in BN7DN sec

B7Phrs :7Ghrs

Iar e volu!e of distribution$ hi hly li#o#hilic

Prevents C>H$ 3uick recovery

O/($(,+ (A) 7Mor#hine 7Aentanyl 7Me#eridine ,+e!erol. 7Sufentanyl

27L hrs :7B hrs 27B hrs

Mini!al CH effects at nor!al dosa es

Hy#otension$ cv de#ression$ re3uires !echanical ventilation$ discoloration of urine , reen. +ose related cardiac de#ression% Me#eridine7 cardiac de#ression

@Q

/H Aluids
H$> M*-3? Ty#e \ H) @ 2 : B Maintenance #er hour @ @ @ @ ,B$ 2$ @ rule$ or k ;BN in anyone over 2N k . +eficit @>2 @>B @>B 7 ,Hrs CP& x Maintenance. /nsensible Ioss ,:7@D cc>hr 6 case de#endent. <sti!ated blood loss ,@6@ colloid$ :6@ crystalloid. A44$>0)4. B4$$, L$++ The allowable loss is calculated by !ulti#lyin the blood volu!e ,2H. by the #ercent fro! startin he!atocrit ,HCTs. to threshold he!atocrit ,HCTt. for transfusion% A2I ] 2H x ,,HCTs7HCTt.>HCTs. 2lood volu!e is deter!ined by !ulti#lyin the wei ht by a constant% Ceonates ] QN cc>k /nfants ] PN cc>k Adult !en ] GN cc>k Adult wo!en ] DN cc>k E905/4. A DN k wo!an co!es in after fastin for @2 hours for elective sur ery% Her #re7o# he!atocrit was :D% Jou decide that in order to transfuse she !ust have a he!atocrit less than 2D% &ver the course of the sur ery she loses 2DN ccs of blood each hour for : hours% She has only !ini!al blood loss durin the last hour of her B hour sur ery% Ty#e \ H) @ 2 : B Maintenance #er hour QN QN QN QN ,B$ 2$ @ rule$ &) k ;BN in anyone over 2N k . +eficit DBN 2LN 2LN 7 ,Hrs CP& x Maintenance. @2 x QN ] @NPN /nsensible Ioss P P P P ,:7@D cc>hr 6 case de#endent. <sti!ated blood loss Col = 2DN Col = 2DN Col = 2DN 7 ,@6@ colloid$ :6@ crystalloid. C'2+- @A! C'2+- @A! C'2+- @A! Total crystalloid @:PP @@@N @@@N QP Additionally$ she should be transfused as she #assed her threshold for transfusion durin the third hour% Since that #oint was close to the end of sur ery$ transfusion #robably

2N

could be held off until arrival at PACU since transfusion reaction is not easily noticed while under eneral anesthesia%

2@

ASA Classification
The #ur#ose of the radin syste! is si!#ly to assess the de ree of a #atients 0sickness0 or 0#hysical state0 #rior to selectin the anesthetic or #rior to #erfor!in sur ery% +escribin #atients #reo#erative #hysical status is used for recordkee#in $ for co!!unicatin between collea ues$ and to create a unifor! syste! for statistical analysis% The radin syste! is not intended for use as a !easure to #redict o#erative risk% The !odern classification syste! consists of six cate ories$ as described below%

ASA P32+(-04 S&0&*+ (PS) C40++(7(-0&($% S2+&.5B ASA PS C0&.6$'2 P'.$/.'0&(1. H.04&3 S&0&*+ Cor!al healthy #atient C$55.%&+, E905/4.+

ASA PS @

Co or anic$ #hysiolo ic$ or #sychiatric disturbance^ excludes the very youn and very old^ healthy with ood exercise tolerance

ASA PS 2

Patients with !ild syste!ic Co functional li!itations^ disease has a well7controlled disease of one body syste!^ controlled hy#ertension or diabetes without syste!ic effects$ ci arette s!okin without chronic obstructive #ul!onary disease ,C&P+.^ !ild obesity$ #re nancy Patients with severe syste!ic disease So!e functional li!itation^ has a controlled disease of !ore than one body syste! or one !aKor syste!^ no i!!ediate dan er of death^ controlled con estive heart failure ,CHA.$ stable an ina$ old heart attack$ #oorly controlled hy#ertension$ !orbid obesity$ chronic renal 22

ASA PS :

failure^ bronchos#astic disease with inter!ittent sy!#to!s ASA PS B Patients with severe syste!ic disease that is a constant threat to life Has at least one severe disease that is #oorly controlled or at end sta e^ #ossible risk of death^ unstable an ina$ sy!#to!atic C&P+$ sy!#to!atic CHA$ he#atorenal failure

ASA PS D

Moribund #atients who are Cot ex#ected to survive S not ex#ected to survive 2B hours without sur ery^ without the o#eration i!!inent risk of death^ !ultior an failure$ se#sis syndro!e with he!odyna!ic instability$ hy#other!ia$ #oorly controlled coa ulo#athy A declared brain7dead #atient who or ans are bein re!oved for donor #ur#oses
BASA PS -40++(7(-0&($%+ 7'$5 &3. A5.'(-0% S$-(.&2 $7 A%.+&3.+($4$6(+&+

ASA PS G

Malla!#ati Classification
The Malla!#ati Classification is based on the structures visuali9ed with !axi!al !outh o#enin and ton ue #rotrusion in the sittin #osition ,ori inally described without #honation$ but others have su ested !ini!u! Malla!#ati Classification with or without #honation best correlates with intubation difficulty.% Class /6 soft #alate$ fauces$ uvula$ #illars Class //6 soft #alate$ fauces$ #ortion of uvula Class ///6 soft #alate$ base of uvula Class /H6 hard #alate only 2:

Uuick )eference>)eview
Pre7Anesthesia <valuation o Cardiac Patient = decreased exercise tolerance i!#ortant si n^ if able to cli!b S2 fli hts of stairs$ cardiac reserve #robably intact Post7M/ = infarction risk stabili9es at D7GM after G !onths Perio#erative M/ !ortality 2N7DNM /f no #rior M/$ #erio#erative risk N%@:M &ccur in BP7L2 hrs #ost7o# Co elective sur ery within G !onths of M/ Prior Cardiac Sur ery or PTCA is not contraindication to sur ery Contraindication to sur ery ] M/ E@ !onth$ unco!#ensated CHA$ severe AS or MS <valuation MaKor risk = unstable coronary syndro!e /nter!ediate risk = !ild an ina$ #rior M/$ CHA$ +M Minor risk = a e$ abnor!al <4*$ arrhyth!ia$ decreased functional ca#acity$ stroke$ uncontrolled HTC Studies = <4*$ Holter$ stress test$ technetiu! QQ!$ thalliu! i!a in $ coronary an io ra#hy o C&P+ <x#lain obstruction +eter!ine severity and res#onsiveness to albuterol$ et PATs$ CT) if hi hly sy!#to!atic /ncreased risk if #re7o# PTs EDNM #redicted Also hel#ful to deter!ine ho!e &2 re3uire!ent$ hos#itali9ation history$ and which !edicines used how often o +M "atch for si ns and sy!#to!s of !yocardial dysfunction$ cerebral ische!ia$ HTC$ renal disease Correct hy#o lyce!ia$ +4A$ and lytes before sur ery Maintain lucose between @2N7@PN )e lan ; H2 blocker Si ns of autono!ic neuro#athy = i!#otence$ HTC$ neuro enic bladder$ orthostasis May also develo# arthro#athy leadin to difficult cervical extension% /f cannot #ut #al!s and fin ers flat to ether$ likely to have !ore difficult airway due to lack of extension%

2B

Mali nant Hy#erther!ia = skeletal !uscle hy#er!etabolic syndro!e o Tri erin anesthetics = halothane$ esflurane$ isoflurane$ desflurane$ sevflurane$ succinylcholine o *ene = Ca channel of skeletal !uscle sarco#las!ic reticulu! with decreased reu#take of Ca o Sy!#to!s = increased H)$ increased breath rate$ increased etC&2 ,!ost sensitive.$ unstable 2P$ cyanosis$ coca7cola colored urine Iate si ns ,G72B hrs. = increased te!#erature$ !uscle swellin $ heart failure$ +/C$ liver failure o Confir! dia nosis by lar e difference between venous C&2 and arterial C&2 o Iabs = )es#iratory and !etabolic acidosis$ hy#oxia$ hy#erkale!ia$ hy#ercalce!ia$ hi h !yo lobin$ hi h CP4$ !yo lobinuria o /ncidence = @622N$NNN^ @6BN$NNN with succinylcholine o Mortality = @NM overall$ LNM without dantrolene o Auture anesthesia = no #retreat!ent with dantrolene$ flush anesthesia !achine o TT @ 7 Call for hel# 2 7 Sto# volatile anesthetic : = @NNM &2 B = Manually hy#erventilate D = Switch to a clean breathin circuit G = Sto# sur ery$ !aintain on sedative7hy#notic anesthesia L = +antrolene 2%D! >k ,!ixed with sterile water. 3 @N !inutes to !ax dose of @N! >k % Maintenance dose at @! >k 3 Ghrs for L2 hours% P = Correct !etabolic acidosis with CaCH&: @72! >k $ Correct hi h 4; Q = Cool #atient with iced /H CS$ and cold fluids in astric lava e$ in #eritoneal or thoracic cavity if o#en$ and P) @N = Maintain urine out#ut with !annitol or lasix% +o not use CC2 o /H Aluids ,I)$ CS. o Maintenance ,B;2;@. ; CP& ti!e ,Maintenance O ? hrs. ; <va#orative loss ,@7Pcc>k >hr. Iocal Anesthetics o <sters = 1 'i( in na!e ,i%e% novocaine.$ !etaboli9ed by #las!a #seudocholinesterases% &ne of its !etabolites is PA2A$ which causes aller ic reactions ,i%e% with Procaine and Tetracaine.% CSA has no esterases% Sulfa aller ic #atients% o A!ides = ;C 'i(s in na!e ,ie% Iidocaine$ 2u#ivicaine.$ !etaboli9ed by liver en9y!es$ !ay cause !ethe!e lobine!ia ,#rilocaine$ bu#ivicaine.$ aller ic reaction rare$ so!e bad hy#eractivity reactions

2D

o Mechanis! = decrease #er!eability to Ca ions$ binds to Ca channel in inactivated state$ no threshold #otential reached$ affects ra#id firin nerves first$ !yelinated SSS un!yelinated o Contraindications = hy#ersensitivity$ severe heart block$ "P" syndro!e o Toxicity = often follows #redictable #attern of tinnitus$ #erioral nu!bness and tin lin $ sense of doo!$ sei9ure$ co!a% Cardio = decreased #hase /H de#olari9ation$ increased P)$ wide U)S Pul!onary = #hrenic>intercostal nerve #aralysis CCS = di99iness$ circu!oral nu!bness$ tinnitus$ blurred vision$ excitatory si ns CCS de#ression Muscle = toxic inKected /M Iidocaine known to decrease coa ulation Airway Mana e!ent o IMA = sub for <T tube as lon as inflation^ !ay be used as uide for intubation Pro#ofol used for induction = relaxes Kaw 4ee# in #lace until #atient o#ens !outh on arousal Co!#lications = as#iration$ !ucosa inKury$ laryn os#as!>cou hin Contraindication = risks for astric as#iration such as *<)+$ #re nancy$ recent !eal Mendelssohns Syndro!e o As#iration #neu!onia secondary to as#iration of astric contents o TT = su##ortive ad!ission to /CU$ continued intubation$ res#iratory thera#y$ suctionin $ &2$ no antibiotics$ 3uestionable steroids Antibiotics only used in #resence of #ositive culture% Should not be iven #rior to this% o Pneu!onia = delay sur ery P7@2 hours$ P& antacids$ H2 blockers$ )e lan$ ra#id se3uence$ on suction after intubation$ suction of #harynx o )isk = anesthesia$ !uscle relaxants$ trau!a$ full sto!ach$ delayed astric e!#tyin $ #re nancy$ obesity$ i!#aired ICS tone o Sx = dys#nea$ tachy#nea$ increased H)$ whee9in $ CT) with lower lobe infiltrates$ hy#oxia )a#id Se3uence /ntubation = used in anyone at risk for as#iration% MaKor difference is that there is no ba 7!ask ventilation followin induction$ as this could introduce air into the */ track causin vo!itin % @% Pre#aration = check Aller ies$ Medications$ Past !ed hx$ Last !eal$ Events surroundin incident ,AMPLE.% Also check su##lies and !onitors% 2% Preoxy enate = @NNM for : !inutes :% Pre7treat = o#ioids to reduce sy!#athetic res#onse to intubation$ ra lan and bicitra to reduce risk of astric as#iration syndro!e

2G

B% Paralysis and anesthesia = /H induction followed i!!ediately by succinylcholine$ often use #ro#ofol due to its anti7e!etic action D% Pass tube = i!!ediately followin fasiculations fro! succinylcholine G% Post7tube !ana e!ent = ta#e tube$ o#ioids$ etc$ etc% <xtubation Criteria o Tidal volu!e S Dcc>k o )es#irations s#ontaneous and SP>!in o C/A of 7@N to 7@D o Patient showin #ur#oseful !ove!ent o Te!#erature of :D C or reater o He!odyna!ic stability o Pa&2 _ GN on Ai&2 BN$ Pco2 ` DD !!H Iaryn os#as! o Children at es#ecially hi h risk o Try to break first by ivin hi h #ositive #ressure o /f cannot break$ !ust use succinylcholine to #araly9e #atient to ba 7!ask or re7intubate%

Pre7o# )oo! Pre# Checklist Machine = !achine checkout$ &2 calibration$ as level Suction Monitors = A line$ central line$ Pulse &x$ 2P$ <4*$ 2/S Airway = laryn osco#e$ oral airway$ !ask$ tube$ &*$ Te!# #robe IH = alcohol$ needle$ flush on he#lock$ ta#e$ /HA Dru s = #ro#ofol$ eto!idate$ #aralytic$ narcotic$ versed$ #henytoin$ atro#ine$ e#ine#hrine$ succinylcholine S#ecial$ Seat Labs = ty#e and cross$ H5H$ coa s

2L

Procedure Checklist
The #ur#ose of this section is to #rovide you with a list of #rocedures you !ay be re3uired to #erfor! or assist durin the rotation% +ue to the fact that these are !ore easily learned in a 'see one$ do one$ teach one( fashion and that #rocedures !ay vary de#endin on available e3ui#!ent$ details on how to #erfor! are intentionally left blank with a!#le roo! for you to take notes% Procedures you are !ore likely to #erfor! and assist on are listed earlier% /f you are lookin to do the! yourself$ it !ay be hel#ful to read u# on that #rocedure before hand and take notes here to hel# Ko your !e!ory when the o##ortunity arises% I%&*)0&($%

IV 4(%. /40-.5.%&

B06 M0+= V.%&(40&($%

2P

V.%&(40&$' S.&&(%6+

A'&.'(04 L(%. P40-.5.%&

C.%&'04 L(%. P40-.5.%&

2Q

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)esources
The followin are a short list of additional resources that you !i ht find hel#ful durin your anesthesia !onth in findin !ore in de#th details about anesthesia% T.9& Mor an *<$ Mikail MS$ Murray MF% 'Clinical Anesthesiolo y( Mc*raw Hill Medical% 2NND ,aYLD. *lidden )S% 'CMS Anesthesiolo y(% Ii##incott "illia!s 5 "ilkins% 2NN:% ,aY2N. W.) Hirtual Anesthesia Text 2ook htt#6>>www%virtual7anesthesia7textbook%co!>index%sht!l "orld Anaesthesia &nline htt#6>>www%nda%ox%ac%uk>wfsa>index%ht!

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