ANESTHESIA POINTERS SURGERY

5.1D
1. Study table on ASA Physical Classification, Study comments and examples of Periop Risk Assessment

Table 1. ASA Physical Status (PS) Classification

I Normal Healthy Patient

II Patient with Mild Systemic Disease

III Patient with Severe Systemic Disease

IV Patient with Severe Systemic Disease that is a constant threat to life

V Moribund Patient who is not expected to survive without the operation
VI Declared Brain Dead Patient whose organs are being removed for donor purposes
We append an “E” if the patient comes in as an emergency

Table 2. ASA Physical Status (PS) Classified System

CATEGORY Perioperative Health Status Comments, Examples
ASA PS 1 Normal healthy patient • NO organic, physiologic, or psychiatric disturbance
• Excludes the very young and very old
• Healthy with good exercise tolerance
ASA PS 2 Patient with Mild Systemic Disease • No functional limitations
• Has a well-controlled disease of one body system
• Controlled hypertension or diabetes without systemic effects,
cigarette smoking without COPD, mild obesity and pregnancy
ASA PS 3 Patient with Severe Systemic Disease • Some functional limitations
• Has a controlled disease of more than one body system or one
major system
• NO immediate danger of death
• Controlled CHF, stable angina, old heart attack, poorly controlled
HTN, morbid obesity, chronic renal failure, bronchospastic disease
with intermittent symptoms
ASA PS 4 Patient with Severe Systemic Disease that is a • Has at least one severe disease that is poorly controlled or at end
constant threat to life stage
• Possible risk of death
• Unstable angina, symptomatic COPD, symptomatic CHF,
hepatorenal failure
ASA PS 5 Moribund Patient who is not expected to • Not expected to survive >24hours without surgery
survive without the operation • Imminent risk of death
• Multi-organ failure, sepsis syndrome with hemodynamic
instability, hypothermia, poorly controlled coagulopathy
ASA PS 6 Declared Brain Dead Patient whose organs are
being removed for donor purposes

2. Study Onset of Common Local Anesthetics

Table 3: ONSET of Common Local Anesthetics

Drug ONSET Local Anesthetics (LA)
AMIDE
Lidocaine 1–5% Rapid • First local anesthetic (Prototype of Amides) that was introduced in 1948
(Xylocaine, Lignocaine) • One of the most widely used, rapid onset, modulate duration, and highly stable
• Not irritating and low toxicity
• Used for infiltration anesthesia, IV block or IV regional anesthesia, peripheral and
regional blocks, and topical anesthesia for the skin and extremities
• Classified as Class 1B antiarrhythmic
• Used for the treatment of ventricular arrhythmia/tachycardia
• A/E: Malignant hyperthermia due to accumulation of Calcium
Etidocaine 0.5–1.5% Rapid • Used for regional block as a preference for motor fiber sensory fibers
(Duranest)
Mepivacaine 1.5% Medium • Fast onset and longer duration
(Carbocain) • Dense motor block and low toxicity
• For shoulders surgery

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SURGERY Anesthesia Pointers 5.1D

• Used for infiltration anesthesia, IV anesthesia, and peripheral and regional block
Ropivacaine 0.5% Medium • Less potent and less cardiotoxic
(Naropin) • Used for infiltration anesthesia, regional blocks, epidural, and spinal anesthesia
• Can be used for children
Prilocaine 4% Medium • 40% less toxic because of metabolite o-toluidine, which can cause
(Citanest) methemoglobinemia
• Used for infiltration anesthesia, peripheral and regional block, and oral anesthetics
by the dentist
Bupivacaine 0.25-0.75% Slow • Slow onset and longer duration
(Marcaine, Sensorcaine) • High potency and toxicity
• Preferential block on the sensory fibers
• 3-4x more potent than lidocaine
• Used for infiltration anesthesia, epidural, and spinal anesthesia
• NOT use for arterial block because of its cardiotoxicity
ESTER
Procaine 0.5–1% Rapid • Rapid onset and short duration
• NOT effective topically
• LA of choice for Malignant Hyperthermia
Chloroprocaine 2–3% Rapid • Rapidly metabolized
• Favored by obstetricians because of its low fetal exposure
Tetracaine 0.1-0.5% Slow • An ester
(Pontocaine, Amethocaine) • Has relatively fast onset of action and longer duration Effective topically
• Treat local illness and used to desensitize venipuncture site or IV insertion sites,
especially for pediatric population
• Least metabolized among the esters
• Possess higher risk of toxicity

3. Study Maximum Daily Dose of Local Anesthetics (LA)

Table 4: Maximum Dosages of Common Local Anesthetics (LA)

DRUG Maximum Dose(mg/kg)
w/o epi w/epi
AMIDE
Lidocaine 1–5% 5 7
Etidocaine 0.5–1.5% 2.5 4
Mepivacaine 1.5% 5 7
Ropivacaine 0.5% 2 3
Prilocaine 4% 5 7.5
Bupivacaine 0.25-0.75% 2.5 3
ESTERS
Procaine 0.5–1% 8 10
Chloroprocaine 2–3% 10 15
Tetracaine 0.1–0.5% 1.5 2.5

4. Study Nerve Block Upper Limb and Lower Limb Table

Table 5: Nerve Block UPPER LIMB

PNB INDICATIONS ADVANTAGES DISADVANTAGES
INTERSCALENE BRACHIAL • Shoulder surgery • Also results in anesthesia in • Hemidiaphragmatic paralysis
PLEXUS BLOCK • Any surgery on supraclavicular nerves • Superficial, easy • Unless certain of inferior trunk
the arm and to perform, and comfortable for patient blockade (by using US or low-
humerus interscalene approach), not
Manipulation of recommended for elbow,
frozen shoulder forearm, hand surgery
SUPRACLAVICULAR Arm surgery of the arm • Anesthesia of all portions of • Potential for pneumothorax (may be
BRACHIAL PLEXUS BLOCK distal to the shoulder the arm distal to the shoulder less with US guidance)
• Fast onset
• Simple to perform under US
guidance
• Superficial/comfortable to the
patient
• Requires relatively small
amount of LA (20– 25mL)

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INFRACLAVICULAR Arm surgery of the arm • Provides anesthesia to the • Deeper block
BRACHIAL PLEXUS BLOCK distal to the axilla entire arm distal to axilla • Greater discomfort during
• Good choice for catheter block placement
placement • Requires more expertise
AXILLARY BRACHIAL Arm surgery on the elbow No risk for pneumothorax, neural axial • Hematoma resulting in post-
PLEXUS BLOCK or below block, or phrenic nerve blockade block local discomfort and/or
discoloration relatively
common (with trans-arterial
technique)
• Site of injection can be tender
post-operatively
DISTAL BLOCKS OF THE Handsurgery • Avoids motor block of biceps • Procedures on lateral
MEDIAN, ULNAR, AND and triceps, allowing patient forearm/wrist require
RADIAL NERVES (AT greater post-operative function separate blockade of either
ELBOW, FOREARM) while maintaining analgesia of lateral cutaneous nerve of
hand forearm or its parent nerve,
• Reduction in dose and volume musculocutaneous nerve
of LA, compared with other • Tourniquet on arm/forearm
proximal brachial plexus block may not be tolerated for long
approaches periods
• Requires separate
sedation/analgesia
PNB=Peripheral Nerve Block; LA=Local Anesthesia; US=Ultrasound

Table 6: Nerve Block Lower Limb

PNB
LUMBAR PLEXUS BLOCK
FEMORAL NERVE BLOCK
POSTERIOR
(TRANSGLUTEAL OR
SUBGLUTEAL) SCIATIC
BLOCK
ANTERIOR SCIATIC BLOCK
INDICATIONS
• Surgical anesthesia
for knee
arthroscopy
• Superficial
procedures of the
anterior high
• Patella tendon
repair
• Quadriceps tendon
repair
• Postoperative
analgesia for hip or
knee arthroplasty
• Knee arthroscopy
• Superficial
procedures of the
anterior high
• Quadriceps tendon
repair
• Patella fracture
ORIF
• Post-operative
analgesia for hip or
knee arthroplasty
Anesthesia for procedures on
the knee (combined with
femoral)
Anesthesia for procedures on
the lower limb below the
knee (i.e. foot and ankle)
ADVANTAGES DISADVANTAGES
• Block of obturator • Risk of bilateral & epidural spread
nerve (supplies • Higher risk of toxicity due to
both hip and knee absorption of LA injected in the
joints) muscles
• Covers lateral • Deep block (care with anticoagulated
femoral cutaneous patient)
nerve, site of • Other reported complications
incision for hip include peritoneal puncture, renal
replacement subcapsular hematoma
• Can be combined • Risk of hypotension due to
easily with spinal high/epidural/spinal anesthesia
anesthesia with • Cardiac arrests reported
patients in lateral
position
• Superficial, simple • Incomplete analgesia for hip or knee
to perform surgery (sciatic, obturator, LFCN)
• Can be used in • Lumbar plexus provides better
anticoagulated coverage for knee and hip
patient
• Reliable landmarks • Relatively deep blocks
makes location • Can be uncomfortable for patients,
easy to find requiring significant premedication
• Provides motor • Requires semiprone/prone position
block of • Requires advanced skill to visualize
hamstrings, if by US
desired • Posterior cutaneous nerve of thigh
• Little risk of not blocked
vascular puncture
• No need for • Risk of femoral vessel puncture
lateral/prone • Deep block; uncomfortable for
patients

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position for block • May require multiple attempts to

placement localize the nerve
• Convenient to
combine with
femoral block
POPLITEAL SCIATIC NERVE • Surgical anesthesia • Can be done in Does not provide anesthesia for tourniquet
BLOCK for procedures on supine, oblique, (calf tourniquet must be used, except for short
the foot and ankle and prone position procedures)
• Lesser saphenous • Posterior approach
nerve stripping simple to perform
Supplementary • Not uncomfortable
analgesia for for patients;
procedures about intertendinous
the knee approach does not
require needle
insertion through
muscle
PNB=Peripheral Nerve Block; LA=Local Anesthesia; US=Ultrasound

5.Study comparison of arachnoid, epidural spaces

Table 7: Characteristics of Different Central Neuraxial Blocks

SUBARACHNOID/SPINAL EPIDURAL
Injection through dura into CSF Catheterization of potential space outside dura
Low volume (up to 3mL) High volume (>10mL)
High concentration local anesthetic 0.5% bupivacaine Variable concentration local anesthetic, analgesia 0.1% bupivacaine,
anesthesia up to 2% lignocaine
Rapid onset dense sensorimotor block Gradual titration of block density, may be motor sparing
Profound vasodilation causing hemodynamic instability Gradual titration causing less hemodynamic disturbance

Table 8: Differences between Spinal Anesthesia and Extradural Anesthesia

Spinal Anesthesia Extradural Anesthesia
Level Below L1/L2, where the spinal cord ends At any level of the vertebral column
Injection Subarachnoid space, i.e. puncture of the Epidural space between ligamentum flavum and
dura mater dura mater, i.e. without puncture of the dura
mater
Identification of space Subarachnoid space: When CSF appears Peridural space: Using the Loss of Resistance
technique
Doses 2.5–3.5mL 15–20mL Bupivacaine 0.5%
Bupivacaine 0.5%
heavy
Onset of Action Rapid (2–5min) Slow (15-20 min)
Density of Block More dense Less dense
Hypotension Rapid Slow
Headache A probable complication NOT a probable complication

Table 9: Comparison of Spinal Anesthesia and Extradural Anesthesia

Spinal Anesthesia Extradural Anesthesia
Needle placement Smaller-gauge needle is easier to place CSF Larger-gauge needle is more difficult to place
flowing through the needle is a more Movement of a fluid drop or loss of resistance
reliable endpoint are more subtle endpoints
Potential for local Anesthetic Toxicity Negligible Considerable
Potential for Headache Higher incidence, often less severe Lower incidence, often more severe
Incidence of neurologic complication Very Low Very Low
Intensity of neurologic complications Profound Less Profound
Incidence of patchy block Very Low More frequent
Spread of anesthesia Highly predictable Less predictable
Onset of anesthesia Rapid Slow
Duration of action Variable based on agents selected Limitless using catheter technique
Hemodynamic alterations More pronounced Less pronounced

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6.Study IV Anesthetic Drugs and Indications

Table 10: TYPES OF IV ANESTHESIA

Total Intravenous Anesthesia (TIVA) INDICATIONS
-Target controlled infusion (TCI) • Malignant hyperthermia Risk
• Prone to PONV
• Brief radiologic or painful procedures
• Frequent, repeated anesthesia
• Major surgery and neurosurgical procedures
• Patients are easier to wake up after the surgery
• Spinal instrumentation
• Airway procedures
ADVANTAGES
• PONV
• Atmospheric pollution
• Rapid recovery
• Hemodynamic stability
• Intact HPV
• ICP
• Organ toxicity
DISADVANTAGES
• IV access is required
• Intraoperative awareness
• Cost
• Profound hypotension
Monitored anesthesia care (MAC)
Conscious sedation without anesthesia

Table 11: Intravenous (IV) Anesthetics

THIOPENTAL • Most widely used BARBITURATE
(Thiopentone, • Available as powder and dissolve in sterile water
Pentothal) • Has limited shelf life
• Only used for IV
• MOA: GABA → ↑Cl conductance and hyperpolarizes
• VERY ACIDIC→ Severe necrosis
• RAPID onset (< 30s) and SHORT duration
• MARKED RESPIRATORY DEPRESSION→ Best form of euthanasia
• Highly Protein Bound
CONTRAINDICATIONS
• Liver Failure
• Porphyria
• Emaciation
CNS EFFECTS
• CMRO2, CBF, ICP and IOP
• Neuroprotection
• Barb Coma –to suppress seizures
CVS EFFECTS
• Peripheral vasodilation
• Blunts baroreceptor response
• Negative inotropy

ETOMIDATE Amidate, Hypnomidate

Carboxylated IMIDAZOLE derivative
Short acting
Non-barbiturate anesthetic
MOA: Acts on GABA receptors in the reticular formation
ADVANTAGES
• Minimal cardiopulmonary depression
• Of all the intravenous anesthetics, etomidate has the least effect on cardiovascular system
• Minimal change in HR, MAP or myocardial performance
DISADVANTAGES
• Cost (versus Thiopental or Propofol)

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• Sneezing, stretching, and myoclonic twitching

• Hemolysis and hematuria,
• Respiratory depression and apnea
• Inhibits adrenocortical function
• Transient acute adrenal syndrome/adrenal insufficiency
• Due to adrenal cortex suppression → Reduced cortisol production; inhibits 11β-hydroxylase
• Painful upon injection due to propylene glycol
• PONV
• Myoclonus
• Chronic use: Vitamin C deficiency
MIDAZOLAM • Clear aqueous solution (Water-soluble BZD)
• MOA: GABAA receptor
• Precipitates in strongly acidic solutions
• Hepatic metabolism and renal elimination
• Mild cardiovascular and respiratory effects
• SHORT duration
• Reversal: Flumazenil

CLINICAL USES
• Sedation
• Premedication
• Sole IV induction
PROPOFOL The one that killed Michael Jackson
Diprivan
2,6 DISOPROPYLPHENOL(phenolic compound)
Milky white emulsion
• Propofol 10 mg
• Soybean oil 100mg
• Egg lecithin 12 mg
• Glycerol 22.5 mg
MOA: GABA transmission effect
FAST onset and SHORT duration
CNS EFFECTS
• Excitatory effect, but anticonvulsant
• Analgesic (but this is still questionable)
• Little psychomotor effect after awakening
PNS EFFECTS
• Potentiates effect of NMJ blockers
• Respiratory effect: Greater incidence of apnea
CVS EFFECT
• ↓SVR, SV, MAP
CLINICAL USES
• Induction and maintenance of anesthesia
• Usually combine with remifentanil
• Mostly used for complete abortion
KETAMINE (KETALAR) Congener of PHENCYCLIDINE(1965)
► First used in horses
NMDA receptor antagonist, (NMDA – an excitatory neurotransmitter)
MOA: Depress thalamocortical system (NMDA)
Metabolite: NORKETAMINE
CNS EFFECTS
• Dissociative anesthesia
• Inhibits thalamic transmission to cortex
• Increased CBF, ICP, IOP
• Hallucinations on emergence (“emergence delirium”)
CVS EFFECTS
• Increased sympathetic tone
• Central and decreased NA uptake
• Increased HR, MAP, PVR
• Direct cardiac depressant
RESPIRATORY EFFECTS
• Retention of airway reflexes in low dose
• Increased secretions

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• Bronchodilation
MUSCULAR EFFECTS
• Increased tone and movements
• Inhibits PlChE
CLINICAL USES
• Induction
• Maintenance
• Analgesia
• Anesthesia
MORPHINE Opioid agonists
PHENANTHRENE derivative (MOP receptors)
Good sedative and anxiolytic
► Used in heart surgeries in combination with scopolamine, which can counteract the effects of morphine
CNS EFFECTS
• Euphoria
• Dysphoria
• Hallucination
• Resp. depression
• Cough suppression
CVS EFFECTS
• Bradycardia
• Hypotension
OTHER EFFECTS
• Rash, itching and bronchospasm
MEPERIDINE Opioid agonists
Synthetic PHENYLPYPERIDINE derivative
30X more lipid soluble than morphine
► Choice as labor anesthesia for labor pain
Metabolite: NORMEPERIDINE
EFFECTS
• Tachycardia
• Dry mouth
• Less marked meiosis
• Less biliary tract spasm
Contraindications: MAO inhibitors
FENTANYL Opioid agonists
Synthetic PHENYLPYPERIDINE derivative
100 times more potent than morphine
500 times more lipid soluble than morphine
Metabolite: NORFENTANYL
EFFECTS
• Dose-dependent respiratory depression
• Chest wall/Truncal rigidity
REMIFENTANIL Opioid agonists
(Ultiva) ULTRA-SHORTacting
Non-specific plasma and tissue esterases
Usually combined with propofol for sedation and analgesia
ADVANTAGES
• Rapid offset
• Organ independent metabolism
• Lack of accumulation
DISADVANTAGES
• Bradycardia
• Hypotension
• Muscle rigidity
NEUROMUSCULAR • Muscle relaxants
BLOCKERS (NMBs) A. DEPOLARIZING
• Ach receptor agonist
• Cause muscle contraction/fasciculation (seizure-like)
• SUCCINYLCHOLINE
B. NON-DEPOLARIZING
Do NOT cause muscle contraction
Aminosteroids

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• Pancuronium
• Pipecuronium
• Rapacuronium
• Rocuronium
• Vecuronium
Benzylisoquinolinium
• Mivacurium
• Cisatracurium
• Atracurium

7.Study GUEDEL’S 4 Stages of Anesthesia (Note from Doc: This is not used nowadays, discussion is for academic purpose
only)

Table 12: GUEDEL’S STAGES OF ANESTHASIA

STAGE CHARACTERISTICS
1st STAGE OF ANESTHESIA The INDUCTION of anesthetic agent
MINOR OPERATIONS
Characterized by:
• MILD depression of higher cortical neurons
• Pain sensation is LOST
• Consciousness is KEPT (But patient is DROWSY)

2nd STAGE OF DELIRIUM/EXCITEMENT Consciousness is LOST

3rd STAGE OF SURGICAL ANESTHESIA
4TH STAGE OF MEDULLARY
DEPRESSION
There is MARKED EXCITEMENT during this stage
Patient may experience LARYNGOSPASM and BRONCHOSPASM
NOT considered as a good stage, so this stage is usually avoided
To avoid this stage, intravenous short-acting barbiturates are given such as Thiopental or Propofol
before induction stage
Newer drugs bypass this stage
MOTOR HYPERACTIVITY
• Muscle tone
• Jaw become set
• Irregular breathing
• Vomiting
• Defecation
• Urination
• Delirium
• Uncontrolled skeletal movements
SYMPATHETIC HYPERACTITY
• Hypertension
• Tachycardia
• Mydriasis
Patient is UNCONSCIOUS and READY for surgery Intercostal ventilation WEAKENS, then ceases
and only the diaphragmatic ventilation REMAINS
Pupil DILATES (Mydriasis) gradually
Various reflexes DISAPPEAR and is divided into FOUR PLANES:
1) P1: Loss of SPINAL REFLEX
2) P2: Loss of CORNEAL AND LARYNGEAL REFLEX
• The operation can be started at this level
3) P3: Loss of PERITONEAL REFLEX
• Paralysis of intercostal muscles
• Pupils DILATE
• Light reflex is lost
4) P4: Loss of PUPILLARY REFLEX
• Loss of muscle tone
• Paralysis of intercostal muscles
• Shallow respiration
Respiration ceases
Heart stops
OVERDOSE
Lethal without cardio or respi support
THIS STAGE SHOULD NOT BE REACHED

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8.Study Volatile Anesthetics

TABLE 13: VOLATILE AGENTS

VOLATILE AGENTS CHARACTERISTICS
DIETHYL ETHER Obsolete
Flammability and explosiveness
Undesirable properties:
• Light sensitive o Causes strong excitation (Stage 2)
• Irritates the airways o Excites the vomiting center
ADVANTAGES
• Good muscle relaxation
• No severe toxic effects
• Does not depress cardiac contractility and respiration
DIVINYL ETHER • Merck and Co –Vinethine 1935
• Rapid induction and recovery
• Very volatile
• Low incidence of PONV
• Flammability
• More potent
• Less irritative
• Short anesthesia
CHLOROFORM • Halogenated hydrocarbon
• 1847 –James Simpson
• Sweet odor
• Hepato-and cardiotoxicity
• Phosgene
HALOTHANE / FLUOTHANE Halogenated hydrocarbon
Bromine atom
Idiosyncratic hepatotoxicity
Highest blood: gas coefficient
ADVANTAGES
• Non-flammable
• Smooth induction
• Rarely induces PONV
• Bronchodilator effect
DISADVANTAGES
• Insufficient decrease in muscle tone
• CVS: Cardiodepressive effects and arrhythmogenic effect
• RESPI: Respiratory depressive effect and depression of mucociliary function
• Halothane hepatitis
• Malignant hyperthermia
ENFLURANE (ETHRANE) Ether and Halothane properties
ADVANTAGES
• Good muscle relaxant effect
• Does sensitize the heart to catecholamines
• Non-flammable
• Smooth induction
DISADVANTAGES
• Mildly stimulate tracheobronchial secretions
• Cause PONV
• Cardiac contractility
• Depresses respiration
RARE ADVERSE EFFECT
• Tonic-clonic seizures (Epileptiform)
• EEG: “spike and dome complexes
ISOFLURANE (FORANE) Isomer of enflurane
Halogenated methyl ethyl ether
NO toxic metabolites
NO cardiac depression
Does NOT induce seizures
Preferred anesthetic for BRAIN SURGERY
UNDESIRABLE PROPERTIES
• Pungent odor

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METHOXYFLURANE (PENTHRANE)
DESFLURANE AND SEVOFLURANE
SEVOFLURANE (ULTANE)
General Endotracheal Anesthesia
[DERAIN, PALAY, SALE]
5.1D
• Irritates airway
Clear, colorless with sweet fruity odor
Non-flammable and non-explosive in air
Most potent of the inhalation anesthetic Arrhythmogenic
Cardiotoxic
Hepatotoxic
Nephrotoxic
METABOLITES
• Methoxyfluoroacetic acid
• Dichloroacetic acid
• Oxalic acid
• Fluoride ion
Fluorinated methyl ethyl ether
Only FLUORINE SUBSTITUTIONS
Lower lipid solubility and blood solubility
• Rapid induction
• Rapid recovery
NO cardiac depression
Cause hypotension and respiratory depression Dehalogenation
Least lipophilic
Expensive
Electric vaporizer
NOT used for anesthesia induction
• Irritates the airways
• Coughing
• Breath holding
• Secretions
• Laryngospasm
Fluorinated isopropyl ether
Agents of choice: Pediatric induction
Metabolite: Hexafluoroisopropanol
Baralyme –CO2absorber
• Airway burns, ignition, and explosion
• “Compound A” –nephrotoxic
• Should not be used in closed circuit as it can produce a nephrotoxic metabolite known as
“Compound A” (Sevoolefin)
Not irritating to the airways
Cardiovascular effect is like isoflurane
One drop of this is rapidly vaporize
Expensive (Php15,000 per bottle)
9.Study Different route for General Anesthesia
Table 2: INDICATIONS
ORAL INTUBATION NASAL INTUBATION
• For ventilation of the • Obstructing mass in oral
patient cavity
• To protect the airway • Oral surgery
• For providing anesthetic • Mandibular fracture
gases • Inadequate mouth opening
• Neck injury
• For awake intubation
• When tube is to be kept for
prolonged periods in ICU
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Face Mask

Laryngeal Mask Airway • INDICATIONS

o Alternative to mask anesthesia
o Short elective procedures (< 1 hour)
o Difficult mask fit (beards, edentulous)
o GA with or without spontaneous ventilation
o Rescue airway
o Facilitation of endotracheal intubation
• Difficult intubation
o Suspected cervical spine trauma
o Inability to extend or rotate the cervical spine
o Severe rheumatoid arthritis or osteoarthritis
o Hx of cervical spine fusion
o Hx of atlantoaxial dislocation
o Pts. with Down syndrome
• Special Applications:
o Opera singers/rock stars/public speakers
o Thyroid surgery
o Difficult airways
o "Second-last-ditch" airway
o Awake prone procedures
• Contraindications:
o Limited or poor mouth opening
o Potential pharyngeal/laryngeal pathology
o Increased airway resistance and Decreased lung compliance
o Non-fasted patient (aspiration risk)
o Long-term mechanical ventilation
o Intact airway reflexes
o Awake patients or patients with gag reflex
o Obstructive or abnormal lesions of the oropharynx
o Morbidly obese patients
o Pregnancy

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10.Study Comparison of LMA and ETT (Supraglottic Vs Endotracheal Device)

Table 14: Supraglottic and Endotracheal Airways

DEVICE Supraglottic (LMA) Endotracheal

FEATURES Sits above vocal cords Passes through vocal cords

Maintains Airway Inflated cuff
No airway protection against aspiration Airway protected

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