High flow disadvantages

 Loss of humidification of the mucosa of the airway thus leading to irritation

 Cost as there is loss of inhalation all gas

 Pollution

Opioid free analgesia for adults above 50 kg

 This cocktail should be given 2 hours before the end of the surgery, or if the
surgery takes less than 2 hours then it should be given after induction

 This cocktail can lead to hypotension and bradycardia secondary to

dexmedetomidine

 The cocktail is allowed to be infused over 15-20 minutes

o Paracetamol 1 gm IV
o Ketamine 0.5 mg/kg
o Dexmedetomidine 0.5-1 mcg/kg
o Magnesium sulfate (MgSo4) 2 gm
o Lidocaine 1-2 mg/kg

TIVA (Dr Igor method)

 Use Masimo to monitor the anesthesia

 Start after induction and the patient has been intubated
 Use syringe pump and start basic infusion rate ml/hr
 Prepare Propafol 1% in syringe
 Prepare remifentanil as 40 mcg/ml (so 2 gm dilute it with 50 ml of normal saline)
 Start the infusion by 50% and 50% method
o 50%-50% is that

 Take the patient weight and divide it by two

 50% of the weight will be covered by Propafol
 The other 50% of the weight will be covered by remifentanil
 Then start the infusion as 50%-50%
 Example
50 kg male is undergoing laparoscopic cholecystectomy
Start induction as normal and intubate the patient
Start infusion of Propafol 1% with 25 ml/hr
 Start infusion of remifentanil (40 mcg/ml) with 25 ml/hr
Never decrease propafol but you can decrease
remifentanil based on your clinical judgment based on
vitals. When you decrease remifentanil you need to
increase propafol to cover the whole weight 50 kg.
 You can use fentanyl instead of remifentanil but there is an issues
with the context sensitive half-life. If you use fentanyl with
propafol then use 50% of the weight covered with propafol and
calculate fentanyl as (1 mcg/kg/hr)> so for the above example
then use 50 mcg/hr of fentanyl

Stroke volume variation with arterial line

 Target
 How will interpret the numbers

Atracurium for patient with kidney and liver disease

 For kidney and liver problems use muscle relaxant atracurium as it does not broken
down in liver or kidney, it’s in Hoffman pathway which occurs in plasma.

The effect of digoxin

 chronotrppy, dromotropy, inotropy

Arterial baroreceptor reflex pathway

 what is it?

Sympathomimetic meds

 alpha 1
 Alpha 2
 Beta 1
  Beta 2

Atrial fibrillation management

- amiadorne
- - Amidrone effect on thyroid, pulmo and

causes atrial dilatation

- mitral stenosis..., re entertaining

Diphenhdramine

- to be prescribed with opioid to prevent itchy ness

Phergan

- Promethazine is a first-generation antihistamine. It is used to treat allergies, trouble

sleeping, and nausea.
- Promethazine is used to prevent and treat nausea and vomiting related to certain
conditions (such as before/after surgery, motion sickness)

Context sensitive half time

- Context-sensitive half-life or context sensitive half-time is defined as the time taken for
blood plasma concentration of a drug to decline by one half after an infusion designed
to maintain a steady state (i.e. a constant plasma concentration) has been stopped. The
"context" is the duration of infusion.

- Context-sensitive half-life or context sensitive half-time is defined as the time taken for
blood plasma concentration of a drug to decline by one half after an infusion designed
 to maintain a steady state (i.e. a constant plasma concentration) has been stopped. The
"context" is the duration of infusion.

- The context-sensitive half-time often cannot be predicted by the elimination half-life (a

measure of the time needed for actual drug metabolism or elimination) because it also
depends on drug dist

- It is a useful concept because it helps explain the duration of action of a drug given by
infusion after stopping the infusion.

https://www.openanesthesia.org/context-sensitive_half_time/

MASIMO (PSI)>>> EEG

- target below 50 and the target 25-50

- we use it during TIVA

Doxopram

- CNS stimulant

Anesthesia acronym

 PROFESSOR TACC is used before touching the patient or even before the patient is in the
room
o P – APL valve must be opened to allow the patient to breath
o R – respiration (enter all the required ventilation parameter for your patient so
when you convert to mechanical ventilation no time is wasted for entering the
parameters)
o O – check your oxygen delivery system
 Check the oxygen flush
 Check the external oxygen cylinder is ready for a backup
 Check the endtidal Oxygen and the FiO2
o F – Flow rate of fresh gas
 Increase it to above 12ml/min
o E – make sure that the end tidal carbon dioxide equipment is ready
 o S – make sure that suction is ready and working
o S - make sure that soda lime is ready and changed
o O – oropharyngeal is ready with different sizes
o R – make sure that everything is ready > ask the anesthesia technician
o T – tube size is estimated, also the expected insertion distance is estimated
o A – Ambu (bag valve mask) bag is ready
o C – oxygen cylinder is working and full
o C – circuit is installed and appropriate

 MOVER P is used after intubation

o M – chose mode of ventilation
o O – (FiO2 and flow)
 FiO2
 FiO2 is 100% during preoxygenation, induction, intubation, prior
and during extubation
 FiO2 is 35-45% during maintainace
 Fresh gas flow rate
 Flow rate is 10 or more ml/min during preoxygenation,
induction, intubation, prior and during extubation
 Flow rate (start with) 2 ml/min during maintainace.
o V – tidal volume
 6-10 ml/kg from intubation until extubation
 3-5 ml/kg is enough to extubate
o E – PEEP
o R – respiratory rate
o P- pPeak keep it under 30

Laryngeal spasm management

 Complete and partial spasm

IV cannula

 14 G gives 300 ml per mints

 16 G gives 200 ml per mints

 18 G gives 100 ml per mints

Fluid management

 4, 2, 1 or take the weight + 40

 Calculate the maintainace

 Then multiply it by the number of fasting hours (this is to replace fluid was not
taken during fasting )

 Then add all together (fluid during fasting + maintainace + loss during surgery
including urine output)

 All this should be divided into two 50%s and given within 3 hours

o The first 50% is giving within one hour (first hour)

o The second 50% is divided into

 25% is given in the next hour (second hour)

 The second 25% is given in the following hour (third hour)

  After this maintainace is followed until patient is able to take fluid orally and able
to produce good urine output. If this is the case IV fluid is stopped.

MASIMO

 It has multiple functions including EEG, cerebral oximeter and Patient state index (PSi)

 EEG is to detect brain activity

 Patient state index (PSi) is used to detect awareness and how deep the patient is during
general anesthesia especially when total intravenous anesthesia (TIVA) is used.

o Optimum value is between 25-50% (optimum hypnotic state during general

anesthesia)

o 100% means the patient is fully awake

 Cerebral oximeter detects the perfusion of the brain

IV cannula sizes and colors

Ways to lose temperature in OR

 Radiation (the body is releasing heat)

 Evaporation

 Conviction

 Conduction (skin touching colder objects)

 IV fluid