-----�El'l_�L NEURAXIAL BLOCKADE __ i
� Spinal cord extents from medulla oblongata to lower
border ofL1 in adults and lower border of Lin infants &
neonates)
c csr volume is[l30-140 ml)cV: in cranium, � in spinal
canal)); pressure is \0.12cm H20 or8-12 mm Hg. produced
@500mUd.
Subarachanoid Block (SAB)/
Spinal anaesthesia
� Spinal block /SAB /Intratheca\ block is given in L3-L_.
interspace in adults (L4-Ls in children)
e Produces differential blockade. i.e. autonomic level is 2
segment higher than sensory, which is 2 segment higher
than motor blockade.
e Sequence of blockade: Autonomic--+ sensory -e motor.
Order of sensitivity of nerve fibres to LA. :
Autonomic preganglionic sympathetic ( 13) > Pain (C &
AO} > sensory >motor . 13 fibres are most sensitive to LA
-
&spinal anesthesia
� Drugs used are:
5% Xylocaine heavy
Levo-bupivacaine
{0.5'% Bupivacaine (sensocaine) heavy j L Siz.e: large bore > small boreneedle(m/c factor)
� Structure pierced by spinal needle -
Skin-e sic tissue -esuprasplnous ligamenr-e interspinous
Jig. � Ligamentum flavum � dura-e arachanoid.
Drug is deposited b/w arachnoid and pia.
Loss of resistance is cl/to piercing of ligamentum flavum.
It.. MOA -Drug acts on spinal nerves and dorsal ganglia.
e Effect:
Tidal volume & ABG remain unchanged.
Only 2 things Ie :Maximum breatlung capacity and active
exhalation becoz of paralysis of ilc muscles.
CVS: Vasodilatation, venous pooling in legs,J. BP &
tachycardia.
e Factors affecting height or level of block.
. 644 - More volume, more height of block.
- Height of patient--in tall patient, more drug is required
- Obesity, ascites, pregnancy t es intra abdominal pres.sure
so produces more height.
- Age --elderly patient has reduced spinal space, so more
height ofblock.
- Position of pt--- head down tilt, higher the level of
block.
e Complications ofSAB
- Hypotension - Mic c/c of SAB. � measures
are preloading with fluids, vasopressors. lfhypotension
develops, head low position tot venous return, 02, and
vassopressors are useful.@phedrine is DOC)
It Bradycardia - Mic arrhythmia
- Apnea
- Cardiacarrest
• N&V
- 6lh cranial nerve is mlc nerve involved di to longest
intracrainal course.
Post Dural Puncture Headache (PDPIQ
� Presents I 2-24 hrs after spinal block.
o, Usually occipital but c/b frontal
e t es on sitting & relieved on lying down
e Lasts for 2-3 days usually but may persist for 3 weeks
� Predisposing factors of PDPH: Tes risk wilh
2.Type of needle: Dura cutting> dura separating
3. No. of punctures: Multiple> single
4. Age : Young> old
5. Gender: Female> male
*�
e Precautions : Use small size , dura seperating needle,
minimize the no. of attempts
" Tit: adequate hydration, prone or supine position, simple
analgesics, Epidural blood patch, Oral or i/v caffei9',
�ntro1,>in ( � CSF production) is newer drug for
tit of PDPH
e Absolute C/i or SAS RelativeC!i
Patient refusal -Shock
- Raised JCT - Septicemia/ bacteremia
- Coagulopathy or bleeding disorders
- Infectionatsite

+ Quinckts netdle is duro cutting spinal nudlL
• Pirkjn/Grrnne nttdfe iJ spiMf �ncil tip nttdk which splila
11,e duro-+ less incickiice of PDPJI
EPIDURAL BLOCK/ EPIDURAL ANESTHESIA
e Mainly used for postoperative analgesia, painless labour
(labour analgesia}, surgeries (abdominal, thoracic, neck)
o Commonly used epidural needle is Tuohy's needle
(directional needle)
o Drugs used are : Lidocaine, bupivacaine, ropivacaine,
mepivacaine, opioids.
LA act a�
Opioids act at substansia gelatinosa of dorsaJ horn cells.
o Given b/wdura and ligamentum ftavum. Methods to locate
epidural space (negative pressure test)
- Hanging drop method (Guirctz sign)
- Loss of resistance
W Macintosh extradural space indicator
*West Pal sign (Absence of knee jerk after epidural
anaesthesia).
- Duran sign (Rapid injection in epidural space, causes sc
in rate & depth of breathing). Seen in comatose pl
o Ad/£ of epidural opioid- nausea, vomiting, urinary
retention, pruritus (itching), respiratory depression.
e Cle : patchy block, apnea, hypotension, total spinal, dural
puncture, subdura[ block, intra vascular injection.
e Advantages of epidural anaesthesia- less hypotension, no
postspina\ headache, level of block can be extended, any
durationofsurgeryca�u.sedfor
post-<>p pain relief."
Labour analgesia ·
o Epidural block is·one'oft!1�:comn{�nly used technique for
labour analgesia.
o Ambulatory epidural labour analgesia or walking epidural
is low dose CSE (combined spinal epidural} technique used
for reliveing pain during labour.
Cit of central neuroxial blockade (CNB}.
CNB sho11fd be avoided ifpatient is 011 --·:
I. Antiplatelet drugs (ticlopidine, clcpidogrel, abciximab
should be stopped l4d/7d/2d respectively before
procedure) .
2. Antifibrinolytic/ thrombolytic therapy
3. Oral anticoagulants : Warfarin should be stopped before
CNB . A normal PT and INR should be documented.
4. Standard heparin in therapeutic dose P1T. Epidural
catheter should be removed after stopping heparin.
5. In case of LMWH catheter should be removed at least 10
hr after the dose.
*-11spirinl NSAIDs. �idose sic heparin ';!!}!!!!_a
cantrai11dicatio11 to epidural block or CNB.} ·
e Total spinal: Drug reaches upto medulla. so blocks CVS
and respiration. Characterised by �s,
no respiratory effort,('G'ra"dycardi}. Patient becomes
unconscious.
o High spinal: Cause-(hypotensioo with bradvcardia/There is
respiratory insufficiency but patient remains conscious.
o Differential blockade: Seen with buplvacaine. Low
concentration produces sensory blockade while high
concentration produces both sensory and motor blockade.
c When adrenaline is given alongwith bupivaeaine, it only
t es sensory blockade.
,lff When adrenaline is given alongwith lignocainc it Tes
sensory+ motor blockade.
1r- Sedation and anaesthesia . '
� (visual evoked
.
response), SSEP (somato-sensory evoked potential) are
intennediately sensitive to anaesthetic agents and so MEP
(motor evoked potential). But brainstem auditory evoked
potential are least affected by anasthetic drugs.
ANAESTHETIC EQ�IPMENTS
Oxygen Delivery Systems
o Non fued performa,,c� device
Nasal ca1111/u
Oz cone' upto 44'/o
OJ by Mask
Oz cone" upto 60'/o by Meny Kattie mask.
o Fixed performance device
O,b1• VC:11111rimask
o, �one" upto 28· 60"/o { Based on Bernoulli's theorum.J
Used in patients with COPD.
e Room air provides21%02.
645 _
 1\0AMS

Open System If we pass whole expired gas through sodalime, it absorbs

.JE. Schimmel Busch Mask was used for ether & chlorofo C02---t rest of gas can be re-used --@lequiremcnt of fresh
e Method: Open drop method. Disadvantages of this method �w, more economical. All anesthetic agents react with
were: open air pollution, can't regulate concentration, initial soda lime to produce CO (Carbon mono oxide toxicity).
deep breathe or more drug can lead to unconsciousness. ..+ Indicator added to sodalime changes the color of sodaiime.
fudicators are -ethyl violet,mimosa-Z & phenopthalcin.
e Mixture of 94% Ca (OH)2+ 5% NaOH +!% KOH
Semi-open/Semi closed Systems c Silicates arc added to prevent powdering.
(Mapelson Circuits) e, Moisture 14-19% is also needed for efficient C02

e, 6systemsarethere: absorption.
(!, It absorbs C02 and produces �O + heat, thus humidifies
and warms inspired gases. 100 gm of soda lime can absorb
26 litre ofC02 and temperature within the canister may t
e A �agill's Spontaneous Freshgasllowrequiredto
up to60°C.
circuit ventilation Prc�entrebreathingisequalio
. alveolarminu1evOl�e(MVs�-r c Agents that should NOT be given with sodalime/dosed
, ,;;70ml/kg{min)·ofpatient ;,f:::: circuit:
Ob used for bo.� spent + .� · - Trichlorocthylcnc (trilene) because it generate phosgene
controlled ventilation._
which is neurotoxic.
- Sevoflurane
- Desfluranc
0, Barylime is altemative to sodalime
c, C waers Obselete �odiliiu.e_ � ��
to&Fro c Mesh size of 4-8
-granules

Q. AbsoEption 14-23 LCO/IOOg 9-18.LCO/IQgg

c E Ayre's T Neonates Inlet is Dear the face maskJETI,
piece used for weaning

I.
,
+ Fresh gas m/et is nearer ta patient end m D,E. and F
+ Valveless c,rcuits are E and F
+ Efficiency grading a/ Mope/son system
in spontaneous ventilation A>D>F:>E>C>B
I
in cantrolledventi/atian D>F>E>B>C>A (A it least effective
ornotata/1) I
l
Closed Circuits/ Soda lime circuit
1
r- Principle: Nonna! patient- ·
Breaths N2 0, 02 and inhalarionat agents.
Expires N2 0, 02, inhalational agents and C02 Pho10graph : Soda lime comainer
I
646
l
!
Flowmeter • Minimal 02 !NzO ratio controller device (hypoxic
• gaurd)
· 02concentratioo monitor & alann
"!tO, analyzer should have a low level al;1rm.
ct Mandatory minimal 02 flow is 50-250 mUmin.

B�,vte's anesthetic machin.e" . .

t.-toprovide1nha\at1on
anesthesia, also used for artificial ventilation.
o It is normally equipped with 2 02 cylinder, 2 Np cylinder,
1-1 C02 & cyclopropanc cylinder each.
o Cylinders arc made up or�olybdenum s/eel)o withstand
high prcssur£_

-:

co1�u�: P�essu�� &·Pin index ofanesthetlc

gases ..

N,O Liquid
© 3-5 Blue
Photograph : Flowmeter co, Liquid . 838 1-6(>7.5%), G,ey
2·6(<7.S%)

Entonox c as 1900 7 �y/whi1c

o Flow tubes(� arc prcsenvnsidc the
anaesthesia machine madcup offJrex g13:ii}
(N,;0+01)

\6
""'"'""
Orange
o Each glass tube is calibrated ale to gas it carries.
" Contain indicator for gas flow: Bobbin made up or
Htfio;r, G" 4,6(>80.5%), Bro=
aluminium.
Htfium 2.4(<80.S%)
02 is downstream. 02 flush can deliver 35-50 Umin of
®��
Halothanc·-�
�
o ROTAMETER- o Halothanc causes corrosion or metals & breathing
* variable orifice constant pressure flowmcter. circuits.
• It has bobbin inside the calibrated thorpe tube, which t />in indcs .wifl'lf �TS/£'"' (PISS) is developed to discourage
indicates flow rate incorcct cylinder attachment. Used for small cylinders (<40
O�: cubic feet).
Static electricity, dirt, non vertical position of tube, o Dwme1,·r11ulc.1·safi.•1r �ytrcm{IJ!SS) is used t� "
backprcssurezbackflow of gascs.(cmckcd tlm;.juij. connections b.'w 1:ylindcrs :ind Oowmcicri'. (Pressure
o Position of 02 is most downstream to all other gases. regulators). Each gas has specific attachments to prevent
�
(To prevent hypoxia if tube breaks). In any event of leak hook up or wrong gas. DISS number for-
02 is last gas to be added for safety N20 1040
e m,:!!)1lused to_prcvcnt hypoxia: o, 1240
- low level 02 pressure alorm "
647_
 _ROAMS

o Cyclopropane: Most inflammable & explosive agent. 2. Sterno-mental distance should be>l2.S cm.
Liquid gas-Orange cylinder. Can cause cyclopropanc 3. Adequate mouth opening: 3 finger breadth.
shock. 4. Mal/am Patri grading
� Used for asscsmCnt or size or tongue for laryngoscopy.
Supraglottic airways (Inspection o(oral cavity for intubation}.
o LMA, \..e"""'is for asscsment or difficult airway during orotrachcal/
e Prosca\-LMA (prevents risk of aspiration) nasotracheal intubation.
o SLIPA, Cobra o SGrades:
o I-gel O Visualise the tip or epiglottis
1 Post. pharyngeal wall,faucia[ pillars, uvula, tip soft
Laryngeal mask airway (LMA) palate.
o Discovercdb�l980. 2 faUCial pillars, uvula without tip, soft palate.
o Definitive sup2ouic airway device. 3 Only soft palate
4 No soft palate.
..f lntu�ation is difficult in Mallampatti grade 3 and 4.

Endo Tracheal Tubes (ETI)

e �e:l��smallholeisprescntdistaltocuff.
Ir tube is blocked ventilation cJb continued with Murphy's
eye.
� Tracheal tube without Murphy eye is k/as Magill lYPS_
!!!!?£. . .. . . . . . .
Cuffi5€igh volume low firessurccuri)t lies in mid trachea
'*
o It is intermediate b/w face mask and ETI.
Propofol causes max" depression of upper ainvay reflexes,
e
(2-2.S cm below the vocal cords)
DOC for LMA insertion. e Cuff pressure should
�er exceed> 30 cm o�O. Prefer
a Uses: 20cmH20.
- Difficultairway t" Cuffed EIT cJb used in long duration surgeries.
!f:: For minor or day care surgery
o C/1: Full stomach, pregnancy, oropharyngcal mass,
obesity
e Adv.:Clb�&indiffi.cu[tairwaybecoz insertion
is easy without laryngoscope, �mis relaxation nccdc.d and

* c/b used by paramedics also.

For controlled ventilation Proseal LMA is used, while for
spontaneous ventilation classical LMA is used.
o Disadvantage: Docs not prevent aspiration of gastric
contents{Selectcd ace/to weight or the patiem}
� Sealed LMA ( Pros ea! LMA) prevents aspiration risk.
$- Oro1rac/1ea/ or nasotrockeal tubes are bo1h supraglauic +
mfragla11icdevice.
Capnography "
e It is monitoring or�C02 (end tidal C02) and its wavefonn.
Nonnally it is 35-45 mm Hg
;t Best tool for confirmation or the endotracheal tube
" placement. Dete;ts early gaseous exchange.
o0otc�in gr
� shows further requirement of mis
relaxant.
o Based on Mass spectroscopy. IR spectrometry (infrared
rays arc absorbed by C02), Raman spectrometry.

ASSESMENT OF AIRWAY e Progressive zeroing in EtC01 is seen in-··

l. Thyro-mental ( blw mentum & thyroid) distance Esophageal intubation
should be >6.5 cm.
-648
 Anesthesiology

o Sudden drop {upto 0) in EtC01 is seen in -- 2. CVP:

Pulmonary venous air embolism
o Flat capnograph (straight line) is seen in -
lntraoperativedi�EJT disconnection ofEIT,
ventilation failure, �ardiac arr"ey,§phageal intubatwj).
o Sudden rise in EtC01 is seen i11-
Malignant hyperthennia (upto 100 mmHg).
'tExhaus1ed sodalim or efective valves of closed circu "L
..:f.. � pnograp shows increased r�e
to airf\Qw. Plateau prolonged.
oMeasu�
c Used for infusion of drugs, fluids, TPN, asp_iration of air
inVAE
.;,- Nonna! CVP is 4-7 cm H�O (3-12 mm Hg is the range)
o Seldinger teehnlque is used for catheterization of vein
(guidcwire technique for central venous access)
.ti: Vcinscommonlyuscd(uv\;�vmg,basiliclcephalic,
femorals. ¥'
-=
3. PAP (Pulmonary Artery Pressure)
o It requirc{,Swan-Ganz pulmonary catheter ( S lumen) J

Temperature Monitoring o Measurcrs

o Siteof Measurement-axilla, rectal, oesophagus, UB, �
atrial temp monitoring is theocitical]y the most accurate;),
nasopharynx, tympanic membrane
o Ways of heat loss : radiation, conduction, convec;tign,
�·
*�h�.
Axillary temperature is l-2"C lower than core temp.
INTRA-OPERATIVE MONITORING, M/M
Pulse Oximetry e Intraoperative awareness can be monitored/ prevented
e Works on principle of Beer-Lambert Law using Bispectral Index (815) •• BIS c/b used to monitor
e Sites of application of probe are: nail bed (fingers), toe, �h of anaesthesia) BIS ranges from 100 to O. BIS 100
earlobe, nose, thenar and hypolhenar eminence, sole of foot, means fully conscious. V�
�Qst in neonat� f�.
� It mc:asures@ saturation). It also monitors pulse rate and
2
cchocardiography@is
perfusion gradient o Transesoph.1geal the monitoring
o Inaccuracy is d/to - tool which gives the best recognition ofQotraopcra!!3
ll- Nail polish (myocardial ischem@.
*(fiethhemoglobinemJ (fixed Sp02 of85% is seen) o Neuromuscular (mis relaxant) 111011itori11g:
,t Poor peripheral circulation� hypo1ension) MJc nerve used is ulnar nerve (common peroneal c/b used
� Carboxyhemoglobio also)
,t (Optical interference)§bient lighYf€in pigmentation) 1\.1/t m.ls used is adductor pollicis s/by ulnar
\.AYl/s to show earliest reversal orbicularis oculi (s/by facial
Invasive Monitoring ..!!l
o Imp. methods arc �*.�:
I. lnlraarteria[ BP. (IBP) TOF (uain offour),PTC (post tetenic counl),tetanus,
2. Central Venous Pressure (CVP) double burst stimulation .
3. Pulmonary Artery Pressure (PAP) ..:\£_ Ionoucpe of choice for intraopcralive management of right
o Usedin heart failure due 10 pulmonary hypertension: ��
- Extensive surgeries involving major fluid shift and milrinon .
*Cardiac patients o Sillin sition is avoided to prevent risk of air embolism
'*-
Long duralion of su�ery during head and neck surgery.
o Induction & intubation
I. IBP: Direct measurement of arterial Bf' by �ulation of �icularis oculi is monitored byTOF (train of four) ratio
radial artcryusually�' � & single twitch stimulation.
649
 ROAMS

o During maintenance profound block is monitored by PTC MAC awake

& TOF ratio using orbicularis ocuti.
o During reversal phase:
- TOF ratio is used to monitor adductor pollicis
(TOF ratio of 0.3 for reversal administration and 0.9 for
extubation).
� GENERAL ANAESTHETICS
lnhalational agents
e No inhalational agent is good analgesic
except@
9.Allinhalational agents have some mis relaxant
effectexceptN20. · � Des, sevoflurane - Burst suppression in high dose.
o Main target of inhalational agents is brain.
o Classification of inhalational anaesthetics
a MAC, at wchich 50% of patients will become awake.
�
B/G
e Blood Gas Partition Coefficienl (BIG) determines speed of
induction and recovery.Recovery will be faster with low
B/G coefficient (e.g. N20, sevofturane. desfluarane).
Electrical (EEG)Activity of lnhalational Agents:
*' Halothane - Typical biphasic pattern
e hQflurane • �lectric EEG
t N20 - iBoth amplitude & frequency.
* A.mo11g IY agents BZD.etomidate produce typical biphosic
pattern.
+ KeUJmine cOU1a UIIUSllol octfration (ryllimic high omplitude
1helaocti1•ityflbbetaoetil'lf)'
� Opioids cause Monophgsfc dqv deperzd,w rfreressio':..J!,n
g!b

Halothane,enflurane,lso,sevo,des
fl=� e Factors affecting amplitude of EEG:

MAC

*' Potency ofin.halational agent is determined by Minimum

Alvelor Concentration (� which is the concentration
of agent , at which. 50% �aticnts will not respond to
the stimulus. So agent wilh'� will be most
potent.

(MACa---)
1
Potency Halothane
o Potent volatile anesthetic (non inflammable, non-toxic)
Methoxyflurnnc is most potent while N20 is minimum in e Sweet smelling agent Causes smooth inhalalional
potency. induction in children.
+ Factors which fse MAC:[Childre}.Eyperthcrmi1',8 e Only alkane among fluorinated inhalational agents.
,fhronic alcohol ingcstio}. e Corrodes metals in vaporizers in the presence of
c MAC -l-es with old age, hypothermia, anaemia, pregnancy, moisture.
hypoxia, coaduunisuaucn with intravenous agent, N20 and c Stored in amber colored bottles to prevent degradation
LA, acute alcohol ingestion. o Vaporiser colour is amber/red.
o Factors that do not effect MAC are -- Sex (male or o 0.01% rhymol is added as preservative
female), thyroid disease ( c.g. hypo/hyper-thyroidism), o Undergoes maximum metabolism.
hyponatrcmia. o Effects:
I. Bradycardia by delaying SA-AV nodal conduction.
_650
 Anesthesiology

2�ydirectdepression
CHLOROFORM
3. Sensitize the myocardium to dysarrythmic effect of e \st agent used for labour analgesia. Toxic agent
catecholamines (adr). Adrenaline containing solutions t Cardiotoxic agent Can cause death due to ventricular
should be avoided with halothanc. fibrillation.
4. Abolishes hypoxic drive even at 0.1 MAC. --k-� Causes post op nausea/vomiting.
S. -lses IOP and BP, but ICT is Ted. e Hcpatotox.ic. Causes profound h)'.perglycemia.Avoided in
of diabetics.
o Admmages: �
I. It is(e?"werful bronehodil� preferred in� ENTONOX
2. Uterine relaxant : DOC for manual removal of e 50:50 mixture of N20 & 02
placenta. C/b used for internal version, tetanic uterine o Cylinder is blue coloured with white shoulder.
contraction. :fc Use of Entonox include analgesia for wound drc�ing, chest
(Wooc fo, HOCM-=:Jtt physiolhcrapy, removal of chest drains, labour analgesia, &
dental surge
o Disadvantages:
I. Malignant hypcrthcnnia
'* It is good analgesic (d/10 N20).

2. Significant relaxation of uterus cant PPH.

3. Does not provide any pain relief. Hyperventilate the pl HELIUM �
prior to halolhanc administration becoz it blunts cerebral e Isolated by�
auroregulation. o Colorless,odorless,inert gas. V
4. Causes shivering· Halothane shakes
f 02 .requirement by 500%. Best antidote for
* a
He/iox is mixture of9% helium+ 21% �
o Density is lighter than air, so useful in upper (NOT lower)
' ;:m:; •;;:od �.l c_,,..,,-?t\,--""-
shivering is pcthidi.nc/;:_�": airway obstruction. Also used to prevent N2 narcosis.
5. Halothanc hepatitis massive centrilobular necrosi is a
fatal condition in which mortality is 50%.
XENON
e Can cause S 'H' -hypcrthcnnia, hepatitis, hypotcnsion,
hypcrcapnia, J.HR (myocardial depression)
,t Shoul�bc used within 3 month in the same pt.
o Ideal but weak anacsthetic.LN�ooe,..,,,=�
o More potent than NzO. rvtAC is 70'/, so can be given with
TRILENE (Trichloroethylene) 300/oOi-
,. ,. ,, ,. e Good analgesic. ./
B/Gcoefficitnt@eastofall.S€testinductionand]
� It is a potent nen-e poison. Vth & Vllth CN arc m/c e

.:Jt.
involved, but dam.age to 3, 4, 6, 10, 12 CN can occur.
Mos! po1e111 anutgesic ,,gent because MAC is low 17% . *� Not metabolizod in body.
Used for trigeminal neuralgia & for labour analgesia -,. Good hcmodynamic stability. Most cardicstablc (Little
o Not used now a days. 2-xcnon 3-N20. change in BP & HR)
,al e Reaction with sodalime :- dichloroacctylene- neurotoxic- f;" Can be used in a patient of MS with some liver compromise,
V, VII. Phosgene - pulmonary toxiciry(ARDS) used for radioactive study ofCBF.
o It is MI used in closed circuit becoz it reacts with sodalimc e Least side effects non teratogenic.

of to form di-chlor acetylene (neurotoxic) and phosgene e Disadvantages : Expensive and not available easily.
(pulmono-roxic) Needs special equipment for delivery, bronchospasm
C2 IICIJ t-Na0H-+C1 Cl2 +NaCl+ H20
o At J25oCor in presence of02 as in cautery, it decomposes
into phosgene (COCl2) & HCI. NITROUS OXIDE (�10) "
o Cardiosteblc. Docs D.Q! depress myocardiwn/respiration. c N20 was named byH�
e Disadventege : Sensitizes heart to action of adrenaline o Synthesized by�.- -
(occasional dysrhythmias), tacbypnea, addiction liability. e Also called \a�as.
651 _
 ROAMS
� Lowest potency I efficacy (MAC !05%) poor anesthesia
o Good Analgesia
q Fast induction d/to concentration effect
o Fast offset (recovery)
c Non-inflammable, Non-irritating [Safes! anesthetic].
o Co\orless,odorless gas, supports combustion.
c Causes bone marrow depression --t mcgaloblastic anaemia,
peripheral ncuropathy, pernicious anaemia.
./" Has tendency to expand any air containing !close cavity,
so Contraindicated in
- Pneumothorax
- Acute intestinal obstruction (vo\vulus)
- Post.fossaSurgcrics
- Tympanoplasty
- Lung cyst/bullae
- Venous air embolism
� lntraocular air bubble
e Highly soluble. Diffusion hypoxia is seen in recovery
�e
*�u�.Sccondgaseffcct
is seen
ETHER ,---L.__,
c lstpublicdcmonstra"on 16thoct 1986by�.
So�is celebrated as World anaesthesia day.
� Pungent smelling (unpleasant)
e High potency (MAC 1.9)
-if: Agent with max'° skeletal muscle relaxation & good
analgcsiafso it is a complete anaesthetic agcnt. f
c Safest anaeshtctic in untrained hands.
l.AI""' Only inhalational agent that stimulates respiration.
o Both induction and recovery arc 8
c. Inflammable /highly explosive. Not to be used with
cautcry .
.:IJ;: Docs not sensitize the heart to the action of adrenaline
(BP & respiration well maintained).
o Highest incidence of nausea & vomitting among inha!ational
. agent.
o Only inhalational agent that preserves /maintains cilliary
funhon (All other agents decrease cilliary activity)
METHOXYFLURANE
c Most potent inhalationa[ agent, �Not in use
now a days. Most potent inhalational agent is M-F(MAC
is0.16%).
o Slowest induction and recovery ��cnl is M-F(B:G 15).
c Non-inflammable, non-explosive. Good analgesic (like
- 652 N20).
e Most ncptiro-toxic agent is M-F (high output renal failure,
highest fluridc toxicity). �� which
are (ex�rcted by kidnc} for u�s. Fl" is toxic to
kidney & causes vasoprcssin resistant high 0111p11r renal
/Qil11re.
,t Advantage: No reaction with soda lime. Only inhalationa1
agent that has boiling point more than water.
it, Disadvantage : (9xalate· stones)� .!!!!.!!.
ncphrolorjc.
Fluoride Nephrotoxicty
e F' is nephrotoxic. F' is a byproduct of metabolism in liver
and kidney.
'*" F opposes ADH leading to� Maximum is seen
with mcthoxyfturanc:
Mcthoxy > Sevo >>>iso> Des. Mcthoxyflurane results
in potentially permanent renal injury. Less of a problem
with modem anesthetics.
=Jr Among newer agents Fluoride content :
Sevo > des> en > iso > batothanc.
NEWER FLURANES
:t:" Sevofluranc & halothanc arc sweet smelling agent,
so 1hcy arc used for inhalational induction in children
c Fluoride content /level is NOT or minimally affected
by isofluranc, & desfluranc.
��--tDesflurane
e Inhaiationol agem of choice for:
I. Ncuro anaesthesia ·-- lsoflurane
2. Cardiac anaesthesia --· lsofluranc
3. Pediatric anaesthesia -- Scvofluranc
4. Ilay care anaesthesia--- D.esfluranc
5. Anaesthesia in Asthma - Halothane
£.njlurw,e
e .Epilcptogenic inhalationa\ agent.
e Caus�markcdrespiratorydcpression/myoclonus,scirurcs.
Contraindicated in renal dis & wilcpsy.
Se1·ojlura11e
c Pleasant smell, non irritant and bronchodilatation makes ii
agent or choice for paediaric anaesthesia.Induction agent
or choice in children b/c or 1wect smell.
c Less potent than isofluranc.
fl Scvoflurane reacts with soda lime used in anesthetic circuit
to form "compound A" compound A is renal toxin.
 Desflurane, Volatile anasthetics and effect on HBF (hepatic
o Fastest acting induction agent. blood flow)
c Agent that boils t room tern ratu Melting I ,tAll volatile anaeslhetic ,l. HBF
boiling point is very low 22.2°c (Special vaporizers needed
i.e. tec6 ). BIG cofficicnt is lowest 0.45. Docs not attenuate
sympathetic stimulation. Pungent smell .
.t Dcsfl.uranc's vaporizing chambe.s are heated to 39°C.
:!. o Hepatic & renal blood flow are minimally deprecscd.So,
Agent of choice for hepatic failure, renal failure. Agent of
choice for geriatric (old) patients. INTRAVENOUS GA AGENTS i
·- - __ i
e. Agent of choice for day care (fastest induction).
THIOPENTONE --"./c.. ---,--...._
e Pale yellow colouredddJto sulphur) powdc�
Isojlurane c First used in 1934.
o Mic used anaesthetic agent. C'> Has very high pH (10.5-11), alkaline.
e TOP is best maintained but can cause coronary steal o Dose 3-5 mg/kg.
phenomena. o Used in concentration of 2.5%. Cone" <2.5% causes
e Renal & hepatic function minimally affected awareness in patients.
e lnhalationalagent of choice for: � Awareness assesment by monitor c/b done by BIS.
- Cardiac anaesthesia I cardiac surgery (If LV function e Cone" >2.5% causes pain, necrosis.
good), :ff_ Should be given in veins in outer aspect of the forearm.
- For controlled hypotcnsion e Never give in amccubital fossa. Chances of inadverent
- Neuro-anaesthcsia /ncurosurgcryJ.n{aintains " intraartcrial injection-+ Massive release of vasoconstrictors
autoregulation & it causes min" tsc in ,en. ., -+ pain, pallor/blanching,loss of distal pulse or even
Liver transplantation (only inha\ational agent that gangrene.
maintains hepatic venous 02 saturation). It is treated by-leave the 'ifv cannula in situ-+ Flush NS
e Fluroidc metabolites arc less. then -+ Injection of vasodilator lignocaine/phentolamine,
t" Concentration effect with Np. -+ Stcl\atc ganglion block, brachia] plexus block.
t�tickcr color is purple. I � Thiopcntonc .!cs ICP and .!cerebral metabolic02 demand
by limiting CBF so ct'rebroprolccfil'(!in nature. DOC for
head injury pt.

+
+
lsojlurane causes �coronary steal phenom1ma".
Thiapentone :sodium co1,ses " reverse COl"Onory steal
phenomena" or {Robhin-hood phe1io111e1Ja".I
+ Halo/hone blunt.! a/l/oregulation.
� lflVfonctimuarepoor- opioidsoreprrfe.-edinducnon agent
ofchoice
+ Metlt0KJff11r011e is 1ighly nephro101cic fl coiua high 011/pul
rc,wlfoilure
+ l.tojlumm• l, anesthetic agent of choice i11 patient with renal I
hepaticd!so11dforwrdioco.-11e11ros11rgery.
-iF/r,roide level is NOT or mi11imolly affected hy isofl11nme. &
<ktjl11rane.
+ Agr:11u tlwl sho11ltl 1101 bl' gll"en ll"ilh sodahme -s-trtelene.
(tncMor elhyfene) ..,evalr,rone and desjlurrme
.:J
AfoJ1conhos1oblew,lotileage11tisLwfiuro11e...
'*
c Ob used as an anticonvulsanr (in status cpilcpticus)
.Cfi in acute intermittent porphyria & varigatc oomhyria.
CJb safely given in PCT.
*" " '
Ultra�hon acting barbiturate becoz of rcdistributign away
from brain is fast Rapid onset GA with sedative, hypnotic
&�
KETAMINE
e Produces dissociouve onestnesio {thalamocortlcal limbic
dlssociatian}, Pt apparently remains conscious but
unresponsive.
e SIL'ep occur within 5-10 minutes ofi.m.injcction or within
10-15 sccordsof'i.v injection.Effect isd/to NMDA receptor
blockade & lasts for 15 min [other NMDA receptor blockers
arc--?�&�J-
o Profound analgesia. Only i.v. induction agent with analgesic
effect. 653 _
 ROAMS
� Rapidly acting parenteral anesthetic causing fedatio�
�,�y, some tin tone, mild CVS
stimulation but only slight J, of pharyngolaryngeal reflexes.
It t es salivation (atropine or glycopyrrolate should be used
with it).
o Advantages:
I. Maintains the upper airway reflexes so DOC for full
stomach patient.
�ti dysrhythmia effec). (more in patient receiving
TCA)
3. Minimal depression of respiration.
4. Potent bronchodilator. Refractory bronchospasm, can
respond to ketamine. Preferred in asthmatic.
5. Sympathetic stimulation -e t HR t BP (both SBP
&DBP). DOC for hypovolemic/shock petients. Dose
ilv l-2mg/kg; ilm 5-10 mg/kg.
Cl< Dis-advantages:
I. tBP : Avoided in IHD &hypertensive patients.
2. tICT : Contraindicated in head injury and ICSOL
patients.
3. tIOP : Contraindicated in glaucoma.
4. Potent bronchodilator. Refractory bronchospasm, can
respond to ketamine. Preferred in asthmatic.
(}) �& t JCP can cause dreaming, ha�tions, lJ: Causes maximum post op nausea, vomiting .
de!irium,non-purposeful limb movements � \.P""My
Sedatives like midaz/ diazepam should be co-administered.
Unsuitable for neuroanaesthesia. Hallucinations caused � Contraindicated in p�tient of porphyria and adrenal
by ketamine c/b J.e by midazolam.
e Particularly useful in burn wound dressing, skin
debridement I graft
f In debilitated patients in which catecholamines have FENTANYL
depleted ketamine can cause myocardial depression.
c Ketamine 'les all pressures i.e. ICP {or ICT), IOP {or
IOT), BP {both SBP& DBP).
+ Keramine causes - t ICP
+ All i11halatio11al agents --- f JCP (i:erebral vosodilatation)
+ Thiopentane, midazolam,propofol i:ause - .J. 1cp
·�-�J,111�.!BP&huermrrulewm1e.Jia \
v4
LA{�--;JRe1rogradeam11e.fla I
_654
PROPOFOL
e Rapid onset (within 40 seconds of administration).
ct DOC for day care .wrgery.
t Propofol is an IV sedative I hypnotic used in induction I
maintenance of anesthesia in day care surgery.
e Max" depression of upper airway reflexes, DOC for LMA
insertion.
f
� Poor analgesia supplementation with narcotic is required
for analgesia).
f:" Causesdosedependcnt ,hypotension
with bradycardia J,
Used with great caution in cardiac patient.
[ Remembert}.anc'uronium causes hypertension+ tach;]
c Reduces nausea and vomiting.
e Propofol is made up of soyabean oil, glycerol & egg lecithin.
Open vial of pro po fol is a good culture media for bacterial
growth. Risk of sepsis if propofol is used after 6 brs.
e @ilky whit9 in colour. Injection is very painful bee/of oiV
lipid emulsion, so xylocaine is either mixed or administered
before propofol injection.
ETOMIDATE
• <t It isja sedative hypnoti4 but not an analgesic
e Most cardiostable agent (Do not t or J.HR) so agent of
choice for aneurysm surgery & pt. with cardiac ds.
�clonus and supression of adrenal cortex, so -l-es
cortisol level. Used for emergency purpose onlv
'*
More potent analgesic than morphine.
c Rapid onset & rapid recovery so used for day care
surgery.
e Rapid injection of high doses produces significant m/s
rigidity/ chest tightness (Wooden chest syndrome)
e Can be given in hepatic & renal ds pt.
REMIFENTANIL
e Ultra short acting oprord
...v1.Jsed in Tl VA along with propofal
o Used as infusion d/to context sensitive half life of 3.5
min.

LOCAL ANAESTHETICS
UDOCAINE (Lignocaine, xylocaine)
* Xylocainc 211/, is used in dose of3-5 mg I kg
(' Xylocainc 2% with adrenaline is used in a dose of
5-7mg/kg.
e Xylocaine with adrenaline should not be used for ring
block. penile block .
e Xylotard (Xylocaine without preservative ) is the only
preparation of xylocainc used i.v.
o Uses· spinal block, epidural blocklregional nerve bloc�
to relieve sticking sensation in throat.
.!f;: LA which anesthetize intact skin· Amethocaine, Pri\ocaine,
Eutectic Lignocaine 5% and prilocaine 5% EMLA cream
(Topically applied for venipuncture, needle procedure and
LP).
� Methemoglobinemia is c/by �£_and �c
mainly.
=
*Cocoi,w wru the fin' U wstd dinicollv '11-Ylilt moroinc war
tM fint synthetic comfJfWII'!:
+ All U an l'OSodi/alOTUctpl cocaine {lVJSOeonstrictor)
+ Shortctocting U is c},lorproeoi11t '11-1,ilt longer acting U U

ventricular fibrillation, as local infiltration, to blunt

hemodynamic response to inlubation
S/E in high dose convulsion, hypotension}1cardiac arrcs'L
(resp. depression)
e Xylocainc is neither vasoconstrictor nor vasodilator(very
liule vasodilatation activity may be seen)
e M/A-By blocking Na' channel.
+ SIE in higlrdoK cor1H1hio11, hypoltruion. audiocorral, resp.
depreuio,1,
�ltr linitd /ocol a11tslht1ic cmut IIIOn! alltrgic reactions
(dlloPA.BA)
vf" -;;;;;;;;;;locol ar,esllltlic4"'mttoboiiudJt.....�i1JttJttrnrt1
whiltomidtli!IUdLA.on-toboliztd�

BUPIVACAINE
e ®ore cardiotoxib than lignocainc.
e Long acting drug. Effect lasts for 6 hrs 't" Prilocaine: Does not causes vasodilatation, hence used
e Hyperbaric solution of B- is injected as; single shot into in Bier's block
CSF to produce intense (usuallr, within 5min)�e c Lignocaine: No effect on blood vis, Eutectic mixture
(spinal/ intra-tlrecal a11estlzesk!). (EMLA cream) is used for vcnipuncture.
o Should not be used in Bier's block (because of its
cardiotoxic potential).
Cardiotoxic.
o Used for skin infiltration, epidural, spinal regional nerve
block MUSCL�R_E�T
o Less placental transfer. Fetomatcma\ ratio is 0.32 so used
in labour/ obstetric analgesia. Classification

Topical Anaesthesia
Used on skin, urethral mucosa, nasal mucosa, cornea etc. e Non-depolarising Long acting d-TC

Agents used are :-

e .-!111c1hncoi11c (Tctrarni11cJ
:agent{NOMR)
(Compe1ilivc) '""""""""'
o,,.,,uriwn
Pipccurium
Well absorbed by mucosa Jntcnnodiate Vecuronium
o Cocaine Atracurium
Only LA which is vasoconstrictor. Cocaine+ adrenaline Rocunxiium
co-admiuistanicn is contra- indicated. Only indication of
cocaine is topical anaesthesia of eye. Short acting Mivacurium,

� l:'MLA cream (Prilox) i�mixture of lignocaine +

Rapacuronium

prilocaine(2.5%/2.5%). Used in children before vcnepuncture o Dcpol:trisng Shortest acting S<h

{to decrease needle phobia@ :i.gents
Dccamethoniwn
(N�iti\-c)
" Lignocaine jelly (LOX jclly)/101.cnges are used sometimes
655_
 I) d-TC' vW(Qftboiceinobstetnci,
{Tubocurane) �Ganglionicblock:ade,
Good for arteriaVvasculat Sx

f: SJ;h(Scoline) ShonestactingMR,
MRwi!hfastestonset,
Vagal&ganglionstimUlation

� Pan�ium �en� in hypovolemic ·

shock.1ongestacri!!B,

<>Vecuroniu;·�

:i-��������¥.::��lti:�:���-;,:"' -. _
Liver .
;��"'.��-
_"' ·

lii><st
. r: iJ!.i"�'""''""'.,!����:f!'!:'!"!\',r,,ii""'.;!!"'�
�- 'givenbycontinuousinfusion_ ·--;-

e Atracurium Safe in renal/liver dis LJ.f6"°ffinan's elimination (70%) Seizures

�
-+Laudanosine

·C- Cts-avacunum _4,timesffi0ripote�1than

A1ra,�his1aminerelease
much lower

4,.- Rocuronium NDMR with fastesl onset By liver

a Metabolised by plasma cholinesterase by rapid hydrolysis.

(Do not require antagonists for reversal of blockade).
e In pt with pscudocholinesterase deficiency duration of
I.Tetanicstimulation action is prolonged, which c/b managed by IPPV, FFP's,
iz.-Trainoffourstimulation neostigmine.
Nofade
e Dose 1-1.5 mg/kg
4.Posttetanicfaeillitation None " Normally causes phase I block( causes muscle fasciculations
and then relaxation) but repeated & large dose (>5mglkg)
c Fading is seen with NDMR in a 'train of four' ratio. can cause phase n block and features ofNDMR like fading
c Post tetanic potentiation is seen in NDMR. & reversal with neostigmine.
t Neostigmine antagonises competitive blockade.

o S/E
- Postoperative muscle soreness I myalgia
- Bradycardia common in children esp after 2nd dose,
Sch (Suxamethoniuml scoline) - Cardiac arrest (Sch acts on SA node)
t: Depolarising MR.(Ac1s by persistent depolarisation) - Hyperkalcmia (seen in bums< 3 month, tetanus. S.C.
c, Shortest acting MR inury, LMND, CP, Duchenne muscle dystrophy)
c Most rapid onset of action & shortest duration of action. Prolonged apnca
Used for Rapid Sequence induction - It f es IOP, ICP and intragastric pressure
Onset of action 10-30 sec. duration 3-5 minutes
_656
 Anesthesiology

�Does not cross placental barrier. so good for operative

obsteterics & LSCS
GALLAMINE
e
.:«:
Least potent MR bu1E3 Not used now a
f:, Can be given in myasthenia gravis but i!s avoided in days.
Duchenne muscle dystrophy o 8001. excreted by kidney.
e Causes hyperblemia and leads to cardiac dysarrythmia e Conlraindicated in pregnancy, renal disease.
and cardiac arrest in patient with bum, massive trauma, c Patient su,/feringfrom MG are most sensuive to gallamine
neurological dis, tetanus, myopathies, severe intra- (compctitve blocker of Ach � more weakness).
abdominal sepsis.
+ Shortut &fastul acting MR (°'1rrafl) -Sch {ScoliM)
MIVACURIUM + ShorteJI ac1i,1g NDAfR (CNMB) -Mivocuri11rn
+ Fastest acting NDMR -Roc:uronium
Shortest acting NDMR. Does not need reversal as rapidly
metabolised by plasma pseudocholinesterases.
+ Lo,1gut c,cting NDMR -- Pa!IOlronium
+ MR ofchoiet log in arterial surgery-4!£
J1,m ofchoia 10 moinlain BP in artuia! ,,/
ATRACURIUM surg<ery -{!'ancuronium{

(CNMB • Compeli1i11e N"blacur)

a Short acting NDMR
o Safein-o:uicntwjth renalorh�
Hoffman degradation (inactivation of drug in body t Mic ustd SMR in rauliM surgery
fluids by spontaneous molecular rearrangements and its VMo.stpatmtSAfR -Dama,riw,,
spontaneous elimination at normal body temperature and + SMR -Sci,
Udftpol�ll
pH) is seen.Also metabolized by ester hydrolysis.
+ Lnu1 potent NDSMR
e Its metabolites are :Laudanosine (epileptogenic property)
(SMR • Skeletal Muscle Rdcualll)
and acrylate.
e Causes histamine release, anaphy\a:ids, seizures (d/to
\audanosine).

ROCURONIUM
D-TUBOCURARINE (d-TC)
.«- lntcnncdiate duration ,fast acting NDMR with onset of e Not used now a days.
�lion within 90-120 seconds in a dose of 0.5 to 0.6 mg/ o J.esBP.
kg and 60 - 90 seconds in a dose of 0.9 to 1.2 mglkg. '-""'Induces histamine release & promote gane:lionic
e Action lasts longer. Providcslrapid intubation conditions.I �-
e Used for RSI (rapid sequence intubation) where Sch is O It requires reversat with n�stigmine

contraindicated.�V o It does not cross placental barrier, so MIR of choice in

Rocuronium has repfaced vccuroniwn in countries where obstetric patient
it is available.

· RAPACURONIUM

,t- New steroidal NDMR with rapid onset of action.

cLeast potent.
Least CVS ad/E, short duration of action.
<'
� Causes histamine release and €verc bronchospa,so
therefore withdrawn from market.
MALIGNANT HYPERTHERMIA
c Life-threatening genetic abnormality of skeletal muscles
char/by S)"lllpathetic .tlim11lntion tachycardia, tacbypnca,
iBMR, hyperkn/emia, muscle rigidity.hypertension, DIC.
and fever.Seen in children of m/s dystrophv.
<1 Massater mis rigidity is the earliest definitive sign and

hypen:apnia is the earliest biochemical change

657 _
 ROAMS

e Triggering anesthetics Safe anesthetics in M- patient upto 5 years.

I. Plucrinated aoesrhetics, l. N20 e Pediatric age group patients with congenital myopathies
vapors are susceptible for
(lialothane, isofluranc, I. Marked hyperkalemia Avoid scoline
Methoxyflurane) 2. Propofol, Ketamine, 2. Ma\ignam hyperthermia ··· Avoid triggering agents
opioids, Barbiturates, (Sch, neuroleptics,
sodium pentonal, BZD volatile agents e.g. ether
2. Depolarizing_ blocker 3. NDMR(d-TC) & fluranes)
(&,.ch, Decamethonium) (Doccu\ocardiac reflex D/totractiononcxtraocular
3. Ether, some ncurolcptics {!)LA mis during surgery
[mnemonic: Etl.S..].vcntually it is trigeminal reflex,
triggerMH] leads to bradycardia and
o Sch causes MH in immediate post op period {within sinus arrest)
hours). Treated by inj atropine,
e Tit: deepening the plane
�wf,erven1ilationwith6;,, of anaesthesia, stop
Specific antidote: Dantrole�e· s.odium (Br�mocriftine is scoline.
also useful). Dantrolcncsodmm interferes with the� :f( lnmalechildren<2yrsavoid scolined/toriskofdangerous
of ca++ ions from srf (sarcoplasmic reticulurrn-e Inhibit hyperkalemia in an undiagnosed case of DMD.
ryanodinercceptors�

+ A child with e.tostrophy of bl&khr + renalfailure war pasted

for repair. MR of choice is ·-Atracurium
vf A child with D11chene MD we.,- posted/or .JUf8t'I)'. anastlretic
agenl ofchoice is- Propofo/

.... -- �--·-·-----
PEDIATRIC ANESTHESIA
o Best inhalational (volatile) induction agent - scvoflurane
-1f:: Narrowest part oflarvm jf cricoid- to avoid pressure
necrosis of it, uncuffcd tube is used in neonates and small
children. OBSTETRICS ANESTHESIA:
* Larynx is anterior and high up so straight blade (Miller's Regional Anesthesia is preferred over GA in pregnant
typc)laryngoscope is used patient hie of risk of aspiration and difficult airway di ICI
e Induction agent of choice : edema.
Method of choice for induction is intravenous if i. v. access e Prolonged labour can lead to carpopedal spasm d/to

is already present).otherwise inhalational. hypcrventilation -e alkelouc/hypocalcemic tetany.

- Best inhalational agent -·· Sevoflurane in N20 & 02
· 1/v rapid acting ··· Thiopentone, pro po fol (> 2 yr)
flbNDMR
. Best Vm agent ••• Kctamine
e lnhalational induction agent of choice is scvoflunranc.
lJ:
Circuits used for pediatric pt. upto 20 kg Jackson Ree's
modification of Avrc'sT piece (JRM Circuit) or Mapelson
.£:
e Rody surface area is larger so prone for hypothermia (to
prevent hypothennia, non shivering thermogensis occur)
� Caudal block is m/c used for postoperative pain relief in
children in lower abdominal. pcrineal, or LL surgeries.
e lsolyte Pis mamtainance i.v. fluid of choice in pediatric age
_658
e Epidural anesthesia is preferred for labour analgesia. Drug
useful in painless Jabour(epidural analgesia) is bupivacaine.
Bupivacaine is the m/c LA used hie of low fetomatemal
ratio, and it produces differtnlia\ blockade i.e. sensory
blockade at low dose while motor blockade at higher
doses.
e lndicoticn of GA
- Manual removal of placenta
· Fetal distress during second stage
• Tetanic uterine contraction
;;: Thiopentonc (and propofol also) is the induction agent of
choice
e �clsonJ"spu:Jrome:
Aspiration of gastric content during anesthesia. Risk factors
 include pH< 2.5, gastic volume >25 ml. It c/b prevented
by
.,t Aspiration prophylaxis wilh sodium citrate, H2
� ��-· Ketamine peseres
'*- Rapid sequence Induction i.e. preoxygenation, Se\lick's
manoeuver, i. v. Induction I Sch intubation
c Supine HyJM/e11sio11.�p1dro111c:
Ocnrrs d/to compression of!VC by gravid uterus and is seen
{fu_ Inst trimeste}. M/m includes lying in left lateral position
or displacement of gravid uterus by keeping wedge under
* right lumbar region to prevent this complication.
Drugs used for obstetric labour analgesia -· �'
� +
,.t- �eful in painless labour .-. Bupivacaine
*'""Pudenda\ block is useful in(episiot�
AN�STHESlt, IN_�ECIAL SITUAT�O-�S
Anaesthesia in Geriatic pt/ Elderly
c Elderly persons require less dose of anaesthetic agent d/10
age related phvsiological changes
of Induction agent of choice: Etomidate, thiopentone.
o Inhelational agent of choice for maintaiuence of anaesthesia:
lsofiurane/desflurane.
*c Methoxyfl.urane is nephrotoxic, so should not be used.
�ore prone for post--0pcrative delirium
Anaesthesia in a patient of epilepsy
e Enflurane: Causes GTCS. So contra-indicated in siczure
disorder.
Q Sevoflurane: Can rarely cause convulsions.
o Atracurium : Its metabolite laudonosine can cause
convulsions. avoided in epilepsy.
c Ketamine; Increases ICP -> Convulsions.
��tJ:�
Anaesthesia in Renal Failure patient
c @eshouldavoid volatile a<>en'rs like cnfluranc, sevoflurane.
mcthoxytlurane(Prefer·-- lsofiurane, desfturane,
haloth;me)
t, MIR to be avoidccl are ··- Gallamine, & pancuronium
(prefer-· Atracurium, vccuronium)
e Pethidine should be avoided in renal failure.
Ana sthesia in Asthamatic patient
Drugs safe in Asthma
e Best inducing agent - Ketamine, propofol
asthmatieus broncl1ospasmJ
�Be:;t skeletal MR ·· Pencuroaium, vecuronium
o Other GA safe in asthma- Halothane (it inhibits cough,
pharyngeal & laryngeal reflexes,
produces bronchodi latation)
�· Thiopentone sodium is contra-indicated in asthma as
j1 precipitates bronchosoasm]
Muscle rtlwanl safe ill renal failure pl--- Atrac11rium,
V.�ronium
+
Safe in hepatic/aifure pt�-Atrac11ri11m
0Suilableane1the1icagentsin�lsojluarane
&Sevoflurane
Anaesthesia for cardiovascular surgery
Induction agent of choice for R-----+ L shunt (Cyanotic
HD) - Ketamine
(Because kctamine t es systemic vascular resistance but
docs not 'lse pulmonary vascular resistance, and thus
does not t R� L shunt)
t Induction in a pediatric patient with L----4 R shunt
(Acyanotic HD) is done by ·- Scvoflurane
1-
Or any other i. v. induction agent except kctamillC
Anaesthesia is maintained in cardiac patient with ···02
+ N20 + opioids.
Anasthetic consideration in spedal situations
o /f patient wi1'4CD (sickle cell traii) postedfor surgery in
leflann-·
Tomiquct should be avoided as it can produce vesccosrrictioe
and stasis of blood leading to hypoxia. tVRA (Beir's bl�
should be avoided
e A patient with{ij_itral ste11osij)s posted/or surgery.
He is
having some liver compromisc-,
Preferred inhalational agent for him is Xenon ands�.
o Anesthesia in bum patient
Ancctinesafe in Isl 24 hrs. Ketamine fordrcssingchang"'..s
�
659 _
 Drugs before surgery I Drugs in PAC
e. Daycare Propofol

c Epilepsy ., Thi�n1cfue · � Antipsychotics

Jsoflurane -4;ufarin Discontinue 4-5

days before
Mi:thohcxitone
-Heparin Delay sic heparin
nllblcck

c, Antipsychotics Tobe continued

.- Lithium To be continued Porentiates DJ,.IR

&NDMR

Tobeconunued --fsensi!ivity to
CA's -

e SSRI Tobe continued Check

s.clectrolytes.,
hyponatremia

-Tranycypromine, Stop2wlaprior
-Phencytlizine,
-lsocarbazide,

-Sclcgillin.? (<IOmg/d)

\?""� G.top�wksprio)
c HRT S1op6wkspriorto
majorSx

< POP CJbcontinued

o CCBs,pblockcr, To be continued
nitrates

�CEi�
Drugs for day care surgery (OPD Anesthesia)
o Inducing agent of choice -- Propofol
�
� Diuretics To be continued
o Volatile anesthetic of choice -- lsoflurane (now-a-days
scvofl.urane, Desflurane) e Antihypcrtensive To be continued
o Analgesic -· Alfentany\,Rcmifentanyl, c, Forinductionincldc:rly Etomidatc/
Fentanyl thiopentone

e Musdc relaxant - Mivacurium, atracurium �

Remember that alfcntanyl. remlfenranyl, mivacurium @Grading for risk of anaesthesia
although ate theoritically best agents but arc not available e Grade I· Patient with no systemic ells.
in India c Grade II - Mild systemic dis (well controlled)
o Grade Ill - Moderate systemic dJs with functional
Selection criteria for Day care surgery limitation .
.- Patient should be managed with oral analgesics. c Grade IV - Severe systemic dis with constant threat lo
e Vitals stable. life.
e Responsible adult accompnying. e Grade V - Moribund patient which is going to die within
e ASH grade 1-111. 24 hr with or without surgery.
e Nohematoma. e Grade VI - Brain dead patient for organ donation.
Walk easily.
 Anesthc:o;iology

Stages of anaesthesia � Supraclavicular block :

e Described on ether by@ Mic used method of brachia! plexus block.
e I • Stage of analgesia e Axillary block, Interscalenae block:
II - excitement (pupils dilated) lnfraclavicularapproachfor upper arm surgeries
Ill - Surgical anesthesia . Has 4 planes intersca\enae approach is preferred.
JU, plane Ill : Laryngeal paralysis c Coeliac plexus block
111, plane IV : fully dilated pupi Used for lumbar sympathetic €3. Decreases pain
IV-Coma in pancreatic cancer, stomach cancer. Can cause
c Intubation c/b done in stage Ill, plane Ill • h!E_olension'.' =

Retrobulbar Anaesthesia
o LA is injected �hind the eye into the cone fonned by�
DIFFERENT BLOCKS
-----
IVRA /Bier's block (1. V. Regional Anesthesia)
(extraocular muscles).
... Effeclivcly blocks all EOM within seconds except suprior
""6'" Large amount of LA is injected in veins after using· �
torniquet. \,,ff"'"""Affects the ciliary ganglio (Results in pupillary
e Lignocaine without adrenaline is the DOC. Prilocaine dilatation)
(0.5%)isalsosafe.
"' Used in both UL & LL i.e. forearms and hands (e.g.
reduction of co lies#)
o Bupivacaine is contraindicated for IVRA bee/of its high
cardiotoxicity which may occur after release of'torniquet. n If a patient undergoing thoracotomy comnlains of severe
e Contraindications for IVRA: Raynauld's, SCD, pain, he should be best managed b){IV fentany}) V
sclerodenna. = "ff �ororalbrufena�int/tofseverepain
in immediate postop period in a thoracotomy patient.
+ Tomiquct timefor/Ulis45-60minmuf"dJo1Uis60-90J
� ""'- �ystem1c op1oids)alone are effective in controlling
background pain.
TIVA (Total Intravenous Anaesthesia) e Pain scale-c-
o Used for day care surgery, neurosurgery. ,t VAS (Visual analog scale) in adults.
n Combination of{propofol)nc(Ramifontang}is used. • FACES scale, and CHEPOES scale (Children's Hospital
e Only inhalational which c/b used: 02, NO. N20 of Eastern Ontario Pain Scale) in children.
e Advantages over inha\ational induction &maintenance: -t- Mc gill questionaires used for pain in adults.
+smooth induction with minimal coughing and
hiccouhgs.
• Easy to control depth of anesthesia.
,f< Less PONV ADIE OF ANAESTHgiC .& '!_ELATED DRUGS
I:" J..CBF & J..cerebral metabolic rate are favorable for c. Methemoglobinemia is seen with :
�- - Prilocaine
• Lignocainc
- Benzocaine
Cadual block( Epidural sacral block)
c h is commonly used regional anaesthetic technique in
children for periperative and postoperative pain relief.
*
- Np.Nitrites
�dc-s, phenacetin

(\ Mainly used in children for perinea I surgeries, genitourinary cJ,1"uscle pain I soreness -- by Sch.
surgeries. J.,!1iscle spasm (intra-operative) - Fenranyl
JM'uscle Tone -- Ketaminc
Brachia! Plexus Block -*" Opioids (fentanyl sufen1anvl. alfcntanyl) induce � Mis
There are many approaches of brachia! plexus blocks rigidity or Chest wall rigidifY..
661_
 ROAMS
� t BP - Ketamine, pancuronium,pentazocine. o �:oiits wbt!: Used in children.
e (i) t JCT - Ketamine, Halorhane, Sch. � Used for microlaryngeal surgery.
(ii) ! ICT - lsoflurane, Propofol,�,lidocainc, f: Zeolite is aluminium hydroxide to absorb nitrogen. Can
cyclopropane, BZD (midaz)
o (ii) t IOT - Kctamine (transient), Sch, Np,etomidate,
thiopcntone.
(ii)(I1�
e (i) Bronchospasmodic - Ether, NzO, thiopentone -.
(i) Brouchodilator - Ketamine, halothane, promethazine,
�c,d�.
o..Jrura-artcrial injection of thiopentone causes -t intense
pain,inflammation & necrosis
Jirtra-venous injection of thiopentone-> No pain
* J,Rtta-venous injection of propofol -> Pain
Propofol supports-{Growth ofbacteril
o Ketamine produces -t Dissociative anaesthesia.
o In MG - Sensitivity of Gallamine and d· TC is increased
while that of Sch. is decreased.
CVS Ad/E - Halothane > Enflurane > lsoflurane
1t"" Ether. !so-, Sevo & Enflurane does not sensitize the heart
to the action of catecholamines /Adr.
e Drugswhich{§sitize·theheart�othe;�
of catecholamines /Adr are---
Halothanc, methoxyflurane, trichlorethylcne, Cyclopropane,
�t so these drugs are not used now a days.
� POINTS QE-SPECIAL MENTION .. __I
\. Plasma cholinesterases degrades :
- Sch.
- Mivacurium, Cis-atrucuriurn
- Propanidid
- Esmolo\
Ketamine produces Nor ketnmine, while midazolam
produces hydroxymidazolam.
,t. Esophageal carcinoma require one lung ventilation &
deflation of another lung. Robertshaw and Karland tube is
used
* Mic cause of hypoxia with one lung ventilation -
malpositioning of tube.
o Left lobe is the best region for ascultation in ETT
intubation.
.../ Flexometallic tube: Used for spine, head and neck surgery·
and for surgery in prone.
_662
(provide 95% oxygeil Electronically powered.
� Muscle relaxant
- Safe in renal failure - Atracurium, Vccuroniwn
Safeinliverfailure-Atracurium
'-'f{Procainc & Bupivacaine arc .1191 used as a surface
anesthetic.
* o Phase-II blockade is seen with Sch.
Maximum respiratory depression is seen with morphine,
fentanyl (+++) & minimum with pentazocine.
o Shortest acting non-depolarising muscle relaxant -
Mivacurium
Shones! acting muscle re/a.rant : &h.
e Mendelson syndrome - Regurgitation of gastric contents
causes aspiration pneumonitis
o Head tilt - chin lift maneuver:
- Used during assisted ventilation 10 secure airway.
- Clind in cervical spine injury
Jaw thrust technique: Can be used in cervical spine injury
where head tilt should not be done.
<t- Se.nick's manoeuvre:To prevent regurgitation pressure
is applied on cricoid cartila_§. which compresses oesopha
gus against vertebral column. This ts done during rapid
sequence intubation.
o TRUP manoeuvre: Pressure over thyroid cartilage (by
pressing it n.,gosl& upward). Used to aid in intubation.
e Helmich's manovure: Used for FB removal. Sudden
pressure applied from back of the pt. by both hands below
the costal cartilage.
it- Brcur Lockguard reflex: Light anaesthesia & cervical
dilatation (cg during anal stretching) can initiate
parasympathetic overactivity causing larngospasm,
brochospasm, bradycardia & even cardiac arrest,
,,,.
i" Low CO, vc::nous air embolism, circuit disconnection
l- Pulmonary embolism
- Venous air embolism
- Circuit leak
-
-
Extubation
Cardiacarrcst
� Po:.1-opem11ve s/111 enng is :,,:t'II ll'ilh :
Halo1hane (m/c), cyclopropane, lhiopentone
sodium,ether.
o D111g used for treatment of Jll).W-11p,m11i1 c shivering -·
 \
pethidine • tramadol, clonidinc, dcxamethasone
..«:- Jndicatio11s for endotrachea/ int11ba1io11 - maintenance of
a patent airway, to provide lPPV, pulmonary toilet.
e Induced hyporenslen
- Drug • sodium nitroprusside NTG, Trimcthophan,
Arphonod
Spinal/epidural block
....-1}-blockers (Esmolol or propanolol)
v-f'fthalational agent - Isofluranc m/c, halothane,
enflurane
�sitioningofpattcnt V C.lnduction with i.v. suxamcthonium and N20: and
,t- World anaesthesia day is€n 16th octobe$ On 16th oct 1846
ether was used first. lime .
e Smoking should ideally be stopped by 6-8 wks before
� (Time required 10 increase ciliary motion) . If
smoking is stopped within 24 hr, decrease carboxy Hb can
cause shift to right.
___ �Ol!!_E_ IMP. NEGATIVE POINTS
e NOT caused by atropine in pre-anesthetic medication --
Bronchoconstriction
e NOT caused by lpratropium bromide---
Bronchoconstriction
e NOT a vasodi!ator LA --- Cocaine
NOT used in clearing airway Head lift
e Bag and mask ventilation is NOT indicated in ---
Diaphragmatic hernia, MAS.
o Drug NOT useful for induction in infants -- Morphine
e NOT true about pneumatic Anti-shock garments - l CO
e NOT used as surface anesthetic-Procaine & Bupivacame
e NOT used as in Beir's block- Bupivacaine
e NOT used for controlled ventilation-- Mapelson A system
or Magill circuit
� ,E!m.capnogram is NOT seen in - Bmnchospasm
e A pt with sickle cell trait is posted for surgery in left arm.
NOT to do is -- lVRA (lmravenous regional anesthesia)
e NOT true of xenon anaesthesia-,- Slow induction and slow
recovery.
C) NOT an adverse effect of neural opioid --· Itching, low BP,
..nausea, vomiting.
e Factors that do not effect MAC are--- Sex-male or female
Thyroid disease.
CLINICAL VIGNETTES
n A 5 year old boy is suffering from Duchennc muscular
dystrophy. He has to undergotcndon lengthening procedure.
The most appropriate anaesthetic agents would be :
[AIPGMEE2003, DNB HRH Delhi' 08)
A.Induction with i.v, tl.Jiopcntonc and Ni_O: and halothanc
for mainlenencc
8. Induction with i. v. suxamcthonium and N10: and 02 for
mainrcnence
ha\othane for maiutcnence
D.Induction with propofol and N20 and02 for maintcnence
(Ans.: D.Induction with propofol and Ni_O and 02 for
maintenence)
DMD patients are susceptible for malign.ant bypcrthemria
so scoline and all volatile agents should be avoided, while
Np and propofol arc safe. Suxamethonium is ruled out.)
r A 5 year old is scheduled for strabismus (squint) correction.
Induction of anaesthesia was uneventful. Afterco1tjunctival
incision as the surgeon grasps the medial rectus, the
anaesthetist looked at the cardiac monitor. Why did he did
that? [AllMS 2002]
A.He wanted to check the depth of anaesthesia
B. He wanted to be sure that the BP did not fall
C.Hc wanted to sec if there was an ocu1ocardiac reflex
D.He wanted to make sure there were no ventricular
arrhythmias accompanying incision
(Ans.:C. He wanted to see if there was an oculocardiac
reflex)
Oculocardiac reflex is a trigeminovagal reflex, afferents
of which are carried out by trigemina\ n. and efferents are
mediated by vagus.lt is seen during ocular surgery either
d/to traction en eye m's or d/to compression or stretching
I pull on eye muscles. Tit includes srop stimulation, inj
atropine, iucreese depth of anaesthesia, infiltration of LA
in mis, and rctrobulbar block.
ro A 6 year old child was posted for elective urological
surgery under genera[ unacsthcsia. He refuses to allow
the anaesthetist for an i. v. access. The best inhalational
inducing agent in this child would be;
[AIIMS May 2004)
A. Sevoflurane B. Methoxyflurane
C.De.-.fluarane D. lsoflurane
(Ans.:A. Sevofluranc)
663 _
 ROAMS

r, A 38 year old man is posted for extraction of last molar tooth r- A severly ill patient was maintained on an infusional
under GA as a day care surgery. He wishes to resume anaesthetic agent. On day 2 of admission he started
his work after 6 hours. Which of the following induction deteriorating. The most probable culprits is/are
agent is preferred- [PGJ 1999, JIPMER 2004]
[ AJPGMEE2003, DNB HRH Delhi' 08] A. Etomidate B. Opioid
A.Thiopentonc sodium B.Ketamine C. Propofol D.Barbiturates
C. Propofol D.Diazcpam (Ans. ,C. Propofol)
(Ans. :C. Propofol) Propofol infusion syndrome: Seen after 48 hours of
Drugs preferred in day care surgery arc : Propofol, continuous infusion of propofol in ICU. Found in cases of
desflurane, atracurium cardiomyopathy, rhabdomyolysis, and bradycardia

r"J A 70 year old man is posted for a surgery which is likely A 21 year old female with a history of hypersensitivity to
to last 4-6 hours. The best inhalational agent of choice for neostigminc is posted for an elective LSCS under GA.
maintenance of anaesthesia in such a case is: Muscle relaxant of choice in this patient is-
[AIIMS May 2004] [AIIMS May 2004]
A.Methoxyflurane B.Ether A.Pancuronium B.Atracurium
C. Trilene D.Oesflurane C. Rocuronium D. Vecuronium
{AIL'i. D: Dcsflurane) (Ans. B.Atracurium)
Rapid onset and rapid offset of anaesthetic effect is seen Atracurium is metabolized by Hoffman's elimination,
withDesflurane so it does not required reversal of N-M blockade with
neostigmine

e- A 30 year old female with coarctation of aorta is admitted

to labour room for elective LSCS. Which of the following is
anaesthetic technique of choice : (AIIMS Nov'2005}
A.Spinal anaesthesia B. Epidural anaesthesia
C.Generalanaesthesia D.LA with nerve block
(Ans.C.Genernlanaesthesia)
Some cardiac lesions, such as aortic 011ifiow obstruction,
right to left shunts,! venous return, and ! systemic
resistance are so grave that they make regional epidural and
spinal anesthesia hazardous. GA has rapid induction, less
hypotension, better airway and ventilation, better recovery.
So GA is preferred in patient with CoA.
r. A patient was administered epidural anaesthesia with 15ml
of 1.5% Lignocaine with adrenaline for hernia surgery. He
developed hypotension and respiratory depression within
3 minutes after administration of block. The most common
cause would be :
[AIIMS may'07]
A.Allergy 10 drug administered.
B.Systemic toxicity to drug administered.
C.Paticnt got vasovagal shock.
D.Drug has entered the subarachnoid space.
(Ans.D.Drug has entered the subarachnoid space }

t.i.>id11ml t11wsthe.�iu!pt'rid11rt1l anesthesia.

c A 20 year old female presented with early pregnancy for During epidural anesthesia there occurs certain
MTP in day care facility. Which of the following induction complications. One of which is total spinal. It occurs if
agentisprcferred- by mistake, dura is punctured during injection and such
[AIIMS May 2006, DNB HRH Delhi' 08] large volume of drug is injected into subarachnoid space.
A.Thiopentone B.Ketamine Manifests by marked hypotension, bradycardra, apnca,
C. Propofol D.l)izepam dilated pupil and unconsciousness.
(Ans. :C. Propofol) Also know
Propofol is preferred for day care surgery Other drug used for epidural block
Only agents which are rapidly eliminated are used for
this purpose; e.g. propofol for induction of anaesthesia, e Lignocaine, bupivacaine
alfentanil, renifentanil, N20, isoflurane, sevoflurane or e Morphine, fentanyl, tramadol
_ 664 desflurane.

Site of action of opioid after intruthecal and epidural
administration
e Opioid after diffusion through meninges reaches the
spinal cord where they bind opioid receptors present
in substantia gelatinosa of dorsal horn cells.
o Site of action of LA is anterior and posterior nerve
roots.
c A 6 month old child is suffering from patent ductus
arteriosus (PDA) with congestive cardiac failure. Ligation
of ductus arteriosus was decided for surgical management.
The most appropriate iohalational anesthetic agent of choice
with minimal hemodynamics alteration for induction of
anesthesia is:
[Al!MS may'07]
A. Sevofturane B.lsoflurane
C.Enflurane D.Halothane
(Ans.:A. Sevof!.uranc)
Induction agents in children and patient profile
Se\'Ojf11ra11e is jnhalatjonal agent of choice in children for
jnduction. It is costly, so use is restricted. Cardiac output
is minimally depressed.
Halothane also used for induction in children but it
decreases cardiac output, causes bradycardia due to
direct myocardial depressant effect. It is cheaper so used
frequently for induction in children, but its effect on heart
limits its use in patient with PDA.
/sojl11ro11eis inhalational agent of choice for cardiac surgery
but is irritan1, so patient compliance is very poor. It is not
used for induction of anaesthesia but for maintenance of
anaesthesia.
1J A 5 year old child is suffering from cyanotic heart disease.
He is planned for corrective surgery. The induction agent
of the choice would be:
A. Thiopentone B. Ketamine
C. Halothanc D. Midazolam.
(Ans; Ketamine)
TOF is cyanotic heart disease.
The goals of anaesthetic mlm in patients with TOF is
to maintain intravascular volume and systemic vascular
resistance(SVR)
Anesthesiology
"Ke1amine is conunonJy used induction agent because it
maintains or tSVR and therefore does not aggravate the
right to left shunt".
e A 30 year old man who was recently started on haloperidol
30 mg/day developed hyperpyrexia, muscle rigidity,
akinesia, mutism, sweating, tachycardia and increased
blood pressure. The investigations showed increased \VBC
count, increased Creatinine Phosphokinase. There is not
history of any other drug intake or any signs of infection.
The most likely diagnosis is:
[Al�\IS May'06]
A.Drug overdose
B.Neuroleptic Malignant Syndrome.
C.Drug induced Parkinsonism
D.Tardive Dyskinesia
(Ans.: B. Neuroleptic Malignant Syndrome)
Neuroleptic Malignant Syndrome
ci Iloccurswithhigbdoseofpotentantipsycborics. Symptoms
develop within first 2 week of an antipsychotic drug tit/.
NMS is a catatonia like state manifested by exuapyramidal
signs. Blood Prcsrutt changes altered consciousness, and
hyperpyn:xia
ci It should be considered in did of malignant hypenhennia
II Patient develops marked rigjdity immobility, tremor,
fever, semiconsciousness, Fluctuating BP and heart rare
(Tachycardia and increased BP).
e Myoglobin may be presents in bloodflncreased creatinine
phosphokinase).E)eyated creatine kinase and leukocvtosis
with a shift to left are present early in about half of cases.
e Tit
• Stop anupsychouc & give iJv dantro\ene
• Bromocriptine (Anticholinergics do not help)
n A 16 yr male withexostrophyofbladderwithchronic renal
failure was admined for blader reconstruction. Anesthetic
of choice would be.
[Al!MS No,'09;AIPGMEE' I OJ
A. Pancuronium B. Vecuronium
C.Rocuronium D.Atracurium
( Ans. D.Atracuriwn)
Atracurium is safe in both liver and renal dis patients as it
is metabolized by Hoffman's degradation (non- enzymatic
degradation).
665 _
 ROAMS

n A female was posted to OT for laparotomy for surgery
of ilea! perforation for which rapid intubation was done.
lmmediately after intubation her EtCO, was raised and on
auscultation breath sounds were J. on-her left side. What
is the most probable cause? [AIPGMEE'IOJ
A.Esophageal intubation
B. Bronchospasm
C. Endobronchial intubation on right side
D. E1T blocked
{ Ans. C. Endobronchial intubation on right side)
EtC02 is a good indicator of ETT status.
e ETC02 becomes zero in --- esophageal intubation,
pulmonary venous air embolism (sudden fall in
EtC02).
c, Flat capnogram is seen in -- lntraoperativedisplacemcnt
ofETT, disconnection ofETT, ventilation failure
r A 70 kg old athe\ete was posted for surgery. Patient
was administered Succinylcholine d/to unavailibility of
vecuronium. It was administered in intermittent dosing.
(total 640mg). During recovery patient was not able
to respire spontaneously and move limbs.What is the
A. Pseudocholinesterase deficiency increasing action of
Sch block.
B. Phase 2 blockade produced by Sch
C. Undiagnosed muscular dystrophy and myopathy
D. Muscular weakness d/to fasciculations produced by
succinylcholine.
( Ans. B. Phase 2 blockade produced by Sch)
In Sch, depolarising block can be changed to phase 2 block
by administration ofa dose 7-!0mglkg.Tetanic fade and
train of four fade appears.

e ETC01 becomes high in --- Exhausted soda\ime or r Which of the following monitoring tool gives you the best
defective valves of closed circuit, malignant hyperthemtia recognition of intraoperativc myocardial ischemia:
(upto 100 mmHg) A. Electrocardiograph
ln bronchospasm and ETT blockade there is slow rise of 8. Intra arterial pressure
EtC02. C.CVP
Accidental intubation on right side is common . ETI goes D. Transcsophagea\ echocardiography
in right main bronchus and it will produce obstructive (Ans. 0. Transesophageal echocardi6graphy)
curve and rise of EtC02 •
rr lonotrope of choice for inrraoperative management of right
heart failure due to pulmonary hypertension:
n. 42.A 65 yr old male known hypertensive, is scheduled for [AlPGMEE'l 1]
laparoscopic cholecystectomy under general anesthesia. A. Dopamine
Which of the following induction agent is contraindicated B. lsoprenalinc
in this patient? {AIPGMEE'l I] C. Milrinonc
D.Halothane
A. Propofol B.Ketamine (Ans.: C.Milrinone)
C. Etomidate D. Midazolam
(Ans.: 8. Ketamine) r. NOT a definite airway : [AIPGMEE'IIJ
Ketamine t es BP and HR A. Orotrachcal intubation
B. Nasotrachcal intubation
C. Laryngeal mask airway
n An Anesthesia senior resident is performing epidural D. Cricothyroidectomy
block. While injecting patient becomes aphonic and losses (Ans.: C. Laryngeal mask airway)
consciousness. The immediate diagnosis is: LMA is supraglottic airway device.
[AIPGMEE'll]
A. Anaphy!actic reaction 8. Total spinal
C. Vasovagal attack D. lntravascular injection.
(Ans. B. Total spinal)
Total spinal is a rare complication manifested by profound
hypotension, apnoea, unconsciousness and dilated pupils

_666
667 _
 __ APJ>.RQASH TO A COMATOSE PATIENT. J
M/m Steps in Comatose Patients
First priority is ABC Airway, .B_reathing, C.ircula1ion
20 IO guidelines recommend use of C-A-B sequence in field.
Airway & breathing
c Open airway by triple manueveur bead tilt, chin lift and
jaw thrust (use only jaw thrust if cervical spine injury is
suspected)
o Oral airway may be used only if atraumatic insertion is
possible.
o Early intubation using rapid sequence (RSI) with full
stomach precautions.
Indications for intubation in comatose patient include -
L Glasgow coma scale < 8.
2. Inability to maintain airway patency/protection.
3. Impaired oxygenation or ventilation.
Circulation
Assess circulatory status. If in shock, treat along standard
guidelines with bolus of isotonic fluid and vasopressors as .
indicated.
Blind nasal intubation is indicated in
TM joint ankylosis
Trismus (tetanus, quinsy)
Neckcontracture
In case of Head injuries
e Widespread cortical destruction (reftected by deep coma
unresponsive to any stimulus)
a Global brainstem damage (Absent corneal reflex, Pupillary
light reflex, oculovestibular reflexes)
o Complete apnea
Patient should not be hypothermic, hypoxemic, and
hypotensive.
An isoelectric EEG may be used as a confinnatory test for
total cerebral damage.
Hypoxic injury to brain
o Brain is extremely sensitive to hypoxia, and occlusion of
its blood supply as short as IO sec may produces
unconsciousness .
o Vegetative structures are more resistant to hypoxia.
Vegetative functions are relatively retained compared to
intellectual functions
o Penumbra, is the area surrounding the most severe brain
damage, or the area potentially salvagable if ischemia is
reversed
o If circulation is restored within 3-5 min, full recovery may
occur without sequelae
o Hippocampus {CA-I neurons) is most vulnerable to
ischemicinjury.
e Golden period to initiate thrombolyti� therapy in thrombotic
stroke is within first 2 hr after the onset of weakness/
palsy.

r,£:i!'<il!J-!!l ul._. �c�!!,ll!IIIJIIID

Initial assessment must follow ATLS guidelines with an Pupillary reaction based on the site of lesion
initial primary survey, alongwith rescucitation, followed bya
secondary survey then definitive management. Cervical spine
Metabolicencephalopalhies Sma!lreactive
must be immobilized during the initial assessment or more
simply: airway (first)-> breathing -e circulation -l- disability .
and exposure. Rush to the emergency with OT sci up.
Midbrain Midposition,fixed

Brain Death
Brain death is a state of cessation of cerebral function while Jrdnerve(� Dilatcd,fixcd
somatic fimction is maintained by artificial means and the heart
iPons �- Pinpoint ,
continues to pump.Prerequisite are
_668
 Critia.lCarc:

Management of Shock in children

Omin
5min

15min Fluid refractory shock**

Fluid respcnsrve"

Fluid refractory--dopamineldobutamine resistant shock

Cateeholamaine-resistant shock

Normal Blood Pressure Low Blood Pressure Low Blood Pressure

Cold Shock Cold Shock Warm Shock
ScPz Sat < 709/• Sc.O?Sat <7091. S("O! Sat< 7091.

I
Add vasodilator or
I
Titrate volume and
I
Titrate volume and
type Ill phosphodiesterase epinephrine norcpinephrine
inhibitor with volume
\oadcing

� I
Persistent Catecholamine-resistant shock
.:
>- Refractory Shock

Consider ECMo
Approach to pediatric shock. "Normalization of blood pressure and tissue perfusion;
••hypotcnsion, abnormal capillary refill or extremity coolness. PALS, Pediatric Advanced Life Support; PICU. pediatric intensive
care unit; CI, cardiac index; ECMO, extracorporea\ membrane oxygcnatmn.
669_
 ROAMS

Oculovestibular response or caloric test

+ Triad in pontme hemorrhage - pin point pupils + loss of EAC is irrigated with cold water to induce convection currents
COIUCiOUSrtfiS+ lryperpyruia
in labyrinths. Nystagmus is fast component
There may be 3 type of response
I. Normal awake patient with intact brainstem - tonic
Transtentorial herniation deviation of both eyes to the side of cold water irrigation
and nystagmus in the opposite direction. Side with the
Enlargement Compression Compression of Compression of slow component towards irrigated ear and fast component
ofthci/L or er cereeot bloodvcsscls towards midline.(acronym COWS)
pupil midbn.in pofu�k pa11icularlypost& 2. Unconscious pt. with intact brainstem
! antr cerebral artcry Fast component abolished, eye move towards stimulus and
+veBabineski remain toxically deviated for> I min.
3. Unconscious pt with brainstem dysfunction/brain dead pt.
Kernohan-Wottman Braininfaraion There is no response to stimuli i.e. eyes remain in midline.
sign

BloodlOSI <15% 15-30% 30..40'/." >40'A

(750ml) (.8-1 litrc) (1.5-2ii�) -(>2ftr.)

3.CTScan Biconvex,

°""'""
Cr�9t
(Cccavc-
1�.1
NCCT-(Non'
contrast CI) is
in'leS!igationof
Pulse rate Slight t 100-120

-
> 120, weak > 120,

� Resuscitation ofthe trauma patient (pediatric/adult) begins

with isotonic crystalloid, in a child 20ml/kg
Q. �is the most important parameter of adequate

inCSFdctectcd tissue perfusion in a patient with shock

by LP (Bloody
tapinCSF).
PCWP or CVP is used to assess volume replacement in
hypovolemic shock
o, In children, hydrocortisone is indicated in septic shock
in children with catecholamine resistance and suspected or
proven adrenal insufficiency (children with severe septic
Induced eye movements shock and purpura , children who have previously received
Oculocephafk/Dolls eye response steroid therapies for chronic illness, and children with
Should only be tested in unconscious patient pituitary or adrenal abnonnalities).
Nonna\ or positive response is conjugate deviation of eyes
in opposite direction to which the head is turned.
Negative response indicates brainstem lesion.
670

TRIAGE COLOUR CODING SYSTEM
e French word meaning to "sort" by priority or life-threatening
nature of injury. Prionize the patient for tit and transport
purpose.
e Retriage occurs when the status of a patient changes either
to a worse condition or if they improve to a less life-
threatening level.
Roi ScriOUSbutsalvageablclife ,. Immediate
threateajng injury/illness �
Black: ,,.
TRAUMA
Trauma : Basic POINTS
<' Following trauma level of stress hormone is fed i.e.
Glucocorticoids, Glucagon. ADH, GH etc.
o M/c abdominal organ injured in blunt trauma abdomen is
spleen and in penetrating trauma- small intestines
o Seat belt causes injury to duodenum
e Prox. Jejunum and ileocecal junction are commonly injured
among intestine in blunt abd. Injuries.
o Marshall's triad in blast injury:
Small contusion + Punctate abrasion + Puncture
laceration.
e CECT is best for blunt trauma abdomen.
e CVP monitoring is ideal to determine fluid administration.
Not in case of abdominal trauma as raised intraabdominal
pressure contributes to CVP.
o TRI SS determines the probability of survival (Ps)of a patient
from ISS and RTS using the formula Ps = l/(l+e41)
o Score for assessing outcome of SAH (subarachnoid
hemorrhage) •• _ HESS and Hunt score
FLAIL CHEST
e Results from # of at least 2 sites of 3 adjacent ribs.
a Often accompanied by physiological dearrangements.
Critical Care
e 0/g: by inspection asymmetrical chest \1131\ movement and
paradoxical movements are seen in spontaneously breathing
patient.
e Tit Mainly ventilatory support. Mechanical ventilation
should be started if Pa02 is <70 mm Hg.
e Surgical stabilization (prcfenably internal) is advocated
now a days.
Scoring Systems for Critical Patients
Glasgow coma scale (GCS)
Mos1 widely used
Originally used to predict the outcome after head injury in
adults.
Normal score is 15
Based on Eye opening, verbal response and motor response
(E4V5M6)
Revised trauma score -
Includes GCS + RR + SBP
Other scoring systems
e. APACHE (Acute Physiology And Chronic Health
Evaluation)
c MPM (Mortality Probability Model)
c SAPS (Simplified Acute Physiology Score)
c PRISM Ill {Pediatric), PIM 2 score
+ APACHE II scori11g system is 1/re sum of acute plrysiofogy
scores (vital signs. o�enation. lob mllla), GCS. age and
chronic Ir.ea/th points. Worst values during the first U hours
in the ICU sliould be used.
+ TRISSscore(Traumaa11dinjuryle\·erityscore) include:s- /SS
+ RTS + Age.
+ Modified Child- Pugh score is used for cirrl!OSis of liver in
adults.
+ CAT.S' is o C0110(/ian �ten,
HEAD INJURY
e Severe head injury is a/w a stress response c/by
hyperglycemia, which worsens the outcome.
e Prognosis in head injury patient is best given by GCS
(Glasgow coma score).
e Hypothermia is ccrebroprotective.
c- IPPV to produce moderately low normal arterial C02
(PaC02 35 mm Hg) is a/w l Cerebral swelling and! ICP.
671 _
 ROAMS

c. Factors advcrsly affecting the prognosis in head injury RESPIRATORY FAILURE

patient
I. Factors which! CBF -Cerebral ischemia
2. Hyperglycemia has always a bad prognosis in patients
of head injury
3. Factors which l ICP ---Cerebral vasodilatation by
hypercapnia
e- Factors a/w good prognosis in head injwy patient
I. Factors which t CBF -Hemodilution, T MAP and TCPP
TYPEI
raoz
<60; Pa001
<50 mm Hg)
Acute Pa01.W.
Pa002++
pH++ort
HC01++
-Pulmonuy embolus,

"'""""""'-
ARDS,
Pneumothorax,
Pneumonia
2. Factors which I ICP (intra cranial pressure)
--Hyperventilation.
3. Hypothermia
0; In a patient of head trauma with unexplained hypotension
evaluation of upper cervical spine is must.
,TypeD
INTRA CRANIAL PRESSURE (ICP) (Pa01 <60;
e Normal ICP is 2-12 mmHg PaC01>50
=Ilg) Respiratory ms paralysis,
II)- Early signs oft ICP include--- drowsiness and .J, level of
Flailcbestinjmy
consciousness. Sleepapnca
Change in level of consciousness is the earliest and m/c Brain stem lesion
N�ticdrugs
manifestation of raised JCT in a patient of head injury.
c Gol.dstandardmethodformonitoriogICP-lntraventricular
catheter
e Tit
- All potentially exacerbating factors must be eliminated
(i.e. hypenhermia, bypcrcarbia, high mean airway
pressure in ventilators, hypoxia)
- Emergent Tit of raised ICP is most quickly achieved by
temporary hypervenulaten, whichcausesvasocoostriction
and reduces cerebral blood volwne.
- Mannito\, 3% saline,
- Drainage of CSF. Head up or reverse Trendelenberg's Type Ill respiratory failure
position. G Is the result of lung atelectasis. Also called perioperative
- High dose barbiturates and hypothermia for refractory respiratory failure.
o Seen after GA, J. in FRC leads to collapse of dependent
lung units.

Type IV respiratory failure

+ Segmentofspine11,hichmust ben"a!uatedmcaseofrmaploined
e Occurs bee/of hypoperfusion of respiratory muscles in
hypotension in a head injury patient --- upper cervical
patients of shock.
+ In head rrauma Of!1 s!_'!*,e,c>,10�Dfic:.��ma is seen.
e Patient of shock often suffer resp. distress d/to pulmonary
+ Stuoidr have been slro.,...,, to be highly effective in reducing
nuogenic edema (around broin tumorslotkr CNS lesions). edema, lactic acidosis & anemia.
ln1roumoticbraininjurysteroidshm-e,iotbeencffective in
reducing /CPI improving neurofogic outcome rother adds
domage by causing hyperglycemia.
ARDS (Adult Respiratory Distress Syndrome
or " Shock lungs ")
e. Predisposing factors arc - Septicemia, fat embolism,
multiple transfusions.
_672
 Critical Care

� Causes are- Trauma, acute pancreatitis, severe falciparum neonates.

malaria, amniotic fluid aspiration, Gram negative sepsis, a Indications of CPAP are -
smoke inhalation/ Cl2 gas • Inability to maintain Pa02 > 50 mm Hg in spiteofFi02
� Pa/ho - pulmonary edema, stiff lungs ('baby lung '), 60%.
fibrosis, alveolar damage. - PH<7.2
o Diagnostic criteria or ARDS are -- - PaC02 > 50 mm Hg
1. Pa02/Fi02 ratio <200 mmHg, - Prolonged apnea of prematurity
2. Onset acute, presence of predisposing factor, - Severe tachypnea and exhaustation.
3. 8/1 intersitial infiltrate, o Mndes alluwi11gfnr sponmneous ventilation
4. Absence of left atrial hypertension. • IMV
e Labtr - SIMV
- Hypoxemia, hypercapnia, pulmonary HTN, PAWP • PSV/CPAV
normal - HFV (High frequenc"y ventilation)
- Normal PCWP in ARDS distinguishes it from - APRV (airway pressure release ventilation).
cardiogenic pulmonary edema Q fPPV is also k/as controlled mechanical ventilation

- Uremic lungs arc char/by diffuse alveolar injury & o, HFV and APRV are used in ARDS patients.

pulmonary edema c CPAP is 1\1/c used fonn or mechanical ventilation in

o Tit children.
- Lung protective ventil\ation (low tidal volume and high
PEEP) Weaning from ventilators
- Oxygen, treat the cause o Modes used for weaning from ventilators are
- Use of newer modes of ventilation like partial liquid SIMV, IMV, CPAP, PSV, SBT, T piece
vcntillation, inverse I: E ratio, prone position vcntillation, <' Criteria to met before initiating weaning in children
APRV,ECMO - Alertmentalstatus
- Good cough and gag reflexes
+ "Wet lung" termi.rusedfQT/unpinCHF - Core temperature -os.ssc
+ Acute life threatening pulmonary edema i.r treated by - - pH 7.43:).47
Morphine./msemide. CPAP. 0.1}'gt'11. Glycerol trinilrote etc.
- Pa02 >60 mmHg
- Fi020.5 or less
• PEEP:9
- No clinical need to t support in last 24 hours
VENTILATO� - No planned operative procedures requiring heavy
sedation in next 12 hours.
Change in settings for Correction of ABG e I: E ratio
- Normal 1:E ratio is 1:2
- During artificial ventilation, it should be set at I : 2 to
ensure complete expiration.
- In HMD & ARDS, the time constant is J.ed and the
tlnspiratorytime desired I : E ratio is set at 1.5 : I or uptc 2 : I (Klas
t PEEP Inverse IE ratio)
- In MAS/obstructive airway dis/ asthma expiration is
+ When Pa02 is lrigh defi"d 1"et1f1101or settings to lower PaO! - prolonged, time constant is t ed and the desired I : E
are--lPEEP. l PIP. l FiOZ ratio is I: 2.7orupto I: 4
e PEEP
e Negative pressure ventilation is currently not in use. - Is generally kept between 4-6 cm of water it should
e Combination of mandatory and spontaneous breath is be kept on the lower side in f ICT,pneumothorax,
intermittent mandatory ventilation (IMV) or SIMV hypovolemia, pericardia! tamponade.
e Most popular mode of ventilation is IPPV & CPAP in - Is used to overcome physiological resistance of circuit.,
673_
 ROAMS
& in case of pulmonary edema.
PIP
- Should be kept below 30 cm of water
o HFV
I. High frequency PPV, HF oscillations and HF jet
ventilation modes are available.
2. Indications are : Bronchoscopy, bronchop\eural fistula,
and cricothyroid membrane puncture, for which jet HFV
is used in emergency.
PULSE OXIMETRY
------
e ls a simple and non-invasive method of monitoring the %
of Hb which is saturated with oxygen (measures ox:ygcn
� not 02 content)
e BasedontheprincipleofBeer-Lambertlaw,whiehstatcs
that the concentration of an unkown solute in a solvent can
be detennincd by light absorption.
L(out)==L(in)-DCA
e Wave length of 660 mm (red) and 940 mm (infrared) are
used by photodetcctor for absorption characteristics of two
Hb, reduced Hb and ox:y Hb respectively.
+ Pulse oxymeter falsely detects 01 soturation of 85% in
methhemoglobinemia.
+ Carboxy lremoglobin will be interpreted as oxy-Hb by 1he
pho1odetector ofpulse oximeter (because carboxy Hb and oxy
Hb have verysimilarabsorboncies al 660 nm) thus�
pulff: orimeler will over estimate the mt11ra1ion in qmence
+ Arterial 0, ihould be maintained bin 92-96 %/or acu/e
condition&. 88-9�.lo/or chronic conditions lo �nt ROP
Potential inaccuracy of pulse oxymetry may bed/to:-
ID Dyshcmoglobinemia (Carboxy-Hb, met-Hb)
III Dyes and pigments (methylene blue), nail polish,
bilirubin
e Low perfusion
ID Interference from external light sources and optic shunt
e Movement interference
e In Methcmoglobincmia 02 saturation is falsely seen around.
85% in pulse oxirneter.
ID Central cyanosis is seen when level of
Reduced Hb > 5gm% or
Methemoglobin > 1.5 gm% or
Sulf-hcmoglobin > .5 gm% or
02saturation<85%
_674
CARDIAC ARREST AND CPR
e M/c type of ECG rythm at the time of cardiac arrest
- in children - Pulse\ess electrical activity
- and in adults -VT without pulse
e Mic cause of cardiac arrest in children is-- hypoxia (rescue
breaths are more effective)
ID i\.1/c cause of cardiac arrest in adult is -- cardiac causes
(chest compression are more effective)
c In hospital setting, tracheal intubation is the preferred
method of maintaining a patent airway in an unconscious
patients with cardiac arrest. Prior to intubation an
J oropharyngeal airway can be used 10 prevent fall of tongue.
Outside hospital settings BMV is still preferred.
e The standard ventilation bags used during CPR have a
volume of 1600 ml
e To minimize the circulatory adverse effects of
hyperventilation, avoid lung ventilation> IO breaths/min.
e Any dextrose containing fluid should be avoided.
«' InCPR
DOC for asystole in CPR: Adrenaline
DOC for bradycardia in CPR : Atropine
a The first step in CPR is circulation now a days ( C-tA-tB
Circulation-t airway-e breathing sequence)
1. A clear airway is obtained by supine positioning and
opening the airway by head tilt, chin lift, or jaw thrust
However; in case of trauma (or head injury) only jaw
thrust is used to open the ainvay, Head tilt and chin lift
should 1101 be used.
a AHA guidelines for CPR
Compression 90/min -100/ -100/min �JOO/
min min
'Coinpressionto 3:1 10:2 15:2� 30:2
ventilationratio 1(2�er) (sing!� l(lf™>ltSCUCr (or15:J)
Newer recommendations in CPR
e Chest compression to ventillation ratio is 30:2
o I-shock strategy instead of 3- shock strategy
e Sequence is now CAB Compression -e airway-e
breathing.
e Look,listen,and feel has been removed.
e Glucose and calcium conuining solutions arc to be avoided