Summary Sheet:

Induction Agents
BAA
GA

l i sm
Propofol b o ↓SVR | ↓Contractility | ↓MAP | +/- ↑ HR
a
et
Weak acid M
lipid emulsion

IV Induction: 1.5-2.5mg/kg Resp. depression | ↓Laryngeal reflexes

pH 7
1% or 2%

Excretion
pKa 11 ↓CBF | ↓CMRO | ↓ICP | Excitation
IV Maintenance : 4-12mg/kg/hr
VD 4L/kg
Antiemetic
IV Sedation : 0.3-4mg/kg/hr Cl 30-60ml/kg/min

A A
GAB

m ↓SVR | ↓Contractility | ↓MAP | ↑ HR

l i s
Thiopentone a b o
et Resp. depression | Laryngo/bronchospam
Weak acid M
IV Induction: 4-6mg/kg pH 11 ↓CBF | ↓CMRO | ↓ICP | Anticonvulsant
Barbiturate
Excretion

pKa 7.6
25mg/ml Reduced Splanchnic/Renal bloodflow
VD 2.5L/kg
Cl 3ml/kg/min Porphyria

BAA
GA
s e Stable | +/- ↓MAP
e ra sm
Etomidate s t ol i
E ab
Weak base et Transient Apnoea | ↓VT with ↑RR
M
IV Induction: 0.3mg/kg Imidazole pH 8.1 ↓CBF | ↓CMRO | Epileptiform EEG
Excretion

& Ester pKa 4.2

PONV | Adrenosuppression
2mg/ml VD ~3L/kg
Enantiopure R (+) Cl 10-20ml/kg/min Antiplatelet

DA
N M

sm
Ketamine bo
l i ↑HR | ↑C.O. | ↑CVP | ↑MAP
t a
e
Weak base M
Phencyclidine

↑RR | Bronchodilation
IV Induction: 1-2mg/kg
Derivative

pH 3.5-4.5
↑CBF | ↑CMRO | Emergence phenomena
Excretion

IV Maintenance : 0.5mg/kg pKa 7.5

VD 3L/kg PONV | Salivation | ↑Uterine tone
IM Induction : 10mg/kg
Cl 17ml/kg/min
 Potency directly
Onset/Offset Speed
proportional to
inversely
Oil :Gas Partition
proportional to
Coeffi cient &
Blood:Gas Partition
inversely
Coeffi cient
proportional to MAC

Summary Sheet:
Volatile Anaesthetics
MAC
O

↑ HR ↓ BP ↓ SVR ↓ Contractility
1.1 Potent

Isoflurane Oil:Gas ↑ RR ↓ VT 0.2%

Trifluoroacetic Cheap
98 ↑ CBF ↓ CMRO Acid
No toxic
metabolites
Blood:Gas
↓ Uterine tone

1.4

MAC
O

↓ BP ↓ SVR ↓ Contractility
2.0 2%
Potent
Flourides
Sevoflurane Oil:Gas ↑ RR ↓ VT Bronchodilation
Cheap
53 ↓ CMRO
Rapid
onset/offset
Blood:Gas
↓ Uterine tone Compounds
A-E
0.7

O
MAC

↑ HR ↓ BP ↓ SVR ↓ Contractility 0.02%

6.6
Trifluoroacetic
Very rapid
Desflurane Oil:Gas ↑ RR ↓ VT Irritant Acid
onset/offset

19 Minimally
↑ CBF ↓ CMRO
metabolised
Blood:Gas Carbon
↓ Uterine tone
Monoxide

Tec 6 Vapouriser
0.4

Minimum Alveolar Concentration: the concentration of inhalation anaesthetic at 1ATM & FiO2
100% at which 50% of subjects will fail to respond to a standard surgical stimulus.
 ↑ Unionised fraction μ1 Receptors
= Fast onset
Analgesia & Euphoria
Miosis
Duration of action
determined by:

Distribution
Summary Sheet: μ2 Receptors
↓ HR

Opioids
(e.g. Fentanyl short due to ↑ VD)

Respiratory Depression
Elimination
(e.g. Remifentanil short due to
rapid ester hydrolysis) ↓ Gut Motility

μ
Induction
analgesia
Fentanyl
pKa 8.4 Fast-acting
Norfentanyl
Unionised at pH 7.4: 9%
50mcg/ml

Short-

Excretion
VD 4L/kg acting
10mcg 1mg
Fent Morph Cl 13ml/kg/min
Renal failure
Terminal t½: 190mins PCAs

Synthetic Piperadine Derivatives

μ

Alfentanil Induction
analgesia
pKa 6.5 Inactive
metabolites Ultrafast-
Unionised at pH 7.4: 90%
acting
500mcg/ml

Excretion

VD 0.4-1.0L/kg
100mcg 1mg Ultrashort-
Alf Morph Cl 6ml/kg/min
acting
Terminal t½: 100mins

μ IV Infusion
analgesia
Remifentanil AFOIs /
pKa 7.1 extubation
1mcg / Unionised at pH 7.4: 70% Esterase Ultrafast-
2mcg / VD 0.2-0.3L/kg Metabolism acting
10mcg 1mg 5mcg
Cl 30-40ml/kg/min
Remi Morph Shortest-
Terminal t½: 3-10mins acting

μ +κ
Phenanthrene

Morphine Intra/Post-op
analgesia
pKa 8.0
Conjugates
Unionised at pH 7.4: 23% Long acting
Excretion
10mg/ml

Generally diluted with VD 2-3L/kg

saline in a 10ml syringe
to 1mg/ml Cl 15-30ml/kg/min PCAs
Terminal t½: 180mins
 Depolarising Non-Depolarising
Neuromuscular Neuromuscular
Blockade Blockade

Aminosteroids
Suxamethonium
Benzylisoquinoliniums
Summary Sheet:
Neuromuscular Blockade

Rocuronium Onset: 1-2 mins RSI

VD 0.2L/kg

Monoquaternary Aminosteroids
50mg Duration: 20-35 mins 50% Fully
Dose: 0.6mg/kg Reversible
in 5ml Cl: 5ml/kg/min
RSI Dose : 1mg/kg
Elimination: Urine & Bile 50% Medium-
acting
S N

No histamine
Vecuronium Onset: 3-5 mins release
10mg VD 0.2L/kg
Fully
Dose: 0.08mg/kg or Duration: 20-35 mins 60% Reversible
20mg Cl: 5ml/kg/min
powder Medium-
Elimination: Urine & Bile 30% acting
S N

Bezylisoquinolinium
Atracurium Onset: 2 mins
VD 0.16L/kg Safe in Renal
& Liver Failure
Duration: 20-35 mins
Dose: 0.5mg/kg Medium-
10mg/ml

Cl: 5ml/kg/min
acting
Elimination: Esterases & Hoffman Degradation
N

Suxamethonium Onset: 30-60 secs RSI

Duration: 2-6 minute
IV Dose: 1-2mg/kg Elimination: Butyrulcholinesterase IM/IV
administration
IM Dose: 3-4mg/kg
50mg/ml

↑ Gastric pressure ↓ HR
↑ LOS tone Short-acting
Irreversible ↑ IOP Myalgia

S = Fully reversible by Sugammadex N = Reversible by Neostigmine

 Summary Sheet:
Reversal Agents
n t i- se
A tera
n e s
ol i
ch Neostigmine increases concentration of ACh at the NMJ to competitively reverse
residual non-depolarising block.
Glycopyrrolate/Neostigmine Glycopyrronium blocks the muscarinic side-effects of neostigmine to achieve CVS
stability.
1ml contains: Can only be used if at least 2 twitches present on Train of Four (ToF).
2.5mg Neostigmine Peak action: 10 mins
0.5mg Glycopyrrolate Duration: 20-30 mins
Dose: 1-2ml Elimination t½: 15-30 mins (hepatic & renal elimination)

l o cks nary
B ater s
no qu eroid
Mo inost
Am

Sugammadex ↓ HR
γ-Cyclodextrin ring chelates Rocuronium
& Vecuronium to reverse even profound
Reversal dosing:- neuromuscular block. Prolonged PT & APTT
2ml of
Immediate: 16mg/kg 100 Onset: <3 mins
mg/ml Elimination t½: 2 hours (renal elimination) Reduces Progesterone
PTC of 1-2: 4-8mg/kg
exposure - missed pill rules
ToF 2 twitches: 2mg/kg

↓/↑ HR & Arrhythmias |

Naloxone Antagonises opioid receptors
↓/↑ BP
Onset: 1-2 mins
400 mcg/ml

Bolus Dose: max. 800mcg Duration: 45 mins - 4 hours Nausea/Vomiting

IVI Dose: initially 60% of Elimination t½: 1-1.5 hours
initial resus bolus dose as (hepatic metabolism & renal
infusion per hour excretion) Dizziness / Headache

Arrhythmias
Flumazenil Competitive inhibitor of benzodiazepines
(& Zopiclone) at the GABAA binding sites.
Dyspnoea | Chest pain
Onset: 1-2 mins
100 mcg/ml

Bolus Dose: 200mcg

Duration: 20-50 mins Nausea/Vomiting
Elimination t½: 40-80 mins (renal
elimination) Altered mental states |
Vertigo | Headache | Seizures

ToF = Train of Four PTC = Post-Tetanic Count

 Summary Sheet:
Antiemetics
HIGHER CENTRES
(e.g. cortex, limbic)

ACh H1

VESTIBULAR +
GI TRACT VOMITING CENTRE CEREBELLAR NUCLEI
ACh 5-HT3 H1

CHEMORECEPTOR
TRIGGER ZONE
D2 5-HT3 μ

-H T 3
5
Synthetic Carbazole
Ondansetron Blocks vagal afferents from GI tract
2mg/ml

Central action at CTZ

Dose: 0.1mg/kg (4-8mg), 8o
Constipation ↓ HR Headache & Flushing

H1
Piperazine derivative
Cyclizine Reduces sensitivity of vestibular apparatus
50mg/ml

Also has anticholinergic properties

Dose: 1mg/kg (25-50mg), 8o
↑LOS tone | Dry mouth ↑ HR Drowsiness Blurred vision

D2
Phenothiazine neuroleptic
Prochlorperazine Central action at CTZ
12.5mg/ml

Occulogyric Crisis Dry mouth

Dose: IM 12.5mg, 12o
VTE, | ↑ QTc NMS | Parkinsonism | Lower seizure threshold

Dexamethasone Glucocorticoid
Unclear mechanism for antiemetic effects
Dose: 0.1mg/kg (4-8mg)
 Summary Sheet:
Vasopressors
Ohm’s Law as Applied to CVS Optimising Perfusion & C.O.
MAP - CVP = HR × SV × SVRα 1

C.O.

SV
Preload A)erload HR β1

β1 Contractility Preload SV β1

Adrenoceptors
α1 Vasoconstriction

α2 Vasodilatation
SVR α1
β1 Inotropy & Chronotropy

β2 Bronchodilatation & Vasodilatation

β2 Lipolysis & Thermogenesis

α1
Various presentations - check concentration!
Metaraminol
Onset: 1-2 minutes
Duration: 20+mins (tapers)
Bolus Dose: 500-2000mcg
Direct & Indirect (↑NA release) sympathomimetic effects
IVI Dose: 15-100mg/hr
Predominant α1 activity, some β1 activity
Conc.: 500mcg/ml
↑SVR therefore ↑ BP (± ↓ HR)

+ β
α 1

Onset: 1-2 minutes

Ephedrine
Duration: 10+mins (tapers)
Direct & Indirect (↑NA release) sympathomimetic effects
Dose: 3-6mg bolus
Monoamine Oxidase Inhibitor
Conc.: 3mg/ml Bronchodilatation
Both α & β activity
↑ HR, ↑ Contractility & ↑ SVR therefore ↑ BP
 Summary Sheet:
Antimuscarinics
Parasympathetic Nerves Parasympathetic Outflow

Miosis CN III Occulomotor

Ganglion
End
organ Glandular secretion
CN VII Facial
nAChR mAChR ↓HR & ↓Contractility CN IX Glossopharyngeal

Bronchoconstriction

Muscarinic ACh Receptors

CN X Vagus

Gall bladder motility

M1 CNS & Gastric Glands

Digestive function
Sacral nerves
M2 Heart
Sexual function
M3 Smooth muscle, GI tract & Glandular tissue
Detrusor contraction
M4 CNS
Vasodilatation
M5 CNS

h R
m AC

Atropine Inhibits post-ganglionic mAChR

Peak action: 2-3 minutes
Bolus Dose: 600mcg Duration: 30 mins
Crosses blood-brain barrier & high VD
Metabolised in liver

h R
mAC

Inhibits post-ganglionic mAChR

Glycopyrrolate

?
Peak action: 3-4 minutes
Duration: 2-3 hours
Bolus Dose: 200mcg
Does not cross blood-brain barrier
Metabolised unknown
Onset Speed
inversely Duration of action
proportional to pKa directly proportional
(i.e. directly to protein-binding
proportional to
unionised fraction)
Summary Sheet:
Local Anaesthetics
Chemistry Mode of Action
Local anaesthetics are all weak bases.
Amide Local Anaesthetics have.a longer
half-life and are metabolised in the liver. B + H+ B H+
Ester Local Anaesthetics are rapidly
inactivated by plasma/liver esterases.
Na+
Extracellular

Toxicity
Intracellular
Paraesthesia | Light-headedness &
Dizziness | Visual/auditory
disturbances | Confusion |
Shivering | Twitching | Seizures B + H+ B H+

Myocardial depression | Prolonged

phase 0 | Dysrhythmias | VF

Lidocaine pKa: 7.9

Max Dose: 3mg/kg
c ̅ Adrenaline: 7mg/kg
Unionised fraction at pH 7.4: 25%
Protein-binding: 70%
Elimination t½: 100 mins
Less lipid-soluble than Bupivicaine (so 8 × less potent)
Amides

pKa: 8.1
Bupivicaine Unionised fraction at pH 7.4: 15% Levobupivicaine
Protein-binding: 95%
Max Dose: 2mg/kg Elimination t½: 160 mins Less motor block & vasodilatation
c ̅ Adrenaline: 2mg/kg More lipid-soluble than Lidocaine 97% Protein-bound
(so 8 × more potent) Lower risk of cardio toxicity
Plasma Composition Maintenance Fluids

Osmolarity: 275-295mOsm/L First 4ml/kg =

Na+: 135-145 mmol/L 10kg
+
K+: 3.5-5.3 mmol/L

Summary Sheet:
Next 2ml/kg =
Cl-: 95-105 mmol/L 10-20kg

Mg2+: 1.5 mmol/L +

IV Fluids
Ca2+: 2.2-2.6 mmol/L >20kg 1ml/kg =
Glucose: 3.5-5.5 mmol/L
Bicarbonate: 24-32 mmol/L Hourly requirements =

Total Body Water IV Fluid Distribution

~60% body weight ~50-55% body weight

Body Fluid Compartments 5%

4%
0.9%
Glucose + Plasmalyte Colloid
Glucose 0.18% NaCl
NaCl

Transcellular
1%
7% 9%
Plasma 18% 18%
7%
25%

42%
Interstitial
25% ⅓ 100%

⅔ 82% 82%
67%
Intracellular
67% 48%

Extracellular Fluid
80% Interstitial 20% Plasma
Intracellular Interstitial Plasma

pH 7.4
308mOsm/L
pH 4.5 Crystalloids
pH 4.5 - 7.0 Na+ 140
pH 3.5-5.5 308mOsm/L K+ 5.0
4% 308mOsm/L
278mOsm/L Na+ 31 Cl- 98
5% Glucose Glucose + 0.9% NaCl Na+ 154 Plasmalyte
Gluc 278 0.18% Cl- 31 Acetate 27
Cl- 154
NaCl Gluc 222 Gluconate 23
Mg2+ 1.5

Good Good Renal

failure 2 hours
Colloids

plasma plasma plasma

expansion expansion Anaphylaxis expansion
Human Minimal risk
Albumin Starches ↓vWF & Dextrans Gelatins Anaphylaxis
side- Deranged
Solution Factor VIII risk
effects clotting