Anesthesia Revision E6.5 (Medicalstudyzone - Com)

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Anaesthesia Revision 1 01 1
ANAESTHESIA REVISION 1 ----- Active space -----
Pre Anaesthetic Checkup (PAC) 00:00:24
Past medical history :

Co-morbid condition Concerns
Continue all except ACE inhibitors & ARBs (as they can cause se-
Hypertension
vere hypotension).
• Target glucose level : 120-200 mg/dl.
• Skip OHGAs & insulin on day of Sx.
Diabetes Mellitus
• Long acting insulin : Reduced to 1/3rd.
• SGLT2 Inhibitors : Stopped 24 hrs prior (Chance of euglycemic
ketoacidosis).
Epilepsy • Continue antiepileptics.
• Avoid Enflurane, Methohexitone (seizure provoking).
Thyroid disorders Continue thyroid supplementation & anti thyroid drugs.
• MAO inhibitors (Interact with synthetic opioids →
hypertensive crisis) : Stopped 3-4 weeks prior.
Psychiatry
• Lithium or Mg2+ interact & prolong muscle relaxation :
Continued depending on patient condition.
• Low dose Aspirin (60-75 mg) : Can be continued.
High dose (150-300 mg) : Stop 3 days prior.
• Clopidogrel & warfarin : Stop 5-7 days prior.
• After stopping other anticoagulants/antiplatelet drugs,
bridged with LMWH :
Past H/O MI
- Prophylactic dose : Stop 12 hours prior.
- Therapeutic dose : Stop 24 hours prior.
- Regular heparin : Stop 6 hours prior.
• Ticlopidine : Stop 10 days prior.
• All other cardiac drugs : Continued.
Estrogen containing pills : High risk category (Stop 4 weeks prior)
OC pills
& Low risk (can be continued).
Steroid therapy Continue steroids.
Herbal medicine Check LFT & wait for 1 to 2 weeks if deranged.
On NSAIDS Stop 24 to 48 hours prior to surgery.
On sildenafil Stop 24 to 48 hours prior (intractable hypotension).
On diuretics Except thiazide, stop all drugs (monitor S. electrolytes).
Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

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2 01 Anaesthesia
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----- Active space -----

Personal history :
Condition Concern
Smoking Stop 6 to 8 weeks.
chance of bronchospasm (presents as wheeze) :
• Treatment : Beta 2 agonist (Salbutamol).
chance of laryngospasm (Stridor→ Desaturation) :
• Treatment : 100 % O2.
Propofol.
Succinyl choline (severe cases).
Alcohol Stop 24 to 48 hours. Check LFT.
Tobacco chewing Chances of difficult intubation.
Allergy history → Anaphylactic shock :

Most common presentation.
Etiology : Antibiotics, latex, Muscle relaxants, local anaesthetics.
Pathophysiology : Release of histamine.
Clinical presentation :
• Sudden unexplained tachycardia.
• Hypotension.
• Increased airway resistance.
• Edema of face, lips, tongue etc.
• Wheeze.
Management : Adrenaline (1 ml of 1 : 10000 IV / 0.5 ml of 1 : 1000 S/C or IM).
Family history → Malignant hyperthermia :

Severe mortality under general anaesthesia.
Etiology : All inhalational anaesthetics & succinylcholine (only in those with family
history/muscular disorders).
Pathophysiology : Mutation of Ryanodine receptors at sarcoplasmic reticulum.
Clinical presentation :
• Sudden unexplained tachycardia.
• Hypertension.
• Increased body temperature.
• Increased ET CO2.
• Ventricular fibrillation (d/t release of K+).
• Sudden cardiac arrest.

Management : ----- Active space -----

• Stop inhalational agents.
• 100 % O2.
• Dantrolene sodium.
• Calcium gluconate, salbutamol, insulin + dextrose (for management of
hyperkalemia.
Postoperative complication : Acute kidney injury (myoglobin release).
ASA grading :
ASA grading
I Normal healthy patient.
II Mild disease with no functional limitations. Eg : Asthma.
III Moderate disease with functional limitations. Eg : CKD, CLD.
IV Severe disease which is threat to life. Eg : Unstable angina, MI.
V Moribund patient who is not expected to survive >24 hrs.
VI Brain dead patient.
Investigations :
1. CBP : Minimum acceptable Hb : 8 gm/dl.
2. Platelet count :
• For invasive procedure : 50,000 (minimum acceptable count).
• For surgery : 80,000 - 1,00,000.
3. ECG.
4. CXR.
Risk stratification 00:26:10
CVS risk stratification :

High risk for post op cardiac events :
1. High-risk surgery.
2. H/o Ischemic heart disease.
3. H/o congestive heart failure.
4. H/o cerebrovascular disease.
5. Diabetes mellitus requiring insulin.
6. Creatinine > 2.0 mg/dL.
• When should be patient operated if he has coronary stenting :
a. > 30 days after bare metal stent.
b. 6 months for drug eluting stents.
• After URTI : wait for 6 weeks.
4 01 Anaesthesia

Pre operative instructions 00:27:13
Pre medications → (5A’s) :

1. Anxiolytic : Short acting benzodiazepines.
2. Anticholinergics : Atropine /Glycopyrrolate (reduce airway secretions).
3. Anti emetics → High risk group include :
• Females. Fasting guidelines :
• History of motion sickness/ opioid use. 1. Adult : 6-8 hours.
• Laparoscopy. 2. Child :
• Middle ear surgery. • 2 hour : Clear fluids.
• Ophthalmic surgery. • 4 hour : Breast milk.
4. Analgesics. • 6 hour : Solids.
5. Antibiotics.
Monitoring of patient 00:30:09
Monitoring the patient
Basic Advanced
CNS CVS Resp Neuro Temperature Blood loss

muscular
CNS monitoring :
Bispectral index :
• Assess depth of anaesthesia.
• Working principle : Analyse EEG wave forms.
• Target value : 40-60.
CVS monitoring :
1. Pulse rate/ heart rate.
2. Non invasive blood pressure monitoring (NIBP) :
• Oscillatory method : Automatic NIBP machine.
3. ECG :
• Monitor lead 2 : To detect arrhythmia.
• Monitor lead V3, V4, V5 : To detect ischemia, infarction.
4. Invasive blood pressure monitoring (IBP) :
• MC site : Radial artery.
• Allens test : To check for adequate collateral circulation.
• Femoral artery : Used for major surgeries.
5. Central venous pressure (CVP) monitoring : ----- Active space -----

• Normal CVP value : 0 - 5 cm.
• M/C site : Internal jugular vein.
• Function :
a. Detect right sided heart function.
b. Fluid status.
Low CVP + Low BP Hypovolemia Triple lumen catheter for CVP
High CVP + Low BP Right heart failure.
• Other sites : Subclavian vein (pneumothorax), femoral vein (infection).
• Not used for rapid resuscitation.
6. Pulmonary capillary wedge pressure (PCWP) :
• Function of left side of heart.
• Normal : 12-16 cm.
• Invasive procedure.
• Complication : Pulmonary artery rupture.
7. Echocardiography. Swan Ganz catheter
Respiratory monitoring :
Pulse oximeter :
• Principle : Beer Lambert’s law.
• Emits : Pulse oximeter
• Red light : Reduced Hb.
• Infrared light : Oxygenated Hb.
• CO poisoning (fire accidents) : Falsely elevated values.
• Meth Hb, dye, henna on hand, jaundice, thick skin : Falsely low values.
Capnography :
• Monitor exhaled CO2.
• Functions :
a. Surest sign of intubation.
b. Recommended to monitor CPR performance. Capnograph
c. Diagnose malignant hyperthermia.
d. Diagnose endotracheal tube disconnection.
e. Diagnose venous air embolism.
III
IV/0
II
Waveforms : I I
Normal :
1. Phase 1 : Exhalation of gases from dead spaces.
2. Phase 11 : Gas exhaled from upper alveoli.
3. Phase 111 : Gas exhaled from middle & lower alveoli.
4. Phase 1V/0 : Inspiratory phase.
6 01 Anaesthesia

Variations of Waveforms
Rebreathing/ exhausted sodalime

(elevated baseline/phase 1) Spontaneous breathing
Normal phenomena
Bronchospasm/COPD (shark fin pattern)

(Increased upstroke of phase III). Cardiogenic oscillations (pediatric)
Hypoventilation
Curare cleft :
• Notch in phase 111.
• Patient recovering from effect of
muscle relaxants.
Hyperventilation
Malignant hyperthermia : Leaky sampling line :

(step ladder pattern). (2 plateaus in phase 111).
Incompetent inspiratory valve Single lung transplant :

(2 peaks in phase 111).
Accidental extubation/ sudden disconnect Esophageal intubation

Neuro- muscular monitoring : ----- Active space -----

M/C : Ulnar nerve.
Patterns of stimulus :
1. Single twitch stimulation : Cannot differentiate
between DMR& NDMR.
2. Train of four (TOF) :
• 4 supramaximal stimulus at every 0.5s (2Hz).
• If TOF Ratio > 0.9 → Safe for extubation.
TOF Ratio = 4th amplitude
1st amplitude
3. Tetanic stimulation : Used for monitoring of deeper blocks (painful).
4. Double Burst Stimulation : Less painful.
Normal NDMR DMR

Train of
Four
Tetanic
Stimulation
Features Constant Fading Constant

(Normal amplitude) (Diminishing amplitude) (Reduced amplitude)
Core body temperature monitoring :

Monitoring sites Procedure
Nasopharynx & tympanic membrane CNS surgery.
Pulmonary capillary temperature
CABG.
(most accurate)
Mid oesophageal temperature
GI surgery.
(M/c done)
• Intermediate between core &
Rectal temperature surface temperature.
• A/C frostbite.

8 02 Anaesthesia
----- Active space ----- ANAESTHESIA REVISION 2
Airway Examination 00:00:26
Examination Inference
Predictors for difficult Obesity, Bearded, Elderly, Snorer, Edentulous, Pregnant
intubation (OBESE Pregnant lady).
Mouth opening Finger breath technique (Normal = 3 fingers).
• Normal : 12-35˚ (<12˚- Difficult intubation (DI)) Seen
in Ankylosing spondylitis.
Atlanto-occipital movement • Angle made by Forehead : From complete flexion to
extension (<80˚ DI).
• Neck circumference (>43 cm DI).
Thyro-mental distance Normal : 6.5 cms (<6 cm DI).
Normal : 13 cms (<12 cm DI).
Sternomental distance
Restricted in post bone contractures.
Mallampati scoring :
Mallampati scoring
Grades Structure seen
Grade I Uvula hanging freely.
Grade II Tip of uvula not visible.
Grade III Half of Uvula not visible.
Grade IV Only hard palate visible.
Intubation :
Preoxygenation
Preoxygenation :
100% O2 (for 3mins) → Apnea period can be Induction agents
Extubate
extended to 10 mins.
Emergency intubation :
• 8 > 4 vital capacity breaths. Muscle relaxants
Attenuate response
Muscle relaxants :
Succinyl choline (Sch) : Rapid sequence intubation/RSI.
Rocuronium : When Sch is C/I (Modified RSI).
Attenuate response :
To attenuate the sympathetic response as a result of laryngoscopy.
Drugs for attenuation : Preservative free lignocaine (IV/spray) (or) Nitroglycerine
(or) Opiods (Alfentanil/Fentanil) (or) short acting β blocker (Esmolol).
Airway Equipments 00:09:27 ----- Active space -----
Anatomical face mask :

Preoxygenation by :
• C & E technique with pressure of <25cms of H2O.
• Triple maneuver : Head tilt, chin lift, jaw thrust. Anatomical face mask
Chin lift Jaw Thrust
Head tilt
Triple maneuver
Guedels airway :
• Prevents tongue fall back.
• Disadvantage : Stimulates Gag reflex.
Guedels airway
• Size : Angle of mouth to tragus/mandible.
Nasopharyngeal airway :
• Prevents collapse of pharynx.
• No gag reflex stimulation.
Nasopharyngeal airway
Laryngoscope :
Macintosh/Curved blade Miller’s/Straight blade
Used in Adults Children.
Method Hold laryngoscope in left hand Same as adults
except :
Insert from Right corner of mouth. • Inserted from
center of oral
Push tongue to side till blade reaches its base cavity.
• Include epiglottis.
On visualising epiglottis (don’t include) : Lift hand
using triceps & deltoid.
Note : Do not use wrist joint.
Image
Endo-tracheal tube (ETT) :

1. PVC cuffed ETT :
• Low pressure high volume cuff.
• Function of cuff : Prevents aspiration.

10 02 Anaesthesia
----- Active space ----- 2. Uncuffed ETT : Used in children.

3. Microcuffed ETT : Preferred in children (as Subglottic region is narrowest)
Size of ETT Formulas to calculate size of ETT :
Adult males : 8.0/8.5/9.0 1. <6 years : Age + 3.75
3
Adult females : 7.0/7.5/8.0 Age
Preterm child : 2.5 2. >6 years : + 4.5
4
Uncuffed ETT
Term baby : 3.0 Age
3. Length of ETT : + 12
Up to 1 year : 3.5 2
Signs of correct placement of ETT :

1. Chest lift : Bilateral & equal.
2. Mist formation inside ETT.
3. Auscultate : Bilateral equal air entry.
4. Capnography (ETCO2) : Surest sign. PVC cuffed ETT
5. Fibre optic bronchoscopy : Gold standard (used for

lung surgeries like pneumonectomy, lobectomy).
6. Last CXR : Used in ICU.
Accessory gadgets for ETT :
Stylet Magills forceps Bougie

Modifications of ETT :
1. Flexometallic tube :
• Does not kink on bending.
• Used for prone position surgeries like spine/head & neck surgeries.
2. RAE ETT : Used for cleft lip/palate.
3. Double lumen ETT : Pneumonectomy/lobectomy (Selectively ventilates lung).
South pole RAE ETT
Flexometallic tube North pole RAE ETT Double lumen ETT

Modern gadgets in intubation : ----- Active space -----
Air traque Video laryngoscope; Tru scope Ambu scope

less aerosol (Similar to fibre
production optic Bronchoscope)
Supraglottic airway devices : 00:26:05
1. Laryngeal mask airway (LMA) :

Advantage : Easy to use.
Disadvantage : Aspiration risk.
Base of tongue
Above esophageal sphincter
2. Proseal LMA : Modification of LMA.

Advantage : Drain tube sucks out secretions.
Preferred LMA.
3. LMA Supreme :
Made up of PVC.
High sealing pressure.
Gastric port present.
4. Fastrac LMA/Intubating LMA :

Gatric port absent.
Only ETT can be passed to secure airway.
5. I-gel/2nd generation airway :

Pilot balloon absent.
Silicon rubber grips the pharynx.
Gastric drain port present.
6. SLIPA (Streamline Liner of the Pharynx Airway)

12 02 Anaesthesia

Modifications for intubation 00:30:45
1. Normal : Flexion at lower cervical spine & extension at atlanto-occipital joint.

2. Obese patient : RAMP position/reverse trendelenburg position.
3. Spine surgery : Prone position.
4. Oral surgery : Nasal intubation.
• Children (adenoid hypertrophy).
• # base of skull. Contraindications
• Coagulopathy.
5. Emergency intubation : RSI - Rapid Sequence Intubation (Cricoid pressure of
40 newtons → Manual occlusion of esophageal lumen).
RSI Modified RSI
Preoxygenation No mask ventilation Gentle mask ventilation
Induction agent Thiopentone sodium Propofol
Muscle relaxant Succinylcholine (Sch) Sch/ Rocuronium
Method Cricoid pressure → ET tube placement →
Inflate the cuff → Release the cricoid pressure.
6. Intubation after Road traffic accident :
• In pneumothorax : Insert ICD → Endotracheal intubation.
• Protect ‘C’ spine : MILS (Manual in line stabilisation).
Difficult Airway Management :
Laryngoscopy Plan A :
Facemask ventilation & tracheal intubation.
Failed
Plan B :
Maintaining oxygenation : Supraglottic airway device insertion.
Failed
Plan C :
Final attempt at facemask ventilation & waking the patient.
Failed
Plan D :
Emergency front of neck access : Cricothyroidotomy.

Anaesthetic pharmacology
Intravenous Inhalational Muscle Local

induction agents induction agents relaxants anaesthetics
Intravenous induction agents 00:00:44
Intravenous induction agents
Barbiturates Non barbiturates

Barbiturates :
1. Thiopentone sodium :
Appearance Yellow amorphous powder with garlic smell

Onset 15 sec
Termination of action Redistribution
Agent of choice (AOC) Neurosurgeries (↓ICP, good anti-epileptic action),
Hyperthyroidism.
Adverse effects Intraarterial injection leads to severe pain, pallor,
cyanosis, edema, gangrene.
M/x : Do not remove cannula, inject NS or heparin
& stellate ganglion block.
2. Methohexitone :
• Can provoke seizures.
• AOC : Electroconvulsive therapy.

14 03 Anaesthesia

Non barbiturates :
1. Propofol :
Appearance White (contains egg lecithin) oily preparation
Contains soyabean oil (painful)
Use Use before 6 hrs
Dosage 1-2.5 mg/kg
Properties Quick recovery, antipruritic & antiemetic properties
Agent of choice (AOC) a. Day care surgeries.
b. Endoscopy, colonoscopy.
c. Sedation in ICU.
d. Treatment of laryngospasm.
Adverse effects Prolonged infusion : Propofol infusion syndrome (severe
metabolic acidosis + refractory bradychardia + arrest +
green color urine).
2. Etomidate :
Appearance Oily preparation (propylene glycol), painful
Properties Most cardiostable
Preferred for • Cardiac surgeries.
• Aneurysm surgeries of brain.
• Cardioversion procedures.
Side effects • Supression of adrenal hormone synthesis.

• Myoclonus.
• Highly emetogenic.
3. Ketamine :
• Stimulant (acts on NMDA receptor), ↑catecholamines.
• Dissociative anaesthesia.
Side effects • Unpleasant hallucinations (R/x midazolam).
• ↑oral secretions (R/x anticholinergics).
Uses AOC for :
• Shock (↑HR, BP), tetralogy of fallot, R→ L shunting.
• Short duration procedure (I & D, burns dressing).
• Post op/chronic pain m/x.
• Low resource setting..
R/x of depression.
Asthmatics (bronchodilation action).
C/I • Neurosurgeries (↑ICP), ocular surgeries (↑IOP).

• HTN, past h/o MI.

Muscle relaxants 00:22:36 ----- Active space -----
Depolarising muscle relaxants Non depolarising muscle relaxants
Depolarising muscle relaxants :

1. Succinyl choline (SCh) :
Dosage 1-2 mg/kg
Duration 10 minutes
Onset of action 30 seconds
AOC Difficult intubation/ rapid sequence intubation
Mechanism of action • Non competitive blockade : ACh receptor.
• Reversed (metabolised) by pseudocholinesterase.
Systemic effects • Bradyarrhythmia (Rx with atropine/glycopyrrolate).
• Sustained extraocular muscle contraction.
• Post op myalgia (d/t muscle fasciculations).
• ↑intragastric pressure & aspiration.
C/I • Family h/o malignant hyperthermia.
• Neuromuscular disorder.
• Preexisting hyperkalemia.
• H/o burns < 6 months
• Closed head injury, open globe injury.
• Sepsis.
• Hemoplegia/ paraplegia.
Reasons for prolonged duration of action
↓ concentration ↓ activity of pseudocholinesterase

• Liver failure • Liver disease
• Pregnancy • Pregnancy, old age, burns
• Drugs, OC pills
• Atypical pseudocholinesterase
• Phase II block : Large doses (> 5mg/kg)
Atypical pseudocholinesterase :
Genetically determined
Homozygous Heterozygous
Prolongs duration by 6-8 hrs Prolongs duration by 45 mins- 1 hr

16 03 Anaesthesia

Dibucaine number : Qualitative analysis of activity of pseudocholinesterase.
M/x :
• Continue mechanical ventilation.
• FFP to terminate action.
Non depolarising muscle relaxants (NDMR) : 00:40:10

MOA : Competitive blockade of ACh receptors.
End of surgery → Reversal agent (neotistigmine).
• Sequence of blockade : Diaphragm → Small muscles→ Intermediate
muscles → Large muscles
• Sequence of recovery : Diaphragm → Large muscles→ Intermediate
muscles → Small muscles
• Upper airway muscles are sensitive (post op head up position).
Pancuronium Sympathethic stimulation (used in shock patients), long acting

Vecuronium Most cardiostable
AOC : Cardiac surgeries, neurosurgeries.
Atracurium Metabolism : Hoffman degradation (non enzymatic clearance)
AOC : Liver & kidney transplant.
S/E : Histamine release → Anaphylactic shock.
Cisatracurium Isomer of atracurium w/o histamine release
Rocuronium Fastest onset (30 sec).
AOC : Rapid sequence intubation when SCh is contraindicated
Reversal : Sugammadex.
Combination is AOC in day care surgeries.
Mivacurium Shortest acting (10 mins).
Metablolism : Plasma esterases
Use : Day care surgeries (Rocuronium > Mivacurium).
Signs of adequate reversal :
• Regular respiration & adeqaute tidal volume.
• Spontaneous eye opening.
• Sponataneous limb movement.
• Able to protrude tongue.
• Able to cough, no cyanosis.
• Able to lift head > 5 sec.
• Able to hold tongue depressor b/w central incisors.
• Train of four ratio > 0.9 : Guaranteed recovery.

Local anaesthetics 00:50:51 ----- Active space -----
Amino amides Amino esters

Metabolised in liver Metabolised by plasma esterases
(except articaine). (except cocaine).
Lignocaine, bupivacaine, ropivacaine Procaine, chlorprocaine.
Structurally similar to PABA.
Can cause allergic reactions
Mechanism of action : Unionised form diffused through cell membrane →
Converted to ionised formed by low intracellular pH → Voltage gated sodium
channel blockade.
Sequence of blockade in regional anaesthesia : B > C > A nerve fibers.
Autonomic > Pain (sensory) > Motor.
Factors affecting action of LA :
Quick Onset ↑ Duration Absorption
• ↑Concentration of drug • ↑Dose of drug. Maximum
• PKa : Close to body pH • Adrenaline 1 : 2,00,000 absorption in
• Small myelinated fibres ↓systemic absorption ; intercostal
• Addition of NaHCO3 (↑non ion- ↑duration & toxic dose. nerve block.
ised form). • Narcotics.
Dose Toxicity
• Lignocaine : 3-5 mg/kg. • Circumoral tinnitus (1st sign of CNS toxicity).
• Lignocaine + adrenaline : 7 • GTCS (mainly lignocaine) : Rx with short
mg/kg. acting BZDs.
• Bupivicaine & ropivicaine : • Ventricular arrhythmias (CVS) : Mainly
2-3 mg/kg. Bupivacaine (R/x 20 % intralipid).
Applications :
• Labour analgesia :
a. 0.125 % bupivacaine (blockade of pain sensation only).
b. 0.2 % ropivacaine.
• EMLA cream : Lignocaine + Prilocaine : Painless IV cannulation
(surface anaesthesia).
• Biers block :
a. IV regional anaesthesia (tourniquet + IV anesthaesia).
b. Lignocaine 0.5 % or Prilocaine.
c. Not recommended : Bupivacaine

18 03 Anaesthesia
----- Active space ----- Cocaine Sympathethic stimulation, severe vasoconstriction, mydriasis.
Procaine Interacts with sulphonamides.
Chlorprocaine Shortest acting LA (used in day care surgery).
Prilocaine Toxicity : Methemoglobinemia
Lignocaine 5% : Spinal anaesthesia
4% : Gargles.
2% : Jelly.
1-2 % : Nerve blocks.
Ropivacaine Less cardiotoxic & motor blockade
Inhalational anaesthetics 01:08:36
For induction & maintenance of anesthesia.

Mayer overton rule : Lipid solubility ∝ potency.
Potency :
Minimum alveolar concentration (MAC) : Minimum amount of drug required to
produce immobility to painful stimuli.
MAC ∝ 1
potency
Factors affecting uptake of agent :
1. From machine → alveoli
• Concentration effect : Inspired concentration ∝ quicker induction.
• Second gas effect (at start of surgery) :
D/t rapid diffusion capcacity of N2O → Rapid onset of action of 2nd gas.
• Diffusion hypoxia/ Fink effect : Seen at end of surgery & opposite to sec-
ond gas effect.
• Alveolar ventilation ∝ more uptake (quick induction).
• FRC : Smaller FRC is easier to induce.
2. From alveoli → pulmonary circulation

• Blood gas partition coefficient (B/G) = Concentration of agent in blood
Concentration of agent in alveoli
• ↑B/G : More concentration in blood→more soluble →delayed induction
• ↓ B/G : Less concentration & solubility in blood → Quicker induction.
BG : Desflurane < N2o < Sevoflurane < Isoflurane < Halothane < Methoxyflurane.
MAC : N2o > Desflurane > Sevoflurane >Isoflurane > Halothane > Methoxyflurane.

Systemic effects of inhalational agents : ----- Active space -----
System Halothane Isoflurane Desflurane Sevoflurane

Pulmonary Sweet (2nd preferred) Pungent. Irritant. Sweet
system :↓ RR. Good bronchodilator. Avoid in Avoid in (1st choice in
asthmatics. asthmatics. children).
Asthmatics :
1st preferred.
↓ Pulmonary vascular resistance except N2O.
↓ Ciliary motility (except ether).
CVS : ↓ HR, BP. Max ↓ HR, Good Irritant Good.
Bradyarrhythmias. cardiostable, causes Cardiostable.
Sensitises Coronary steal initial
myocardium to phenomenon. tachycardia.
adrenaline.
CNS : ↑ Cere- Max ↑ CBF, ↑ICP. The rise in ICP is countered by hyperventilation
bral blood flow C/I in neurosurgery (↓etCO2 = ↓ICP).
→ ↑ ICP. Used in neurosurgery.
Enflurane causes seizures.
GIT, liver and Max ↓ LBF. - Minimally -
biliary tract : Metabolite metabolised.
↓ Liver blood causes halothane
flow. hepatitis in old age,
female, >40 yrs, mul-
tiple exposure.
Renal - Best agent Max fluoride
system : (Desflurane > Isoflurane) ions.
Fluride ions Sevoflurane
(added to + Soda lime =
make it non Compound A
inflammable) (nephrotoxic in
causes lower animals).
nephrotoxicity. Max nephrotoxicity : Methoxyflurane.
Uterus Good uterine relaxants (↑risk of PPH).
N2O : Teratogenic.
Muscular ↓ muscle relaxant usage.
system Trilene : Good analgesic.
Ocular ↓ IOP
Metabolism Max - Minimal -
Xenon N2O
Ideal anaesthetic agents. Blue cylinder at 760 psi pressure
But ostly Prolonged exposure : Interferes with Vit B12 metabolism caus-
ing megaloblastic anemia, SACD of spinal cord.
Avoided in pneumothorax, middle ear surgeries, ocular sur-
geries.
50% O2+ 50% N2O (Entenox) : Labour analgesia
20 04 Anesthesia
----- Active space ----- ANESTHESIA REVISION 4
Regional anesthesia
Central neuraxial blockade Peripheral neuraxial blockade
Spinal Epidural Caudal Nerve blocks
Spinal Anesthesia 00:01:02
Indications : Any surgery below the level of umbilicus.

Absolute C/I :
• ↑ ICP. • Severe hypovolemia.
• Coagulopathy. • Severe MS/AS.
• Patient refusal. • Allergy to drugs.
• Local site infection.
Location :
• Adults : L3-L4. • Children : L4-L5.
Procedure : 3 Ps.
1. Preparation : Strict aseptic precaution.
2. Position of patient : Prone, left lateral (or) sitting.
3. Projection of needle (layers encountered) : Skin → Subcutaneous tissue
→ Supraspinous ligament → Interspinous ligament → Ligamentum flavum
(toughest layer) → Dura mater → Arachnoid mater.
Needles :
Types
Based on action on Dura Based on gauge

size
Dura Cutting : Dura Splitting :
Eg. : Quincke, Babcock. Eg. : Whitacre, Sprotte.
Technically easier. ↑ PDPH. Technically difficult. ↓ PDPH.
Note : ↓ Gauge size → ↑ Bore size → ↑ PDPH (Post Dural Puncture Headache).

Www.Medicalstudyzone.comAnesthesia Revision 4 04 21
Post-Dural Puncture Headache (PDPH) : ----- Active space -----

Typically seen in women after LSCS.
Presentation : Dura cutting (Quincke needle)
• Occipital and frontal region.
• 24-48h after surgery.
• Dull, boring type.
• Aggravated by change in posture.
Dura splitting (Whiteacre needle)
• Relieved : Rest.
• Associated with nausea, vomiting, photophobia.
• Never associated with fever, neck rigidity.
Timing of ambulation doesn’t affect PDPH.
Treatment :
• Adequate bed rest + Plenty of oral fluids.
• Simple analgesics : Caffeine + paracetamol.
• Severe cases : Epidural blood patch. Gauges
Factors affecting height/Level Of Anesthesia (LOA) :

Drug factors :
• Baricity of drug = Density of drug
Density of CSF
• Drug + Dextrose → Hyperbaric → ↓ LOA.
• Drug + Distilled water → Hypobaric → ↑ LOA.
Patient factors :
• CSF volume ∝ 1 .
LOA
• Pregnancy : ↑ IAP → ↑ LOA → Dose of LA ↓ by 30-40%.
• Height ∝ 1 .
LOA
Procedure factors :
• Position : Hyperbaric drug in head down position → ↑ LOA.
• Epidural injection immediately post-spinal → ↑ Pressure → ↑ LOA.
Side effects :
Spinal anesthesia → Sympathetic blockade.

22 04 Anesthesia
----- Active space ----- Side effects of spinal anesthesia

1. CVS 1. ↓ HR (Rx : Atropine).
2. ↓ BP :
• Prevention : Preloading IV fluids.
• Rx : Pregnant → Phenylephrine
Non-pregnant → Ephedrine.
2. Respiratory 1. Low LOA : No effect.
system 2. High LOA : Only ICM paralysed (c/o shortness of breath).
3. GIT Sphincters relaxed.
4. GUT Urinary retention (M/C).
Epidural Anesthesia 00:16:11
Identification of epidural space :

Loss of resistance technique.
Epidural catheter set with Tuohy needle

Advantages Disadvantages
1. Prolong duration of anesthesia. 1. Technically difficult → Sometimes patchy block.
2. No chance of PDPH. 2. Delayed onset → Not suitable for emergencies.
3. LOA can be altered. 3. Catheter migration.
4. Stable hemodynamics. 4. Severe PDPH : If catheter pierces dura
High spinal Total spinal LA toxicity
C/o Shortness Enters arachnoid space Enters blood vessel.
of breath → Unresponsive patient Lignocaine : Seizures.
Bupivacaine : Arrhythmia.
Caudal Anesthesia 00:22:22
Only in children.
Location : S4-S5.
Advantage : No chance of neurological injury.
Disadvantage : Always accompanied by GA.
• Strict aseptic precautions to be taken.

Peripheral Nerve Block 00:24:15 ----- Active space -----
Brachial plexus block :

Can be done at 4 levels.
1. Inter-scalene approach : Shoulder and 2. Supra-clavicular approach :
upper arm surgeries.
Used for fracture of :

SA : Scalenus Anterior. • Lower humerus.
SM : Scalenus Medius. • Radius and ulna.
3. Axillary approach : 4. Infra-clavicular approach :
Blocks : Radial, ulnar & median nerves. Used for Radial, ulnar &
Used for : Forearm surgeries. Musculocutaneous nerve
Disadvantage : Doesn’t block blockade.
musculocutaneous nerve. Given under USG guidance.
Blocks at elbow :
Radial nerve block Median nerve block Ulnar nerve block

a : Finger palpating lateral a : Median nerve.
humeral condyle. b : Biceps tendon.
b : Biceps tendon. c : Brachial artery

24 04 Anesthesia

Blocks at wrist :
Ulnar nerve
Radial nerve
Median nerve
Blocks of the face :
Supraorbital
Infraorbital Anterior ethmoidal
Mental
Ankle block :


Anesthesia machine 00:31:40
Boyle’s machine Anesthesia workstation

Zones :
3 zones :
1. High pressure : Consists of gas cylinders.
2. Intermediate pressure.
3. Low pressure.
Gas cylinders :
Classification :
• Non-liquifiable. Eg. : O2 (2000 psi).
• Liquifiable. Eg. : N2O (760 psi).
Identification :
Gas Cylinder
O2 Black body with white shoulder.
CO2 Grey.
N2O Blue.
He Brown.
N2 Black.
Air White body with black shoulder.
Cyclopropane Orange.
Entonox Blue body with white shoulder.
Entonox : 50% O2 + 50% N2O.
Make of cylinders :
• Molybdenum steel alloy.
• Cylinders made of aluminium used in MRI rooms.

26 04 Anesthesia
----- Active space ----- Measurement of contents :

Bourdon’s pressure gauge :
Not required for N2O cylinder.
Safety feature :
1. Pin Index Safety Feature (PISS).
2. Bodock’s pressure seal.
PISS :
Prevents wrong connection beyween cylinder &
machine.
Gas PISS
O2 2, 5
N2O 3, 5
Air 1, 5
CO2 <7.5% 2, 6
>7.5% 1, 6
Entonox 7
Cyclopropane 3, 6
Bodock’s pressure seal :

Also called gasket/washer.
Prevents leakage of gases.
One pressure seal should be present.
Note : 1 mL of liquid O2 = 840 mL of gas O2.

O2 concentrator : ----- Active space -----

Principle : Pressure swing adsorbent
technology.
Provides 90-95% pure O2.
Intermediate pressure zone :

Components : Pipelines, O2 flush.
Pipelines : Unique feature : O2 fail safe valve.
O2 flush :
Denoted by O2+.
Temporarily hyperinflates lungs.
Low pressure zone :

Components : Flowmeters (aka rotameters).
Location of O2 flowmeter : Downstream.
Back bar
Flowmeters
Vaporiser installed on back bar → Vapourised liquid anesthetic → Patient
28 04 Anesthesia
----- Active space ----- Breathing circuits :
Mapleson circuit Other name Use

Mapleson A circuit Lack circuit Spontaneous respiration.
Mapleson D circuit Bain circuit Controlled ventilation
Mapleson F circuit Jackson Rees circuit Used in children.
Mapleson circuits
Soda lime/closed circuit :

aka circle system.
Key component : Soda lime.
Mechanism : CO2 is reabsorbed
and gases are recirculated.

Critical Care 00:00:36
Care of patient on vventilator.

Ventilator modes
Pressure control : VT , FiO2 , RR, I : E is provided. Pressure is fixed. Tidal volume is monitored.
Volume control : VT is fixed. Pressure/airway resistance is monitored.
PEEP (Positive End Expiratory Pressure) : Invasive FiO2 , BP.

CPAP (Continuous Positive Airway Pressure) : Non invasive.
In the table above, VT-Tidal volume , RR - Respiratory Rate, I:E - Inspiratory : Expiratory ratio.
Applied aspect :
• Acute pancreatitis → ARDS like presentation → If PaO2 is normal, FiO2 is re-
duced to avoid O2 toxicity.
• COPD → RR : Increased & PEEP : Minimal to eliminate excess CO2.
Oxygen Therapy 00:10:25
Indications of oxygen therapy :

• Acute hypoxemia (PaO2 < 60 mm Hg; SpO2 < 98 %).
• Cardiac/Respiratory arrest.
• Hypotension (systolic BP < 100 mm Hg).
• Low cardiac output + metabolic acidosis (HCO-3 < 18 mmol/L).
• Respiratory distress (RR > 24/min)
Oxygen Delivering devices :
1. Low flow variable performance devices :
Nasal prongs Simple O2 mask Non Re-Breather mask/
O2 mask with reservoir bag
Flow rate 1-6 litres/min 6-10 litres/min 10-15 Litres/min
Max FiO2 44% 60-65 % 90-95 %

30 05 Anaesthesia

2. High flow fixed performance devices :
• Venturi Mask :
Used in COPD.
Fixed O2 concentration.
• High Flow Nasal Cannula (HFNC) :
Used in COVID.
Flow rate : 40-80 Litres/min. Venturi mask High flow nasal cannula
Basic and Advanced Life Support 00:13:12
Adult BLS Algorithm :

Adult Cardiac Arrest Algorithm : ----- Active space -----

32 05 Anaesthesia

High Quality CPR :
• Push hard at least 2 inches (5 cm) and fast (100-120/min) and allow complete
chest recoil. Minimize interruptions in compressions.
• Avoid excessive ventilation.
• Change compressor every 2 minutes, or sooner if fatigued.
• If no advanced airway, 30 : 2 compression-ventilation ratio.
• Quantitative waveform capnography :
If PETCO2 is low or decreasing reassess CPR Quality.
Shock energy for defibrillation :

• Biphasic : 120-200J
• Monophasic : 360 J
Drug therapy :
• Epinephrine IV/10 dose : 1 mg every 3-5 minutes
• Amiodarone IV/10 doses :
First dose : 300 mg bolus.
Second dose : 150 mg or Lidocaine IV/IO (First dose : 1-1.5 mg).
Advanced airway :
• Endotracheal intubation or supraglottic advanced airway.
• Waveform capnography /capnometry to confirm & monitor ET tube placement.
• Once an advanced airway is in place, Give 1 breath every 6 seconds (10
breaths/min) with continuous chest compressions.
Return of Spontaneous Circulation (ROSC) :

• Monitor pulse & blood pressure.
• Abrupt sustained increase in PETCO2 (typically 40 mm Hg).
• Spontaneous arterial pressure waves with intra-arterial monitoring.
Reversible causes : (5H & 5T)

• Hypovolemia • Tension pneumothorax
• Hypoxia • Cardiac Tamponade
• Hydrogen ion (acidosis) • Toxins
• Hypo/hyperkalemia • Thrombosis (Pulmonary)
• Hypothermia • Thrombosis (Coronoary)

Adult tachycardia with a pulse algorithm 00:17:02

Assess responsiveness, HR ≥ 150 Note :

• Tachycardia : HR ≥ 100 bpm.
maintained Airway, Breathing, Circulation. • Tachyarrhythmia : HR ≥ 150 bpm.
Connect ECG, and IV access. 5 features of hemodynamic instability :
Identify and treat underlying cause • BP .
• Shock.
Persistent Tachyarrhythmia • Altered mental status.
• Ischemic discomfort.
• Acute heart failure.
Assess hemodynamic stability
Unstable Stable
Synchronised Cardioversion/ DC shock. Check if wide QRS complex

Consider Adenosine if narrow QRS Complex.
Yes No
Antiarrhythmic infusion. 1. Vagal maneuvers.

Consider Adenosine only if 2. Adenosine.
regular and monomorphic. 3. β blockers/ Ca2+
channel blockers.
Antiarrhythmic infusion :
1. Procainamide : 20-50 mg/min until arrhythmia is suppressed. maximum dose : 17 mg/kg.
Maintenance infusion : 1-4 mg/min. Avoid if prolonged QT or CHF.
2. Amiodarone : First dose : 150 mg over 10 mins. Repeat if VT recurs.
Maintenance : Infusion of 1 mg/min for first 6 hrs.
3. Sotalol : 100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.
Adult bradycardia algorithm 00:18:40
Bradycardia
Note :
• Bradycardia : HR < 60 bpm.
Hemodynamically Hemodynamically • Bradyarrhythmia : HR < 50 bpm.
stable unstable
Monitor & Atropine IV 1 mg bolus.

observe Repeat every 3-5 mins.
Maximum dose : 3 mg
Not effective
Transcutaneous pacing/
Dopamine infusion

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ANAESTHESIA REVISION 1 ----- Active space -----

Pre Anaesthetic Checkup (PAC) 00:00:24

Past medical history :

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

Furthermore You can also request a specific

----- Active space -----

Allergy history → Anaphylactic shock :

Family history → Malignant hyperthermia :

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

Management : ----- Active space -----

Risk stratification 00:26:10

CVS risk stratification :

----- Active space -----

Pre medications → (5A’s) :

Monitoring of patient 00:30:09

Monitoring the patient

CNS CVS Resp Neuro Temperature Blood loss

5. Central venous pressure (CVP) monitoring : ----- Active space -----

----- Active space -----

Rebreathing/ exhausted sodalime

Bronchospasm/COPD (shark fin pattern)

Malignant hyperthermia : Leaky sampling line :

Incompetent inspiratory valve Single lung transplant :

Accidental extubation/ sudden disconnect Esophageal intubation

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

Neuro- muscular monitoring : ----- Active space -----

Normal NDMR DMR

Features Constant Fading Constant

Core body temperature monitoring :

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

----- Active space ----- ANAESTHESIA REVISION 2

Airway Examination 00:00:26

Airway Equipments 00:09:27 ----- Active space -----

Anatomical face mask :

Endo-tracheal tube (ETT) :

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

----- Active space ----- 2. Uncuffed ETT : Used in children.

Signs of correct placement of ETT :

5. Fibre optic bronchoscopy : Gold standard (used for

Stylet Magills forceps Bougie

South pole RAE ETT

Flexometallic tube North pole RAE ETT Double lumen ETT

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

Modern gadgets in intubation : ----- Active space -----

Air traque Video laryngoscope; Tru scope Ambu scope

Supraglottic airway devices : 00:26:05

1. Laryngeal mask airway (LMA) :

2. Proseal LMA : Modification of LMA.

4. Fastrac LMA/Intubating LMA :

5. I-gel/2nd generation airway :

6. SLIPA (Streamline Liner of the Pharynx Airway)

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

----- Active space -----

1. Normal : Flexion at lower cervical spine & extension at atlanto-occipital joint.

Difficult Airway Management :

Anaesthesia Revision • 1.0 • Marrow 6.5 • 2023

ANAESTHESIA REVISION 3 ----- Active space -----

Intravenous Inhalational Muscle Local

Intravenous induction agents 00:00:44

Intravenous induction agents

Barbiturates Non barbiturates