Subject: ANESTHESIA

ONE SHOT REVISION

HISTORY

Dr. Ajay Yadav

HISTORY
• FIRST PUBLIC DEMOSTRATION-
MORTON = 16th OCT (WORLD ANESTHESIA DAY)

• FIRST SPINAL:
• AUGUST BIER
 ANESTHESIA DELIVERY
SYSTEMS
ANESTHESIA DELIVERY SYSTEMS
• CYLINDERS
• OXYGEN
COLOR- BLACK BODY WITH WHITE
SHOULDER
PRESSURE- 2000 PSI
• NITROUS OXIDE
COLOR- BLUE
PRESSURE- 760 PSI
• ENTONOX
50% OXYGEN + 50% N20
COLOR- BLUE BODY WITH
BLUE AND WHITE SHOULDERS
PRESSURE- 2000 PSI
PIN INDEX SYSTEM- TO PREVENT
WRONG FITTING OF CYLINDERS
• OXYGEN – 2,5
• N2O - 2,5 Bodok seal

• AIR -1,5 1
2 3
7
4 5
6

• ENTONOX -7
Pins
• Central supply- 60 PSI
ANESTHESIA MACHINE
ANESTHESIA WORK STATION
ROTAMETER- TO SET FLOW RATES
VAPORIZER- DELIVERY OF VOLATILE
AGENTS
BREATHING CIRCUITS
• Open- Obsolete
• Semiopen- Mapleson circuits
• Semiclosed/closed – Circle system
SEMIOPEN CIRCUITS/MAPLESON
CIRCUITS
• Mapleson A- F
• Mapleson A
- Magill circuit
- circuit of choice for spontaneous
ventilation
• Fresh gas flow= minute volume
• B and C- Obsolete
• Mapleson D
- Co-axial
- Circuit of choice for controlled
ventilation
FGG= 1.6 minute volume
Pediatric semiopen
• Mapleson E:
Ayres T piece – incomplete
• Mapleson F:
- Jackson Rees
- Most commonly used
Pediatric circuit
SEMICLOSED/CLOSED CIRCUIT- CIRCLE
SYSTEM
SODA LIME COMPOSITION-
Ca (OH)2 – 80% Inspiratory tubing

NaOH- 3% Soda lim e

Pre ssure relie f valve caniste r

KOH- 1%
M ask

E xpiratory tubing

H2O- 15% B re athing bag

Color indicator
• TOXIC COMPOUNDS WITH INHALATIONAL AGENTS
• Trielene- neurotoxic and ARDS
• Sevoflurane: Compound A
• Desflurane- Carbonmonoxide with desiccated sodalime
• Sevoflurane- Burns with desiccated sevoflurane
EQUIPMENTS
AMBU BAG- USED FOR RESUSCIATION
GUDELS AIRWAY- T0 PREVENT TOUNGE
FALL
LARYNGEAL MASK AIRWAY
• ADVANTAGES-
• AVOID COMLICATIONS OF INTUBATION
• DISADVANATGES
INCREASED RISK OF ASPIRATION
• SECOND GENERATION LMA
- Separate tube for gastric deflation
PROSEAL
I GEL
LMA SUPREME
FACE MASK- INCREASE RISK OF
ASPIRATION
LARYNGOSCOPE- MACINTOSH,M/C USED FOR ADULTS
MILLER- PREFERED FOR CHILDREN
ENDOTRACHEAL TUBE
CUFF

• CUFFED CAN BE USED IN CHILDREN

• CONFIRMATION OF POSITION
• CAPNOGRAPHY- 100% CONFIRMATORY
FLEXOMETALLIC- USED FOR HEAD AND NECK
SURGERIES
PREOOPEARTIVE ASSESMENT
 AIRWAY ASSESMENT
• MODIFIED MALLAMPATI SCORING-
• TO ASSESS MOUTH OPENING
Hard palate
Faucial pillars Soft palate

Uvula
Class I Class II Class III Class IV
PREMEDICATION
• DONE WITH AIM

• MOST COMMON GOAL- TO RELIEVE ANXIETY

MANAGEMENT OF PREEXISTING
DRUG THERAPY
• TO BE STOPPED:
1. VIGRA- 24 HOURS

2. ANTICOAGULANTS ( WARFARIN) – 5 DAYS

3. ANTIPLATELETS
• ASPIRIN- 72 HOURS
Except
-Recent MI
-Recent stroke
- Coronary stents
• CLOPIDOGREL- 5 DAYS
4. ORAL CONTRACEPTIVES ( HIGH DOSE ESTROGEN) – 4 WEEKS

5. HERBAL MEDICATIONS- 7 DAYS

6.ACE inhibitors and ARB- 24 HOURS

7. SMOKING – 8 WEEKS
MORNING DOSE TO BE OMMITED

1. DIURETICS

2. TOPICAL CREAMS

3. ORAL HYPOGLYCEMICS
• MODIFICATIONS REQUIRED
1. CHOLINESTERASE INHIBITORS

2. STEROIDS

3. ATT
FLUIDS
• MAINTENECE -RL

• REPLACEMENT -RL
MONITORING
• CNS
• DEPTH OF ANESTHESIA
CVS monitoring
• IBP- GOLD STANDARD FOR BP

• ECG- LEAD V3 PREFRED OVER V5 FOR ISCHEMIA

• TRANSESOPHAGEAL ECHOCARDIOGRAPHY- BEST
RESPIRATORY MONITORING
• PULSE OXIMETERY
• CANNOT DETECT ABNORMAL HB
CAPNOGRAPHY
• USES
• CONFIRM INTUBATION
• DETECT ACCIDENT EXTUBATION – ZERO, GRAPH-FLATLINE
CAPNOGRAPHY GRAPHS
• Normal graph for mechanical ventilated patient

40

0
• Spontaneous breath

40

0
• COPD/ASTHMA ( SHARK FIN PATTERN)

40

0
• Exhausted sodalime

0
In sp ired C O 2
• Recovery of spontaneous breath ( curae notch)
• ETCO2 becoming zero
• Extubation
• Apnea
• Disconnection
• Complete obstruction
TEMPRATURE
• SITES FOR CORE TEMPEARATURE
• BEST- LOWER ESOPHAGUS
• MOST ACCURATE- PULMONARY ARTERY
 INTRODUCTION

GENERAL ANESTHESIA
• Preoxygenation – 100% oxygen for 3 minutes
• Induction – IV
• Intubation- Suxamethonium
• Maintenance- N20 75%+ O2 25% + Inhalational agents + non-
depolarizer
• Reversal – Neostigmine
• Extubation
 INTRAVENOUS AGENTS- USED
FOR INDUCTION

GENERAL ANESTHESIA
THIOPENTONE
• ALKALINE PH

• REDISTRIBUTION

• ANTICONVULSANT

• CEREBPPROTECTIVE
INTRA-ARTERIAL INJECTION
• Due to alkaline Ph
• Commonly seen in antecubital fossa
• Most preferred vasodilator- Papaverine intraarterially
PROPOFOL
• PREPARED IN SOYABEAN OIL- PAINFUL

• CONTAINS EGG LECITHIN- BACTERIAL CONTAMINATION

- Discard injection in 6 hours
• HALF LIFE- 2-3 HOURS

• ANTIEMETIC
• IV AGENT OF CHOICE
-FOR INDUCTION
-DAY CARE SURGERIES
ETOMIDATE
• MOST CARDIAC STABLE

• ADRENAL SUPPRESSION
BENZODIAZEPINES
• MOST COMMONLY USED IS MIDAZOLAM- SHORT HALF LIFE
KETAMINE
• DISSOCATIVE ANESTHESIA
Advantages
. I/V OF CHOICE FOR
-SHOCK PATIENTS

- FULL STOMACH

- ACTIVE ASTHMATICS
-LOW CARDIAC OUTPUT

-RT-LT SHUNTS
S/E
• VIVID REACTIONS
• M/C- HALLUCINATION

• INCREASED IOP, ICT AND IGP

OPIODS
• ANALGESIA
S/E
• RESPIRATORY DEPRESSION

• MUSCLE RIGIDITY :
MAX- ALFENTANYL
2 AGONISTS
ADJUVANT AND SEDATION

-CLONIDINE (OBSOLETE)

-DEXMEDETOMIDINE
 INHALATIONAL AGENTS

GENERAL ANESTHESIA
POTENCY
• MAC

• MOST POTENT- HALOTHANE

• LEAST POTENT – N2O

BLOOD GAS COFFICIENT
• INDICATES INDUCTION AND RECOVERY
• FASTEST- XENON

• SLOWEST – HALOTHANE
INDIVIDUAL AGENTS
• NITROUS OXIDE
• 35 TIMES MORE SOLUBLE THAN AIR
C/I
PNEUMOTHORAX
PNEUMOMEDIASTINUM
PNEUMOPERICARDIUM

• OZONE DEPLETION
XENON
ADVANTAGES:
• NO S/E LIKE NITROUS OXIDE

• EXPENSIVE
HALOTHANE

• MOST POTENT

• SLOWEST RECOVERY
• SENSITIZES HEART TO ADRENALINE
• HALOTHANE HEPATITIS
• AUTOMIMMUNE
ISOFLURANE
• IRRITATING INDUCTION

• INHALATIONAL AGENT OF CHOICE FOR CARDIAC PATIENT

• NO CORONARY STEAL
DESFLURANE
• IRRITATING INDUCTION

• CAN PRODUCE CO
• MINIMAL METABOLISM
• NO FLUORIDE
• INHALATIONAL AGENT OF CHOICE FOR RENAL PATIENTS
SEVOFLURANE
• IAOC
1. PEDIATRIC INDUCTION-SMOOTHEST

2. ASTHMA – MAXIMUM BRONCHODILATION

3. NEUROSURGEY – MINIMUM INCREASE IN IOP

4. HEPATIC PATIENT –LEAST DECREASE IN HBF

 MUSCLE RELAXANT

GENERAL ANESTHESIA
NM MONITORING
• MUSCLES
• IDEAL MUSCLE – CORRUGATOR SUPERCILLI

• MOST COMMONLY USED – ADDUCTOR POLLOCIS

• MODALITY - TRAIN OF FOUR

CLASSIFICATION
• DEPOLARIZERS
• NON- DEPOLARIZERS
SUXAMETHONIUM
• IDEAL FOR INTUBATION
SYSTEMIC EFFECTS
• HYPERKALEMIA

• INCREASE IGP, IOP AND I.C.T.

• MALIGNANT HYPERTHERMIA – M/C IMPLICATED DRUG

NON- DEPOLARIZERS
• VECURONIUM:
MOST CRADIAC STABLE
• ATRACURIUM
• HOFFMAN DEGRATION
• MUSCLE RELAXANT OF CHOICE FOR
- HEPATIC AND RENAL PATIENT
• CIS- ATRACURIUM
• LESS S/E THAN ATRACURIUM
• ROCURNOIUM:
NON- DEPOLARIZER OF CHOICE FOR INTUBATION

• RAPACURONIUM :
• BRONCHOSPASM
• MIVACURIUM:
• MUSCLE RELAXANT OF CHOICE FOR DAY CARE SURGERY
REVERSAL
• CHOLINESTERASE INHIBTORS
• NEOSTIGMINE+ GLYCOPYROLARE (TO PREVENT MUSCARINIC SIDE
EFFECTS)
• GAMMA CYCLODEXTRINS- DIRECTLY BINDS TO MUSCLE RELAXANTS
 COMPLICATIONS OF GA

GENERAL ANESTHESIA
ASPIRATION
• PREVENTABLE

• FASTING RECOMMENDATIONS
SOLID FOOD – 6 HOURS
FATTY/NON- VEG- 8 HOURS
CLEAR FLUIDS- 2 HOURS
BREAST MILK- 4 HOURS
• ANESTHETIC MANAGEMENT FOR HIGH RISK

• RAPID SEQUENCE INDUCTION

- Bag and mask ventilation – Absolutely C/I
- Cricoid pressure
CNS
• CONVULSIONS
- Hypoxia
- Methohexitone
- Propofol
- Etomidate
- Enflurane
- Sevoflurane
- Local anesthetic toxicity
• GI
• Nausea and vomiting-
• Most common post- op complication of GA
ANAPHYLAXIS
• Most common cause- Antibiotics
THERMAL
• MALIGNANT HYPERTHERMIA

• CAUSATIVE AGENTS
-Suxamethonium – most commonly implicated drug
- Volatile agents
- Halothane- most commonly implicated volatile agent
TREATMENT
Dantrolene sodium
• MANAGEMENT OF SUSEPTIBLE PATIENT
IV- Propofol
Maintenance- IV opioids
POSITION RELATED
• PERIPHERAL NEUROPATHY
• Most common- Ulnar nerve
• VENOUS AIR EMBOLISM
• Seen in posterior fossa surgeries
• Most sensitive- TEE
 LOCAL ANESTEHTICS

REGIONAL ANESTHESIA
SEQUENCE OF NERVE BLOCKADE
• NERVE FIBRES
PERIPHERAL BERVE BLOCKS – A>B>C
CENTRAL NERVE BLOCKS – B>A>C

• RECOVERY- REVERSE ORDER

• FUNCTIONAL
• PNB- MOTOR> SENSORY > AUTONOMIC
• CNB- AUTONOMIC> SENSORY > MOTOR

• RECOVERY- REVERESE ORDER

TOXICITY
• CNS earlier than CVS
• LA WITH ADRENALINE
• C/I for ring block of finger, toes, penis and pinna
PRILOCAINE
• Methhemoglobemia

• Extrahepatic metabolism
LIGNOCAINE (LIDOCAINE,
XYLOCAINE)

• CONC. USED:
• SURFACE ANALGESIA: 4%, 10%
• NERVE BLOCKS, EPIDURAL: 1-2%
• BIERS BLOCKS: 0.5%
• SPINAL: 5%
• JELLY: 2%
• DURATION
Without adrenaline- 45-60 minutes
With adrenaline- 2-3 hours
• MAX. SAFE DOSES
Without adrenaline - 4.5 mg/kg
With adrenaline – 7 mg/kg
BUPIVACAINE
• DURATION – 2-3 hours

• MAX SAFE DOSE- 2 mg/kg

• Can be used for painless labour and post-op pain relief
• CARDIOTOXICITY

• D.O.C for Ventricular tachycardia- Amiodarone

• Antidote- Intralipid
• LEVOBUPIVACAINE AND ROPIVACAINE
S- isomers of Bupivacaine
Less cardiotoxic
 PERIPHERAL NERVE BLOCKS

REGIONAL ANESTHESIA
BRACHIAL PLEXUS BLOCK
• INTERSCALENE
- Ulnar nerve is spared
• SUPRACLAVICULAR
- Pneumothorax
• INFRACLAVICULAR
- High failure

• AXILLARY
- Musculocutaneous is spared
STELLATE GANGLION BLOCK
• INDICATIONS
Reflex sympathetic dystrophies

• SITE
Chassaignac tubercle
SIGNS OF SUCCESSFUL BLOCK:
• HORNER SYNDROME
 CENTRAL NEURAXIAL BLOCKS

REGIONAL ANESTHESIA
ANATOMY
• EXTENSION OF SPINAL CORD
In infants- lower border of L3
In adults- lower border of L1
• STRUCTURES ENCOUNTERED
• Posterior to anterior Arachno id D ura

-skin
Ep idu ra l space
Vertebral bod ies
Su barachnoid space
Po ste rior lo ngitudin al

-subcutaneous tissue
ligam ent Skin

Su bcu taneo us tissu e

An terior longitudinal Su prasp ino us lig am en t

-supraspinous ligament ligam ent

Sp ina l ne edle

-interspinous ligament S p ina l cord Ligam e ntum

flavu m
Inte rspinous ligam ent

-Ligamentum flavum
- Dura
- Arachnoid
SPINAL ANESTHESIA
• DRUGS
• Lignocaine – 5%
- Not used- cauda equina syndrome
• Bupivacaine- 0.5%
SYSTEMIC EFFECTS
• HYPOTENSION- Most common

• BRADYCARDIA

• HIGH SPINAL/ TOTAL SPINAL

• POST-OPERATIVE
• URINARY RETENTION- most common S/E
• POST SPINAL HEADACHE
- Low pressure, meningovascular
• PREVENTION
- Fine gauge
- Dura separating ( Pencil tip)
EPIDURAL
• NEEDLE- Touhy's

• TECHNIQUE
Loss of resistance
C/I of Central neuraxial blocks
• ABSOLUTE
RAISED ICT

COAGULOPATIES/ANTOCAOGULANTS

PATIENT REFUSAL
• SEVERE HYPOVOLEMIA

• INFECTION AT LOCAL SITE

• SEVERE FIXED CARDIAC OUTPUT LESIONS

SPECIALITY MANAGEMENT
CVS
IHD
• DEFERAL TIMINGS
- Conservatively- 2 months
- With bare metal stent- 4 weeks
- With drug eluded stent- 6 months
- By pass surgery- 6 weeks
• CARDIAC PATIENTS
- Regional- safe
-Induction – Etomidate
- Maintenance- Isoflurane
- Muscle relaxant- Vecuronium
RESPIRATORY SYSTEM
Regional- Preferred over GA
-Induction – Propofol
- Maintenance- Sevoflurane
- Muscle relaxant- Steroidal
HEPATIC
Anesthesia of choice- GA
-Induction – Propofol
- Maintenance- Sevoflurane
- Muscle relaxant- Cis-atracurium >atracurium
RENAL
Anesthesia of choice- GA
-Induction – Propofol
- Maintenance- Desflurane
- Muscle relaxant- Cis-atracurium >atracurium
NEUROMUSCULAR DISEASES
Myasthenia gravis/muscular dystrophies
Anesthesia of choice- Regional
-Induction – Propofol
- Maintenance- Desflurane
- Muscle relaxant- Mivacurium/ Cis-atracurium >atracurium
- Suxamethonium – C/I for Muscular dystrophies
NEUROSURGICAL ANESTHESIA

-Induction – Thiopentone
- Maintenance- Sevoflurane
- Muscle relaxant- non- depolarizers
- Avoid- Suxamethonium
OBSTETRIC ANESTHESIA
CESAREAN SECTION
•CHOICE OF ANESTHESIA:
- Spinal
• Avoid GA- increased risk of aspiration
• GA- rapid sequence induction
• VASOPRESSOR:
• Phenylephrine> Ephedrine
• PIH
• Choice of anesthesia – Spinal
• PAINLESS LABOR

Most preferred- LUMBAR EPIDURAL

Entonox
PEDIATRIC ANESTHESIA
GA:
INDUCTION:
1st – IV
2nd – Inhalational
• Sevoflurane- first choice
• Halothane

• Isoflurane and desflurane cannot be used for induction

 DAY CARE SURGERY
• ANESTHETIC TECHNIQUES
1.GA: LMA > ETT
• DRUGS:
• I/V AGENT - Propofol
• OPOID – Remifentanil
• INHALATIONAL – Sevoflurane > Desflurane
• MUSCLE RELAXANT – Mivacurium
• BENZODIAZEPINE – Midazolam
• COMPLICATIONS

• MOST COMMON- DROWSINESS

• DELAYED DISCHARGE, OVERNIGHT STAY AND READMISSION- SURGICAL

COMPLICATIONS
ANESTHESIA FOR LAPAROSCOPY

• PREFERRED GAS: CO2 – high diffusibility

• IDEAL GAS: Argon – inert

• Intraabdominal pressure- 12-14 mmHg

CRITICAL CARE
OXYGEN DELIVERY DEVICES

1. SIMPLE OXYGEN DEVICES

MAXIMUM OXYGEN AND FLOWS
DEVICE MAXIMUM FLOW MAXIMUM FIO2

NASAL CANNULA 6 L/minute 0.4

O2 Mask 10L /minute 0.6

O2 mask with reservoir 15L/ minute 0.8

Venturi mask 15 L/minute 0.6

High flow nasal cannula
• 50-60 L/minute
• Humidified gases
• Provides PEEP
• Decreases dead space
NON- INVASIVE VENTILATION
• ADVANTAGES
• Decreases Ventilator
Associated pneumonia

• DISADVANTAGES
Claustrophobia
LUNG PROTECTIVE STARGERY
• Tidal volume – 4-6 ml/kg of ideal body weight
• Plateau pressure- < 30 cmH20
• PEEP- start with 5 cmH20 and titrate
• FIO2 < 0.6
CPCR
SUMMARY OF CHANGES IN AHA 2020

1. RECOVERY – 4th chain of survival

2. ADRENALINE ASAP
• 4. LAY MAN, PULSE CHECK- NOT EXPECTED

• 5. AUDIO VISUAL FEED BACK

• PEDIATRIC CPR
• RESPIRATORY RATE
- 20-30 /minute

• Propyhlatic EEG
• MONITORING

• DBP- INFANTS >25MMHG

• CHILDREN > 30 MM HG
TRAINING
• GAMIFIED IN MIDDLE AND HIGH SCHOOL

• LAYMAN TRAINING IN LOW SOCIO-ECONOMIC

• MOBILE TECHNOLOGY
• INTRAOSSEOUS
- Preferred over endotracheal
- Anything can be given
- Can be used at any age
Thank You