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Last Leg > Anaesthesia > Flashcards

Anaesthesia Flashcards

1
Q

Does not have any CI

A

General anaesthesia

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2
Q 
LOC ✔
Loss of reflex ✔
Amnesia ✔
Analesia
Muscle relaxn
A

Components of GA

✔ = All drugs

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3
Q

Multiple drugs in titration for diff components of anaesthesia

A

Balanced anaesthesia

Dr John Lundy

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4
Q

Triad of GA

A

Narcosis
Relaxn
Analgesia

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5
Q

Methods of Induction

A
  1. IV - faster, smoother, less anxiety
    PREFFERED, BEST
  2. Inhalational - in peds
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6
Q

Methods of Maintainance

A
  1. IV

2. Inhalational

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7
Q

TIVA = Propofol

A

Induction + Maintenance

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8
Q

Pre O2

A

100% O2 mask with patient’s own efforts

  • 3 to 5 min Normal TV breathing
  • 4 full VC breaths
  • 8 full breaths/ 1 mintute
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9
Q

Steps of GA

A 
1 Attach monitors 
2 Secure IV
3 Pre O2
4 Induction
5 Maintain
6 Reversal
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10
Q

Min of __% of O2 out of A. machine

A

30%

Except 25% in high combustion

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11
Q

Inhalational A. agents

A
  1. Potent

2. Carrier gas (due to long pathway)

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12
Q

Potent A. inhalational agents

A 
NEW 
Halo
Iso
Sevo
Des
NOT USED NOW Enflurane and Methoxy

OLD
Ether
Chloroform

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13
Q

Carrier gases

A

N2O

Xenon

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14
Q

High combustion operation triad

A

FUEL - tube/cuff/drape
OXIDANT - O2/N2O/Volatile agent
IGNITION - laser

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15
Q

MAC

A

Min alveolar conc to produce UNCONSCIOUSNESS (no movement on Std Sx Stimulus in 50% of popluation
MAC = 1/POTENCY = DOSE

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16
Q

MAC = HISD

A

MAC increases, and potency decreases

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17
Q

Overall
Most potent
Least potent

A

Most potent - Methoxyflurane

Least potent - N2O (104 MAC)

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18
Q

Conditions DECREASING MAC (decrease dose)

A 
Hypoxia
Hypercapnia
Hypovolemia
Hypothermia
Hyperthermia (upto 42 deg) 
HypoNa
HyperCa
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19
Q

Condn INCREASING MAC

A

> 42 deg - Heat stroke

Hypernatremia

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20
Q

Age = 1/MAC (6% per decade)

Order

A

Infant > Neonate > Adult > Elderly

HIGHEST MAC - Infant

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21
Q

Why low MAC in Pregnancy

A
  1. Preogesterone sedates the brain

2. Increase sensitivity to drugs

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22
Q

Acute Alcoholism

Any drug contributing to any effect of GA (NSAID, opioid)

A

Low MAC

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23
Q

Chronic Alcoholism
Amphetamine
HyperNa

A

High MAC

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24
Q

Endocrines and MAC?

A

No EFFECT

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25
MAC50 = MAC MAC95 Submaximal MAC
MAC95 = 1.3 - 1.5 MAC50 Submaximal MAC = (just less that reqd dose of drug) causes compensatory Sympathetic stimulation
26
GA | Sleep
Beta - Alpha - Theta - Delta
27
Meyer Overton Rule
Potency of A. agent = Lipid solubility
28
B-G partition coefficient Blood - Gas solubility Diffusion Coefficient
One of the factors affecting Speed of INDUCTION | Alv conc = CNS conc
29
High BG coefficient
Slow speed of induction
30
BG coefficient | HISD
BG decreases and spleed increases
31
1. Jasmine smell 2. Rotten egg smell (laryngeal spasm) 3. Sweet smell
1. Sevo 2. Des (irritant) 3. Halo
32
a. Induction Inhalational agent of choice for ALL cases, NO EXCEPTION, NO CI b. Most appropriate inhalational agent in Peds
Sevoflurane
33
Maintenance inhalational agent of choice
Desflurane
34
``` Fast recovery (Day care Surgery) POST OP DELIRIUM + HALLUCINATION ```
Sevo and Desflurane
35
Cardiac Output and Speed of induction?
High CO = Slower speed of induction
36
CNS Conc and ventillation | CNS conc and Second gas effect
Directly proportional
37
Halogenated ethane
Halothane
38
Halogenated Ethers
All except Halothane - Iso - Sevo - Des
39
Isomer of Enflurane
Isoflurane
40
Structural analogue of Isoflurane (FLURONATED ISOFLURANE)
Desflurane
41
``` STABLE Least metabolized Most fluorinated Least F release Least inflammable ```
Desflurane
42
Highest fluride release | Least F content
Methoxyflurane | BANNED
43
Boiling point (B.P.)
``` HIS = 50 +- 2 deg Des = 23 deg (Room temp) ```
44
Desflurane B.P.
- Tec 6 special vapouriser for delivery of DESFLURANE - Highest Vapour Pressure - Has to be electrically heated to 35 deg
45
``` Color codes Halo Iso Sevo Des ```
Halo - RED Iso - PURPLE Sevo - YELLOW Des - BLUE
46
Most unstable | Preservative = Tymol 0.01%
Halothane
47
Stability | HISD
H - Most instable I - Quite stable S - Quite stable D - Most Stable :)
48
Metabolism of Halothane
>30% Acyl halide + Surface Ag of liver | Autoimmune Hepatitis VERY COMMON :(
49
Metabolism of Isoflurane
0.1% | Neither Hepato/Nephrotoxic
50
Metabolism of Sevoflurane
Compound A released NEPHROTOXIC (Max - Methoxy>Sevo) But can be used in Kidney # tho
51
Not metabolised :))
Desflurane :)
52
Smell | HISD
H - Good I - Irritant S - Sweet D - Irritant
53
Uses | HISD
H - I+M I - M S - I+M (I. Agent of Choice) D - M (M. Agent of Choice)
54
30-40% hepatitis | Acute, self-limiting in which liver funtion is deranged 3-6 wks post exposure to Halo
Type I HH
55
Acute NECROTISING/FULMINANT hepatitis | 1 in 35,000-45,000
``` Type II HH Predisposing: 1. Obese 2. Female 3. Middle age (Peds is Protected) 4. Pre-existing liver # 5. Re-exposure <3 months of use ```
56
Effect on CNS by gaseous A. agents | 🧠
``` CNS uncouplers ⬇️CMRO2 ⬆️⬆️CBF ⬆️⬆️ICP ⬇️EEG ```
57
CNS Coupling
CBF = CMRO2
58
Gaseous for NeuroSx 1. CI 2. Agent of Choice 3. m/c inhalational
1. CI - Halothane 2. Agent of Choice - DESFLURANE (safest) > Iso > Sevo 3. m/c - Isoflurane
59
Preferred in ICP/ Neuro Sx
TIVA
60
Agents as Antiepileptics 1. Seizures 2. Epilepsy
``` Seizure = Sevo Epilepsy = Enflurane ```
61
Agents decreasing EEG
All inhalational EXCEPT (increasing EEG) 1. N2O 2. Ketamine
62
Decrease in EEG
Hypoxia Hypercapnia Hypothermia Hypovolemia
63
Increase in EEG
Early staged of 4H's - sympath stimulation Ketamine N2O
64
Effect on CVS HISD 🫀
H - UNSTABLE | ISD - Stable :))
65
``` Direct myocardial depressant ⬇️SAN activity ⬇️HR, CO and BP ⬆️sensitivity to catecholamines on heart 🔄 ARRYTHMIAS CI - CV Sx ```
Halothane
66
``` ⬇️Systemic vascular resistance ⬇️MAP ⬇️BP ⬆️HR Can be used for CV Sx ```
ISD
67
Most cardiostable
Desflurane
68
Coronary steal phenomenon
Isoflurane | Use cautiously not CI tho
69
Effect on RS by all HISD | 🫁
1. Depress Resp centre 2. Blunt hypoxic and hypercapnic drive (TIVA maintains 🤍) 3. All bronchodilators
70
Best bronchodilator | Agent of choice in asthma
Halothane | 2nd Sevo
71
Hypoxic and hypercapnic drive
Worst blunting by Halothane
72
Thoracic Sx
TIVA
73
CI in liver disease
``` Halothane #Dual blood supply ```
74
Inhalation agent for hepatic Sx | Agent of choice?
ISD Desflurane - agent of choice :) PBF ⬆️ due to Adenosine vasodiln Hepatic artery ⬇️ (hypoxia)
75
Nephrotoxic
Sevo | Compound A
76
Uterine relaxant
Halothane | PPH😥 also avoided in CSection
77
LOC LORP Amnesia Muscle relaxation
All inhalational
78
Analgesia in inhalational
None
79
Controlled hypotension (For vascular surgical sites FESS) Doc?
Doc - SNP GTN Esmolol ✔️ultra short acting
80
Most potent Most F release Most Nephrotoxic - high output, diuretic resistant, vasopressin resistant RENAL FAILURE 😞
Methoxy
81
Epilepsy | Isomer of isoflurane
Enflurane
82
Pharmacogenetic disease AD Drugs?
Malignant hyperthermia 1. SCh 2. All HALOGENATED inhalational 3. Lignocaine
83
``` Hyper CO2 HTN Hyperthermia 🥵 HR⬆️ Arrhythmia ```
Hypermetabolism in MH
84
``` Acidosis Hyper K Myoglobinuria Rhabdomyolysis Renal failure HYPO Ca ```
Cell lysis in MH
85
Management of MH
Stop trigger agent Start IV Dantrolene Symptomatic Rx
86
Agent of choice in MH
Propofol
87
``` Good analgesic Good muscle relaxation CardioSTABLE ♥️ Maintains hypoxia and hypercapnic drive 😇 Very GOOD Bronchodilator Cheap ```
Ether
88
Very slow induction and recovery 🤡 Irritant ➡️ laryngospasm Hyper stimulates mucus and serous (trachea and bronchi) Highly inflammable 🔥
Ether
89
Good speed 🦸‍♂️ and smell 👃🏻 Unstable :( Ventricular arrhythmia refractory to Rx 😥 Most HEPATOTOXIC
Chloroform | 🤧
90
N2O Newer agent 1. BG 2. CVS
BG - 0.45 ➡️ fast agent Sympathomimetic - ⬆️BP ⬆️HR CV unstable Good analgesic
91
Absolutely CI in laser Sx
N2O | Highly combustible
92
Entonox
50:50 or (70:30) N2O:O2
93
Blue body white shoulder | Pin index: 7
Entonox
94
Entonox uses
Good analgesic for dental and labour Supporter of combustion (CI laserSx) Expands air cavities (35x more sol than N2)
95
Absolutely CI In 1. Pneumothorax/pericardium 2. Intestinal obstruction 3. Vitreoretinal 4. Laser 5. Cochlear implant
Entonox
96
Inhibits B12 dependent enzymes • Peri neuropathy • Megaloblastic anemia Bone marrow suppression
Entonox
97
Effects of N2O
Second gas 😇 Diffusion hypoxia 🧟‍♀️ Fink effect/ Third gas ⛽️
98
During INDUCTION | Effect on accompanying gas to increase conc of said gas in alveoli
Second gas effect Good effect ⬆️ speed of induction
99
During REVERSAL | Hypoxia due to rapid diffusion of N2O from blood ➡️ alveoli during reversal
Diffusion hypoxia | Rx and Px - 100% O2 😷
100
``` MAC - 70 BG: 0.19 (fastest agent) Better analgesic Not supporter of combustion CV stable 🫀 Metabolically inert Environmental friendly 🌳 ```
Xenon | Very very costly 💵
101
1. GABA mimetic | 2. NMDA facilitatory
1. All inhalational and IV | 2. Xenon and Ketamine and N2O (slightly)
102
IV agents
Opioids | Non opioids
103
Morphine | Fentanyl and congeners
Opioids Fenta - CV stable ♥️🫀
104
Non opioids (4)
Sodium’s thiopentone Propofol Etomidate Ketamine CV unstable ;(
105
Ultrashort barbiturate pH > 10.5 (NS/ distilled water) Vial 🧪 recon 2.5%
Sod thiopentone - induction dose : 4-5mg/kg - 1 brain arm circulation = 11 sec to become unconscious but regains in 4-5 min - re distribution (all IV ✔️)
106
Thiopentone uses
1. Induction 2. Neuro protection 3. Narcoanalysis
107
Doc Neuro protection by primary mech of ⬇️ brain 🧠 meta by 50%
All GA ate Neuro protection but THIOPENTONE is best Antianalgesic 🤔
108
Truth serum in sub anaesthetic doses
Scopolamine ⬇️ Thiopentone (safest)
109
CNS couplers
``` All IV agents ⬇️CMRO2 ⬇️EEG ⬇️CBF and ICP Cerebroprotective ```
110
CI in Shock
IV agents Peripheral vasodilation ⬇️BP ant ⬇️HR
111
CI bronchial asthma
All IV agents 1. Depress resp centre 2. Blunt HH drive 3. Bronchoconstriction
112
CI AIP/ Porphyria
Enzyme inducers IV agents Hepatic/Renal - no untoward effect
113
Wonderful A. Agent Milky white 🥛 liquid Diisopropylalcohol
Propofol
114
Additives in propofol
EGS Egg lecithin- egg allergy NOT A CI Glycerol Soyabean oil
115
Single best agent - Day Care Sx | Why?
``` Propofol 1. Rapid meta/No residual effect 20% extrahepatic and 80% liver and kidney 2. ONLY DRUG that #CTZ 🤮🚫 3. Pleasant recovery (euphoria ➕) ```
116
Propofol effect on CNS
CNS coupler - cerebroprotective 🧠 ❤️ ⬇️CMRO2 ⬇️CBF ⬇️ICP ⬇️EEG
117
Propofol on CVS | CI in SHOCK 💥
Peripheral vasodilation ⬇️BP ⬇️HR
118
Propofol on RS
Resp centre depressed BronchoDILATOR 🫁 Hypoxic pul vc maintained UPPER AIWARY REFLEXES 🚫 (Endoscopies!)
119
``` AA of choice in; Day care Sx Neuro Sx Thoracic Sx Endoscopy Pre existing liver and kidney # Malignant hyperthermia Porphyria Normal patient ```
TIVA | Propofol
120
Used in 1 Sedation in ICU 2. Antiemetic 3. Anti pruritic
Propofol
121
Local pain on IV injection | Bradykinin in intima
Propofol Premix with 2% 1ml Ligno + 10ml 1% propofol
122
Propofol infusion syndrome
``` After >48h of use (Peds) ⬇️ Metabolises accumulate ⬇️ ➖(inhibits) Mito enzymes ⬇️ Lactic acidosis ```
123
Imidazolone derivatives Milky white 🥛 Local pain on IV
Etomidate
124
Etomidate on CVS
Cv stable🫀:) | Only drug!
125
Adrenal gland suppression ⬇️➖ 11 B hydroxylase
Etomidate Mild-mod cv compromise - Cortisol ➕ VIT c
126
``` Phencyclidine derivative Multiple routes (all except SC) Dissociative anaesthesia Increases all pressures Sympathomimetic Good ANALGESIC ```
Ketamine Thalamo-cortical dissociation ⬆️BP, IOP, HR, ICP
127
In absence of catecholamines acts as myocardial depressant
Ketamine
128
CNS effect of Ketamine
💀 | ⬆️CMRO2, CBF, ICP, EEG
129
CI Epilepsy Elective Neuro Sx
Ketamine
130
IV induction of choice in Cyanotic CHD
Ketamine All other thoracic Sx - CI 💀
131
Best bronchodilator
Ketamine
132
AA of choice in 1. Acute shock 2. B. Asthma 3. Sedation and analgesia
Ketamine
133
Ketamine CI
``` Critically ill (myo dep) IHD CAD HTN Epilepsy Elective Neuro Sx Glaucoma ```
134
Causes post op delirium and hallucination | Rx?
Ketamine Rx BZD iv Midazolam
135
Dexmedetomidate
a2:a1 = 1640:1 (Clonidine = 1:90) | Pure alpha 2 agonist
136
Good analgesic Good sedative Min hemodynamic alteration Min resp depression
Dexmedetomidate
137
CONSCIOUS SEDATION | Agent of choice for stereodatic surgery
Dexmed
138
Mc combo of TIVA
Propofol + Remifentanyl
139
TIVA advantages
``` ⬇️CMRO2 ⬇️CBF,ICP cerebroprotective Maintains pul vc Drive Maintains auto regulation in LIVER Safe in MH Rapid metabolism ⬇️PONV Pleasant recovery ```
140
Accidental intra arterial injection 💉 of Thiopentone | What will u do?
``` 1st sign Pallor 1st symptom Pain - leave cannula in situ - 500U Heparin - 10ml 1% Ligno (pain) - Arterial dilators PAPAVERINE - Stellate ganglion block ⬇️ (fails) - Brachial plexus block ```
141
Drugs given IA
None | Heparin
142
Signs of successful ganglion block
``` Flushing ⬆️Temp and redness of limbs Horners (loss of ciliospinal reflex) Conjunctival congestion 👁 I/L Nasal stuffiness I/L redness of TM ```
143
Guttman sign | Muller sign
I/L Nasal stuffiness | I/L redness of TM
144
Types of NM Blockers
Depolarising (Sch) | Non depolarising
145
SCh ``` MOA Fasciculation? Post op myalgia 😞 Reversal by neostigmine TOF a. Repose b. Ratio NM monitoring PTF (post tetanus fasciculation) ```
``` MOA - Persistent depolarisation of Nm Fasciculation? ➕ Post op myalgia 😞 ➕ Reversal by neostigmine 🚫 TOF a. Repose ➖ b. Ratio = 1 (B/A) NM monitoring ➖ PTF (post tetanus fasciculation) ➖ ```
146
Non depolarising ``` MOA Fasciculation? Post op myalgia 😞 Reversal by neostigmine TOF a. Repose b. Ratio NM monitoring PTF (post tetanus fasciculation) ```
``` MOA Competetive antagonism Fasciculation? ➖ Post op myalgia 😞 ➖ Reversal by neostigmine ➕🙂 TOF a. Repose ➕ b. Ratio <1 NM monitoring ➕ PTF (post tetanus fasciculation) ➕ ```
147
Fastest shortest NM#
SCh (mirror image of Ach) Suxamethonium Scoline
148
SCh Onset Duration
30-40s 5-6 min Metabolism by PseudoCh esterase (85-95%) Produced - LIVER Present - PLASMA
149
Paralysing dose of SCh
1.5-2mg/kg
150
SCh apnea
Single normal dose of SCh producing prolonged apnea | Rx Ventillation
151
SCh apnea Acquired Inherited
Acquired - deficiency of 🔱ChE | Inherited - Atypical 🔱ChE
152
Phase 1 Agent TOF PTF
Depolarising ➖ ➖ SCh not used for maintenance
153
Phase 2 block Agent TOF PTF
NDM ➕ ➕ Only SCh shows phase 2
154
1. Single normal dose 2. Multiple normal dose 3. Single large dose
1. SCh apnea | 2. and 3. Phase 2 block
155
SE of SCh
Fasciculation Post op myalgia ⬆️ICP ⬆️IOP ⬆️IGP ↪️(after ketamine)
156
HyperK caused by?
SCh
157
Exaggerated hyperK
``` Muscle dystrophy NM diseases Paraplegia Trauma Burns ```
158
Why avoid SCh in <3-4 boy? | Why avoid in trauma and burns 🥵?
Risk of unDx DMD Immediate COD ☠️ : HyperK
159
What can trigger MH if gene is present?
SCh
160
Why SCh premixed with atropine?
Due to Brady by SCh
161
``` RSI intubation (Rapid sequence induction) ```
FULL STOMACH + Emergency 🆘 | Use SCh
162
Rationale behind the Use of RSI
To prevent aspiration
163
RSI Steps
1. PreO2 😷 (replace N2 in alveoli) 2. Sellick/ cricoid pressure - BURP 3. IV thiopentone + IV SCh 4. PPV by BMV - CONTRAINDICATED 💀 5. Laryngoscope + Intubate
164
SCh uses Shelf life - 2-4 deg: 2 y Room temp: 6 months
RSI Anticipated diff airway Very short GA (ECT, intubate, trach)
165
Non depolarising/ competitive
Amino steroid | Benzylisoquinolines
166
Amino steroids NDMB CVS stable 😌 no histamine release (except PAN) Meta by liver and kidney
Long: Pan and Pipe Inter: Vecu and Roc mc Short: Rapa Pancuronium- vagal block, hypotension and tachycardia
167
Benzylisoquinolines Histamine release 😣 Cvs unstable
Long: dTC (1st discovery), doxa I: atra and cisatra (safe in liver and kidney) Short: miva
168
Fastest acting NMB Fastest acting NDMB 2nd fast NDMB
SCh - 30-45 sec Rapa- not used clinically Rocu
169
What can replace SCh in RSI
Rocuronium
170
IV drugs causing pain on injection
Rocuronium Propofol Etomidate
171
Causes bronchospasm and abandoned for clinical use
Rapacurium
172
``` Releases histamine CVS unstable HOFFMAN DEGRADATION m/S of choice in 1. Acute/chronic liver/kidney # 2. Preg 3. Peds 4. Old age 5. HYPERSENSITIVITY to NEOSTIGMINE Produces LAUDANOSINE ➡️ Epilepsy on accumulation ```
Atracurium
173
``` More potent than Atra Lesser laudanosine No histamine release No CVS unstable HOFFMAN ✅ ```
Cisatracurium
174
``` Atra Mixture of isomers More histamine Cvs unstable Less potent 0.5-0.6 More laudanosine ```
``` Cisatra Cis isomer No or less histamine Cvs stable More potent 0.1-0.15 mg Less laudanosine ```
175
Onset 4-5 min Shortest acting among NDMB 18min Meta by 🔱E
Mivacurium
176
Types of ChE
Acetyl: NMJ #ACh Butyryl 🔱: in plasma, but produced by liver Tissue: RBC WBC
177
Butyryl ChE 🔱E examples
SCh Miva Ester LA except cocaine Propanidid
178
Tissue ChE examples
Esmolol | Remifentanyl
179
Drugs potentiating NMB
Antibiotics ATP (AGs, Tetra, Polypeptides) Antiarrythmics (CCB,Quinine) Inhalational anaesthetic ⬆️Mg Acidosis ⬇️thermia 🥶 Myasthenia Gravis (1/3rd dose)
180
Resistant to depolarising MB | More susceptible to NDMB
MG
181
Reversal agents
Neostigmine + Atropine/ glycopyrolate (muscarinic SE#) INDIRECT Sugamadex DIRECT
182
Cyclodextrin compd Aminosteroid structure- acts only against aminosteroid gp Best against VECU&ROCU DIRECT reversal agent
Sugammadex
183
ET tube parts - nasal (dirty 🤮) - oral (Dr Ivan Magill)
``` Murphy eye (proximal, better visibility, bevelled) Cuff (prevents aspiration) globular/cylindrical Glottis opening (3-4cm above carina) Distal universal connector 22mm internal dia ``` Length 30cm Optimum pressure 25-30cmH2O Low pressure high vol
184
Morning sniff/ barking dog AOJ - E/NJ - F Hold laryngoscope in left hand (non dominant) Introduce from RIGHT angle of mouth to middle Locate epiglottis and AE fold Hinge tip of laryngoscope in AE fold and lift laryngoscope Visualise glottis opening
Steps of introduction of laryngoscope
185
Sits 3-4 cm above carina Seal in trachea to prevent aspiration Optimum cuff pressure 25-30 cm h2o
Placement of ETT Dead space ⬇️1/2 Resistance ⬆️ 1/r^4 WOB ⬆️
186
Sure shot confirmation of correct placement of ETT
Capnography
187
Narrowest part of airway in child
Glottis Use straight blade MILLER BLADE Cuffed tube ✔️ (old - uncuff in <6y for subglottis ❌)
188
Flexetallic/armour/reinforced
``` Prevent kinks - NeuroSx - head and neck Sx - dental - prone Sx NOT ABD SX ```
189
Double lumen tube
Only in thorax Sx And lung separation Correct placement - fibreoptic bronchoscopy
190
RAE tube/ Pre bent
Cleft lip Sx
191
Indication of intubation
1. GA 2. Secure airway in IPPV 3. Protect airway from aspiration 4. Pul toileting
192
Management of diff airway
A. Re optimisation B. Alt airway use LMA C. Sx securement of airway Tracheostomy or cricothyroidectomy
193
``` Supraglottic airway device Tip sits on hypopharynx Easy to insert and fast Less invasive Less complication ASPIRATION NOT PREVENTED 1-2h Not definitive airway Dr. Archie Brian - classic lma ```
LMA Proseal = ETT (preventing aspiration ❇️)
194
Indication of LMA
GA Secure airway for PPV Aid to intubation (Fast trach LMA)
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``` LMA size <5kg 5-10 10-20 20-30 30-50 50-70 >70 >100 ```
``` 1 1.5 2 2.5 3 4 5 6 ``` Total 8 sizes
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LMA vs ETT 3 4 5
ETT 5. 5 - 6.5 mm 6. 5 - 7.5 7. 5 - 9
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Maxillofacial # C spine # Elective
Tracheostomy Manual inline stabilise ➡️ orotrach intubation Nasal fibre optic intubation
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Types of circuit
Open obsolete Semi closed MAPELSON closed Circle ⭕️ system
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``` Less economical More OT pollution Light weight Simple and portable No need of advanced monitoring ```
Semi closed
200
More economical Less OT pollution Heavy bulky complex and fixed Needs of advanced monitoring for exp gases
Closed or circle ⭕️
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``` Mapleson A B C D F ```
ADULTS A - Magills SPONT VENTI B&C useless D - Bains CONTROLLED VENTI PEDS (<6y, <20kg) E - Ayres T piece F - Jackson Reeves modfn of Ayre SPONT & CONTROLLED
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Magills
FGF = 3 MV
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Bains
FGF = 1.8 MV
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Controlled ventillation circuits
Dead Babies Can’t Assist | DBCA
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Spontaneous ventilation circuits
A Dog Can Bite spontaneously | ADCB
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Jackson Reeves Spontaneous Controlled
Spontaneous FGF = 3-4 MV Controlled FGF = 2-3 MV
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Single most imp determinant of exp flow
FGF
208
Mc absorbent of co2 in closed
Sodalime mc Barylime Amsorb
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``` Pink granules not powder! Naoh 4% Koh 1% Caoh2 rest Water 11-18% SILICA - hardness to prevent dust fromn DYE - check exhaustion ```
Soda lime
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Naoh function in sodalime
Prevents chemical pneumonitis
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____g sodalime ➡️ ___L of co2
150g | 21L
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Signs of sodalime exhaustion
Sympath stimulation 1. Bp⬆️ HR⬆️ 2. Sweating in anaesthetised pt 3. ⬆️ oozing from Sx site 4. Change in color of granules 5. Change in capnograph
213
Predisposing factors for co prodn in closed circuit
1. DIE (des, iso, enflurane) 2. Very ⬆️ conc or DIE 3. Dry co2 absorber 4. Barylime
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1st anaesthesia machine
Boyles machine
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High pressure system
``` Gas cylinder (steel + Mb) high tensile MRI comparable (Ti/Al) Size A-HH Type E cylinder attached to A. Machine 2000psi ```
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Black body white shoulder 2,5 2000 Min mandatory pressure to start case under Gs = 1000psi (type E for GA: 100psi with flow rate - 2-3L/min last for 2-3h)
O2 cylinder
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Blue color 3,5 760 psi
N2O cylinder
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Grey color with black and white shoulder | 1,5
Air cylinder
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Grey color | 1,6 (>7%) or 2,6 (<7%)
Co2 cylinder
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Orange color 3,6 Not in clinical use
Cyclopropane
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Brown color 2,4 (70+30) 4,6 (60+40)
``` Heliox (He+O2) ⬇️viscosity ⬇️resistance ⬇️WOB ⬇️Turbulence ```
222
Intermediate pressure system
Pipeline supply | 55-60 psi
223
``` Color coding of pipelines Yello Blue Black White ```
Yello VACUUM Blue N2O Black AIR White O2
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DISS
Diameter index safety system | Safety system which prevents incorrect attachment of pipeline to A. machine
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Low pressure system
``` O2 and N2O flow control valve Vaporiser Common gas outlet Emergency O2 flush Hypoxia guard ``` Order given by Boyle.
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Flow meter function
Tells about the true flow of gas 🥢 Thores tube
227
Hypoxia guard
Basal O2 flow to A. Work station N2O opens in fixed proportion of O2 O2 safely alarms/ analyser
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Emergency O2 flush
Min - 15L at 10-12 psi Max - 35L at 55-60 psi (INTERMEDIATE Pres system) Anatomically present at low pressure system
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Most A machines are downstream | High P ➡️ Low P except?
Boyles ↗️ upstream
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Monitors mandatory by ASA
``` ECG Pulse ox Non invasive BP Temp Capnography ``` BIS exceptional
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BIS
``` Bispectral index Parietal Frontal and temporal areas Target 40-60 (0-100) (coma - conscious and alert) Monitors depth of Anaesthesia ```
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Measures intra op awareness (Modified EEG) Titration of A agents Fast post op recovery
BIS uses
233
Expired CO2 vs Time
Capnograph | MULTISYSTEM monitor
234
Ddx flat capno
``` Stoppage of mech venti Circuit discontinuity Accidental extubation Absolute only (not partial) Bronchospasm Cardiac arrest Eso intubation ```
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Normal Capno
35-45 mmHg Box shape with base line at 0 X axis volume Y axis ETCO2 (⏩ metabolism)
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⬆️ETCO2
Hyper metabolic state
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⬇️ETCO2
Hypo meta | Hypoperfusion
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Normal shape | Double conc of ETCO2
MH
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Sudden small boxes or fall of ETCO2
Neuro Sx | Air embolism
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Raise in baseline
Co2 rebreathing Soda lime exhaustion FGF inadequate Unidirectional valve incompetence
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Shark fin
Partial obs of lung Bronchospasm ET obstruction COPD
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Curare cleft
Return of spont respi | Repeats NM blocker
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Biphasic capnogram
Severe kyohoscoliosis
244
Pulse ox or Plethysmograph or spo2
O2 sat in arterial blood Infrared red 🩸 1. Law of plethysmograph (sense pulse of blood) 2. Law of oximetry BEER LAMBER LAW
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Inaccuracies of spo2
``` Hypoperfusion Hypothermia Other Hb (smoker ) Dark skin Skin pigmentation Dye Mail polish Polycythemia ``` NOT BY ANEMIA JAUNDICE
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Tee
Most sensitive for periop cardiac monitoring | Most sens monitor for intra op air embolism
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Air embolism 0.1 ml/kg BW >0.9
0.1 ml/kg BW: CO near normal TEE 🤩 >0.9: CO⬇️⬇️ Capno BP
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ECG Lead 2 Lead V5 Lead V4&5
Lead 2 Arrythmia Lead V5 70% sens MI Lead V4&5 99% sens MI
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PAE
ASA grading: Current physical status Risk with Sx
250
ASA grades 1-6 Elective Emergency
``` 1 localised prob 2 controlled co morb with min or no limitation 3 comorb with mod limitation 4 constant threat to life 5 only Sx can save him 6 coma for Tx ```
251
Airway eval
Mallampatti SIZE OF TONGUE wrt oral cavity 1 hard soft uvula tonsil fauces pillar 2 hard soft uvula fauces 3 hard soft 4 hard 12 Normal 34 large tongue
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Pre anaesthetic orders Npo Adult Child
Adult 8h solid 6h liquids ``` Child 8 solid 6 liquid 4 Breast milk 2 clear fluid ```
253
``` Prev meds orders Oral HTN OHA Anti dep psych epileptic Anticoag Thyroid ```
``` Oral HTN TILL DAY OF SX OHA mild and mod - stop 24 h prior Severe - shift to INSULIN Anti dep psych epileptic TILL DAY OF SX TCA - STOP 🛑 3wks before (arrhythmia 💀) Li - STOP 24h prior Thyroid - TILL DAY OF SX ```
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Anticoags ``` Aspirin Clopidogrel Ticlopidine Warfarin Lmwh Ufh ```
``` Aspirin TILL DAY OF SX 😌 Clopidogrel 7 days 🛑 Ticlopidine 14 days stop 🛑 Warfarin 3-4 days 🛑 Lmwh 12 h prior 🛑 Ufh 6h prior stop 🛑 ```
255
Steroid | All other drugs
``` Continue peri op supplementation CI DM Active infection Immune def ``` All others - TILL DAY OF SX
256
Regional anaesthesia
Peripheral LA CNB Spinal Epidural
257
Action Best on active nerve fibre Depends on 1. Voltage gated. 2. Time dep Adding vc prolongs Adr/ phenylephrine
LA
258
Types of Na channels
Active FAST 💨 Inactive SLOW Resting SLOW
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Advantage of LA
Less toxicity system ⬆️ duration Fast onset Better intensity ⬆️⬆️PAIN 😥 on injection CI end arteries
260
Adv of adding soda bicarbonate to LA
Fast onset Longer duration More intense LESS PAIN
261
Order of block
BCA B - Pre gang C - post gang and PAIN SLOW A - abcd ANS ➡️ sensory ➡️ Motor ASM Temp COLD ➡️ Pain ➡️ Touch ➡️ Proprio
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LIGNO | LIDO
Ligno - 2% ASM | Lido - 1% AS (M spared) Dofferential block
263
Blocking sensory sparing motor
Differential block
264
Systemic absorption of LA
IV > Tracheal > Intercostal > paracervical > caudal > brachial plexus > lumbar epidural > sciatic > SC
265
Esters vs Amides
Amide - 2i | Ester -1i
266
Esters
SA Cocaine 1st LA, vc Procaine Chloroprocaine SHORTEST LA Benzocaine Tetracaine
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Meta by pseudo choline esterase (except cocaine) PABA release + (ALLERGY) Not much clinical use
Esters
268
LA of choice in day care Sx
Chloroprocaine
269
Amides | No PABA :))
IA Ligno SAFEST Mepiva Prilocaine LA Bupivacaine WORST Ropivavaine Dibucaine
270
LA of choice in IVRA or BIER BLOCK
Lignocaine
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C/I for IVRA
Bupivacaine 1. Sickle cell 2. PVD 3. Scleroderma
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LA Causing methHbnemia
Benzocaine Prilocaine EMLA
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SE of LA in CNS
Apprehension Peri oral numbness Seizure Tinnitus
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SE of LA in CVS
Arrhythmia | Cardiac arrest
275
CC/CNS ratio 8 2
8 Ligno SAFEST | 2 Bupi MOST DANGER ⛔️
276
Max safe dose of Ligno 1. Alone 2. With Adr
1. 4.5mg/kg | 2. 7 mg/kg
277
EMLA cream Contact pd Surface anaesthesia Max SA
``` Only on intact skin Ligno:Prilo = 1:1 2.5% and 2.5% each Contact pd = 1 h Surface anaesthesia 2-4mm depth Max SA - 2000cm2 ```
278
CI to EMLA
Abrasion Mucous membrane Neonate (infant can use)
279
Most cardio toxic ♥️ CI IVRA 0.5% 0.25%
Bupivacaine 0. 5% ASM 0. 25% AS (M is spared)
280
``` La of choice in differential block S- isomer of bupivacaine Less cardio toxic Less motor block Less potent ```
Ropivacaine
281
Central neuraxial blockade
Epidural (catheter is left in situ) | Spinal
282
``` Drug in SAS Immediate onset Min quantity of drug used Less toxic Drug made heavy/ hyperbaric (dextrose) Easy to do less failure Fixed duration Intra op anaesthesia Segmental block NOT possible More hemodynamic imbalance QUINCKE SPROTTER WHITTACKRE ```
Spinal
283
``` Skin SC fascia Supra infra spinatous lig Lig flava Duramater Arachnoid matter CSF return SAS ```
Spinal
284
``` Drug in epidural space Delayed onset Per segment 1.5-2ml drug More drug more systemic toxicity Plain drug used More experience needed Can be prolonged with catheter Intra op + post op analgesia SEGMENTAL block possible Less hemodynamic imbalance TUWHYS 18 G ```
Epidural
285
``` Skin S fascia S/I ligament Lig flavum Loss of resistance (give way) Epidural space ```
Epidural
286
Complication of CNB
``` Hypotension mc (fluids pressors ionotropes) Bradycardia Resp depression Urinary retention mc POST OP Total spinal high spinal all 31# Systemic toxicity Vasovagal Infection PDPH ```
287
PDPH
Post dural puncture headache Low csf Low icp Rare nowadays
288
Absolute CI to CNB
``` Raise ICP Local infection of site Hypovolemia shock RELATIVE Coag dis Pts REFUSE Severe heart dis (graded epidural) ```
289
Drugs used in epidural
LA | Opioids
290
⬆️hemodynamic imbalance Muscle paralysed Narrow dosing time
LA in epidural
291
``` Hemodynamic imbalance ⬇️ Muscle spared ✔️ Wide dosing time Causes CNS depression Acts at substantia gelatinosa ```
Morphine/Opioid in CNB
292
Post op analgesia MAJOR pain Adult Child
Adult - epidural Opioid | Child - IV Opioid infuse
293
Post op analgesia MINOR pain Adult Child
Both - IV IM Oral Rectal NSAID
294
Labour analgesia types
Systemic- IV fentanyl- needs fetal resuscitation Resp dep Regional - GOLD STD Epidural LA+Opioid
295
Modes of ventilation Fully controlled Intermediate Fully spontaneous
``` CMV SIMV PCV PSV PAP ```
296
TV 500 12bpm ``` Disadv Needs ms paralysis heavy sedation Creates VQ mismatch Causes disuse atrophy Weaning not possible ```
CMV | Controlled mode ventilation
297
Overcomes all disadv of CMV | Syncs with pt breathing
SIMV | Synchronised intermittent minute ventilation
298
``` ARDS and Peds BEST Lung protective mode Upper limit of pressure - 50 mmHg Rate 12bpm (HIGH PEEP LOW TV ) Stops as soon as upper limit is reached until just adeq venti is reached Not weaning mode ```
PCV Pressure controlled Volume cycled
299
``` Pressure support ventilation Just ⬇️ WOB WEANING Pts effort + 15/5/10 +ve pressure in upper and lower lobe ```
PSV | Pressure support
300
+ve pressure only in upper airway
CPAP

Last Leg (9 decks)

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