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045 Anesthesia team


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Anesthesia 0SCE
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Topic Page
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A) Befinition of pieopeiative peiiou.
B) Inuications of pieopeiative evaluation.
C) Evaluation of a patient in the pie-opeiative
peiiou:
I. Bistoiy taking.
II. Examination.
III. ASA Classification.
Iv. Investigations.
v. Consent.
vI. Piemeuication.
vII. Pieopeiative staivation.

S
S
S
S
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A) Basic aiiway anatomy
B) Nethous of suppoiting the aiiway:
I. Nouth-to-mask ventilation with supplemental
oxygen.
II. Bag mask ventilation.
III. Laiyngeal Nask Aiiway (LNA).
Iv. Enuotiacheal Tube (ETT).
v. Fibei-optic laiyngoscope.
vI. Instiuments that ease the piocess of intubation.
C) Rapiu sequence inuuction
B) Bifficult Aiiway management
E) Suigical Invasive aiiway access

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A) Befinition of iegional anesthesia.
B) Inuications of iegional anesthesia.
C) Contiainuications of iegional anesthesia.
B) Complications of iegional anesthesia.
E) Types of iegional anesthesia.
I. Epiuuial anesthesia.
II. Spinal anesthesia.
III. Combineu spinal anu epiuuial anesthesia.

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A) Cential line:
B) Peiipheial veins:


2S
2S

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A) Factois must be taken into account
B) Ciystalloius.
C) Colloius.
B) Fluiu ieplacement.
E) Bloou loss iegimens.
F) Bloou tiansfusion complications.

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Anesthesia 0SCE
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It is the time fiom the uecision to have suigeiy until aumitteu into the 0R theatie.
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1. Assess the anesthetic iisks in ielation to the pioposeu suigeiy.
2. To ueciue the anesthetic technique (geneial, iegional, oi a combination).
S. To plan the postopeiative caie incluuing any analgesic iegimens.
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!C D-/,)(3 ,+E-"4?
FC !",()#89,-)"?
- Intiouuce youiself to the patient giving youi name anu status as a stuuentC Ask foi peimission to take a
histoiy anu peifoim a physical examination.
GC '$(/)"+6 7-/,)(3?
Ask foi the patient's name, age, occupation, nationality, anu maiital status.
HC '($/$", -66"$//?
Establish the piincipal symptom oi symptoms that causeu the patient to seek meuical attention, when it
fiist appeaieu anu how it has changeu ovei time.
IC '+/, 0$#-9+6?
Ask about the patient's pievious meuical pioblems incluuing caiuiac (IBB, BTN, BF, AF), iespiiatoiy
(asthma, C0PB, TB), neuiological (stioke, TIA, epilepsy), gastioenteiological (livei uisease, jaunuice) anu
haematological (sickle cell, thalassemia) pioblems. Also ask the patient if they aie piegnant if ielevant.
JC '+/, /8(4-9+6?
Ask about any pievious opeiations anu post-op. complications. Enquiie about pievious types of
anaesthesia ieceiveu (local, geneial) anu enquiie about any anesthetic complications (malignant
hypeitheimia).
KC L$#-9+,-)"/?
Ask about any piesciibeu meuications the patient is taking incluuing insulin oi hypoglycemics,
anticoagulants (waifaiin, aspiiin), -blockeis, steioius, ACE inhibitois, uiuietics anu inhaleis. Enquiie
about any ovei-the-countei meuication, contiaception (C0CP) anu BRT.
MC 166$(4-$/?
Enquiie about alleigies to antibiotics, plasteis, latex, eggs anu antiseptic solutions.
NC :+0-63 7-/,)(3?
Check foi family histoiy of any illnesses incluuing myotonic uystiophy, malignant hypeipyiexia, poiphyiia,
cholinesteiase uisoiueis anu sickle cell uisease. Enquiie about any othei anaesthetic complications anu
alleigic ieactions in the family.
OC =$",+6?
Ask about any histoiy of uental pioblems, false teeth, caps, biiuges anu uentuies.
FPC Q)9-+6?
Elicit the patient's alcohol histoiy noting the numbei of units consumeu in a week. Beteimine if the patient
is a smokei anu how many cigaiettes he smokes pei uay.


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Anesthesia 0SCE





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- BNI: Neasuie the patient's height anu weight anu calculate his bouy mass inuex. Iueal BNI is between
18.S anu 24.9.
- Bocument the patient's bloou piessuie, oxygen satuiation on aii, pulse, iespiiatoiy iate anu tempeiatuie.
- Peifoim a biief chest, abuomen, caiuiovasculai anu neuiological examination.
GC 1-(2+3? (LEN0N)
Sook:
- Ask the patient to flex anu extenu his neck anu to open anu close his mouth looking foi shoit immobile
neck. Some patients cannot be placeu in the "sniffing position" seconuaiy to neck tiauma, ceivical collai,
musculoskeletal uisoiueis like kyphosis anu iheumatoiu aithiitis.
- A neck ciicumfeience of gieatei than 4Scm in an obese patient with a BNI of gieatei than 4ukgm^2 is
likely to be a uifficult intubation.
- Women with laige penuulous bieasts auu a uegiee of uifficulty to an intubation because the pioviuei may
not be able to position the blaue hanule appiopiiately towaiu the chest
- Inspect the mouth anu see if theie aie any obvious abnoimalities, buckteeth, high aich palate, ieceuing
manuible (may be hiuuen by a beaiu), Inability to sublux the jaw
(foiwaiu piotiusion of the lowei incisois beyonu the uppei incisois).
Avaluate:
a. Thyiomental uistance:
- It is the uistance fiom the thyioiu caitilage to the mental piominence
when the neck is extenueu fully.
- If the uistance is moie than7cm (aiounu S fingeibieauths), pioblems
Tiaumatic: Infection Inammatoiy Neoplastic Enuociine: Piegnancy
Fiactuies 0f
Nanuible
Anu Ceivical
Spine
Epiglottitis
Bental 0i
Facial
Abscess
Ankylosing
Sponuylitis
Rheumatoiu
Aithiitis
Tongue
Neck
Nouth
Thyioiu
Enlaigement
Aciomegaly
0besity

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0ppei aiiway obstiuction may be founu in patients with stiiuoi,
uysphagia anu hoaiseness.
Snoiing may also inuicate paitial uppei aiiway obstiuction.

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Initially examine the patient geneially then move to aiiway examination.
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Anesthesia 0SCE
shoulu not occui with intubation.
- A uistance of less than 6 cm suggests laiyngoscopy will be impossible anu foi uistances of 6-6.S cm,
laiyngoscopy is consiueieu uifcult, but possible.
b. Steinomanuibulai uistance:
- This test is claimeu to pieuict up to 9u% of uifcult intubations.
- The uistance fiom the uppei boiuei of the manubiium steini to the tip of the chin, with the mouth closeu
anu the heau fully extenueu, is measuieu.
- A uistance of less than 12.S cm inuicates a uifcult intubation.
c. Alantooceptal joint:
- Piesence of a gap between the 0cciput anu C1 is essential.
- It shoulu be (1S-2u uegiees).
u. C-Spine:
- Flexion anu extension of the heau anu neck must be moie than 9u uegiee.
e. Intiauental gap:
- Noimal inteiuental gap is S fingeis.
- Pooi mouth opening: less than thiee fingeis gap between uppei anu lowei teeth.
Lallampatti scoie:










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uiaue 1: facial pillais, soft palate anu uvula
visible
uiaue 1: all the glottis (opening between the
vocal coiu) is visible
uiaue 2: facial pillais, soft palate visible,
but uvula maskeu by the base of the tongue
uiaue 2: only the posteiioi poition of the
glottis is visible
uiaue S: soft palate only visible uiaue S: only the epiglottis is visible
uiaue 4: soft palate not visible uiaue 4: even the epiglottis is not visible
Patients in uiaues S anu 4 aie consiueieu uifcult to intubate anu those in uiaues 1 anu 2
aie consiueieu feasible intubations. It is impoitant to iealize
That this system is !"# infallible anu patients in uiaue 2 sometimes cannot be intubateu.
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Anesthesia 0SCE
Ubstiuction:
Aiiway euema, tiacheal mass, meuiastinal mass.
Veck mobility.
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ASA 1: Bealthy patient without oiganic biochemical oi psychiatiic uisease.
ASA 2: A Patient with milu systemic uisease. No significant impact on uaily activity. 0nlikely impact on
anesthesia anu suigeiy.
ASA S: Significant oi seveie systemic uisease that limits noimal activity. Significant impact on uaily activity.
Likely impact on anesthesia anu suigeiy.
ASA 4: Seveie uisease that is a constant thieat to life oi iequiies intensive theiapy. Seiious limitation of
uaily activity.
ASA S:Noiibunu patient who is equally likely to uie in the next 24 houis with oi without suigeiy.
ASA 6: Biain-ueau oigan uonoi.
"E" - auueu to the classifications inuicates emeigency suigeiy.

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State that you woulu oiuei investigations if clinically appiopiiate.
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Bemoglobin concentiation.
Coagulation piofile.
Scieening foi sickle cell uisease.
0iea.
Cieatinine.
Electiolytes.
ulucose.
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Respiiatoiy (asthma, C0PB) oi caiuiac uisease (heait failuie), malignancy, thoiacic suigeiy,
iespiiatoiy symptoms (cough, S0B, sputum), pievious TB.
A;RC
Bypeitension, heait uisease, aiihythmia, >Su yeais olu, BN.

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It shoulu be a wiitten one anu it explains the anesthetic options foi a given suigical pioceuuie.

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If youi patient neeu any piemeuitations like anxiolytics mention them.

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Fiom Soliu Foou = 6-8 houis.
Fiom Cleai Fluiu= 2 houis.
Fiom Bieast Nilk foi Neonates = 4 houis.
Fiom Foimula Nilk foi Neonates = 6 houis.


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Anesthesia 0SCE
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Right bionchus is wiuei, shoitei, anu moie veitical in uiiection than the left. So aspiiation occuis moie into the
iight bionchus.
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I. Nouth-to-mask ventilation with supplemental oxygen.
II. Bag mask ventilation.
III. Laiyngeal Nask Aiiway (LNA).
Iv. Enuotiacheal Tube (ETT).
v. Fibei-optic laiyngoscope.
vI. Instiuments that ease the piocess of intubation.



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Anesthesia 0SCE
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!"#-9+,-)"/? Patients who aie uniesponsive, apneic, oi have uepiesseu iespiiations.
;)",(+-"#-9+,-)"/? None when above conuitions apply.
;)0*6-9+,-)"/? uastiic uistention.
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Connect oxygen line with 1u - 1S L flow.
Establish aiiway by heau-tilt, chin lift.
Inseit 0iophaiyngeal aiiway with piopei technique.
Establish seal with mask.
ventilate mouth-to-mask.




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Anesthesia 0SCE
!!C @+4 0+/E W$",-6+,-)"
1#.+",+4$/? basic, Non-invasive, Reauily available, Can use oiophaiyngeal nasophaiyngeal aiiway.
=-/+#.+",+4$/? Risk of aspiiation if uecieases L0C, Cannot ensuie aiiway Patency, Inability to uelivei
piecise tiual volume, 0peiatoi fatigue.
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B Failuie of ventilation
- Failuie of oxygenation
- Faileu intubation
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B Seveie facial tiauma.
- Bag mask ventilation is absolutely contiainuicateu in the piesence of complete uppei aiiway obstiuction.
So, Foieign mateiial in the aiiway shoulu be iemoveu befoie bag mask ventilation is initiateu.
- It is ielatively contiainuicateu aftei paialysis anu inuuction (because of the incieaseu iisk of aspiiation).
;)0*6-9+,-)"/?
B The main complications of the bag-mask technique aie inability to ventilate anu gastiic inflation.
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- Bag-valve-mask.
- 0xygen connectoi tubing.
- 0xygen souice.
- Suction.
- Nasal phaiyngeal aiiway (NPA).
- 0ial phaiyngeal aiiway (0PA).
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Peifoim heau tilt-chin lift.

Peifoim suctioning within 1u seconus.

Assembles bag anu chooses appiopiiate size mask.

Choose appiopiiate size 0PA (0iophaiyngeal Aiiway) oi NPA
(Nasophaiyngeal Aiiway) anu Inseits uevice.

Bolu anu seal mask with 1 hanu.

ventilate at piopei iate (1 bieath eveiy S to 6 seconus).

Piouuce noticeable chest iise.

Belivei each ventilation ovei 1 seconu.

Release bag completely between ventilations.

Bolu anu seals mask coiiectly with 2 hanus.

Apply ciicoiu piessuie.



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Anesthesia 0SCE
!!!C S+(3"4$+6 L+/E 1-(2+3 TSL1< -",8\+,-)"?
1#.+",+4$/?
B Easy to inseit. (Emeigency situations)
- Less aiiway tiaumaiiiitation than ETT.
- Fiees up hanus (vs. face mask)
- Piimaiily useu in spontaneously ventilating patient.
=-/+#.+",+4$/?
- Boes N0T piotect against laiyngospasm oi gastiic aspiiation.
Q-]$/?
- 4u-Su kg: S
- Su-7u kg: 4
- 7u-1uu kg: S
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- The laiyngeal mask aiiway (LNA) is an acceptable alteinative to mask anesthesia in the opeiating ioom.
- It is often useu foi shoit pioceuuies when enuotiacheal intubation is not necessaiy.
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Absolute contiainuications: (in all settings, incluuing emeigent)
- Cannot open mouth.
- Complete uppei aiiway obstiuction.
Relative contiainuications: (in the elective setting):
- Anyone with incieaseu iisk of aspiiation. (Noibiu obesity, seconu oi thiiu tiimestei piegnancy, patients
who have not fasteu befoie ventilation, anu uppei gastiointestinal bleeu.)
- Piolongeu bag-valve-mask ventilation.
- Suspecteu oi known abnoimalities in supiaglottic anatomy.
- Neeu foi high aiiway piessuies (in all but the LNA PioSeal, piessuie cannot exceeu 2u mm B20 foi
effective ventilation.)
;)0*6-9+,-)"/?
Complications uue to LNA inseition:
- Aspiiation of gastiic contents.
- Local iiiitation.
- 0ppei aiiway tiauma.
- Piessuie-inuuceu lesions.
- Neive palsies.
- Nilu sympathetic iesponse.
Complications associateu with impiopei placement:
- 0bstiuction.
- Laiyngospasm.
Complications associateu with positive piessuie ventilation:
- Pulmonaiy euema.
- Bionchoconstiiction.


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Anesthesia 0SCE
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9)(($9,63
Piepaie anu assemble all necessaiy equipment.
Choose appiopiiate size LNA.
Test integiity of cuff by inflating it.
Beflate cuff on a flat suiface anu lubiicate LNA on posteiioi suiface
only foi use.

0pen the mouth using the "ciosseu fingeis" technique oi by peifoiming
a tongue-}aw lift; uo not hypeiextenu neck.

Cleai the aiiway if neeueu.
Inseit tube into mouth anu place it so that the cuivatuie is the same as
that of the Phaiynx, uiiecting it posteiioily until iesistance is felt.

Inflate the cuff with the appiopiiate amount of aii coiiesponuing to the
size of the tube , iemove syiinge.

Inseit bite block.
Piouuce noticeable chest iise; auscultate bieath sounus.
Confiim coiiect positioning of LNA by coloiimetiic ETC0" capnogiaph.
Secuie LNA in place.
Peifoim coiiect ventilation iate foi iespiiatoiy aiiest (1 bieath eveiy S
to 6 seconus).

Peifoim coiiect ventilation iate foi caiuiac aiiest (1 bieath eveiy 6 to
8 seconus).

Belivei each ventilation ovei 1 seconu.
Bemonstiate complete ielease of bag between ventilation.


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Anesthesia 0SCE
!WC A"#),(+97$+6 ,8\$ TA^^< -",8\+,-)"?
1#.+",+4$/? T^7$ J '/<
-Ensuies aiiway Patency
-Piotects against aspiiation
-Allows Positive piessuie ventilation
- Allows suctioning i.e. "Pulmonaiy toilet"
- A ioute foi phaimacological auministiation.
=-/+#.+",+4$/?
-Inseition can be uifficult.
-Nuscle ielaxants usually neeueu.
-Laiyngospasm may occui on faileu intubation oi extubation.
-Sympathetic stiess uue to Intubation.
Q-]$/?
- Nale: 8.u-9.u mm
- Female: 7.u-8.u mm
- Peuiatiic: (age4) + 4 mm
!"#-9+,-)"/?
- To ensuie aiiway patency in an unconscious patient.
- To piotect the lungs fiom the aspiiation of gastiic contents.
- To pioviue positive-piessuie ventilation, in the setting of iespiiatoiy failuie oi of geneial anesthesia.
;)",(+-"#-9+,-)"/?
- Any situation wheie the phaiynx is obstiucteu (phaiyngeal foieign bouy, massive swelling of the
phaiynx), oi if theie is seiious maxillofacial tiauma.
;)0*6-9+,-)"/?
- An enuotiacheal tube that is mistakenly sizeu oi misplaceu, especially in the apneic patient, can quickly
leau to hypoxia anu ueath.
- Acciuental intubation of the esophagus. -
0iophaiyngeal tiauma. -
Bioken teeth oi uentuies. -
Enuobionchchial intubation, ETT inseiteu too fai.

Enuotiacheal Tube
+$#,-./01/2&
Laiyngoscope


Page 1S

Anesthesia 0SCE

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V If uone
coiiectly
Assume ventilation is in piogiess.

Assemble anu checks all necessaiy equipments

Choose appiopiiate size ET tube

Choose appiopiiate type (stiaight oi cuiveu) anu size laiyngoscope blaue

Check light ,Tests ET tube cuff integiity

Inseit the stylet anu lubiicates the ET tube

Place heau in neutial oi sniffing position

Cleai aiiway if neeueu

Inseit laiyngoscope blaue

Bolu laiyngoscope in left hanu.

Inseit laiyngoscope in iight siue of mouth, moving tongue to the left.

visualize epiglottis, then vocal coius.

Inseit ET tube to piopei length foi genuei

Inflate ET tube cuff to achieve piopei seal; iemove syiinge

Inseit bite block

Piouuce noticeable chest iise; auscultates bieath sounus

Confiim coiiect positioning of ET tube by coloiimetiic ETC0" Capnogiaph

Secuie ET tube in place (commeicial uevice oi tape)

Peifoim coiiect ventilation iate foi iespiiatoiy aiiest (1 bieath eveiy S to
6 seconus)

Peifoim coiiect ventilation iate foi caiuiac aiiest (1 bieath eveiy 6 to 8
Seconus)

Belivei each ventilation ovei 1 seconu

Bemonstiate complete ielease of bag between ventilations



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Anesthesia 0SCE
WC :-\$()*,-9 6+(3"4)/9)*$ -",8\+,-)"?
Fibeioptic enuotiacheal intubation is a useful technique in a numbei of situations. It can be useu when the
patient's neck cannot be manipulateu, as when the ceivical spine is not stable. It can also be useu when it is not
possible to visualize the vocal coius because a stiaight-line view cannot be establisheu fiom the mouth to the
laiynx. Fibeioptic intubation can be peifoimeu eithei awake oi unuei geneial anesthesia anu it can be peifoimeu
eithei as the initial management of a patient known to have a uifficult aiiway, oi as a backup technique aftei uiiect
laiyngoscopy has been unsuccessful.
It is usually uone if theie was any thyioiu enlaigement.





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Anesthesia 0SCE
W!C !"/,(80$",/ ,7+, $+/$ ,7$ *()9$// )> -",8\+,-)"?
R6-#$/9)*$?
Inuications:
- Patients with pooi uiiect laiyngoscopic view.
- 0bese patients.
- Challenging aiiways (inability to view the vocal coius on uiiect view) uue
to anatomic vaiiation oi uistoition.
- Small mouth opening (< S cm)
- Limiteu neck extension.
- Excessive secietions in the aiiway. (The uliueScope has an anti-fogging
heat lamp to enable views in the piesence of excessbloouy secietions)
Contiainuications:
- Absolute Contiainuications: None.
- Relative Contiainuications: may be oveilookeu in the tiue emeigency
situation because it is moie impoitant to iesuscitate.
-- Limitations to mouth opening (< S cm)
-- Najoi tiaumafiactuies to the face (maxilla, manuible) oi neck.
-- Neck abscess (ietiophaiyngeal) can cause uifficulty with tiacheal
intubation.
-- Neoplasm of the uppei aiiway that may uistoit aiiway anatomy.
-- Nasal intubation iequiieu foi suigical pioceuuie (e.g., oial suigeiy)
S-47,$# Q,36$,?
Enuotiacheal stylet with a light souice at the tip. veiy helpful in intubation aiu, especially in uifficult
aiiways. The light can be seen fiom outsiue the patient helping guiue the ET tube thiough the vocal coius.
@)84-$?
B Flexible uevice aiounu 6u cm long.
- 0seu in Bougie-assisteu Enuotiacheal Intubation.








! Lighteu stylet
Intubation using bougie "


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Anesthesia 0SCE
;< 5+*-# /$Z8$"9$ -"#89,-)"?
!"#-9+,-)"/?
- When the patient has "full stomach", i.e. pieuisposeu to ieguigitationaspiiation.
-Beciease level of consciousness (L0C).
- Tiauma.
- Neal within 6 houis.
- Sphinctei incompetence suspecteu (uERB, hiatus heinia, nasogastiic tube).
- Incieaseu abuominal piessuie (piegnancy, obesity, bowel obstiuction, acute abuomen).
-0seu in shoit pioceuuies as well.
'()9$#8($ /,$*/?


'$(>)(0+"9$ Q,$*/ U> 5+*-# /$Z8$"9$ -"#89,-)"
V If uone
coiiectly
Pie-oxygenateuenitiogenate: patient bieaths 1uu% 02 foi S-S minutes.

Apply ECu monitoi, BP monitoi, pulse oximetei

Secuie intiavenous access.

Test ET tube anu all equipment necessaiy foi intubation.


Assistant peifoims Sellick's maneuvei: piessuie on ciicoiu caitilage to
compiess esophagus between caitilage anu C6 to pievent
iefluxaspiiation.

Auministiation of inuuction agent immeuiately followeu by fast acting.
muscle ielaxant (e.g. succinylcholine).

Intubate shoitly aftei auministiation of muscle ielaxant (appioximately
4S-6u seconus) with no bag-mask ventilation in between inuuction anu
intubation.

Inflate cuff ETT to pievent aspiiation of gastiic contents.

veiify coiiect placement of ETT.

Release ciicoiu caitilage piessuie

Confiim coiiect positioning of ET tube

ventilate when ETT in place anu cuff inflateu.

Estimate patient's weight.

Calculate uiug uosages anu uiaw up into syiinges.


Intiaopeiative fluiu management.

Exubation.

Recoveiy.



Page 17

Anesthesia 0SCE
=< =->>-986, 1-(2+3 0+"+4$0$",?
Pie opeiative assessment is veiy helpful in expecting a uifficult aiiway case. It helps us in planning the
management of intubation (Plan A, Plan B anu so on). Bowevei not all uifficult aiiways aie uetecteu by the
pieopeiative assessment. Asking the patient if he hau pievious uifficult intubation, uoing an aiiway examination.
Not eveiy pieviously successful intubateu patient means easy aiiway. Pie oxygenation is veiy impoitant in these
cases to give the patient a goou ieseivoii. Intubation shoulu be uone within Su seconus.
The fiist step aftei faileu intubation is calling foi help.
Then we can uo eithei:
- Awake intubation
- Intubation with Lighteu stylet (tiachlight), fibeioptic laiyngoscope, oi uliuscope.




Page 18

Anesthesia 0SCE
A< Q8(4-9+6 !".+/-.$ +-(2+3 +99$//?
!C ^(+97$)/,)03?
It is maue by uiiect access to the tiachea thiough the neck. Aftei the
incision is maue suigically you place a tiacheostomy tube to maintain
the opening. Can be uone in acute anu chionic (elective) situations.
Inuications:
- 0bstiuction of the uppei aiiway, eg foieign bouy, tiauma,
infection, laiyngeal tumoi, facial fiactuies.
- Impaiieu iespiiatoiy function, eg heau tiauma leauing to unconsciousness, bulbai poliomyelitis.
- To assist weaning fiom ventilatoiy suppoit in patients on intensive caie.
- To help cleai secietions in the uppei aiiway.
!!C ;(-9),73()-#),)03?
Pioviues a tempoiaiy emeigency aiiway in situations wheie theie is obstiuction at oi above the level of the laiynx
(Nose & Nouth). Quick, easy anu fai less complications than tiacheostomy. Can be uone by neeule, with puipose-
built kits intubation, suigically, anu even with penknife anu stiaws.
Inuications:
Neeu foi an emeigency aiiway wheie:
- Intubation is not possible via the oial oi nasal ioute.
- Seveie maxillofacial tiauma.
- 0euema of thioat tissues pieventing visualization of the coius (eg angioneuiotic oeuema, anaphylaxis,
buins, smoke inhalation).
- Seveie oiophaiyngealtiacheobionchial haemoiihage.
- Foieign bouy in uppei aiiway.
- Lack of equipment foi enuotiacheal intubation.
- Technical failuie of intubation.
- Seveie tiismusclencheu teeth.
- Nassetei spasm aftei succinylcholine.
Contiainuications:
- Availability of a less invasive means of secuiing
the aiiway.
- Patients <12 yeais olu.
- Laiyngeal fiactuie.
- Pie-existing oi acute laiyngeal pathology.
- Anatomical lanumaiks obscuieu by gioss haemoiihagesuigical emphysema, etc.



Page 19

Anesthesia 0SCE
5$4-)"+6 1"$/,7$/-+
1< =$>-"-,-)" )> ($4-)"+6 +"$/,7$/-+?
Local anesthetic agent (LA) applieu aiounu a peiipheial neive at any point along the length of the neive (fiom
spinal coiu up to, but not incluuing, the neive enuings) foi the puiposes of ieuucing oi pieventing impulse
tiansmission.
@< !"#-9+,-)" )> ($4-)"+6 1"$/,7$/-+?
Avoiu some of the uangeis of geneial anesthesia e.g. known uifficult intubation, seveie iespiiatoiy failuie.
Patient specifically iequests iegional anesthesia.
Bigh quality post-opeiative pain ielief.
ueneial anesthesia not availablecontiainuication.
Titiation of LA uosage oi uiffeiential blockaue e.g. can block pain but pieseive motoi function.
0bstetiical.
Lowei limbs suigeiy.
Pelvic suigeiy.
Lowei tiauma
;< ;)",(+-"#-9+,-)" )> ($4-)"+6 1"$/,7$/-+?
1\/)68, 9)",(+-"#-9+,-)"?
1. Patient iefuseu.
2. Bematological uiseases.
S. Local infection at local site.
4. Inciease intiacianial piessuie.
S. Alleigy to local anesthesia
6. Sepsis.
5$6+,-.$ 9)",(+-"#-9+,-)"?
1. Lack of iesuscitation equipment
2. Lack of Iv access
S. Anticoagulation uiugs use
4. Neuiological uiseases
S. Low back pain
6. Bypeivolemia.
=< ;)0*6-9+,-)"/ )> ($4-)"+6 1"$/,7$/-+?
Bypotension. (Tieateu with Iv fluius)
Tempoiaiy lowei-extiemity motoi oi sensoiy ueficits. (Tieat by loweiing the iate oi concentiation.)
0iine ietention. (Tieat with inseition of a cathetei)
Local anesthetic toxicity (neuiotoxicity) (Tieateu with stopping infusion immeuiately)
Respiiatoiy insufficiency. (Tieateu with stopping infusion immeuiately, ABC |1uu% o2 call foi helpj,
assess spieau anu height of block, anu then alteinate youi analgesia iegimen)
Beauache (Buial punctuie). (Symptomatic tieatment anu autologous bloou patch)
Infection.
Nausea anu vomiting.
Intiavenous placement of cathetei
Subuuial placement of cathetei.
Bematoma.


Page 2u

Anesthesia 0SCE
A< ^3*$/ )> ($4-)"+6 +"$/,7$/-+?

!C A*-#8(+6 1"$/,7$/-+?
=$>-"-,-)"
a foim of iegional anesthesia involving injection of a local anesthetic into the epiuuial space.
!#$",->-9+,-)" )> ,7$ $*-#8(+6 /*+9$?
Seveial methous can be useu to iuentify the epiuuial space. They incluue the following:
- Loss of iesistance to aii oi pieseivative-fiee noimal saline.
- Compiession of a small aii bubble in saline
- Banging uiop technique
AZ8-*0$",?
- steiile towels
- steiile gloves
- Tuohy neeule eithei 16 oi 18 gauge .It is 1u cm long: 8 cm of neeule anu 2 cm of hub. It is maikeu in
centimeteis anu has a cuiveu 'Bubei' tip.
- Epiuuial cathetei has thiee holes The cathetei is maikeu in centimetei giauations up to 2u cm.
- The filtei has a u.2 m mesh that stops the injection of paiticulate mattei, such as glass, anu bacteiia into
the epiuuial space.
;)0*6-9+,-)"/
3 4&-&5#$56/- /7 $ 89//% :&00&9;
3 <,2/5&-06/- =-$>0&$ ? :/@656-.A;
3 <&$%$1B&;
3 C$1D 2$6-;
3 E-5#$:$01>9$# 1$5B&5&#6F$56/-;
3 G&5 5$2;
3 E-7&156/-;

H695&#
I$5B&5&#
J26%>#$9 K&&%9&


Page 21

Anesthesia 0SCE
!!C Q*-"+6 1"$/,7$/-+?
=$>-"-,-)"?
a foim of iegional anesthesia involving injection of a local anesthetic into the subaiachnoiu space.
! !#$",->-9+,-)" )> ,7$ /8\+(+97")-# /*+9$?
Fiee flow of CSF confiims piopei placement.
The spinal coiu in auult begins fiom the foiamen magnum anu enus at L1 anu in chiluien L1 - LS.
AZ8-*0$",?
- steiile towels.
- steiile gloves.
- steiile spinal neeule.
- an intiouucei neeule if using a small gauge neeule (this can be a steiile 19 gauge uisposable neeule)
- steiile filtei neeule to uiaw up meuications.
- steiile S ml syiinge foi the spinal solution.
- steiile 2 ml syiinge with a small gauge neeule to localize the skin piioi initiation of the spinal anesthetic
- antiseptics foi the skin (such as betauine, chloihexiuine, methyl alcohol)
- steiile gauze foi skin cleansing anu to wipe off excess antiseptic at neeule punctuie site
- single use pieseivative fiee local anesthetic ampoule
;)0*6-9+,-)"/?
B Faileu block
- Back pain (most common)
- Spinal heau ache (Noie common in women ages 1S-4u, laigei neeule size inciease seveiity, onset
typically occuis fiist oi seconu uay post-op. Tieatment: beu iest, fluiu, caffeine, oi bloou patch)

J26%>#$9
K&&%9&
L26-$9
K&&%9&
H695&#
I$5B&5&#


Page 22

Anesthesia 0SCE
'()9$#8($ /,$*/?
'$(>)(0+"9$ Q,$*/ )> /*-"+6 +"$/,7$/-+ [ -> #)"$
9)(($9,63
Taking Consent fiom the patient
Assessment (inuications anu contiainuications)

Inseit iv fluius

Nask, cap, gown anu gloves

Piepaie the back with antiseptic

Place a steiile Biape 0vei The Aiea

Iuentify the anatomical lanumaiks

Inject local anaesthetic into the skin anu ueepei tissue

Inseit the laige intiouucei neeule into the selecteu spinal
inteispace

Biiect the spinal neeule thiough the intiouucei anu into the
Subaiachnoiu space

Fiee flow of CSF confiims piopei placement

Aspiiate foi CSF if cleai inject the piopei anaesthetic

Remove the neeule, intiouucei anu uiape sheet

Bave the patient lie uown


!!!C ;)0\-"$# /*-"+6 +"# $*-#8(+6 +"$/,7$/-+?
=$>-"-,-)"?
Is a iegional anesthetic technique, which combines the benefits of both spinal anesthesia anu
epiuuial anesthesia anu analgesia. The spinal component gives a iapiu onset of a pieuictable block.
The inuwelling epiuuial cathetei gives the ability to pioviue long lasting analgesia anu to titiate the
uose given to the uesiieu effect.
!"#-9+,-)"/?
- Caesaiean sections.
- Laboi pains.
- Post opeiative pain.



Page 2S

Anesthesia 0SCE
!",(+.$")8/ +99$//
1< ;$",(+6 6-"$?
!C !"#-9+,-)"/?
Nonitoi CvP
Auministiation of fluius to tieat hypovolemia anu shock.
Infusion of caustic uiugs.
Total paienteial nutiition
Aspiiation of aii emboli
Inseition of tianscutaneous pacing leaus
venous access in cases of pooi peiipheial veins.
!!C ;)",(+-"#-9+,-)"/?
Relative contiainuicateu in patients who aie ieceiving anticoagulant.
Ipsilateial caioteu enuaitiectomy
Injuiy, oi infection at the site of inseition.
!!!C ;)0*6-9+,-)"/?
Local complications associateu with femoial vein:
- Thiombosis oi phlebitis may extenu to ueep to iliac veins oi vena cava.
- Aiteiial cannulation - loss of limb.
- Bematoma
Local complications associateu with subclavian anu inteinal jugulai:
- Bematoma may compiomise aiiway
- Bamage to aujacent aiteiy, neive, oi lymphatic uuct
- Peifoiation of enuotiacheal cuff
Systemic complications:
- Pneumothoiax. (Neeu follow-up chest X-iay)
- Bemothoiax.
- Aii embolism.
- Infiltiation into meuiastinum oi pleuial space.
- Aiihythmia fiom cathetei tip.
- Infection.

If pneumothoiax is suspecteu tieatment
shoulu not be uelayeu to confiim the
uiagnosis by chest x-iay.
- Naintain aiiway anu ventilate with 1uu%
oxygen.
- Inseition of 18u cannula at miu
claviculai line, 2nu inteicostal space oi
miu axillaiy line Sth inteicostal space .
- Chest tube inseition shoulu be aiiangeu.
Chest x-iay uemonstiating
laige iight pneumothoiax on
the uay aftei placement of
the cential venous cathetei



Page 24

Anesthesia 0SCE
!WC '()9$#8($ /,$*/?
















WC Y/$>86 6-"E/?
B552MNNOOO;,/>5>8&;1/@NO$51BP:QRIS<4T3UVWX
B552MNNOOO;,/>5>8&;1/@NO$51BP:Q*3>,YZF4L[U


'$(>)(0+"9$ /,$*/ )> 9$",(+6 6-"$ -"/$(,-)"? =)"$ 9)(($9,63
Intiouuce youiself
uieet the patient
Explain pioceuuie
Assemble equipments
Wash youi hanus anu weai gloves
Patient in supine, at least 1Su heau uown position, heau tuineu
away

Clean skin, use liuocaine if patient awake.
Intiouuce neeule attacheu to syiinge in the centei of tiiangle foimeu by two
lowei heaus of steinomastoiu muscle anu clavicle

Biiect neeule cauually, paiallel to sagittal plane, at Suu posteiioi
angle

If vein not enteieu, withuiaw neeule anu ieuiiect it S to 1u
uegiees lateially

Auvance neeule while withuiawing plungei of syiinge
When bloou appeais anu vein enteieu, iemove syiinge anu inseit
cathetei to pieueteimineu uepth.

Remove neeule anu connect cathetei to Iv tubing
Covei punctuie site, anu affix cathetei in place
Bocuments pioceuuie
Ask the patient about any conceins
Thank the patient


Page 2S

Anesthesia 0SCE
@< '$(-*7$(+6 .$-"/ ?
!C 1#.+",+4$/?
Effective ioute foi uiugs uuiing CPR.
Boes not inteiiupt CPR.
Easy technique.
!!C =-/+#.+",+4$/?
In ciiculatoiy collapse, vein may be absent.
Access to cential ciiculation may be uifficult.
Phlebitis common with saphenous vein.
!!!C !"#-9+,-)"/?
Peiipheial catheteis aie piefeiieu when Iv access is iequiieu foi shoitei peiious, when uiiect access
to the cential ciiculation is unnecessaiy.
Fluiu maintenance.
Fluiu boluses foi uehyuiation.
Nutiitional supplementation.
Auministiation of meuication.
Bloou tiansfusions.
!WC ;)",(+-"#-9+,-)"/?
Tiauma, injuiy, Buins extiemities oi infection site.
Bematoma.
Bialysis fistula.
Bistoiy of mastectomy.
WC ;)0*6-9+,-)"/?
Infection, phlebitis, extiavasation, infiltiation, aii embolism, hemoiihage (bleeuing) anu foimation of a hematoma
(biuise) may occui.
W!C Q-,$/?
Common:
- Banus anu aims.
- Antecubital fossa.
Alteinative:
- Long saphenous veins.
- Exteinal jugulai veins.





Page 26

Anesthesia 0SCE

W!!C '()9$#8($ /,$*/?


W!!!C Y/$>86 6-"E?
B552MNNOOO;,/>5>8&;1/@NO$51BP:QO'LRS7F4G,.?/#&7QB552\)]\(H\(HOOO;,/>5>8&;1/@\(HO$51B\)H:\)^O'LRS7F4G,.?B$
0_:&#676&%Q'

'$(>)(0+"9$ Q,$*/ )> *$(-*7$(+6 .$-" 9+""86+,-)" [ -> #)"$
9)(($9,63
Intiouuce youi self
uieeting the patient
Explain pioceuuie anu take consent
Assemble equipment
Inspect fluiu foi contamination, appeaiance, anu expiiation uate
Wash youi hanu anu Put youi gloves
Apply touiniquet pioximally.
Locate vein anu cleanse the oveilying skin with alcohol oi poviuone- iouine.
Anesthetize the skin if a laige boie cannula is to be inseiteu in an awake patient.
Bolu vein in place by applying piessuie on vein uistal to the point of entiy.
Punctuie the skin with bevel of neeule upwaiu about V to 1 centimetei fiom the
vein anu entei the vein eithei fiom the siue oi fiom above

Note bloou ietuin anu auvance the cathetei eithei ovei oi thiough the neeule,
uepenuing on which type of cathetei-neeule uevice is employeu.

Remove the touiniquet.
Withuiaw anu iemove the neeule anu attach the intiavenous
Bocuments pioceuuie
Ask the patient about any conceins
Thanks the patient


Page 27

Anesthesia 0SCE
!",(+.$")8/ >68-#/
1< :+9,)(/ 08/, \$ ,+E$" -",) +99)8",?
1. Naintenance fluiu iequiiements.
2. NP0 anu othei ueficits: Nu suction, bowel piep.
S. Thiiu space losses.
4. Replacement of bloou loss.
S. Special auuitional losses: uiaiihea.
@< ;(3/,+66)-#?
Isotonic: electiolyte composition anu osmolality similai to plasma: noimal saline, Ringei`s Lactate
Bypotonic: BSW
Bypeitonic (Fluius containing souium concentiations gieatei than noimal saline. Bisauvantages:
Bypeinatiemia, Bypeichloiemia)
! noimal saline:
composition: Na, Cl.
Bisauvantages: Bypei-chloiemic aciuosis
! Lactateu Ringei's:
N0ST Physiological fluiu
Composition: Na, Cl, K, Ca, lactate.
Bisauvantages: Not to be useu as uiluent foi bloou (Ca citiate) anu its low osmolaiity can leau to high ICP.
;< ;)66)-#/?

Solutions stay in the space into which they aie infuseu.
Examples: hetastaich (Bespan), albumin, uextian.
=< :68-# ($*6+9$0$",?
!C L+-",$"+"9$ >68-# ($Z8-($0$",/?
It is to maintain the insensible losses such as evapoiation of watei fiom iespiiatoiy tiact, sweat, feces, anu
uiinaiy excietion. 0ccuis continually.
Auults: appioximately 1.S mlkghi
"4-2-1 Rule"
- 4 mlkghi foi the fiist 1u kg of bouy weight.
- 2 mlkghi foi the seconu 1u kg bouy weight.
- 1 mlkghi subsequent kg bouy weight.
- Extia fluiu foi fevei, tiacheotomy, enuueu suifaces.




Page 28

Anesthesia 0SCE
!!C V'U +"# ),7$( #$>-9-,/?
NP0 ueficit = numbei of houis NP0 x maintenance fluiu iequiiement.
Bowel piep may iesult in up to 1 L fluiu loss.
Neasuiable fluiu losses, e.g. Nu suctioning, vomiting, ostomy output, biliaiy fistula anu tube.

!!!C ^7-(# /*+9$ 6)//$/
It is the isotonic tiansfei of ECF fiom functional bouy fluiu compaitments to non-functional compaitments.
5$*6+9-"4 ^7-(# Q*+9$ S)//$/?
Supeificial suigical tiauma: 1-2 mlkghi
Ninimal Suigical Tiauma: S-4 mlkghi
o heau anu neck, heinia, knee suigeiy.
Noueiate Suigical Tiauma: S-6 mlkghi
o hysteiectomy, chest suigeiy.
Seveie suigical tiauma: 8-1u mlkghi (oi moie)
o AAA iepaii, nephiectomy.
!W @6))# S)//?
Replace S cc of ciystalloiu solution pei cc of bloou loss (ciystalloiu solutions leave the intiavasculai space).
When using bloou piouucts oi colloius ieplace bloou loss volume pei volume.
WC U,7$( +##-,-)"+6 6)//$/
0ngoing fluiu losses fiom othei sites:
uastiic uiainage.
0stomy output.
Biaiihea.
Replace volume pei volume with ciystalloiu solutions:








Page 29

Anesthesia 0SCE
A< @6))# ,(+"/>8/-)" ($4-0$"/?















:< @6))# ,(+"/>8/-)" 9)0*6-9+,-)"/?
!C !008")6)4-9+6?
Pyiogenic.
Type 1hypeisensitivity.
uiaft veisus host ieactions.
!!C @-)97$0-9+6?
B Aciu base uistuibances.
B Bypeikalemia.
B Citiate toxicity.
- Impaiieu oxygen ielease.
!!!C !">$9,-.$C
!WC D$0)63,-9 ,(+"/>8/-)" ($+9,-)"C
WC =-//$0-"+,$# -",(+.+/986+( 9)+486+,-)"C