Ketamine Is the inauction agent of choice in patients with Tetralogy of Fallot because it maintains or Increases systemic vascular resistance and creases cardiac output ‘Tetralogy of Fatlot is characterized by subpulmonie stenosis, right ventrioular hypertrophy, ventricular septat Gefect and overriding of the aorta. This results in fight to fen shunt through the ventricular septal cerect land consequent cyanosis ‘Sevoflurane is the inhalatonal agent of choice for induction in a child undergoing cardiac surgery. Halothane and sevoflurane are non-pungent and hence can be used for induction in pediatric patients, Sevotlurane Is not associated with significant myocarcial depression as Is Seen with nalotnane. Hence, sevomurane is preferred over halothane especially in cardiac patients. Following induction, isorturane and sevonturane the mest commonly used inhalation agents for maintenance. “The antihypertensive that iz discontinued 24hr= prior to surgery i= ACE inhibitor due to the risk of hemodynamic instability, Ainough the continuation of ACE Inhibitors or ARAs Is controversial, among the given options this Is ine Pear! #2093: Drugs that can be continued on the day of surgery Drugs that can be continued on the day of surgery = Antinypertensive medications: continuation of ACE inhibitors and ARB - Controversial. According to ACC/AHA recommendations, continuation of ACE inhibtars or AROs periaperatively Is reasonable (evel of evicence') Cardiac medications (@.g., p-blocker=, cigoxin) Antidepressants, anoles, ang otner payeniatne medications ‘Thyroia meaieations, Eye arops Steraiae (oral ana innate) Mone Amine Guidase innibrors : MAO inhibitors generally should be continued when two criteria are met. (1) the anesthesiologist Is comfortable with use of MAO_aate procedures: ana (2) ine payeniatriat believes temporary witharawal of the agent will exacerbate or precipitate a depressive synerome. + Levedopa ‘The correct statement regarding VAE fs, a decrease in oxygen saturation will not lager embon Physiological monitors (heart rate, blood pressure, oxygen saturation, and encitidal carbon dioxide) have peor sensitwity and specifieily and the clinical signs are manifested late Iways Be seen, even with Transesophagest echocardiogram (TEE) Is the most sensitive montior and can doteet up to @.02mIKG oF Patients with a right to left shunt are susceptibie to paradoxical emboll Surgeons should be notined Immediately In order to apply fluid to the surgical Nele to prevent rurther + The patient is in renal failure with elevated serum creatinine(normal valic- 0.8—1.9 mg/dL. in men and 0.6—1 mg/dL in women) with normal serum potassium levels (3.5-5.5 mea/)). succinyl choline. can be safely administered to patients with Giminished or absent kidney function provided serum potassium levels are normal = Ihine serum potassium is increased, then a non-depolarizing muscle relaxant like atracurium or cisatracurium which Is non-dependent on renal excretion Is to be used. Atacurlum or cisatracurium Underge Homann elimination which Is nonenzymatic spontaneous degradation. = Pancuronium 1s almost entirely dependent on kidney tor exeration (60-90%). Pancuronium nas a prolonged elimination hatfiife in renal fallure patients and thus should be used very cautiously. + 30% of Vecuronium excretion occurs via the Kidney and so Its elimination half Ife 1S also protonged in renal failure, + 40-60% of d-tubocurarine is excreted via the kidney and so prolonged effects are seen with renal Insummctency‘The given case scenario Is suggestive of pneumocepnalus. Hence, nitrous oxide Is responsible tor aggravating tnis conaition. Pearl #2301: Unique features of Nitrous oxide = N20 atthough insoluble when compared to volatile agents, its about 35 times more soluble than O2 + Rapid uptake of nitrous oxide diminishes ine volume to the alveolus Second gas errect = Concentration-sttect of one gas over anotner 's known as secona gas effect 2 Increase in the partial procure of iho 2nd gas (Oxygen and volatile agents) due to the rapid uptake 6rN20 during induction lon hypoxia Teasing to hypoxia. + Avoided by aaministering 100% oxygen for about 10 minutes during recovery from anesthesia. = N20 difuses into a gas-filled cavity more rapidly than the air (principally nitrogen) diffuses out + This increases the pressure within the cavity ifthe volume of the cavily 1s F310. Pneumacepnalus, pneumatnarax Pulmonary air cysts, Tympante membrane granting = Propofol induction is used for general anesthesia in cirrhotic patients + Propotol Is preferred because: hae a better safety profile associated with rapid awakening does not precipitate hepatic encephalopathy + Liver transplantation Is carried out under general anestnesia with an innatational agent usually 10 oF better than isofurane in preserving hepatic arterial blood flow and hepatic oxygen delivery. = There is an autoraguiatory machaniam in the liver called the hepatie arterial buffer feapanse(HABF)- Srterlal blood flow increases in order to maintain tolal hepalic blood Now. This fesponse fs best + Hepatic artery vasoconstriction Ie seen with halothane along with an increase in hepatic arterial fesistance. There Is also the reduction in hepatic oxygen delivery and hepatic venous oxygen saturation. This is because of the greater reduction in cardiac output seen with halothane than the other votatie agente + In patients with Severe encepnalopathy, the concentration of sevomurane to be used is less than one minimum alveolar concentration + Ketamine Is the anesthetic of choice to provide analgesia and anesthesia in the prehospital setung, + Anesthesia may be required by the emergency medical service(EMS) team pricr to arrival at the hospital This may be provided by non-anesthesia personnel like paramedics and nurses who are less experiences witn the use of anestnesia drugs. So agents with wide therapeutic index are pretemed. + Ketamine is an ideal agent to provide prehospital sedation and analgesia, maintains hemodynamic ‘stability In patients in shock. + Ketamine causes bronchoallation. Respiratory depression Is minimal + Sut the disadvantage with ketamine Is that it = Nallueinogente and hence a benzodiazepine must be added, ‘Other Options: + Propofol causes hemodynamic instability and respiratory depression, + Thiopentone produces effects similar to proporol + Etomidate nas better emoaynamic stability but It can cause myoctonus and adrenocortical Suppression. + Benzodiazepines like diazepam and midazolam can be used to provide sedation but ne analgesic action.Remifentany! is the opioid of choice in elderly patients: + Remifentany! is nyarolysed by plasma and tissue esterases and so its metabolism Is independent of hepatic and renal function- no dose adjustments required and is safe in liver failure patients and renal fare patents. + Because of this nyarotysis, nas a high clearance and is elmminates raplaly with a quick recovery (1 Joss than 10 minutes) and thus Is proferred in elgeryy pationts, + Besides the variabiity in pharmacokinetics in less with remifentany! than with other intravenous opios. Spinal anestheata: High level of anesthesia Is required 10 cover ihe thoracis dermatames whieh wou tntrapleurat block But carries the risk or aystermie tomicity oF the loear anes = Administering blood products in the appropriate ratios in order to facilitate resuscitation from trauma ‘ang avert trauma Induced coagulopathy Is termed Damage Centro! ResusertatlonDCR). = INDCR, Ine ratio of red blood calla: fresh frozen plasma: platelets t= 1" + Rea blood colt component will improve oxygen delivery to lechomic tissues. 2 Fresh frozen plasma improves clotting by providing cloting factors V and Vill and fibrinogen. + Platelet transfusion Is required If the platelet count !s Below 50.000 / hig power Niels, SkInIMEAnt Blood loss or prolonged resuscitation. = Though the ctrront hemostatic resusckation ratio is 4:1:41, use of less fresh frozen plasma and more: of antitionnolyties le advocated by some exper. with local anesthesia. Open nasal fracture reduction, septoplasty. rmineplasty are performed under Mallinckrodt oral RAE (RiNg—AdalrElwyn) endotracheal tube — It has 2 preformed Hant-angie Femifentanit infusion and Injecting lidocaine down the endotracheal ube coukd be Used + Propofol is preferred for Induction in patients undergoing ear surgery, especially Inner ear. = The inner ear Is considered with nearing and balance ang nence inner ear Surgeries are likely 10 cause post operative nausea and vomiting ana vertigo. + Propofol is an intravenous induction agent with antiemetic properties and so is the agent of choice in such conditions. + The patient may also need prophylaxis with dexamethasone before induction ang also a SHTS. antagonist prior to emergence to reduce the Incidence of vomiting. += Oxymetazoline is the vasoconstrictor of choice for ENT surgeries. + Itis an imidazoline derivative. a selective a1, and partial a2 agonist. Has a high safely profile. (0.05% solution is used which is administered as 3 nasal sprays in each nostril + Butt should be avoided in patients who are on monoamine oxidase inhibitors. + Cocaine has cardiovascular effects. it is sympathomimetic and when administered at a concentration of 4%, it inhibits the reupiake of norepinephrine at sympathetic nerve terminals thus making It unsate in patients with coronary artery disease or those on monoamine oxidase Innipitors. So if cocaine is used, its dose should be less than 1.5ma/kg, + Phenylephrine is an a-adrenergic agonist topical vasoconstrictor It can cause severe hypertension and so blocd pressure monitoring is required. + Lidocaine as such does not nave vasoconstrictor properties but may be used with phenylephrine.Muscle relaxants are avoided during parotid surgeries Most common surgery for pleomorphic adenoma Is superficial parotidectomy with facial nerve dissection. Its essential to preserve facial netve and so nerve stimulators are used during the surgery to identify the Facial nerve and lls branches. This cannot be possible If muscle relaxation fs present ‘The anestnetic technique involves the use of high doses of opioids and Innalational anesthetics without muscle relaxants. Anotner technique involves a single, small dose of rocuronium te facilitate endotracneal Intubation. tolowed by Sevoflurane anesthesia with a remifentanil infusion. Rocuronium is used as tne muscie relaxant as if can be reversed with sugammadex Alltne above-mentioned drugs are used for hypotensive anesthesia except phenylephrine. Phenylephrine ip. a selective aradrenerglc receptor agonist of the phenethylamine class. Phenylephrine causes, Pearl #405: Hypotensive Anesthesia 2 Reduction of moan arterial prosoure (MAP) to. 80-68 MMHG, OF Controtied hypotension has been used to reduce Bleeding and the need for bloed transfusions, and provicte Itnas been inaicated in Gro-maxilofacial surgery (menaibular osteotomy. racial repain), endoscopic sinus oF ihlucite sar microsurgery. spinal surgery and ether neurosurgery (an aneutyam), major ortheapecte Surgery (hip oF knoe replacement, spina), prostatectomy, cardiovascular Surgery ahd iver Tansplant SUISTY. Agents used successtully Include inhalation anesthetics, sodium nitroprusside, nitroglycerin, Shestnecia for onhopedie surgeries Newer nypotensive aruge, such as fenoidepam, adenosine, and alprostadil, are currently being evaiuates rectus 1s the bast answer among the given options Pear! #406: Oculocardiac Reflex + 111s a trigemine vagal reftex. 2 Resunts from traction on the medial rectus musele, orbital periosieum ete. It could also result trom trauma to the eye. administering a retronulbar black or by even compression of the globe. = More common in pediatric patients undergoing squine surgery- 1 The ronex arc involves the afferents passing from the orbital contents to ciliary ganglion to ophtnalmic division of the geminal nerve to the sensory nucious of the trigeminal near the fourth venvicle. The Stterent passes via the vagus which is parasympathetic to the heart + The reniax results in bradycardia, atfioventricular block, Ventricular sctopy or sometimes asystote. 2 This'can be prevented by pre-treatment with atropine oF glycopyrrolate iScnnique used in apnthaimic aurgery which invelves the injection of a local anearnete inte te Saraocular muscic cone. The nosale penetrates tho lower lid at the Juneton and Midge thira oF the Saneonjunctva nemornage Gngeminat nerve pisete I pateiman' smear comer aaife Retrogenie pulmonary edema (arety) + Open sic iajan penctating aye injury). injection of local anesinetle behind the globe Could Increane“The Retropulbar block Is @ regional anesthesia technique Used in opntnaimic summery which involves the Injection of a local anesthetic inte the oxtraccular muscle cone. Pearl #407: Complications of Retrobulbar Block Retropuibar nemormage (mest commen complication) Subconjuncval hemormnage ‘Sete nerve atropty Accidental intravascular Injection of the local anesinetic Trigeminal nerve block Rezpiratory arrest Acute neurogenic pulmonary edema (rarety) Pearl #408: Contraindications of Retrobulbar Block + Blecaing disorders (because of the risk of retrobulbar nemorhage) = Given in tne question is a case of penetrating eye injury with a full stomach (patient assumes to be in full stomach upto 8 hours following the last meal) + In such cases, general anesinesia with rapid sequence Intubation and induction of trachea is preferred, + Usually. the muscle relaxant of choice for rapid sequence intubation is suecinyleholine. But succiny! choline has the disadvantage of a rise in intraocular pressure (IOP). Though succinyl choline raises Intraocular pressure, the rise Is small and outweighs the benemts of succinyl choline in Its rapid onset of action that decreases ine risk of aspiration anc profound muscle relaxation produced whicn Prevents tne nse in IOP caused by laryngoscopy and intubation + Regional anesthesia techniques like retrobuibar block, Sub-lenon block, and peribulbar block are relatively contraindicated because injection of local anesthetic benina the globe could increase tne Intraocular pressure whieh could lead to extrusion of the orbital contents. Ketamine use may cause nystagmus and blepharospasm. It is also known to increase intra-ocular pressure. Hence should be avoided in eye surgeries.