Anaesthesia Workbook

(1) Pharmacology related to Drugs used during Anaesthesia, fill in the blanks, answer the questions briefly:
Drug Indication/use Mechanism(s) of Usual dosage (per Adverse effects Antidote(s), state
action kg of body weight) “none”, if there is
no antidote
Midazolam Sedation, Positive 0.1mg/kg i.v. Excessive sedation Flumazenil
anxiolysis, modulation of Respiratory depression
antegrade amnesia GABA-A receptors
to increase
inhibition
Ketamine Anaesthesia, Blocks excitatory IV bolus 1 to 4.5 Drug of abuse None
analgesia NMDA receptors mg/kg, then 0.1 to Hallucinogenic
0.5mg/min infusion Sympathetic overdrive
Propofol Anaesthesia, GABA-A receptors Induction: 2 to 2.5 Deep sedation and None
sedation agonist and NMDA mg/kg i.v. anaesthesia
receptor blockade Maintenance: 100-
200 mcg/kg/min i.v.
for 10-15 min, then
50-100 mcg/kg/min
Atrophine Prevent excessive Muscarinic 15 to 30 mcg/kg i.v. Tachycardia, flushing Physostigmine or
cholinergic effect receptor antagonist administered with Dry mouth, dry eyes pilocarpine
from neostigmine neostigmine Blurred vision
Constipation
Urinary retention
Confusion, delirium
Fentanyl Analgesia, sedation μ-opioid receptors Initial: 2 to 4 Miosis, sedation, Naloxone
agonist mcg/kg i.v.; euphoria, respiratory
Maintenance depression,
(bolus or infusion): dependence, itching,
25 to 50 mcg i.v. nausea, vomiting,
every 15 to 30 constipation,
minutes rentention of urine
Remifentanil Analgesia, sedation μ-opioid receptors 0.5-0.1 mcg/kg/min Same as above Naloxone
i.v. infusion
 agonist
Morphine Analgesia, sedation μ-opioid receptors 2.5 to 5 mg i.v. Q4h Same as above Naloxone
agonist 5 to 15 mg s.c. Q4h
Neostigmine Reversal of Anti- 0.03 to 0.07 mg/kg Miosis, salivation, Atropine
neuromuscular cholinesterase, i.v. lacrimation, cramps,
blockade increase ACh at diarhoea, muscle
NMJ paralysis, bradycardia,
respiratory failure
Atracurium Non-depolarizing Competitive IV (bolus): 0.4 to Urticaria, pruitis, Neostigmine
Muscle relaxant antagonist of 0.5 mg/kg, then wheezing,
postsynaptic 0.08 to 0.1 mg/kg bronchorrhoea,
nicotinic receptor administered 20 to bronchospasm,
45 minutes after laryngospasm
initial dose to
maintain
neuromuscular
block
Rocuronium Non-depolarizing Competitive Initial: 0.45-0.6 Hypersensitivity, Sugammadex
Muscle relaxant antagonist of mg/kg i.v. tachycardia,
postsynaptic Maintenance: 0.1- hypertension,
nicotinic receptor 0.2 mg/kg i.v. as arrhythmia, pruitis, skin
needed or 4-16 rash, nausea, vomiting
mcg/kg/min
infusion
Suxamethonium Depolarizing Agonist of post- 0.3 to 1.1 mg/kg Myalgia, hyperkalemia, Neostigmine
Muscle relaxant synaptic nicotinic scoline apnea,
receptors malignant
hyperthermia
(2) For the following monitors, what are the parameters being measured, its physiological importance, normal range and
limitations?

Drug Parameters Importance / Usefulness Normal range Limitations

measured
Electrocardiogram Rate, rhythm, axis, Detect myocardial Rate 60-100 bpm Leads cannot be
(ECG) waveform, interval, ischaemia, arrthymia, heart Sinus rhythm applied on surgical
segments chamber size, electrolyte Axis -30 to 90 degree sites
disturbance Electricity from
diathermy can
interfere with ECG
voltage
Pulse oximeter Oxygen saturation Detect respiratory failure SpO2 > 90% Intervened by poor
and hypoxaemia peripheral perfusion,
nail polish, lipaemia,
excessive motion,
carboxyhaemoglobin
Sphygmomanomete Blood pressure Easy, convenient, non- SBP > 100 -120 Inaccurate when BP in
r invasice way of mmHg extreme range and
haemodynamic monitoring DBP > 60 - 80 mmHg cuff size is not
appropriate
Arterial line Blood pressure Accurate, real time pH 7.35-7.45 Inaccurate when there
ABG sampling measurement of BP, monitor PaO2 8 – 14.7 kPa is atherosclerosis and
acid-base status PaCO2 4.5 – 6kPa aneurysm
HCO3 22-26 mEq/L
Central venous line Central venous measurement of fluid status 3-8 mmHg Not truly representing
pressure and preload right ventricular end
diastolic volume
Temperature Body temperature Detect any fever or 36.1 – 37.2 Celsius Not truly reflecting
hypothermia core body
temperature
 Urine Output Volume of urine Measurement of renal 0.5 – 1 mL/kg/h Accuracy affected by
excreted perfusion urinary retention and
renal impairment
End-tidal gas Alveolar gas Check adequacy of PetCO2: 4.5 – 6 kPa Presence of dead
monitor concentration ventilation and titration of MAC 0.6 - 0.7 space so end tital
(CO2, volatiles) volatile anaesthetics volume CO2 may nor
reflect PaCO2
Bispectral index Weighted sum of Keep track of depth of 40-60 Depth of anesthesia
several EEG anaesthesia cannot be solely relied
subparameters on BIS
It can be affected by
abnormal EEG
discharge

(3) What are the equipotent doses of the following commonly used opioids?
Drug Dose

Morphine IV 10 mg

Morphine po 30mg

Fentanyl IV 0.1 – 0.2 mg

Pethidine IM / IV 100mg

Methadone po 20mg
Oxycodone 20mg
(4) For the following monitors, what are the parameters being measured, its physiological importance, normal range and limitations.

Drug Crystalloid Sodium Potassium Glucose Chloride Osmolality Others

or colloid? (mmol/L) (mmol/L) (mmol/L) (mmol/L) (mOsm/L)
Normal saline Crystalloid 154 - - 154 308 -

Compound sodium Crystalloid 131 5 - 111 279 Ca++ 2 mmol/L

lactate (Hartmann’s Lactate 29 mmol/L
solution)
0.45% Saline, 2.5% Crystalloid 77 - 126 77 280 -
Dextrose

5% Dextrose Crystalloid - - 252 - 252 -

Gelofusine Colloid 154 - - 120 274 Gelatin 40g/L

NaOH 1.36g/L

Voluven Colloid 154 - - 154 308 6% Hydroxyethyl starch

60g/L

In a few sentences (<100 words), answer Questions 5-7:

(5) What is the “TIME OUT” procedure? What is the importance of this and what are the important points that should be noted
during the time out procedure?
Time out" procedure is done before skin incision in an operation.  All people in the room must introduce themselves by
name and role. It is a final verification before surgery to make sure it is right patient, right side, right site and right
surgical procedure. Clinicians also discuss the need for antibiotics and imaging.

(6) List the ways in which drug errors can be minimized.

Constant vigilance with the recognition of human factors involved
 Careful checking of labels on ampoules, including name of drug, dosage and concentration and expiry date
Label all syringes clearly with universal labels
Standardise syringe sizes for particular drugs
Keep ancillary drugs such as on separate trays away from the agents used for general anaesthesia
Any drugs employed in an anaesthetic holding area must be double checked immediately before use and used
sparingly

(7) How are adverse events documented, reported and managed?