Class 1: (0.06-0.08%) : American Society of Anesthesiologist Physical Status Classification

American Society of Anesthesiologist Physical Status
Classification:
Class 1: (0.06-0.08%)
No organic, physiologic, biochemical, or psychiatric disturbance.
Class 2: (0.27-0.4%)
Mild to moderate systemic disturbance that may not be related
to the reason of surgery.
Class 3: (1.8-4.3%)
Severe systemic disturbance that may or may not be related to
the reason for surgery.
Class 4: (7.8-23%)
Severe systemic disturbance that is life threatening with or
without surgery.
Class 5: (9.4-51%)
Moribund patient who has little chance of survival but is
submitted to surgery as a last resort.
Emergency(E) –any patient in whom an emergency operation is

required.
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Compiled Anesthesia Notes: WVMC- Dept of Anesthesiology
Mallampati’s Classification
Class I: Hard palate

Soft palate
Tip of epiglottis
Tonsillar pillars
Class II: Tonsillar pillars not seen
Class III: Tip of uvula not seen
Class IV: Only hard palate is visible
2
Goals of Pre-op Meds:
 Relieve anxiety
 Amnesia
 Analgesia
 Reduce salivation & bronchial secretion
 Block vagal reflexes
 Prevention of hypertension
 Anticonvulsant
 ↓ pH
 Prevent nausea & vomiting
 Prevent infection
3
Pre-op Evaluation/Orders
 NPO now
 Pre-op meds
 V/S and weigh patient PTOR
 To or with the following materials
 Inform OR/ AROD once ready
Stat Cases:
>60 yo – for CP evaluation
Elective Cases:
>40 yo – for CP evaluation
Pre-op Meds:
1. Benzodiazepines
 Route: well absorbed in the stomach
 Timing: night before OR, awakening for AM
operation, few hours later for afternoon OR
a. Midazolam (5mg/5ml, 5mg/ml)
0.1-0.2 mg/kg
b. Diazepam (2,5,10 mg tab)
0.15 mg/kg
2. Atropine SO4 (1mg/ml)

0.01-0.02 mg/kg
↓ salivation, tachycardia
3. Ranitidine (50mg/amp)
50 mg BID
4
4. Famotidine (20mg/amp)
20 mg q12h
5. Metoclopramide (10mg/amp)
10-20mg over 1-2 min
5 mg IVTT q4h
OR Materials:
1. Spinal
 SN g25 #1
 Bupivacaine 0.5% heavy/isobaric #1
 Ephedrine 50mg/ml #1
2. Epidural
 Epidural set g18 #1
 Tetracaine hcl 20mg/amp #1
 Lidocaine 2%
 Morphine 16mg/ml
 Epinephrine 5mg/ml, 1mg/ml
3. General
 Propofol 10mg/vial
 Atracurium 25mg/2.5ml
 Fentanyl 0.05mg/ml
50 mcg/ml
 Nubain 10mg/ml
 ET tube
 Isoflurane
5
Anesthesia Post-op Orders:
 To RR
 V/S q15min until stable & record
 O2 @ 5LPM via face mask
 MIO qhourly & record; refer urine output if < 30-40cc/hr
 Meds:
 Attach to pulse oximeter
 Encourage deep breathing
 Morphine precaution pls!!!! refer to AROD once observed:
↑ somnolence, N/V, pruritus, resp depression, RR <
10cpm, & other untoward s/sx.
 Keep patient warm
 Refer PRN
 Thank you!
Post-op Medications:
1. Toradol (ketorolac) 30mg/amp slow IVTT q8h x __
days/doses ANST
2. Butorphanol tartrate (Stadol) 1mg/ml, 2mg/ml, 4mg/2ml

2mg q4h
3. Tramadol (Tramal) 50mg/ml, 100mg/2ml

50-100mg as single dose up to 400mg/day
50 mg/cap q6h
(e.g. 50mg IVTT q6h PRN for severe pain)
6
4. Nalbuphine hcl (Nubain) 10mg/amp
ID: 0.05-0.1 mg/kg
10 mg q6h
5. Naproxen Na (Flanax)
275mg/tab q8h
550 mg/tab q12h
6. Ibuprofen (Advil)
400 mg/tab, 200mg/tab
300-800mg/day; 3-4 doses
7. Ketoprofen (Ketofen)
50mg/cap TID
8. Meloxicam (Mobic)
7.5mg/tab BID
9. Diclofenac Na (Neo-pyrazon)
50mg/tab BID-TID
10. Famotidine
20 mg IVTT q12h while pt on NPO
11. Ranitidine
50 mg IVTT q8h
12. Parecoxib
40 mg IVTT q12h x __ dose
7
Spinal Anesthesia Technique:
 Position the patient
 Locate the site
 Prep
 Infiltrate with local anesthetic
 Insert spinal needle
Layers:
1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Dura
7. Arachnoid
8. Subarachnoid
*popping sensation 4-7 cms

RA SAB, hydration done, LLDP, ASAS, drapes, LP @L3-L4 using SN
g25, atraumatic, with clear free flowing CSF, LOA T5
8
Local Anesthetics:
Esters – hydrolyzed in plasma

Ex. Procaine, chlorprocaine tetracaine,
Amines – metabolized in liver

Ex. Lidocaine, mepivacaine, bupivacaine, etodocaine,
ropivacaine
9
What to prepare:
 O2
 BP apparatus
 Cardiac monitor
 Pulse oximeter
 Check fluids
 Check time
 Check output
 Get initial BP
10
GA Rapid Sequence Sellick’s
1. Fentanyl 0.5mg/ml
ID: 2.5mcg/kg, 1-2 mcg/kg
MD: 2-10 mcg/kg
2. Atracurium 25mg/2.5ml
Pre-treatment 10% of ID
ID: 0.5-0.6 mg/kg
3. Propofol 10mg/ml
ID: 2-2.5mg/kg
4. Succinylcholine 20mg/ml
ID: 1-2 mg/kg
*GETA, preoxygenation done, DL done using Machblade 3, ET

tube 7.5 ID level 21 cm, laryngeal grade 1, attached to SCCS with
CO2 absorber, equal breath sounds
11
Inhaled Anesthetics
1. Halothane ( 0.75-0.77)
halogenated alkane
- thynol preservative
-amber colored bottles
-trifluroacetic acid disulfiram
A/E: Hepatic necrosis, dysrhythmia
2. Enflurane (1.8)
halogenated ether
-contraindicated use of Isoniazid
-sweet ethereal
-free fluoride
A/E: Seizure
3. Isoflurane (1.12-1.15)
pungent ethereal odor
-trifluroacetic acid
A/E: Tachycardia
4. Desflurane
CO
A/E: Airway irritation
5. Sevoflurane (2)
inorganic fluoride
A/E: Reacts with CO2 absorber
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Non-Opioid IV Anesthetics
1. Barbiturates
 Thiopental
2. Sedatives
 Benzodiazepines
3. Other induction agent
 Ketamine
 Propofol
 Etomidate
Opioids
1. Morphine
2. Fentanyl 1-2mcg/kg
3. Sufentanil
4. Nalbuphine 0.5-1mg/kg
5. Butorphaol
6. Nloxone
7. Meperidine
13
Muscle Relaxants:
1. Succinylcholine ID: 1-2mg/kg
2. Atracurium ID: 0.5-0.6mg/kg
MD: 0.3-0.4mg/kg
3. Vecuronium ID: 0.08-0.1mg/kg
4. Mivacurium 0.2-0.25mg
5. Doxacurium
6. Pancurium
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Epidural Block:
TD: 4cc lidocaine + 20 mcg epinephrine
FD: 16cc sensorcaine 0.5% isobaric + 2.4 mg
morphine
 Epidural block L3-L4, g18 tuohy needle, loss of
resistance technique
 Sensorcaine 0.5% isobaric 50mg top up dose
 Midazolam 1.5mg
15
Other Common Drugs:
1. Bupivacaine (Sensorcaine) 0.5%
Isobaric = 0.6 mg/kg
Heavy = 0.4 mg/kg
20mg/4ml, 25mg/5ml
2. Tetracaine hcl (Pontocaine) 20mg/amp

18-20 mg +0.1cc epinephrine wash + 0.4mg morphine
3. Diazepam ID: 0.2-0.6mg/kg

MD 0.2-0.3mg/kg
4. Ketamine 50mg/ml
ID: 1-2 mg/kg
Subanesthetic dose: 0.25-0.5mg/kg
Drip: 1000mg + 1L D5LRS
2 vials in 1 L IVF
5. Ephedrine 50mg/ml
1ml + 9ml NSS = 10cc solution
1ml = 5mg → Inc. BP
6. Atropine SO4 1mg/ml

Dose: 0.01-0.02 mg/k
A/E: ↓ secretion, ↑ HR
16
Estimated Fluid Deficit (EFD)
- Maintenance + loss since last oral intake
½ EFD + MF given over 1 hr
¼ EFD + MF “ on 2nd hr
¼ EFD + MF “ on 3rd hr
Estimated Blood Volume (EBV)

Neonate: 90ml/kg
Infant up to 1 yr: 80ml/kg
>1 yo : 70ml/kg
Adult female: 65
Adult male: 70
Allowable Blood Loss (ABL)

ABL = EBV x pt hct – acceptable hct
Average hct
EBV= wt x 65(70)
Acceptable hct = 0.30
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Fluids
 Maintenance (Pedia)
0-10 kg = 4ml/kg
11-20 kg = 2ml/kg
>20 kg = 1ml/kg
 Intra-op: Maintenance + state of hydration

Mild = 4ml/kg
Moderate = 6ml/kg
Severe = 8ml/kg
 Preload = 10cc/kg (adult)

Mild = 4-6cc/kg/hr
Moderate= 6-8cc/kg/hr
Severe = 8-10cc/kg/hr
Urine Output
Infants= 1 ml/kg/hr
Children= 0.5 ml/kg/hr
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Morphine Precaution
1. RR < 10 cpm
Naloxone 0.4mg IV q2-3min until
depression resolves
2. ↑ somnolence
Naloxone (same dose)
3. Pruritus
Diphenhydramine Hcl slow IVTT 50 mg
4. Nausea/Vomiting
Droperidol 1.25mg slow IVTT
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Size of LMA
I – 10 kg (neonate)
II – 6.5-20 kg
III – 20-30 kg
IV – 30 ↑
V – big adult
Laryngeal Grading (Cormack-Lehane)

I- Visualization of entire glottic aperture
II- Only posterior aspect of glottic aperture
III- Tip of the epiglottis
IV- Soft palate
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Total Gas Flow → TV= DS x 3
TGF=MV x RR(wt in lbs x 3 x 20 x 2-3)
MV = TV x RR
TV = wt in lbs x 3
TV = DS x 3
N anatomical DS = 150cc (nose-alveolar ducts)
DS in face mask = 80cc
Smallest DS = Rendel Baker
 ET ↓ DS by 70cc
 Flexing head ↓ DS by 30cc
 Extending head ↑ DS by 40cc
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Components of General Anesthesia
1. Analgesia
2. Hypnosis
3. Blunting of reflexes
4. Muscle relaxant
Stages of General Anesthesia

1. Amnesia
2. Excitement/Delirium
3. Surgical Anesthesia
4. Impending death
Minimum Dermatome Level
Site of Operation Level Reqd

Lower Extremity T12
Hip T10
Prostate T10
Testes T6
Herniorrhapy T4
Intraabdominal T4
22
PEDIA
Atropine 0.02mg/kg 1mg/ml
Midazolam 0.2mg 15mg/ml
Nubain 0.14mg 10mg/ml
Propofol 2.5mg 10mg/ml
Tracrium 0.5mg 25mg/2.5ml
Fentanyl 1.2mg
Terbutaline 0.01mg
Ketamine 1.2mg 50mg/ml
Pentothal 2.4mg
LMA sizing and inflammation volumes

Size Wt. Max. Inf. Vol.
1 Neonate <5kg 4
1.5 5-10 kg 7
2 10-20 kg 10
2.5 20-30 kg 14
3 >30kg 20
4 small adults 30
5 N adults 40
6 Large adults
23
Partition Coefficients of Volume Anesthetic
Agent B/G Br/Bl

Nitrous Oxide 0.47 1.1
Halothane 2.4 2.9
Methoxyflurane 12 2.0
Enflurane 1.9 1.5
Isoflurane 1.4 2.6
Desflurane 0.42 1.3
Sevoflurane 0.65 1.7
Soda Lime - Ca(OH)2, NaOH, KOH

Barium OH Lime – BaOH, Ca(OH)2
Carbon dioxide absorbent

Fast reaction: H2CO3 + 2NaOH → NaCO3 + @H2O + heat
Slow reaction: N2CO3 + Ca(OH)2 → CaCO3 + 2NaOH
Liquid O2 critical temp – 119 C

Air - 140.6 C
Basal metabolic oxygen consumption

VO2 = 10 (wt in kg) ¾
*CO2 consumption is 80% of O2 consumption
24
Mapleson:
A – Magill attachment (CBA) – most efficient for spontaneous
B - (BCA)
C – Water’s to & fro (short BCA)
D – Bain circuit (BAC) – most efficient for controlled
E – Ayre’s T-piece (C)
F – Jackson-Rees modification (ABC)
Properties of Inhalational Anesthetics
Agent MAC Vapor Press at 20C

Nitrous Oxide 105 -
Halothane 0.75 243
Methoxyflurane 0.16 22.5
(Penthrane)
Enflurane 1.7 175

(Ethrane)
Isoflurane 1.2 240

(Forane)
Desflurane 6.0 681

Sevoflurane 2.0 160
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The Anesthesia Machine
Oxygen is supplied at 45.55 psig

O2 flush 35.75 L/min
Yoke assembly index pins
Washer
Gas filter
Check Valve
Thorpe Tube
Vapor Output=CGxVP
BP-VP
VP- Vapor pressure of anesthetic agent

CG-Flow rate of carrier gas
BP-Barometric pressure
Anes. Conc. = Vapor Output

Total gas flow
26
Cardiac Index= N: 2.2-4.2
= CO L/min
BSA M2
TPR= N: 1200-1500
= (MAP-CVP) x 80
CO
Pulm. Vasc. Res. = N: 100-300

= PA-PAOPx80
CO
Stroke Vol. = N: 60-90

= CO L/Mx1000
HR beats/min
Stroke Index= N: 20-65

= SV
BSA
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PHARMACOLOGY
1. Fentanyl- Narcotic analgesic, opiate,

Synthetic phenylpiperidine der.
-Alters pain perception by binding to opiate receptors.
> S/E: Bradycardia, Arrest, Resp. Depression, Laryngospasm
> Pharmacokinetics
Absorption: Completely absorbed (IV)
Distribution: Crosses Placenta
Metabolism: Extensively. Liver, 80% bound to plasma protein
Excretion: Kidneys-up to 25%

Unchanged
Breastmilk
>t ½: 2 ½ - 4 hrs
> Dosage: 1-2 mcg/Kg
>Pharmacodynamics
Onset: Rapid
Peak: 3-5 min
Duration: ½ - 1 hr
>Tx Overdose: Narcan 0.2-0.8,

Fluids,
Vasopressors
28
2. Ketamine- gen. anesthetic; phencyclidine der.
>Action: Acts on limbic system, cortex by blocking pain impulses

>Dosage: 1-2 mg/kg
>Available forms: 10, 50, 100 mg/ml/vial
>S/E: Hallucinations Hypotension

Confusion ↑ BP
Delirium Tachycardia
Tremors Bradycardia
Polyneuropathy Diplopia
Fasciculation Salivation
Pseudoconvulsions
Pain at inj. Site
C/I: CVA, Cardiac decompensation

↑ ICP Child < 2 y.o.
Severe hpn
>Pharmacokinetics
Dist = rapid, crosses placenta
Met = liver
Exc = kidney
T ½ = 2 ½ hrs
29
>Pharmacodynamics
IM IV
Onset unknown
Peak 3-8 min 40 sec
Duration 25 min 10 min
>N-methyl- D- aspartate receptor antagonist

>Analogue of phencyclidine
30
3. Ketorolac – NSAID, Non-narcotic pyrrolopyrrole
>Axn: Inhibits prostaglandin synthesis

>Dosage: 30 mg q8h
>SE: Nephrotoxicity, dysuria, hematuria, oliguria, azotemia,
blood dyscrasias
>Pharmacokinetics
Abs= Rapidly, completely

Dist= Bound to plasma protein 99%
Met= Liver <50%
Exc= Kidney metabolites (92%)
Breast milk (6%), feces
t ½ = 6 hrs
>Pharmacodynamics
Onset: up to 10 mins (IM)
Peak: 50 mins
Duration: 4-6 hrs
>Preparations: 30 mg/ amp

10 mg / tab
31
4. Atracurium- Neuromuscular blocker, non-depolarizing,
Biquaternary ammonium ester
>Axn: antagonizes action of acetylcholine

>Dosage: 0.5-0.6 mg/kg
>Form: 10 mg/ml
>S/E: prolonged apnea, bronchospasm, cyanosis, resp.
depression
>Pharmacokinetics
Abs: complete bioavailability

Dist: Extracellular space, crosses placenta
Met: Plasma
T ½: Biphasic, 2 min, 29 min
>Pharmacodynamics
Onset: 2 min
Peak: 5 min
Duration: 20-60 min
>Tx overdose: Endrophonium

Neostigmine
Atropine
32
5. Ephedrine- adrenergic, bronchodilator, vasopressor,
phenylisopropylamine
>Axn: ↑ contractility & HR; vasoconstriction

>Dosage: 10-25 mg (not to exceed 150 mg / 24 hr)
>S/E: tremors, anxiety, convulsion, CNS depression, dysrhytmias,
dyspnea
>Pharmacokinetics
Abs: well absorbed/complete

Met: Liver
Exc: kidney-unchanged
T ½: 3-5 hr
>Pharmacodynamics
Onset: 5 min
Duration: 2 hrs
Tx overdose: β2- adrenergic blocker
33
6. Lidocaine- antidysrhytmic
-local anesthetic
-aminoacyl amide
>Axn: ↑ electrical stimln of threshold of ventricle & His-
purkinjie system, stabilizes cardiac memb, ↓ automaticity
>Dosage: 1 mg/kg
>Form: 2%, 20% mg/ml
1% 10 mg/ml
S/E: Convulsions HA
Heart block Drowsiness
CV collapse Hypotension
Arrest Bradycardia
>CI: Severe heart block
Supraventricular dysrhytmias
WPW syndrome
>Pharmacokinetics
Abs: complete bioavailability
Dist: RBC, Cardiovascular endothelium
Met: Liver
Exc: Kidney
T ½ : Biphasic 8 min, 1-2 hrs
34
>Pharmacodynamics
Onset: 2 min
Duration: 20 min
>Tx of overdose: Diazepam for convulsion
35
7. Atropine- anticholinergic, parasympathetic belladonna alkaloid
Axn: Blocks Ach at parasympathetic neuroeffector sites

: ↑ CO, HR, dries secretion
Dose: 0.01-0.02 mg/kg

Form: 1 mg/ml
S/E: HPN, tachycardia
C/I: GI obstruction
>Pharmacokinetics
-well absorbed
-crosses BBB, placenta
-metabolizes in liver
-excreted in kidney, breast milk
-t ½ : 13-40 hrs
>Pharmacodynamics
Onset: 2-4 min

Peak: 2-4 min
Duration: 4-6 hrs
36
8. Midazolam- sedative/hypnotic
- Benzodiazepine
- Short acting
>Axn: depresses subcortical levels in CNS

>S/E: Nausea
Vomiting
Bronchospasm
Laryngospasm
>Pharmacokinetics
-well absorbed
- crosses placenta, BBB
- metabolized in liver
- excreted in kidneys, breast milk
- t ½ : 1-12 hrs
>Pharmacodynamics
Onset: 3-5 min

Peak: unknown
Duration: 2-6 hrs
>Tx of overdose: O2
Vasopressor
Physostigmine
Resuscitation
37
9. Nalbuphine – opiod analgesic
-synthetic opiod agonist/antagonist
Axn: inhibits ascending pain pathways in limbic system,
thalamus
Dosage: 0.5-1 mg/kg

Form: 10 mg/ml
S/E: Drowsiness Constipation
Dizziness Cramps
Confusion Rash
HA Diaphoresis
N/V Resp. Dep.
Sedation Anorexia
Euphoria
>Pharmacokinetics
- Completely absorbed
- Crosses placenta
- Liver metabolized
- Excreted in feces, kidney, breast milk
- t ½ : 5 hrs
>Pharmacodynamics
- Rapid onset
- Peak: ½ hr
- Duration: 3-6 hrs
>Tx of overdose: Naloxone 0.2-0.8
38
10. Profopol- gen anesthetic
-produces dose dependent CNS depression and amnesia
>Dose: 2-2.5 mg/kg – 10

1-1.5 mg/kg – elderly
0.1-0.2/min – MD
>Form: 10 mg/ml in 20 mg/amp
>S/E:
Bradycardia N/V
Hypotension Apnea
Abdl cramping Cough
Phlebitis at inj site Hiccups
Stinging at inj
>Pharmacokinetics
- Completely absorbed
- Crosses placenta
- Liver by conjugation
- 70% kidneys
- t ½ : biphasic 1-8 min 5-10hrs
>Pharmacodynamics
-Onset: 40 sec
-Peak: unknown
-Duration: 3-5 min
(2, 6 diisapropylphenol)
39
11. Tetracaine- local anesthetic
-ester
-decreased ion permeability by stabilizing neuronal
membrane
>18-20 mg + 0.1 cc epi +0.25 mg morphine + D10 H2O (2cc)

>20 mg/amp (10 mg/ml)
>18-20 mg+ epiwash + MSO4 0.15 mg
(dilute Tetracaine powder in 2cc)
>20 mg+75mcg clonidine+ MSO4 0.15 mg
40
12. Butorphanol- Narcotic analgesic
-opiate
-inhibits ascending pain pathways in limbic system,
thalamus, midbrain
>Dosage: 0.5-2mg q3-4 hrs prn

>Form: 4mg/2ml
>S/E:
Drowsiness Weakness
Dizziness Hallucination
Confusion N/V
HA Anorexia
Sedation Constipation
Euphoria Cramps
Resp. Dep
>Pharmacokinetics
Abs: Complete
Dist: Crosses placenta
Met: Liver
Exc: Feces 10-15%, kidney
T ½ : 3-4 hrs
>Pharmacodynamics
Onset: 1min
Peak: 5min
Duration: 2-4 hrs
>Tx of overdose: Narcan 0.2-0.8 IV
41
13. Morphine Sulfate- opiod
>Preparation: 10mg,30,60,100mg/tab
10 mg/amp
16 mg/amp
>N- 0.1-0.2 mg
>0.1 MSO4 + D10W 0.9
42
Compound A- fluoro-methyl 2, 2 difluoro- 1-vinyl ether
- Trifluromethyl vinyl ether
HOFMANN ELIMINATION
- A spontaneous non-enzymatic chemical breakdown occurs at
physiologic ph & temp.
Laudonosine Toxicity
Laudonosine- breakdown prod of Atracurium
43
Dosages of Barbiturates
1. Thiopental: induction= 3-6 mg/kg

Sedation= 0.5-1.5 mg/kg
2. Methobexital: induction= 1-2
Sedation= 0.2-0.4
3. Secobarbital: Pre-med
PO: 2-4
IM: 2-4
Rectal: 3
BENZODIAZEPINES
Premed Sed Ind

Diazepam PO 0.2-0.5 IV 0.04-0.2 0.3-0.6
Midazolam IM 0.07-0.15 IV 0.01-0.1 0.1-0.4
Lorazepam PO 0.05 0.03-0.04
IM 0.03-0.05
44
CHOLINESTERASE INHIBITORS
1. Neostigmine- 0.04-0.08
2. Pyridostigmine- 0.1-0.4
3. Edrophonium- 0.5-1
4. Physostigmine- 0.01-0.03
45
OPIODS RECEPTORS
Clinical Effect Agonist

MU Supraspinal Analgesia Morphine
Resp Dep Met . enk
Phys. Dependent β-endor
Ms. Rigidity fenta
KAPPA sedation morphine

Spinal analgesia nubain
Stadol
Dynorphine
Oxycodeine
DELTA Analgesia leu-enkeph

Behavioral β-endor
SIGMA dysphoria pentasocine

Hallucination nalorphine
Resp stimulant ketamine
46
OPIODS DOSES
USE ROUTE DOSE
Morphine premed IM 0.05-0.2

Intra op IV 0.1-1
Post op IM 0.05-0.2
IV 0.03-0.05
Mepiridine premed IM 0.5-1

Intra op IV 2.5-5
Fentanyl premed IV 2-150 mcg

Post op IV 0.5-1.5
47
AGENT USE ROUTE DOSE
Ketamine Ind IV 1.2 mg/kg

IM 3-5
Etomidate Ind IV 0.2-0.5

Propofol Ind IV 1-2.5
Main Inf. IV 50-200 ug
Sedation IV 25-100 ug
Draperidol Premed IM 0.04-0.07

(Butyrophenone) Sed IV 0.02-0.07
Anti-emetic IV 0.05
48
MUSCLE RELAXANT
Depolarizing
Short acting- succinylcholine
Decamethonium
Non-depolarizing
Long acting- tubocurarine
- metocurine
Noxacurium
Pancuronium
Pipecuronium
Gallamine
Intermediate- Atracurium
Vacuronium
Cisatracurium
Rocuronium
Short-acting- mivacurium
Rapacurorium
49
Differences bet. Adult & Pediatric Airway
1. Obligate nose breathers, narrow naves
2. Large tongue
3. Large occiput
4. Glottis C3 in premature
C3C4 Newborns
C5 Aduts
5. Larynx & trachea- funnel shaped

Narrowest portion is at the cricoid
6. Vocal cords slants anteriorly
7. Decreased, smaller alveoli
8. Decreased compliance
9. Decreased elastin
10. Increased airway resistance
11. Smaller airways
12. Horizontal ribs,more pliable ribs
13. Decreased TLC
14. Faster RR & MR
15. ↑ closing volumes
50
LARYNX & CARTILAGES
In pairs arytenoid- 2
Corniculate- 2
Cuneiform- 2
Thyroid- 1
Cricoid- 1
Epiglottic- 1
9
PEDIATRICS(ref: Stoelting/Dierdorf- Anesthesia & Co-existing disease)
Anatomy of the airway

- Large head & tongue
- Mobile epiglottis
- Ant position of the larynx
- Cricoids cartilage- narrowest portion of the larynx
Convenient guideline for depth of insertion from lips:

- 1 kg neonate 7 cm
- Additional 1cm of depth for each kg increase in body weight
- Max of 10cm in neonate term
Respiratory System
- Surfactant- type II pneumocytes
51
MEAN PULMONARY FXN VALUES
Neonate(3kg) Adult(70kg)
O2 consumptio 6.4 3.5
ml/kg/min
alveolar ventilation 130 60

CO2 prod. 6 3
TV ml/kg 35 15
Vital capacity ml/kg 35 70
FRC 30 35
Tracheal length 5.5 12
PaO2 65-85 85-95
PaCO2 30-36 36-44
pH 7.34-7.40 7.36-7.44
PULMONARY CAPACITIES
Inspiratory Capacity= TV+IRV

= 3500
Fxnal Residual Capacity= IRV+TV+ERV

=3000=500=1100
=4600
Total Lung Capacity= VC+RV

=4600+1200
=5800
52
PULMONARY VOLUMES
1. Tidal Volume: volume inspired or expired with each normal

breath
= 500 ml
2. Inspiratory Reserve Volume

- Extra volume of air that can be inspired over & above the
normal tidal volume.
= 3000 ml
3. Expiratory Reserve Volume

- Extra amount of air that can be expired by forceful expiration
after the end of normal exp.
- 1100 ml
4. Residual Volume
- Vol of air remaining in the lungs after the most forceful exp.
- 1200 ml
Minute Ventilation- alveolar ventilation & vent of anatomic dead

space + equip dead space.
Anatomic Dead Space- 1ml/kg/breath

Equipment Dead Space- compliance x pressure
TV= 500 cc
IRV= 3000 cc
53
ERV= 1100 cc
RV= 1200 cc
TLC (RV+ERV+VT+IRV) = 5800
FRC (RV+ERV) = 2300
Raw= 8xLx gas viscosity

TT x r4
Reynold’s #= Linear VxDGd

Gas viscosity
Minute Vent. = RRxTV
Hagen Poiseuille Equation (Laminar)

Resistance= 8NL/TT R4
Law of Laplace= P=2T

R
P=distending pressure w/in the alveolar

T=surface tension of alveolar fluid
R=radius of alveolus
Boyle’s Law- the volume of gas in a closed space varies inversely

with the pressure to which it is subjected.
- Constant= temp
= V/P
54
OHM’s Law: P= Flow
Resistance
PRINCIPLES
1. FICK:
CO= O2 consumption
a-v O2 content difference
= VO2
CaO2-CvO2
2. Lamber-Beur Law
- Oxygenated & reduced hgb differ in their absorption of red
and infrared light
- Oxyhgb absorbs more infrared, deoxyhgb absorbs more red
3. Meyer-Overton Rule
- Anesthetic potency of inhalational agents correlates directly
with their lipid solubility.
55
Afterload- ventricular wall tension during contraction. The
resistance that must be overcome during contraction of the left
ventricle. This is influenced by aortic pressure and systemic vascular
resistance.
Preload- ventricular wall tension at the end of diastole. Right

ventricular preload is reflected in PA, diastolic pressure and PCWP.
Baroreceptor
Carotid Sinus- wall of int carotid wall of aortic arch
Carotid Body- chemoreceptor

Aortic Body- chemoreceptor
MAP= diastole + 2 pulse pressure

3
= diastole + (2 s-D)
3
= 3 diastole + 2s-2 diastole

3
= 2S+D
3
56
IV Fluids Component
N values LRS NSS
Na 131 154
K 5.4
Ca 2.5
Cl 15.4
Lactate 28
Osmolarity 273
1 Atm= 760 mmHg

= 1000 mbar
= 100 kpa
= 1030 cm H2O
= 14.7 psi
57
Interscalene Block
- Provides excellent anesthesia of he caudad cervical plexus &
cephalad portion of the brachial plexus
- Small risk for pneomothorax
- Supplementary ulnar block
- Can be performed with the arm in any position
- Pneumothorax is small
- Landmarks easily identifiable in obese pt.
Twitch- single pulse that is delivered in every second to every 10

sec.
Train of Four- 4 successive 200 usec

-stimuli in 2 sec
-progressive fade
-disappearnce of the
th
4 twitch 75%
3rd twitch 80%
2nd twitch 90%
58
Double Burst Stimulation
- 2 variations of tetany, less painful to pt.
DBS 3.3 - 3 short 200 usec separated by 20 msec followed by
750 msec later by 3 burst
DBS 3.2
The diaphragm, vectus abdominis, laryngeal adductors,

orbicularis oculi recover from NMB sooner than adductor
sollicis
Pharmacokinetics (How the body affects the drug)

- The study of the rel bet drug dose, tissue conc & elapsed time
Pharmacodynamics (How a drug affects the body)

- The study of drug action including toxic responses.
Factors Affecting anesthetic Uptake

1. Solubility in the blood
2. Alveolar blood flow
3. Partial pressure diff bet alveolar gas and venous blood
59
History of Anesthesia
Ether- Valerius Cordus
Used it: William T.G. Morton
Oct 16, 1846
Chloroform: Von Leibig, Guthrie, Goubevon

Used it: Simpson
Nitrous Oxide: Joseph Priestly

Used it: Colton, Wells
Modern Local Anesthesia: Carl Koller

Cocaine- eye
Halsted- nerve blocks
Spinal Anesthesia- August Bier
Procaine- Alfred Ethorn

Used it: Heinrich Brown
Caudal Epidural (1901)- Ferdinand Cathelin, Jean Sicard
Lumbar Epidural (1921) - Fidel Page
60
Criteria for Estimation of Extubation
1. Awake & responsive with stable VS
2. Adequate reversal of neuromuscular blockade, sustained
head lift.
3. Negative inspiratory force >20mmHg
Need to perform ET intubation:

1. RR > 35 bpm
2. VC > 15 ml/kg in adults & 10 ml/kg in children
3. Inability to generate a neg inspiratory force of 20 mmHg
4. Arterial partial pressure of O2 (PaO2) <70 mmHg on 10%
O2
5. Alv. Art. (A.a) gradient >350 mmHg on100% O2
6. Art. Partial pressure of CO2 (PaCO2) >55mmHg except in
chronic
7. Dead space (VD/VT) >0.6
61
Bupivacaine
= 0.4 (4cc=20 mg) = 5mg/ml
= pregnant = 12-15 mg
= 3mg/kg
Tetracaine= 0.5 mg (15 mg IVTT)
Lidocaine= 5mg/kilo w/o epi

7 mg/kilo w/ epi
= 20 mg/ 5ml
Eg. 50 kg pt x 5 = 250 mg
Epinephrine = 0.15 mcg

Eg. Epi 0.1 ml
PNSS 0.9
ANS>Sensory>Motor
Eg. ANS- T4
Sensory- T6
Motor- T8
Optha Pt:
If ↓ CR= let surgeon stop

= if persisted give atropine
62
DRUGS RD Preparation
Atropine 0.02 1mg/ml

Midazolam 0.2 5mg/ml
Nalbuphine 0.14 10mg/ml
Propofol 2-2.5 10mg/ml
Atracurium ID:0.5-06 10mg/ml
MD:0.3-0.4
Fentanyl 1-2 50 mcg/ml

Ketamine 1-2 50 mg/ml
Subanesthetic dose: 0.25-0.5
Terbutaline 0.01 0.5 mg/ml

900 mcg/ml
Hydrocortisone 3-4 100 g/ vial
Succinylcholine 1.5 20mg/ml
Esmolol 10 mg/ml
Diazepam ID:0.2-0.6 5mg/ml
MD:0.2-0.3
Ephidrine 1ml+9ml PNSS 50 mg/ml

1ml=5mg
Tetracaine 0.5 20mg/amp

Bupivacaine 0.4 0.5% heavy
0.5% Isobaric
63
AGE ETT SIZE LENGTH
1-2 3, 3.5, 4.0 12.5 cm
3 3.5, 4, 4.5 13.0 cm
4 4, 4.5, 5.0 14.0 cm
5 4.5, 5.0, 5.5 14.5 cm
6 5, 5.5, 6.0 15.0 cm
7 5, 5.5, 6.0 15.5 cm
8 5.5, 6.0, 6.5 16.0 cm
9 5.5, 6.0, 6.5 16.5 cm
10 6.0, 6.5, 7.0 17.0 cm
11 6.0, 6.5, 7.0 17.5 cm
12 6.5, 7.0, 7.5 18.0 cm
13 6.5, 7.0, 7.5 18.5 cm
14 7.0, 7.5 8.0 19 cm
ETT for uncuffed tubes= age/4+4

Cuffed tubes= age/4+3.5
2X ETT= NG/OG/Foley size
3x ETT= depth of ETT insertion
4x ETT= chest tube size (max..)
64

Class 1: (0.06-0.08%) : American Society of Anesthesiologist Physical Status Classification

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Class 1: (0.06-0.08%) : American Society of Anesthesiologist Physical Status Classification

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American Society of Anesthesiologist Physical Status

Emergency(E) –any patient in whom an emergency operation is

Class I: Hard palate

Class II: Tonsillar pillars not seen

Class III: Tip of uvula not seen

Class IV: Only hard palate is visible

2. Atropine SO4 (1mg/ml)

2. Butorphanol tartrate (Stadol) 1mg/ml, 2mg/ml, 4mg/2ml

3. Tramadol (Tramal) 50mg/ml, 100mg/2ml

*popping sensation 4-7 cms

Esters – hydrolyzed in plasma

Amines – metabolized in liver

*GETA, preoxygenation done, DL done using Machblade 3, ET

2. Tetracaine hcl (Pontocaine) 20mg/amp

3. Diazepam ID: 0.2-0.6mg/kg

6. Atropine SO4 1mg/ml

Estimated Blood Volume (EBV)

Allowable Blood Loss (ABL)

 Intra-op: Maintenance + state of hydration

 Preload = 10cc/kg (adult)

Laryngeal Grading (Cormack-Lehane)

Stages of General Anesthesia

Minimum Dermatome Level

Site of Operation Level Reqd

LMA sizing and inflammation volumes

Agent B/G Br/Bl

Soda Lime - Ca(OH)2, NaOH, KOH

Carbon dioxide absorbent

Liquid O2 critical temp – 119 C

Basal metabolic oxygen consumption

*CO2 consumption is 80% of O2 consumption

Properties of Inhalational Anesthetics

Agent MAC Vapor Press at 20C

Enflurane 1.7 175

Isoflurane 1.2 240

Desflurane 6.0 681

Oxygen is supplied at 45.55 psig

VP- Vapor pressure of anesthetic agent

Anes. Conc. = Vapor Output

Pulm. Vasc. Res. = N: 100-300

Stroke Vol. = N: 60-90

Stroke Index= N: 20-65

1. Fentanyl- Narcotic analgesic, opiate,

> S/E: Bradycardia, Arrest, Resp. Depression, Laryngospasm

Excretion: Kidneys-up to 25%

>Tx Overdose: Narcan 0.2-0.8,

>Action: Acts on limbic system, cortex by blocking pain impulses

>S/E: Hallucinations Hypotension

C/I: CVA, Cardiac decompensation

>N-methyl- D- aspartate receptor antagonist

>Axn: Inhibits prostaglandin synthesis

Abs= Rapidly, completely

>Preparations: 30 mg/ amp

>Axn: antagonizes action of acetylcholine

Abs: complete bioavailability

>Tx overdose: Endrophonium

>Axn: ↑ contractility & HR; vasoconstriction

Abs: well absorbed/complete

Tx overdose: β2- adrenergic blocker

>Tx of overdose: Diazepam for convulsion

Axn: Blocks Ach at parasympathetic neuroeffector sites

Dose: 0.01-0.02 mg/kg

Onset: 2-4 min