• Safety checklists

• Anaesthetist - peri operative

physician
• Inhalational induction done in
children, needle-phobic adults and
in difficult airway
• TIVA:
Used in Neurosurgery, airway laser
surgery, cardiopulmonary bypass
and day-care anaesthesia
 Nitrous Oxide Disadvantages...

• Nausea and Vomiting

• Air bubble
• Mutagenic
• Powerful greenhouse gas
 Laryngeal Mask Airway

• Seal around the glottic opening

• Advantages
1. Less irritating
2. Less traumatic
3. Easily taught to others
4. Emergency airway management tool
5. In high BMI index patients
 Double lumen and endobronchial tubes

• Used in thoracoscopic,
pulmonary and oesophageal
surgery
• Allows collapse of one lung while
ventilating the other
 Depolarising

• Suxamethonium
• Binds to nicotine acetylcholine receptors- opens cationic channel-
depolarisation
• Quick onset & short duration of action
• Used for rapid endotracheal intubation/short duration surgery
 Non-depolarising

• Competitive blockade of postsynaptic receptors

• Requires reversal of their action by drugs- Neostigmine, Sugammadex
• Peripheral nerve stimulator- depth of muscle block & confirm recovery
 Volume control ventilation

• Preset volume is delivered

• Explanation
Take a patient whose tidal volume is 400ml. If we preset the volume to 600ml,
the machine will inflate the lungs such that it will try to accommodate 600ml.
Since the patient capacity is less it will cause high pressure damage
 Pressure control mode

• Pre set pressure is set

• Depends on airway resistance, intra abdominal pressure, degree of relaxation
• Explanation
For example, take a person whose lung is adequately ventilated at 30mmHg.
For this person if we deliver a preset pressure of 20mmHg his lung won’t be
adequately ventilated.
 Positive and End expiratory pressure PEEP

• Applied to maintain Functional Residual Capacity(FRC)

• Maintains greater area for gas exchange
• Explanation
After expiration a minimum amount of air is present in the alveoli. This prevents
its collapse. In case of artificial ventilation, the entire air may be vented out
which may collapse the alveoli. In order to prevent this PEEP is maintained
 Role of Adrenaline

• Hastings onset
• Pronounce duration of action
• Permits a higher upper dose limit
• Contradiction- Cardiovascular disease, those taking Tricycluc and Monoamine
oxidase inhibitors, end arterial locations
• Involves central neuroaxial, peripheral nerve or plexus block
• Advantages
A. Done where GA carries high risk
B. Cardiovascular disease
C. Obstetric care
D. Excellent pain relief in postoperative care
 Topical anaesthesia

• EMLA(Eutetic mixture of local anaesthetics)

1. Mixture of lignocaine & prilocaine
2. For venepuncture in children and skin graft
• Cocaine
A. Mofatt’s solution (Cocaine+ adrenaline + sodium bicarbonate)
B. Nasal surgery and vasoconstriction
• Lignocaine - anaesthetise airway during awake fibreoptic intubation
 Nerve blocks

• Interscalene block- shoulder surgery

• Axillary brachial plexus block- upper
limb surgery
• Femoral & Sciatic block - lower limb
surgery
 Transversus Abdominis Plane block

• The T6-L1 segmental nerves enter

the triangle of Petit just medial to the
anterior axillary line
• Injection between the internal oblique
and transverse abdominis muscle
 Intravenous regional anaesthesia (Bier’s Block)

• Proximal cuff inflation

• IV prilocaine
• Distal cuff inflated after 5 mins
• Proximal cuff deflated
• After surgery wait for LA to bind to tissues (20mins)
• Deflate distal cuff
• Eg: used in Carpal tunnel release
 Spinal Anaesthesia

• Intrathecal injection
• Addition of opioids cause late respiratory depression
• Autonomic sympathetic blockade occurs if block occurs above T10
• How to minimise Durai puncture headaches?
1. Limiting number of punctures
2. Fine bore needle
3. Split rather than cut the dura
 Epidural Anaesthesia

• Advantages
1. Hypotension from sympathetic blockade can be better controlled and can
reduce blood loss
2. Early mobilisation
3. Reduces respiratory complications
4. Excellent analgesia for upper abdominal & thoracic surgical operations
• Disadvantages
1. Nerve damage
2. Spinal injuries
3. May inject large volumes of LA
4. Risk of infection
5. Epidural he atoms
 Nociceptive pain

• Musculoskeletal disorders or cancer activating cutaneous nociceptors

• Prolonged ischaemic or inflammatory processes- sensitisation of peripheral
nocireceptors
• Exaggerated response in dorsal horn of the spinal cord
 Neuropathic pain

• Dysfunction in peripheral or central nerves

• Burning shooting or stabbing sensation
• Poorly responsive to opioids
• Monoaminergic, tricyclic inhibitors and anticonvulsant drugs-mainstay
treatment
 Psychogenic pain

• Associated with depressive illness;chronic pain and the illness may

exacerbate each other
• More than 3 months - chronic
• In phantom limb pain, continuous regional local anaesthetic blockade
established before operation and continued post-operatively for a few days, is
believed to effectively reduce the risk of phantom limb pain
• Local anaesthetic and steroid injections can be effective around and inflamed
nerve in disc prolapse case followed by physiotherapist
• Nerve stimulation procedures: spinal cord stimulation by dorsal column
stimulation is now recognised and effective management of intractable
neuropathic pain.
 Drugs in the chronic non malignant pain

• NSAIDS is the mainstay treatment of musculoskeletal pain

• Tricyclic antidepressants and anti-convulsant agents are also used but reduce
compliance
• Opioid patches are used for chronic non-malignant pain
 Treatment of pain dependent on sympathetic nervous system activity

• Interventional treatment -local anaesthetic injection of stellate ganglion.

• Percutaneous chemical lumbar sympathetic to me with local anaesthetic
 Paint step ladder

• Simple Analgesics: Aspirin, paracetamol, non-steroidal anti-inflammatory

agents, tricyclic drugs or anti-convulsant drugs
• Inter mediate strength: codeine, tramadol, dextripropoxyphene
• Strong opioids: morphine, pethidine(withdrawn)
• Fear that patient may develop an
addiction to opioids is usually not
justified in malignant disease
• Addiction (psychosocial
phenomenon)
• Dependence( physiological)
 Administration of morphine

• Oral morphine in liquid or tablet form should be administered regularly every

four hours until adequate dose has been titrated to control the pain over 24
hours
• Once this is established the dose can be split and given BD
• Disadvantage: constipation
 Infusion of subcutaneous, intravenous, intrathecal or epidural opiate drugs

• Intravenous narcotic agents may be reserved for acute crisis, such as

pathological fractures
 Neurolytic techniques in cancer pain

• Phenol - Subcostal injection

• Alcohol - Coeliac plexus block
• Hyperbaric phenol - Intrathecal neurolytic injection
• Percutaneous anterolateral cordotomy divides the spinothalamic ascending
pain pathways
 Alternative strategies

• Anti - pituitary hormones drugs within brackets Tamoxifen and Cyproterone-

widespread metastasis
• Palliative radiotherapy
• Corticosteroids, Tricyclic antidepressants, anticonvulsants and flecainide
• Psychotherapy also relieves pain