Anaesthesia Image Bank

Anaesthesia
Image Bank
Index
Sl.No. Topic Pg.No.
1. Hitsorical Milestones 09
2. Pre-Operative Assessment 13
3. Pre-Operative Medications 19
4. Neuromuscular Blocking Drugs 20
5. Inhaled Anesthetics 23
6. Intravenous Anesthetics 27
7. Monitoring Anesthesia 29
8. Anesthesia Delivery system 47
9. Anesthesia Equipments 55
10. Spinal,Epidural Anesthesia 74
11. Peripheral Nerve Blocks 78
12. Patient Positioning and Associated Risks 86
13. Fluid Management 93
14. Special Anesthetic Conditions 98
15. Critical Care Medicine 101
16. Miscellaneous 108

9
Anaesthesia
Historical Milestones
Oliver Wendell Holmes Horace Wells
American dentist who pioneered the use

Suggested the word “anesthesia“ of anesthesia in dentistry, specifically
refers to the inhibition of sensation. nitrous oxide (or laughing gas).
Karl Koller Joseph Priestley
Koller introduced cocaine as a local

Synthesised Nitrous Oxide and Oxygen
anaesthetic for eye surgery.
Reference :
https://www.britannica.com/biography/Joseph-Priestley
https://en.wikipedia.org
10
Humphry Davy Valerius Cordus
In 1799 he experimented with nitrous oxide,

nicknamed it "laughing gas" and wrote about Credited with developing a method
its potential anaesthetic properties in for synthesizing ether or "sweet oil
relieving pain during surgery. of vitriol".
James young simpson JOHN S. LUNDY
Scottish obstetrician,first physician

Balanced anesthesia is a anesthetic
to demonstrate the anaesthetic
method for surgical patients during
properties of chloroform on humans
their operation, which was proposed
and helped to popularise its use in
by John Lundy in 1926.
medicine.
Reference : https://en.wikipedia.org
11
William Thomas Green Morton

first publicly demonstrated the use of inhaled
:
ooo
ether as a surgical anesthetic in 1846.
“World Anaesthesia Day“ is on October 16th.
Father of Modern Anaesthesia.
John Snow August Karl Gustav Bier
German surgeon.
Father of Anaesthesia. He was the first to perform spinal
On 7 April 1853, Queen Victoria asked John anesthesia and intravenous regional
Snow to administer chloroform during the anesthesia.
delivery of her eighth child, Leopold. When is wold World Anesthesia Day ?
12
Harold Randall Griffith Arthur Ernest Guedel
ooo
Canadian anesthesiologist
on January 23, 1942, when he and
resident Enid Johnson used curare for ooo
American anesthesiologist.
the first time during anesthesia to
ooo
He was known for his studies on the
produce muscle relaxation uptake and distribution of
inhalational anesthetics, as well for
defining the various stages of
general anesthesia.
Henry Edmund Gaskin Boyle
ooo
The development of early anaesthetic machines.
ooo
His design included cylinders for the gases and a "Boyle's Bottle" to vaporize diethyl ether.
an anaesthetic machine was often referred to as a "Boyle's Machine" in honour of his
contribution.
13
Preoperative Assessment
American Society of Anesthesiologists Physical
Status Classification System
•
Most commonly used method by anesthesiologists to assess overall perioperative
risk is the ASA-PS classification system
AIRWAY EVALUATION
Mallampati classification
•
Used to predict the ease of endotracheal intubation(difficult airway).
class I - soft palate, fauces, entire uvula, pillars;
: class II - soft palate, fauces, portion of uvula;

'
MEET 18
•
class III - soft palate, base of uvula; Mallampati Grading is
class IV - hard palate only. used for assessment of ?
Reference :
Basics of Anesthesia by Manuela C.Pardo,Ronald D. Miller 7th Ed. Pg:190
Miller’s Anesthesia 9th Ed,Pg : 987,925
14
Thyromental distance (TMD) (Patil’s Test)

•
defined as the distance from the
chin (mentum) to the top of the
notch of the thyroid cartilage
with the head fully extended and
can be measured with a ruler for
accuracy.
Cormack and Lehane’s laryngeal grades of the airway
•
Grade - 1 : Entire glottic opening from the Anterior to Posterior Commissure can be
visualised.
• Grade - 2 : Just the posterior portion of glottis can be visualised.
•
Grade - 3 : Epiglottis only
• Grade - 4 : Only Soft tissue with nor identifiable airway anatomy.
Grade 1 Grade 2
Grade 3 Grade 4
Reference : https://openairway.org/tag/cormack-lehane/
15
Atlanto-occipital (AO) joint extension

•
The sniffing or Magill position is
considered the optimal “classical”
position of the head and neck for
facilitating tracheal intubation.
Any reduction in extension is
expressed in grades:
• Grade I: >35 degrees
•
• Grade II: 22 to 34 degrees

•
• Grade III: 12 to 21 degrees

•
• Grade IV: <12 degrees

•
A reduction in the extension of the joint can cause difficulty with laryngoscopic
view and intubation.
Other ways of assessment include

1.Thyromental Distance (TM Distance)
A : Thyromental distance
: It is measured from thyroid
cartilage to Mentum(chin)
2.Jaw Protrusion Test or Mandibular Protrusion Test
Reference :
Basics of Anesthesia by Manuela C.Pardo,Ronald D. Miller. Pg: 209
https://openairway.org/tag/cormack-lehane/
16
Guidelines for Food and Fluid Intake Before Elective Surgery in

Healthy Patients
Medications need to be stopped

MAO A inhibitors -(3 weeks before)
÷
Oral anticoagulants -(Warfarin 4 days prior)
Heparin -(Low molecular weight 12 hours before)
Anti platelets except aspirin (Clopidogrel 7 days prior)
Thrombolytic -(10 days prior)
NSAIDs -(48 hours prior if used with other antiplatets)
• High dose estrogen OCP -(4 weeks prior)
• Viagra -(24 hours prior)
• Disulfiram -(10 days prior)
All herbal medications -(7 days before)
: Smoking -(8 weeks before)
Medications for which only morning dose to be omitted

ACE inhibitors and angiotensin II antagonist.
•
Oral hypoglycemics.
•
Topical creams and ointments.

•
Vitamins and iron.

•
Reference:
Short Textbook of Anesthesia by Ajay Yadav 6th Ed Pg 51
17
Dose adjustment is needed for

Cholinesterase inhibitors
:
•
Corticosteroids
Insulin
•
Rest all medications are continued in the same dosages and same regime with
morning dose on the day of surgery to be taken with a sip of water.
STOP-Bang Questionaire Screening for Sleep Apnea
Reference :
Short Textbook of Anesthesia by Ajay Yadav 6th Ed 51
Miller’s Anesthesia 9th Ed,Pg : 952
18
Difficult Airway Society difficult intubation guidelines
Reference :
https://www.researchgate.net/figure/Fig1-Difficult-Airway-Society-difficult-intubation-guidelines-overview-Difficult-
Airway_fig1_283686715
19
Preoperative medications
Goals
1.To relieve anxiety.
•
benzodiazepine of choice is Midazolam.
2.To produce hemodynamic stability.
3.To induce sedation (good sleep) and reduce metabolic rate.
4.To provide analgesia and amnesia.
5.To decrease the chances of aspiration.
•drugs for aspiration prophylax:is, i.e. metoclopramide, antacids and
H2 blockers
6.To control oral and respiratory secretions.
•
Anticholinergics available to control secretions are atropine, glycopyrrolate.
they should be used only when required (like oral surgeries where dry mouth
is the requirement of surgery), not routinely in all patients.
7.To prevent postoperative nausea and vomiting.
•
In current dny practice 5-HT3 antagonists are the first-line medications
for prophylaxis as well as treatment of postoperative nausea and vomiting.
8.To control infection.
•antibiotic prophylaxis must be given within 60 minutes before skin incision.
A- 1114519
Glycopyrrolate is used as a
Pre Anesthetic agent for ?
20
Neuromuscular Blocking Drugs

•
Neuromuscular blocking drugs (NMBDs) interrupt transmission of nerve impulses at the
neuromuscular junction (NMJ) and thereby produce paresis or paralysis of skeletal
muscles.
NMBDs
Depolarizing NMBDs Nondepolarizing NMBDs
mimic the actions of ACh interfere with the actions of ACh.

: Succinylcholine (SCh) is the only
depolarizing NMBD used clinically.
: Long acting : Pancuronium
Intermediate acting
-Vecuronium
-Rocuronium
-Atracurium
-Cisatracurium
• Short acting : Mivacurium
DEPOLARIZING NEUROMUSCULAR BLOCKING DRUGS

Succinylcholine
mimics the action of ACh and produces a sustained
•
depolarization of the postjunctional membrane.

Depolarizing neuromuscular blockade is also referred to as
•
Phase I blockade.
Phase II blockade, which resembles the blockade produced by
•
nondepolarizing NMBDs, predominates when the intravenous

dose of SCh exceeds 3 to 5 mg/kg
Rapid onset ( 30-60sec)
: Duration of action less than 10 min
Variants of Plasma CholinesterasePlasma Cholinesterase & Duration of Action of Succinylcholine
Reference :
Basics of Anesthesia by Manuela C.Pardo,Ronald D. Miller. Pg:161
21
Long acting NON DEpolarizing DEPOLARIZING NEUROMUSCULAR

BLOCKING DRUGS
Pancuronium
bisquaternary aminosteroid
:
onset of action of 3 to 5 minutes
•
duration of action of 60 to 90 minutes

eliminated unchanged in urine.
•
selective blockade of cardiac muscarinic receptors

•
(atropine-like effect), principally in the sinoatrial node.

I
increased HR
•
Histamine release and autonomic ganglion blockade are
not produced by pancuronium.
INTERMEDIATE-ACTING NONDEPOLARIZING NEUROMUSCULAR BLOCKING DRUGS
Vecuronium
monoquaternary aminosteroid
: onset of action of 3 to 5 minutes
•duration of action of 20 to 35 minutes
•undergoes both hepatic and renal excretion
•devoid of circulatory effects, emphasizing its lack of vagolytic
effects (pancuronium) or histamine release (atracurium).
Atracurium
•Bisquaternary benzylisoquinolinium
Onset of action of 3 to 5 minutes
: Duration of action of 20 to 35 minutes
Clearance of this drug is by :
:
-a chemical mechanism (Hofmann elimination) and
-biologic mechanism
(ester hydrolysis by nonspecific plasma esterases).
Laudanosine is the major metabolite of both pathways.(In high,
nonclinical concentrations, cause central nervous system stimulation)
•
Clearance independent of hepatic and renal function.
•Can cause hypotension and tachycardia.
22
Cisatracurium
•
benzylisoquinolinium nondepolarizing NMBD.
•an onset of action of 3 to 5 minutes
•duration of action of 20 to 35 minutes.
•principally undergoes degradation by Hofmann elimination.
•
Drug clearance is organ independent.
•
devoid of histamine-releasing effects
Rocuronium
monoquaternary aminosteroid
•
onset of action of 1 to 2 minutes (Rapid Onset)

•
duration of action of 20 to 35 minutes

•
Excreted in bile and urine.

•
SHORT-ACTING NONDEPOLARIZING NEUROMUSCULAR BLOCKING DRUG
Mivacurium
benzylisoquinolinium nondepolarizing NMBD
: onset of action of 2 to 3 minutes
duration of action of 12 to 20 minutes.
•
consists of three stereoisomers, with the two most

•
• active isomers undergoing hydrolysis by plasma

cholinesterase at a rate equivalent to 88% that of SCh.
Hydrolysis of these two isomers is responsible for the
•
short duration of action of mivacurium.

23
Inhaled Anesthetics
most commonly used inhaled anesthetics in modern anesthesia include volatile liquids
i.
(i.e., halothane, enflurane, isoflurane, desflurane, and sevoflurane) and a single gas (i.e.,
nitrous oxide)
Halothane
Advantages includes : non-flammability,a pleasant
odor,lesser organ toxicity, and pharmacokinetic
properties allowing a much faster induction of anesthesia
and emergence.
Disadvantages :
•
-unpredictable liver damage

-sensitizes the myocardium to the dysrhythmogenic
effects of catecholamines.
Methoxyflurane Enflurane
•
metabolized to inorganic fluoride and
could cause evidence of seizure activity
•
dose-related nephrotoxicity because of on the electroencephalogram (EEG),
the inorganic fluoride that resulted from especially when administered at high
the metabolism of this anesthetic. concentrations and in the presence of
hypocapnia.
Reference :
24
Stages of General Anesthesia
Comparative Characteristics of Inhaled Anesthetics

25
Factors Decreasing MAC Factors Increasing MAC

•
Drugs Drugs
•
-Propofol -Amphetamine (acute use)

-Etomidate -Cocaine
-Barbiturates -Ephedrine
-Benzodiazepines -Ethanol (chronic use)
-Ketamine Age
-α2Agonists (clonidine, dexmedetomidine)
-Ethanol (acute use)
: -Highest at age 6 months
Electrolytes
-Local anesthetics -Hypernatremia
-Opioids -Hyperthermia
-Amphetamines (chronic use) Lithium
-Verapamil
Age
:
-Elderly patients
Electrolyte Disturbance
-Hyponatremia
Other Factors
-Anemia (hemoglobin < 5 g/dL)
-Hypercarbia
-Hypothermia
-Hypoxia
-Pregnancy
POTENCY
Inversely proportional to MAC (Minimum Alveolar Concentration).
: Halothane > Isoflurane > Enflurane > Ether > Sevoflurane > Desflurane > Xenon > Nitrous
Oxide
Speed of Onset and Recovery
Inversely proportional to Blood Gas Partition Coefficient
: Desflurane > N2O > Sevoflurane > Isoflurane > Halothane > Methoxyflurane
26
Sevoflurane and Desflurane
halogenated exclusively with fluorine
:
less soluble in blood and tissues, allowing faster awakening and recovery
Isoflurane
isoflurane was associated with

less toxicity. Isoflurane allowed
a more rapid onset of surgical
anesthesia and faster awakening
compared with its predecessors.
27
Intravenous Anesthesia
Pharmokinetics of Drugs
PROPOFOL
•
most frequently administered anesthetic drug for
induction of anesthesia.
used during maintenance of anesthesia
: utilized for sedation and short-duration general

anesthesia(Day care surgery).
Pain from injection
decreases in cerebral blood volume, intracranial
• pressure (ICP), and intraocular pressure.
•
Cause profound bradycardia and hypotension.
•
Fospropofol is a water-soluble phosphate ester
prodrug of propofol.
KETAMINE
•phencyclidine derivative
NMDA inhibitor
:
Cause “dissociative anesthesia”
can be administered by multiple routes (intravenous,
intramuscular, oral, rectal, epidural).
•Norketamine, the primary active metabolite excreted
in urine.
unique properties, including profound analgesia,
stimulation of the sympathetic nervous system,
bronchodilation, and minimal respiratory depression
28
ETOMIDATE
•intravenous anesthetic with hypnotic.
•carboxylated imidazole derivative.
•Pain on injection (Maximum)
•potent cerebral vasoconstrictor.
•produces minimal changes in heart rate and cardiac output.
Minimal effect on respiration
i.
causes adrenocortical suppression by producing a dose-dependent
inhibition of 11β-hydroxylase.
BARBITURATEs
Derived from barbituric acid
grouped into thiobarbiturates, substituted with a sulfur
•
(thiopental), or oxybarbiturates, substituted with an

oxygen (methohexital).
Barbiturates except for phenobarbital undergo hepatic
•
metabolism, phenobarbital is mainly eliminated

unchanged via renal excretion.
dose-dependent CNS depression ranging from sedation
•
to general anesthesia.
do not have analgesic properties
•
potent cerebral vasoconstrictors

•
provides neuroprotection from focal cerebral ischemia

•
not from global cerebral ischemia (cardiac arrest).

Respiratory depressants and lead to decreased minute
•
ventilation via smaller tidal volumes and respiratory

rates.
Accidental intra-arterial injection results in
•
excruciating pain and intense vasoconstriction.

an anesthetic of choice for electroconvulsive therapy,
•
methohexital may allow for longer seizure duration.

29
Monitoring of Anesthesia
Respiratory system monitoring
Pulse oximetry noninvasive, in vivo, and continuous assessment of
: functional SaO2 (SpO2).

Based on BEER LAMBERT LAW
composed of a light emitter and a photodetector.
At 660 nm, greater light absorption by deO2Hb
than by O2Hb.
•
At 940 nm,greater light absorption by O2Hb than
by deO2Hb
'
MEET 19
Device shown in image is used to assess ?
Source of Error Source of Error Effect on SpO2 Relative to SaO2

Cyanmethemoglobin No significant effect
Nail polish
Black, dark blue, purple ↓
Jaundice
Methemoglobinemia No significant effect
Hypotension ↓/↑ (SpO2 approaches
Anemia 85%)
Polycythemia
Motion
Decreased
Carboxyhemoglobinemia Decreased
Methylene blue No significant effect
Decreased
Capnography Increased
•
Capnography refers not onlyDecreased
to the method of CO2 measurement, but also to its
graphic display as a function of time or volume.
-Representative Time Capnogram for Three Breaths.

-The expiratory segment is divided into phases I, II, III, and IV.
α denotes the angle between phases II and III,
β denotes the angle between phase III and the descending limb of phase 0.
-Phase IV (dashed line in third breath) denotes the upstroke observed at the end of phase III in some patients.
-PET CO2, Partial pressure of end-tidal carbon dioxide.
Reference :
Miller’s Anesthesia 9th Ed,Pg : 1304,1308
30
TIME CAPNOGRAM
Normal capnogram during controlled mechanical ventilation
Normal capnogram during spontaneous breathing
Increased upslope of phase III, as may occur during bronchospasm (asthma, chronic
obstructive pulmonary disease), or partially obstructed endotracheal tube/breathing circuit.
Cardiogenic oscillations at the end of exhalation as flow decreases to zero and the beating
heart causes emptying of different lung regions and back-and-forth motion between exhaled
and fresh gas
I Reference :
31
Curare notch
t
Clefts during phase III indicating spontaneous breathing efforts during controlled
mechanical ventilation
'
NEET 20
Capnograph shown below is due to ?
Esophageal intubation
Rebreathing of CO2, as may occur with faulty expiratory valve or exhausted absorber
system. Inspiratory CO2 is consistently above 0
Faulty inspiratory valve, resulting in a slower downslope, which extends into the
inhalation phase (phase 0) as CO2 in the inspiratory limb is rebreathed.
Reference :
32
Two peaks in phase III suggestive of sequential emptying of two heterogeneous

compartments, as may be seen in a patient with a single lung transplant
Faulty inspiratory valve
sudden shortening of the duration of phase III during controlled mechanical ventilation,
suggesting the abrupt onset of a ruptured or leaking endotracheal tube cuff.
Dual plateau in phase III, suggesting the presence of a leak in a sidestream sample line.
Early portion of phase III abnormally low due to dilution of exhaled gas with ambient air.
The sharp increase in CO2 at the end of phase III reflects a diminished leak resulting from
the increased circuit pressure at the onset of inspiration.
Reference :
33
VOLUME CAPNOGRAM
volume capnogram is a graphic display of CO2 concentration or partial pressure versus
: exhaled volume.
The inspiratory phase is not defined in a volume capnogram.
It is partitioned into three distinct phases (I, II, and III) corresponding to anatomic dead
space, transitional, and alveolar gas samples
Anatomic dead space (phase I, red)
Transitional (phase II, blue)
Alveolar gas (phase III, green)
Total tidal volume (VT)
Airway dead space volume (VDaw)
Effective alveolar tidal volume (VTalv)
FETCO2, Fraction of end-tidal CO2
Area X - total volume of CO2 exhaled over a tidal breath.

Area Y represents wasted ventilation due to alveolar dead space
Area Z corresponds to wasted ventilation due to anatomic deadspace (VDaw).
Y + Z represent the total physiologic dead space.
sudden drop in CO2 due to catastrophic loss of ventilation
Reference :
34
leak or partial obstruction in breathing circuit
Sudden interruption in pulmonary perfusion, as may occur during cardiac arrest
Gradual decrease in CO2 due to hyperventilation, decreased metabolism, or decreased

pulmonary perfusion
Gradual increase in CO2 as may occur during hypoventilation, laparoscopic insufflation,

increased metabolism, or increased pulmonary perfusion
Reference :
35
Transient rise in CO2 indicated acute increase in CO2 delivery to the lungs, as may
occur during release of a tourniquet or administration of a bicarbonate bolus
Rise in both the baseline and end-tidal CO2,consistent with a contaminated sample cell
Gradual rise in baseline and end-tidal CO2, consistent with rebreathing. PCO2, Partial
pressure of CO2
Reference :
36
Cardiovascular system monitoring

•
Includes :
1.Heart Rate and Pulse Rate
2.ECG
3.Blood Pressure
4.Central Venous Pressure
ECG
Situation Condition Comments ECG Display
Normal ECG P wave, QRS Function of normal
complex, T wave electrolytes and
conduction
Dysrhythmia Heart block Drug effect or

injury to
conduction system
Atrial fibrillation Atrial overdistention,

intrinsic disease
Hypovolemia, light
Sinus tachycardia anesthesia, hypoxia,
hypercarbia
Reference :
37

Sinus bradycardia Excess vagal tone,
drug effects,
hypoxia
Asystole Extreme vagal tone,

extreme hypoxia
Torsades Genetic ion channel

differences,
long QT syndrome,
drugs
Ventricular Coronary artery

tachycardia disease, mechanical
irritation from
central line
Ventricular Intrinsic myocardial

fibrillation disease
Active ischemia ST-segment Ischemia, demand or

changes supply
38
Completed old Q waves Localized to

infarction area of injury
Electrolyte Hypokalemia Depressed T wave,

Abnormality U wave
Hyperkalemia Peaked T waves,

sinusoidal ECG in
the extreme
Hypercalcemia Shortened QT
interval,
possible J wave
Temperature Hypothermia Osborne J wave

39
Blood Pressure monitoring

Riva-Rocci
•
Obtained by : Palpate pulse, inflate cuff, slowly
deflate until pulse returns
Adv :Can be used without a stethoscope, by
: palpation of pulse or Doppler flow detection

DisAdv :Only gives a systolic pressure, can work
with nonpulsatile flow Scipione Riva-Rocci
Korotkoff method
•
Auscultate over antecubital fossa,
inflate cuff, slowly deflate, noting first
auscultation sounds and last sounds.
Gives diastolic as well as systolic
: pressure
Needs stethoscope, quiet environment
Noninvasive blood pressure (NIBP)

•
Choose correct cuff size, initiate cuff inflation.
•
Can be automated, for routine monitoring, measures mean pressure,
interpolates systolic and diastolic pressure.
• Does not work with severe hypotension, motion artifact, or patient with left
ventricular assist device
•
Eg:
1. The Finapress blood pressure
2.The CNAP Monitor 500 system
A.The Finapres blood pressure cuff. LED, light-emitting diode.

B. The finger cuff, transducer, and monitor.
Reference :
40
A, The CNAP Monitor 500 with arm and finger blood pressure cuffs.
B, The CNAP monitor double finger cuff and transducer.
Invasive blood pressure (IBP)
•
Connect intra-arterial catheter to transducer intra-arterial catheter to
Adv : Wide range of pressure, measures a mean pressure, transducer
systolic and diastolic pressure,can serve as access route for

blood draws.
DisAdv : Invasive, potential for amplification artifact, dampening,
hemorrhage, hematoma, infection, injury to artery or distal
areas
•
Radial Artery :
Adv :Most commonly used as generally accessible; hand typically
has dual blood supply.
DisAdv : Can produce artificially low values with severe systemic
vasoconstriction
Central Venous Monitoring
Reference :
Basics of Anesthesia by Manuela C.Pardo,Ronald D. Miller. Pg: 353,354
Anesthesia Equipment Principles and Applications 2nd Ed. Pg 279,280
41
Central Venous Catheter
Central venous pressure waveform
• The mean central venous pressure (CVP) value can be used to assess right-sided heart
filling pressure.
•
a wave - reflects atrial contraction against the closed tricuspid valve
• v wave - occurs during atrial filling
• c wave - reflects tricuspid bulging as the ventricle contracts
• x descent - corresponds to atrial relaxation
• y descent - reflects atrial emptying
Pulmonary Artery Catheter (PAC)

•a.k.a Swanz-Ganz Pulmonary Artery Catheter
is an access catheter advanced from the right
atrium to the right ventricle into a wedge
position in the pulmonary artery.
• measures right- and left-sided heart f illing
pressures as well as cardiac output.
Note as the catheter is advanced from the right ventricle into the pulmonary artery the diastolic
pressure is cut off and rises to the PA diastolic, which is only slightly higher than the pulmonary
artery wedge pressure. PA, Pulmonary artery;PCWP,pulmonary capillary wedge pressure.
42
Transesophageal Echocardiogram Monitoring

•Information on
-cardiac structure (heart valves, chamber size),
-contractile activity (ejection fraction),
-systolic and diastolic dysfunction, and
-pericardial disease (effusion, tamponade).
•
Limitations include:
-the need for expertise on the part of the
provider,
-access to the head of the patient,
-the risk of esophageal injury.
•
Gold standard for determining the adequacy of intravascular volume and cardiac function
is transesophageal echocardiography (TEE).
Central nervous system monitoring
bispectral index (BIS) monitor
•
Specific ranges of 40 to 60 are
recommended to reduce the risk of
consciousness during general anesthesia.
used to supplement Guedel's classification
system for determining depth of
anesthesia.
Intracranial Pressure Monitoring MEET

'
19
•
Cerebral Perfusion Pressure = MAP - ICP Which among the following is most
•
2 methods for ICP monitoring are : commonly used for assessing depth of
i)ventriculostomy catheter anesthesia ?
ii)fiberoptic pressure transducer
Reference :
43
ventriculostomy catheter
inserted percutaneously into a lateral
•
ventricle of the brain.

An advantage of ICP monitoring with a
•
ventriculostomy is that cerebrospinal

fluid may be removed to reduce
intracranial volume and thus ICP
fiberoptic pressure transducer
on the tip of a catheter
inserted into the brain parenchyma
: or the subdural space.
These devices do not require zeroing.
Cerebral Oximetry
•oxygenation of a portion of the brain (i.e.,
portion of the cerebral cortex) can be
monitored with a reflectance oximeter.
Parameter is called regional oxygen
:saturation (rS O2).

rS O2 values are usually about 70% (like
mixed venous blood).
Normal Electroencephalogram
Reference :
44
Neuromuscular Monitoring
Neuromuscular Blockade Monitor
• most common method to follow the effects of a nondepolarizing neuromuscular blocking
drug is to use a “twitch monitor” and follow a train-of-four (TOF) count.
• TOF stimulation (four electrical stimulations at 2 Hz delivered every 0.5 second) is based
on the concept that ACh is depleted by successive stimulations.
• In the presence of effects produced at the NMJ by nondepolarizing NMBDs, the height of the
fourth twitch is lower than that of the first twitch, thereby allowing calculation of a TOF
ratio (fade).
Recovery of the TOF ratio to greater than 0.7 correlates with complete return to control
: height of a single twitch response.
In the presence of effects produced at the NMJ by SCh(Depolrizing NMBD), the TOF ratio
remains near 1.0 because the height of all four twitch responses is decreased by a similar
amount (phase I blockade).A TOF ratio of less than 0.3 in the presence of SCh reflects
phase II blockade.
Pattern of electrical stimulation and evoked muscle responses to single-twitch nerve

stimulation (at frequencies of 0.1-1.0 Hz) after injection of nondepolarizing (Non-dep.)
and depolarizing (Dep.) neuromuscular blocking drugs (arrows).
45
Pattern of electrical stimulation and evoked muscle responses to train-of-four

(TOF) nerve stimulation before and after injection of nondepolarizing (Non-dep.)
and depolarizing (Dep.) neuromuscular blocking drugs (arrows).
Pattern of electrical stimulation and evoked muscle responses to train-of-four (TOF)

nerve stimulation and double-burst nerve stimulation (i.e., three impulses in each of two
tetanic bursts, DBS3,3) before injection of muscle relaxants (control) and during
recovery from nondepolarizing neuromuscular block.
46
• Pattern of stimulation and evoked muscle

responses to tetanic (50 Hz) nerve
stimulation for 5 seconds (Te) and
post-tetanic twitch stimulation (1.0 Hz;
arrows).
•
Stimulation was applied before the
injection of neuromuscular blocking drugs
and during moderate nondepolarizing
(non-dep.) and depolarizing (dep.) blocks.
• nondepolarizing block - fade in the
response to tetanic stimulation +
posttetanic facilitation of transmission.
• depolarizing block - the tetanic response
is well sustained + no posttetanic
facilitation of transmission.
• Pattern of electrical stimulation and evoked muscle responses to train-of-four (TOF)

nerve stimulation, 50-Hz tetanic nerve stimulation for 5 seconds (TE), and 1.0-Hz
posttetanic twitch stimulation (PTS) during four different levels of nondepolarizing
neuromuscular block.
•
During intense block of peripheral muscles (A), no response to any of the forms of
stimulation occurs. During less pronounced block (deep block, B and C), there is still no
response to TOF stimulation, but posttetanic facilitation of transmission is present.
• During surgical block (D), the first response to TOF appears and posttetanic facilitation
increases further. The posttetanic count is 1 during very deep block (B), 3 during less
deep block (C), and 8 during surgical (or moderate) block (D).
47
Anesthesia Delivery Systems
Boyle Type Anesthesia Machine Dräger Apollo Anesthesia Workstation
Schematic diagram of the internal circuitry of an anesthesia machine.

- High Pressure Systems
- Intermediate Pressure Systems
Reference :
48
Flowmeters
•upper end of the bobbin or the equator of the ball indicates the gas flow in milliliters or
liters per minute.
•oxygen flowmeter should be the last in the sequence of flowmeters.
For emergency purposes, provision is made for delivery of a large volume of oxygen
•(35 to 75 L/min) to the outlet port through an oxygen flush valve that bypasses the
flowmeters and manifold.
VAPORIZERS
Volatile anesthetics are liquids at room temperature and atmospheric pressure.
•
Vaporization, which is the conversion of a liquid to a vapor,takes place in a closed
:
container, referred to as a vaporizer.
Commonly, two to three anesthetic-specific vaporizers are present on the
anesthesia machine.
Reference :
49
ANESTHETIC BREATHING SYSTEMS
Classification of Anesthetic Breathing Systems

• most commonly used anesthetic breathing systems are the
(1) Mapleson F (Jackson-Rees) system, (2) Bain circuit, and (3) circle system.
Mapleson Breathing Systems
There are 5 different semiopen anesthetic breathing systems are designated
:
Mapleson A to E.
The Mapleson F system, which is a Jackson-Rees modification of the
Mapleson E system, was added later.
The Bain circuit is a modification of the Mapleson D system
•
All the circuits except for Mapleson E use a bag as an additional reservoir.
•
The Mapleson A, B, and C systems are rarely used today, but the D, E, and F
•
systems are commonly used.

Mapleson A spring-loaded pop-off valve
i
FGF, Fresh gas flow.
a.k.a the “Magill circuit,” has a spring-loaded pop-off valve located near the facemask.
: It is the only Mapleson circuit where fresh gas flow enters from the end of the circuit
opposite the patient (in this case, near the reservoir bag).
Reference :
50
Mapleson b and c
• In the B and C systems, both the pop-off valve and fresh gas inlet tubing are located near
the patient.
The Mapleson C is known as the “Waters to-and-fro” circuit and lacks a corrugated tube.
: The reservoir tubing and breathing bag serve as a blind limb where fresh gas, dead space
gas, and alveolar gas can collect.
MAPLESON d, e and f
Mapleson D, E, and F, or “T-piece” group, fresh gas enters near the patient, and excess
:
•
gas is vented off at the opposite end of the circuit.
Mapleson E (also known as “Ayre’s T-piece”).
The Mapleson F system :
- commonly used for controlled ventilation during transport of tracheally intubated
patients.
- ideal for pediatric anesthesia.
- may be used for both spontaneous and controlled ventilation.
- Disadvantages :
(1) the need for high fresh gas
inflow to prevent rebreathing,
(2) the possibility of high airway
pressure and barotrauma should
the overflow valve become occluded.
(3) the lack of humidification.
Breathing system used in pediatric anesthesia ?

51
The relative efficiency of different Mapleson systems with respect to prevention of

rebreathing are:
'
NEET 18
- A > DFE > CB during spontaneous ventilation Most effective circuit used for anesthesia
- DFE > BC > A during controlled ventilation. under spontaneous breathing ?
Bain System
is a coaxial version of the Mapleson D system in which the fresh gas supply tube
•
runs coaxially inside the corrugated expiratory tubing.

may be used for both spontaneous and controlled ventilation.
: Prevention of rebreathing during
- spontaneous ventilation requires a FGF of 200 to 300 mL/kg/min
- Controlled ventilation requires a FGF 70 mL/kg/min
Schematic diagram of the Bain system showing fresh gas flow (FGF)
entering a narrow tube within the larger corrugated expiratory limb (A).
The only valve in the system (B) is an adjustable pressure-limiting
(overflow) valve located near the FGF inlet and reservoir bag (C).
Circle System
• prevents rebreathing of CO2 by chemical
neutralization of carbon dioxide with carbon
dioxide absorbents.
anesthesia machine ventilator (V)
: reservoir bag (B)

adjustable pressure-limiting (APL) valve
52
Carbon Dioxide Absorbents

Comparison of Carbon Dioxide Absorbents
Amsorb Plus Litholyme
Soda Lime
Yoke assembly with bodok seal and yoke plug

53
Colour coding of gas cylinders used in hospitals
Heliox
Is mixture of 21 % oxygen and 79% helium
: - named as Heliox 21.

Used to improve gaseous exchange in acute
exacerbation of asthma and COPD.
Entonox
• Is 50 :50 mixture of nitrous oxide and oxygen.
Compressed in cylinders at 13,700 kPa
: PISS -7
Cyclopropane Pipeline supply

Is relatively potent,non
• • White - Oxygen
irritating and sweat smelling • Blue - Nitrous oxide
agent with minimum alveolar •
Black - Air
concentration. •
Yellow - Central suction
Cynlinders and flow meters are
•
Orange in colour.
PISS - 3,6
•
\
54
Pin Index Safety System

•
is a means of connecting high pressure cylinders containing medical gases to a
regulator or other utilization equipment.
O2 2,5
N2O 3,5
Entonox 7
Air 1,5
CO2 1,6
Helium No pin
Heliox 2,4
Cyclopropane 3,6
Ethylene 1,3
Nitrogen 1,4
55
Anesthesia Equipments
Guedel's oropharyngeal airway
•
Aim of airway- prevent the tongue fall.
• Most commonly used is Guedels airway.
• Airways are available in many sizes.
•
The appropriate length is the distance
between tip of nose and tragus plus 1 cm.
Waters Airway
•Metal airway with flattened anatomically
curved tube and holes at side and on top at
end of tube.
•has a side port or “nipple” to deliver air or
oxygen via tubing.
Berman Airway Binasal Aiway
• consists of two nasal airways joined

together by an adaptor for attachment
• Side channels enable use of to the breathing system.
suction catheters without •
These silicone nasopharyngeal prongs
obstructing the airway, are easy to insert and remove and stay
allowing for additional air flow. securely in place.
Available in different lengths.
.
Reference:
56
Nasopharyngeal airway
•
Was introduced by Hans Karl Wendl
•Are made from soft, flexible materials
•Tolerated better in awake patients than are oropharyngeal airways.
•
Appropriate sizing determined by measuring the distance from the
patient’s bony mandible or nostril to the meatus of the ear.
FACEMASKS
used to ventilate the patient without intubation.
•
available in sizes from 0 (smallest) to 6 (largest).

made of antistatic rubber.
Disadvantages are:•
-Dead space volume is increased

-Ventilation with mask is tiring
-A significant amount of air leaks into esophagus
can cause aspiration.
Anesthesia Face Mask with air cushion and valve.
RENDELL BAKER SOUCEK MASK

Designed for pediatric patients.
: Has a Triangular body

Available in sizes 00,0,1,2
• Has Low dead space.
•
Adequately fits the child’s face and no special
seal needed.
57
Non - Rebreather Face mask

•
Uses a reservoir bag ( 1000ml ) to
deliver high concentrations of oxygen
Deliver oxygen between 10 and 15 L /min
: Oxygen flow less than 10 L/min can cause
bag to collapse during inspiration
Reservoir bag
•
Is a device used to assist in the delivery of oxygen therapy.
•
An NRB requires that the patient can breathe unassisted, but unlike low-flow nasal
cannulae, the NRB allows for the delivery of higher concentrations of oxygen.
•
Utilized for patients with physical trauma, chronic airway limitation, cluster headache,
smoke inhalation, and carbon monoxide poisoning, or any other patients who require high-
concentration oxygen, but do not require breathing assistance.
The flow rate and approximate for different FiO2 oxygen delivery devices
Oxygen delivery devices Flow rate (litre/min) Approximate FiO2
Nasal cannula 1-6 0.24-0.44
Simple face mask 5-8 0.40-0.60
Partial rebreathing mask 6-10 0.60-0.80
Non rebreathing mask 10-15 0.90-1.00
Venturi mask 2-15 0.24-0.60
Among the following devices which one delivers maximum FiO2 ?

A.Nasal Canula C.Non rebreathing mask
B.Venturi mask D.Hudson mask [INICET 2021]
58
Yankauer-Gwathmey Mask Schimmelbusch mask
ap le.g
• is an open breathing system for delivering
•
Was used for the drop method of an anesthetic.
anesthesia.
Mask headstrap
Endotracheal Tubes
• An endotracheal tube is a specific type of tracheal tube that is nearly always inserted
through the mouth (orotracheal) or nose (nasotracheal).
‘Standard' endotracheal tube
Reference:
Anesthesia Equipment Principles and Applications 2nd Ed. Pg :332
59
Tube tip design
'
NEET 18
Murphy’s eye is
seen in which
device ?
•
Murphy eye provides an alternate gas passage way should this type of occlusion
at the tip occur.
Cuff design
•Most endotracheal tubes for use in adults
have a tracheal cuff near their distal end.
•Cuff-less ETTs are also available, and a
more commonly used in pediatric patients.
•
two types of endotracheal tube cuffs in
use, high volume-low pressure cuffs and
low volume- high pressure cuffs.
Valve and pilot balloon
• The cuff is inflated through a spring-loaded valve with a Luer lock connector.
•
Attached to the valve is a pilot balloon which allows for (rough) tactile and visual
• confirmation of cuff inflation after intubation or deflation just before extubation.
Reference :https://aam.ucsf.edu
60
Markings on the tube

•
all ET tubes have is the size
(measured as the inner diameter
in mm) and length markings
(measured in cm from the tip).
Microlaryngoscopy tube
•
is in essence a pediatric-sized standard ETT with an adult length or an adult standard
ETT with a pediatric-sized diameter.
• comes in three sizes, 4.0, 5.0 and 6.0mm.
• The size 5.0mm tube is the most commonly used.
Diﬀerences in cuﬀ length/ size and distance from

tip between MLT® and 'standard' pediatric ETT
Parker Flex-Tip tube

has a curved and tapered tip which is meant to reduce the risk of trauma during
•
intubation.
Oral Parker Flex-Tip® tube

61
Side-by-side comparison of the

Parker Flex-Tip® and a 'standard'
ETT with regards to the 'step up'
between tube and conduit, e.g bougie
Laryngeal model demonstrating the 'hang up' (red arrow) of

the 'standard' ETT (left) versus the Parker Flex-Tip® (right)
USES
•
designed to reduce the risk of traumatic intubation, which is more likely to occur in
(mainly) two situations:
1.Nasal intubation, particularly with a narrow passage, e.g. due to relatively large
turbinates
2.Intubation with a Seldinger technique
62
Armored Tubes
•
both anode or flexometallic,have a reinforced metal or nylon wire wound in a spiral
throughout the shaft of the tube.
resistant to kinking and compression
: used in head, neck and tracheal surgery and in positions in which the neck is flexed.
Preformed Tubes
such as Ring-Adair-Elwyn (RAE) tubes,have a preformed bend and are available for
iboth oral and nasal intubations to prevent the ETT from hindering access to the
surgical field.
They are predominantly used in oromaxillofacial and nasal procedures.
Oral RAE tube with preformed bend ( SOUTH facing) Oral RAE tube in-situ
Nasal RAE tube with preformed bend ( NORTH Facing ) Nasal RAE tube in-situ
63
Gum-elastic bougie
•also called 'introducer', 'gum-elastic bougie' or 'GEB', is a device which allows a
Seldinger-like technique of intubating a patient's airway.
•moderately flexible and can be bent into shape from its straight form.
•
Bougies are commonly about 15F in diameter and 70cm in length.
•
tip of the bougie is angled at 30 degrees and should point anteriorly during
•intubation to facilitate navigation of the device towards an anteriorly located larynx.
Gum-elastic bougie
Aintree catheter
is a blunt-tipped, 19 Fr radio-opaque catheter
:with an internal diameter of 4.7 mm and an

outer diameter of 6.5 mm.
USES :
-for intubating through a laryngeal mask with
fiberoptic guidance.
-the exchange of an endotracheal tube
Rapi-Fit® adapters supplied with Aintree

catheter kit; Luer lock connector (left) and
standard 15 mm connector (right)
Distal tip of Aintree catheter with end hole and two side holes
64
Frova intubating catheter

The catheter is available in two sizes, 8 and 14 Fr.
: It has length markings in centimeters on the side
which start at 10 cm from the tip.
• The catheter contains a central lumen for
oxygenation, which opens through two side holes
at the blunt and closed tip.
•
Uses :
1. 'standard' orotracheal intubation with a
conventional laryngoscope when visualization of
the larynx in suboptimal, as in grade 2 or 3
Cormack-Lehane views.
Tip of Frova catheter
Comparison fo the tips of the Frova and the gum-elastic bougie
Magill forceps
•help with ET tube placement during nasal
intubation.
The design remains pretty much unchanged.
:It is a right-handed instrument which is

angled in two planes.
USES :
maneuver the tip of the ET tube. Close-up view of serrated grip surfaces
clearing foreign bodies from the

upper airway in anesthetized or
unconscious patients.
placing and removing throat packs.
65
AMBU BAG RESUSCITATOR
AMBU - artificial manual
: breathing unit.
available in a capacity of
-I,200 mL for adults,
-500 mL for children
-250 mL for newborns.
•
100% oxygen can be delivered by AMBU bag by attaching O2 source and O2 reservoir
Laryngoscopes
•
used for visualizing the glottis to facilitate intubation.
Direct Rigid Laryngoscopes
McCoy Miller
It has got a movable lip, which can be used
•
• It has a straight blade with
to maneuver the glottis curve at the tip.
Reference:
66
Macintosh Oxford infant blade
Used for infants.

most commonly used.
÷ has curved blade available in 4 sizes

smallest for children
largest for adults with long necks.
Stylets
•are malleable metal rods which are covered
with a clear plastic sheath with a more or
less atraumatic tip.
•They come in adult as well as pediatric
lengths and diameters.
•
Stylets are used inside an endotracheal tube
to give it a certain bent shape which aids
navigation of the tube towards the
laryngeal inlet.
67
Magill
straight blade used for neonates.
: Neonatal epiglottis is large, leafy
and more anterior, therefore it need
to be lifted by straight blade to
visualize glottis.
polio laryngoscope Blade

•
Blade in line with handle.
• Developed for the “iron lung” patient.
• Avoids obstructions over the patient’s
chest (large breasts,morbid
obesity,operator hand performing Sellick
maneuver).
Indirect Rigid Laryngoscopes (Fiberoptic)

the glottis is not visualized directly but through the fiberoptic channels.
•
Bullard Laryngoscope
•
the prototypical anatomically shaped
rigid fiberscope.
• Accessories include hollow tracheal
tube stylet, a single-use blade
extender, and an external light
source cable adaptor.
• Pediatric and adult sizes are
available
68
Flexible Laryngoscopes/Bronchoscopes (Fiberoptic)

gold standard technique for the management of difficult/ failed intubation.
: It is less traumatic, does not require any specific position of neck and can be performed in
awake patients.
•
The limitations are cost, technical expertise and time consuming.
Video Laryngoscopes
video of the real time refracted image of glottis is obtained on a screen.
•
most commonly used and prototype is C-MAC the design of which is based on the
•
Macintosh blade.
69
McGrath Laryngoscope
•
is a portable rigid glottic imaging device that replicates the look and
feel of the direct laryngoscope.
Shikani Optical Stylet

is a high-resolution fiberoptic stylet that has a preformed curvature.
: Made of stainless steel, it is available in adult and pediatric sizes and can be used as an
adjunct to direct laryngoscopy or as an independent device.
70
SUPRAGLOTTIC AIRWAY DEVICES
Laryngeal mask airways (LMA)
First Generation LMA

Classical LMA
• also called as Brain Mask.
• placed blindly in oropharynx and the cuff is inflated
with large volume of air (30 to 40 mL for adult size).
• available in 7 different sizes
• Advantage
-Easy to insert
-Does not require any laryngoscope and muscle relaxants.
-can be used in cervical injuries.
-Less sympathetic stimulation as compared to intubation.
-Reusable (up to 40 times)
Disadvantages/Complications Contraindications
increases the risk of aspiration. Full stomach patients.
Can cause laryngospasm and airway Hiatus hernia, pregnancy (where
obstruction, if displaces anteriorly. chances of aspiration are high).
Sore throat-incidence is 10-20%. Oropharyngeal abscess or mass.
Trauma to oral cavity and injury
tohypoglossal and lingual nerve, if excessive
pressures are being used.(pressure should be
kept between 40-60 cm H20)
LMA Flexible
•
The tube of LMA is enforced with a
wire making it flexible(nonkinkable
making it useful for head and neck
surgeries.)
Reference:
Short Textbook of Anesthesia by Ajay Yadav 6th Ed 35,36
71
LMA Unique : single use disposable LMA

Second Generation LMA
provides better seal thereby decreasing the chances of aspiration.
•
Intubating LMA
• also called as LMA Fastrach
• Up to 8 no. endotracheal tube can be guided through it.
Fastrach
Fastrach with plunger.

Proseal LMA
It has larger and posterior cuff, which provides better seal.
•
Moreover, it has drain tube which can be used to deflate the stomach
•
ProSeal Larygneal Mask Airway

72
Supreme LMA
• Supreme LMA is like proseal LMA
with a bite block to avoid damage
to LMA tube, if the patient bites.
available in adult sizes 3 to 5
I-Gel
The cuff is prefilled with gel avoiding the
•
complications of air filled cuff such as cuff

leakage, damage and puncture.
Like Proseal,I-gel also contains a drain
•
tube, which can be used to deflate the

stomach.
Peripharyngeal airway(Cobra-PLMA)
It has high volume oval cuff, which seals
•
the hypopharynx while patient can be

ventilated through the ventilation slots
at the tip
LMA C-Trach
•
Like video laryngoscopy, the LMA is
attached to screen to visualize the
structures
73
SLIPA Pharyngeal Liner

is a hollow,cuffless,preformed pharyngeal liner.
: named because it is shaped like a slipper,

with a “toe,” “bridge,” and “heel.”
The bridge fits into the piriform fossa,
sealing the upward outlet at the base of
the tongue.
• The nonlatex SLIPA is available in 6 sizes.
• This is a single-use device
Combitube
a double-lumen airway composed of a
:pharyngeal lumen and a tracheoesophageal

lumen.
available in two sizes:
37 Fr size - patients 120 cm to 180 cm Ht
41 Fr size - patients taller than 180 cm
74
Spinal ,Epidural Anesthesia

• Spinal, epidural, and caudal blocks are collectively referred to as central neuraxial blocks.
SPINAL ANESTHESIA
• Spinal anesthesia requires a small amount of drug to produce rapid, profound,
reproducible, but finite sensory analgesia. AIIMS 18
'
•
Distal termination of Spinal cord : At what level does the spinal
- infants - L3 cord end in Adults ?
- adults - the lower border of L1
CSF resides in the subarachnoid (or intrathecal) space between the pia mater and the
: arachnoid mater.
No drug metabolism takes place in the CSF.
Baricity is the ratio of the density of a local anesthetic solution to the density of CSF.
Surface landmarks for spinal levels
Spinal needles
Sharp/Cutting tipped Blunt tipped/pencil point

Pitkin and the Quincke-Babcock Whitacre and Sprotte
•• Reduced incidence of postdural puncture
•
You are doing the lumbar puncture.Which is the last structure to be encountered :
headache.
A. Ligamentum lavum C. Arachnoid • rounded points and side injection.
B. Dura D. Pia • pencil-point needles of 25 G, 26 G, and
27 G probably represent the optimal
needle choice.
Reference :
75
• Single-injection spinal or epidural

anesthesia is commonly used for
surgery to the lower abdomen, pelvic
organs (e.g., prostate), and lower
limbs and for cesarean deliveries.
Scanning electron micrographs of spinal needle tip

designs: Quincke(left), Sprotte(middle), and
Whitacre (right).
Quincke–Babcock needle
Pitkin needle
Whitacre needle
Reference :https://associationofanaesthetists-publications.onlinelibrary.wiley.com
76
Gauge Colour Code Spinal needles
18G Pink
19G Ivory
20G Yellow
21G Green
22G Black
23G Blue
24G Violet
25G Orange
26G Brown
27G Grey
EPIDURAL ANESTHESIA
Continuous catheter-based epidural infusions
:
are used for obstetric labor analgesia and to
provide postoperative pain relief for days after
major surgery (e.g., thoracic, abdominal, lower
limb).
Tuohy needles are most commonly used.
Suggested Epidural Insertion Nature of Surgery Sites for Common Surgical Procedures
Tuohy needles
77
A spinal needle and epidural needle are used for the combined
spinal-epidural technique.
Tuohy needle with a “back eye” that permits placement of the spinal needle
directly into the subarachnoid space (left panel) and subsequent threading of
the epidural catheter into the epidural space after removal of the spinal needle.
•
Some Types of epidural needles include :
1)The Crawford Needle
2)The Tuohy Needle
3)The Hustead Needle
4)The Weiss Needle
5)The Sprotte Spezial Needle
78
Peripheral Nerve Blocks
Cervical Plexus Blocks

cervical plexus is formed by the second,
:third, and fourth cervical nerves.

anesthesia produced by a cervical plexus
block includes the area from the inferior
surface of the mandible to the level
of the clavicle.
most often used to provide anesthesia in
•
conscious patients undergoing carotid

endarterectomy
UPPER EXTREMITY BLOCKS

Brachial Plexus Blocks
•brachial plexus is a network of nerves that is composed of five nerve roots
(C5, C6, C7, C8, and T1)
Reference :
79
Interscalene Block
•
targets the ventral rami of the brachial
plexus (derived from C5, C6, C7, C8, and T1
nerve roots).
•
suited for surgeries that involve the distal
clavicle, shoulder, and upper arm.
• has the potential risk of Horner syndrome,
recurrent laryngeal nerve block, epidural
or subarachnoid injection, vertebral artery
injection and pneumothorax.
Supraclavicular Block
Pneumothorax is the most common
: serious complication.
Advantages are rapid onset and
ability to perform the block with the
arm in any position.
• Bilateral supraclavicular blocks are
not recommended for fear of
bilateral pneumothorax or phrenic
nerve paralysis.
Infraclavicular Block
•
targets the medial, lateral, and posterior
cords of the brachial plexus.
Suitable for surgeries of the arm below the
: shoulder.
Aadvantages are the close proximity of the
brachial plexus to the artery, relatively
consistent anatomy and a stable site for
placement of a continuous peripheral nerve
catheter.
•
BP, Brachial plexus; LC, lateral cord; MC, medial cord; PC, posterior cord;
PMa, pectoralis major muscle; PMi, pectoralis minor muscle; SA, subclavian artery.
Reference :
Basics of Anesthesia by Manuela C.Pardo,Ronald D. Miller. Pg:308,310
80
Axillary Block
targets the terminal branches of the brachial plexus in the axilla: the median, ulnar,
•
radial, and musculocutaneous nerves.

suitable for surgeries of the elbow, forearm, wrist, and hand.
: Advantages :
- a lower risk of complications when compared to other brachial plexus blocks (e.g., no
risk of concomitant phrenic nerve block or pneumothorax).
Disadvantages :
•
- the potential risk of intravascular injection and hematoma

- unsuitability for a peripheral nerve catheter
- lack of coverage for the upper arm and shoulder.
AA, Axillary artery; LA, local anesthetic; MCN, musculocutaneous

nerve; MN, median nerve; RN, radial nerve; UN, ulnar nerve.
Intercostobrachial Nerve Block

The intercostobrachial nerve is a thoracic nerve (derived from T2 and T3) that provides
:
cutaneous innervation to the medial half of the arm.
may be used as a supplement to brachial plexus blocks to improve tolerance of an arm
tourniquet or to improve surgical conditions for proximal arm surgery.
LOWER EXTREMITY BLOCKS

lower extremity nerves originate from the lumbar and sacral plexuses
÷ The lumbar plexus - first four lumbar nerves (L1-L4).Nerves that arise from the
lumbar plexus include the lateral femoral cutaneous, femoral, and obturator nerves.
• The sacral plexus - first four sacral nerves (S1-S4) and also receives contributions
from L4 and L5. This plexus gives rise to the sciatic nerve.
Reference :
81
Femoral Nerve Block

largest branch of the lumbar plexus and derives from the ventral rami of L2 to L4.
: suitable for surgeries of the anterior thigh (e.g., quadriceps tendon surgery) and provides
analgesia for hip, femur, and knee surgeries.
• Advantage :
i)reliability in providing analgesia to the anterior thigh and medial leg.
ii)good location for a peripheral nerve catheter
•
Disadvantage :
-cause quadriceps muscle weakness, which may not be favorable for early mobilization
and may increase the risk of falls postoperatively.
Adductor Canal and Saphenous Nerve Blocks

targets distal branches of the femoral nerve(Sensory nerves - e.g., the saphenous
:nerve and infrapatellar nerve) as they travel deep to the sartorius muscle in the thigh.
Advantage analgesia for knee surgery, with minimal quadriceps muscle weakness.
FA, Femoral artery;SM, sartorius muscle; SN, saphenous nerve; VM, vastus medialis muscle.
Reference :
82
Proximal Sciatic Nerve Block

•suitable for surgeries involving the posterior thigh, lower leg, foot and ankle and can also
improve analgesia following knee surgery.
Advantages :
:-reliable posterior thigh and leg analgesia for the surgeries

-Placement of a continuous peripheral nerve catheter.
Disadvantages :
-hamstring weakness
-potential procedural discomfort and difficulty due to the increased depth of the block.
Popliteal Block of the Sciatic Nerve

targets the sciatic nerve as it enters the popliteal fossa, at which point the nerve
: divides into its common peroneal and tibial nerve components.

commonly used for foot and ankle surgery, usually combined with a saphenous nerve
block to cover the medial aspect of the leg.
Reference :
83
Ankle Block
•
All five peripheral nerves that supply the foot can be
blocked (ankle block) at the level of the malleoli.
i. tibial nerve
ii.sural nerve
iii.saphenous nerve
iv.deep peroneal nerve
v.superficial peroneal nerve
•
Because the foot does not have a generous blood
supply, systemic toxicity after an ankle block is rare.
CHEST AND ABDOMEN BLOCKS
Intercostal Nerve Block

target the ventral rami of the thoracic spinal
: nerves.
beneficial for thoracic and upper abdominal
surgery, as well as following chest wall trauma.
there is a potential risk of a pneumothorax.
Transversus Abdominis Plane Block

•abdominal wall field block targeting the ventral rami of
the thoracic and lumbar spinal nerves (T 7 to L1).
•provides analgesia for lower abdominal surgery and may
help with laparoscopic surgery.
•Disadvanatages :
-Risk of local anesthetic toxicity.
-Risk for intraperitoneal injection and intrahepatic
injection.
Reference :
84
INTRAVENOUS REGIONAL ANESTHESIA (BIER BLOCK)

is a method of producing anesthesia of the arm or leg.
:
used for surgical procedures with minimal postoperative pain and duration of 2 hours or
less.
Contraindications :
- sickle cell disease,
- ischemic vascular disease
- infection in the extremity.
Commonly used local anesthetic solutions for intravenous regional anesthesia are 0.5%
•
lidocaine or chloroprocaine (plain solutions without epinephrine).

Racemic bupivacaine is avoided (potential systemic toxicity,malignant ventricular cardiac
•
dysrhythmias,refractory cardiac arrest).
(A) Placement and securing of a small intravenous catheter.

(B) Exsanguination of the arm with an Esmarch bandage before inflation of the tourniquet and injection
of the local anesthetic solution through the catheter.
Block of the Nose: Nasociliary Nerve Block and External
Nasal Nerve Block
•
The innervation of the nose and nasal cavity is quite complex, implicating both the
ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve.
The nasociliary nerve is blocked before its division into nasal branches of the anterior
: ethmoidal nerve and the infratrochlear nerve, and near the ethmoidal foramen.
A 25- or 27-gauge needle is inserted 1 cm above the medial canthus, halfway between the
posterior palpebral fold and the eyebrow.
•
It is then directed medially and backward in contact with the bony roof of the orbit. At a
depth of 1.5 cm the needle should be at the anterior ethmoidal foramen, and a maximum of
2 mL of local anesthetic solution is then slowly injected after a negative aspiration test.
•
The external nasal branch of the anterior ethmoidal nerve can be blocked by infiltration at
the junction of nasal bone with cartilage.
•
Combined with infraorbital nerve block, the external nasal nerve block is very effective
for perioperative pain control in cleft lip repair.
Reference :
85
Which nerve is blocked according to the following image

A.Greater Palatine nerve
B.Nasociliary nerve
C.Sphenopalatine nerve
D.Anterior ethmoidal nerve [INICET 2021]
86
Patient Positioning and Associated Risks

supine position
also called the dorsal decubitus position, is the most common position for surgery.
: One or both arms can be abducted or adducted alongside the patient. Arm abduction
should be limited to less than 90 degrees in order to prevent brachial plexus injury
from the head of the humerus pushing into the axilla.
• should pad all bony prominences as well as stopcocks or intravenous lines that may
exert pressure on the skin during the operation
Variations of the Supine Position
Lawn-chair position
flexes the hips and knees slightly, which reduces stress on the back, hips, and knees.
:This modified supine position is often better tolerated by patients who are awake or
undergoing monitored anesthesia care.
facilitates venous drainage from the lower extremities
Reference :
87
frog-leg position
the hips and knees are f lexed and the hips are externally rotated with the soles of the
:feet facing each other, facilitates procedures to the perineum, medial thighs, genitalia,
and rectum.
The knees must be supported in order to minimize stress or dislocation of the hips.
Lateral Decubitus
•
the patient lies on the non- operative side in order to facilitate surgery in the thorax,
retroperitoneum, or hip.
Neither arm should be abducted more than 90 degrees in order to prevent injury to the
:brachial plexus from the humeral head.

patient’s head must be kept in a neutral position to prevent excessive lateral rotation of
the neck and stretch injuries to the brachial plexus.
88
Trendelenburg position
•commonly used today to increase venous return during hypotension, improve exposure
during abdominal and laparoscopic surgery, and prevent air emboli during central line
placement.
•It is part of the initial resuscitative efforts to treat hypovolemia.
•Intraocular pressure and intracranial pressure (ICP) can increase.
•Nonsliding mattresses are recommended to prevent the patient from sliding cephalad.
Endotracheal intubation is strongly recommended over supraglottic airways because of
:
the risk of pulmonary aspiration of gastric contents.
reverse Trendelenburg position
Tilts the supine patient upward so that the head is higher than any other part of the body.
•
Most often used to facilitate upper abdominal surgery.
Patients who are hypovolemic, are at risk for hypotension due to decreased venous return.
reverse
Trendelenburg
position
Trendelenburg
position
Jackknife position
Also called the Kraske position.
: Patient's abdomen lies flat on
the bed.
•
The bed is scissored so the hip
is lifted and the legs and head
are low.
Reference :
89
Lithotomy
frequently used during gynecologic, rectal, and urologic surgeries.
i
lithotomy position causes some physiologic changes :
1. transient increase in cardiac output
2. decreased tidal volume.
Lower extremity compartment syndrome is a rare but devastating complication
associated with the lithotomy position.
LLOYD DAVIS POSITION

used in pelvic and rectal surgery
i
a.k.a Tredelenburg position with legs apart or head down Lithotomy.
It is defined as supine position of the body with hips flexed at 15 ̊ as the basic angle and
with a 30 ̊ head-down tilt.
The key difference between lithotomy and Lloyd-Davies is the degree of hip and knee
flexion.
Reference :
90
SITTING
patient’s head and also the operative field are located above the level of the heart.
: excellent surgical exposure for some cervical spine and neurosurgical procedures,
particularly of the posterior fossa and superior cervical spine.
Sitting position with Mayfield head pins
•
The patient is typically semirecumbent rather
than sitting as the legs are kept as high as
possible to promote venous return.
• Arms must be supported to prevent shoulder
traction.
•
head holder support is preferably attached to
the back section rather than the thigh section
of the table so that the patient’s back may be
adjusted or lowered emergently without first
detaching the head holder.
lawn or beach chair position Complication of sitting position

variation of the sitting position.
•
The most significant complication is risk
•
increasingly used for shoulder surgeries of venous air embolism (VAE).

including arthroscopic procedures. Pneumocephalus
;:
Hypoperfusion of the brain.
Macroglossia can also occur with
excessive neck flexion.
Currently TEE is the gold standard for
detection of intracardiac shunts.
91
Prone position
a.k.a ventral decubitus position.
: used primarily for surgical access to the posterior fossa of the skull, the posterior
spine, the buttocks and perirectal area, and the lower extremities.
•
Prone position with Wilson frame.
Arms are abducted less than 90 degrees whenever possible.
: Pressure points are padded, and chest and abdomen are supported away from the bed to
minimize abdominal pressure and preserve pulmonary compliance.
•
Foam head pillow has cutouts for eyes and nose and a slot to permit the endotracheal
tube to exit.
•
Is a risk factor for perioperative visual loss (POVL)
Mirror system for prone position.

Prone position, face seen from below. Bony structures of the head and
Horseshoe adapter permits superior access to face are supported, and monitoring
airway and visualization of eyes. Width may be of eyes and airway is facilitated with
adjusted to ensure proper support by facial a plastic mirror.
bones.
92
Sims' position
•
Is a variation of the left lateral position.
•
The patient is usually awake and helps
with the positioning.
• The patient will roll to his or her left
side. Keeping the left leg straight, the
patient will slide the left hip back and
bend the right leg. This position allows _IeI_-
access to the anus.
Fowlers position
Begins with patient in supine position.
•
Upper torso is slowly raised to a 90 degree position.

•
Semi-Fowlers position
Lower torso is in supine position and the upper torso is bent at a nearly 85 degree position.
•
The patient's head is secured by a restraint.

•
93
F luid Management
PERIOPERATIVE FLUID BALANCE
Normal Electrolyte Composition in Body Compartments

•preoperative fasting produces a fluid deficit (calculated as the maintenance fluid
requirement multiplied by the duration of fasting since fluid intake)
• After fasting for 8 to 10 hours, the normal state after sleep, requirements in the
noncomatose individual may be little more than 250 mL.
•Very few patients are likely to require 1500 to 2000 mL fluid within the first 1 to 2
hours of surgery.
•
Preoperative fasting causes a slight decrease in extracellular fluid while maintaining
intravascular volume.
FLUID REPLACEMENT SOLUTIONS
Crystalloids
grouped as balanced, isotonic, hypertonic, and hypotonic salt solutions in water,
:depending on the amount of electrolytes they contain.

cross rapidly from the vascular to the interstitial spaces (e.g., gut, lungs, dependent
parts) with only about one third remaining intravascular.
Balanced Salt Solutions

•electrolyte composition is similar to that of extracellular fluid.
Examples include lactated Ringer solution (similar to Hartmann
solution), Plasma-Lyte, and Normosol.
•are hypotonic with respect to sodium.
•They each contain small amounts of other electrolytes such as
potassium, magnesium, and calcium.
Reference :
94
Ringer lactate
•
Composition :
i) Na (mEq/L) - 130
ii)K (mEq/L) (g/L) - 4
iii)Glucose (g/L) - 0
iv)Osm - 273
v) pH - 6.5
vi)Other -(Lactate 28 mEq/L)
Plasma-Lyte A
• Composition :
i) Na (mEq/L) - 140
iv)Osm - 295
v) pH - 7.4
Normosol
•Composition :
i) Na (mEq/L) - 140
iv)Osm - 294
v) pH - 6.6
vi)Other - Mg 3 mEq/L,
Acetate 27 mEq/L,
Gluconate 23 mEq/L
95
Normal Saline
Normal saline (0.9% NaCl) is hypertonic with
: equal concentrations of Na+ and Cl−.

Composition :
i) Na (mEq/L) - 154
iv)Osm - 308
v) pH - 6.0
Hypertonic Saline
•
Generally used in specific situations such as
control of intracranial hypertension or the
need for rapid intravascular resuscitation.
•
The sodium concentrations range from 250 to
1200 mEq/L.
•Patients predisposed to tissue edema might
benefit from use of a hypertonic solution.
•
However, the half-life of hypertonic solutions
is similar to that of isotonic solu tions.
Five Percent Dextrose

•similar to free water as the dextrose is
metabolized.
•iso-osmotic and does not cause hemolysis.
•
Composition :
i) Na (mEq/L) - 154
iv)Osm - 308
v) pH - 6.0
Reference :
96
dextrose 5% Ringer lactae(D5LR)

•
Composition :
i) Na (mEq/L) - 130
iv)Osm - 525
v) pH - 5.0
Dextrose 50, 0.45% NaCl

•
Composition :
i) Na (mEq/L) - 77
iv)Osm - 406
v) pH - 4.0
Colloids
•
Colloid solutions, albumin, and starches contain large molecular weight substances.
The synthetic starches have little to no risk of infection, but allergic reactions can occur.
Albumin
supplied as a 5% or 25% solution.
:
The initial volume of distribution is equivalent to the
plasma volume, and it remains in the intravascular
space for a longer duration than crystalloids.
Composition :
i) Na (mEq/L) - 145 ± 15
ii)K (mEq/L) (g/L) - <2.5
iv)Osm - 330
v) pH - 7.4
97
Dextran
• The two used medically are dextran 40 (40 kDa) and
dextran 70 (70 kDa).
synthesized from sucrose by lactic acid bacteria,
:
such as Leuconostoc mesenteroides and
Streptococcus mutans.
used as antithrombotics to reduce blood viscosity,
and as intravascular volume expanders in
hypovolemia.
Side effects :
- anaphylactic or anaphylactoid reactions
- increased bleeding times
•
Composition :
- noncardiogenic pulmonary edema(rare) i)Osm - 255
ii)pH - 4.0
Hydroxyethyl Starch
nonionic starch derivatives and were one of the
:
most frequently used intravascular volume
expanders.
HES interferes with von Willebrand, factor VIII,
and platelet function.
most common complication associated with HES
•
administration is pruritus.
Composition :
•
i) Na (mEq/L) - 154
iv)Osm - 310
v) pH - 5.9
The dose-dependent risk of dilutional coagulopathy differs between colloids

(dextran > heta- starch > pentastarch > tetrastarch, gelatins > albumin).
98
Special Anesthetic Considerations
• Needle-based regional anesthesia for

ophthalmic surgery.
(A) An intraconal (retrobulbar)
block is placed deeper and is more
steeply angled.
(B) An extraconal (peribulbar) block
is shallower and minimally angled.
Asterisk indicates needle entry
point.
Sub-Tenon block
•
Local anesthetic is infused via a cannula into the potential space between
Capsule of Tenon and the sclera, ultimately arriving at the optic nerve.
Reference :
99
OTHER NERVE BLOCKS FOR LABOR

Paracervical Block
infrequently used to provide pain relief
:
during the first stage of labor.
•
Blocks transmission of pain impulses at the
paracervical ganglion.
Complications from systemic absorption
can occur as well as the possibility of direct
fetal trauma or injection.
Paracervical block is associated fetal
bradycardia.
Pudendal Block
is infrequently used to provide pain relief during
:the second stage of labor at the time of delivery.

Local anesthesia injection around the pudendal
nerve blocks sensation of the lower vagina and
perineum.
Although the technique provides analgesia for
:vaginal delivery or uncomplicated instrumented

vaginal delivery, the rate of failure is high.
Complications in addition to failure include
systemic local anesthetic toxicity, ischiorectal or
vaginal hematoma, and, rarely, fetal injection of
local anesthetic.
Fluid Replacement in Children
Reference :
100
Oral Endotracheal Tube (ETT) Size for Age
•
Options for Lung Isolation
- facilitate selective ventilation of one lung.
- These include DLTs , bronchial blockers (BBs) placed through a single-lumen endo-
tracheal tube (SLT) and a single-lumen tube (standard endotracheal tube or
endobronchial tube) placed directly into a bronchus.
Double Lumen Endobronchial Tubes
•
Absolute indications for use :
- Surgical exposure in video-assisted
thoracoscopic surgery (VATS)
- Single lung lavage: Treatment for pulmonary
alveolar proteinosis or cystic fibrosis
101
Critical Care Medicine

RESPIRATORY FAILURE
Hypoxemic respiratory failure Hypercapnic respiratory failure

• occurs because of ventilation/ •
Due to hypoventilation caused by drug
perfusion(V/Q) mismatch leading to intoxication or neuromuscular weakness,
a large alveolar-arterial (A-a) or increased dead space.
gradient. Eg : COPD
Causes :
i)trauma
ii)ARDS)
iii)sepsis
iv)pneumonia
v)pulmonary embolism
vi)cardiogenic pulmonary edema and
vii)obstructive lung disease.
Mechanical Ventilation
•performed entirely via positive-pressure ventilation
noninvasive approach invasive approach

(via face mask or nasal mask) (via endotracheal tube [ETT] or tracheostomy)
Different type of Modes
Assist Control (AC)

•
ventilator is set to deliver a minimum number of breaths per minute, while
allowing the patient to initiate breaths as well.
All mandatory and spontaneous breaths are fully supported to the same
:degree.
So, if tidal volume is set at 500 mL, then all breaths (i.e., mandatory and
spontaneous) will receive a tidal volume of 500 mL.
Reference :
102
Synchronized Intermittent Mandatory Ventilation

The ventilator attempts to synchronize the mandatory mechanical breaths
•
with the patient’s spontaneous breaths in order to decrease ventilator

dyssynchrony.
If there are no spontaneous breaths within the preset time interval, then
•
the ventilator will deliver the mandatory breath.

The breaths in between the mandatory breaths are not fully supported,
•
unlike the AC mode.
Pressure Support
PS mode is used only with spontaneously breathing patients, as all breaths are
:
triggered by patient effort.
The driving pressure (ΔP), positive end-expiratory pressure (PEEP), and fraction
of inspired oxygen (F io2) are the only variables set in this mode.
Inspiratory flows are based on patient demand. The ventilator ends inspiration when
the flow rate has decreased to a predetermined level (usually 25% of the peak flow
rate).
There is no backup respiratory rate in PS mode unless it is combined with SIMV.
Classifying Oxygen Therapy Equipment
A. Low-Flow or Variable-Performance Equipment

are adequate for patients with:
•
- Minute ventilation less than ∼8 to 10 L/min

-Breathing frequencies less than ∼20 breaths/min
-Tidal volumes (VT) less than ∼0.8 L
- Normal inspiratory flow (10–30 L/min)
103
B. High-Flow or Fixed-Performance Equipment

•
Inspired gas at a preset FiO2 is supplied continuously at high flow or by
providing a sufficiently large reservoir of premixed gas.
•
Ideally, the delivered FiO2 is not affected by variations in ventilatory level or
breathing pattern.
• High-flow systems are indicated for patients who require:
- Consistent FiO2
- Larger inspiratory flows of gas (>40 L/min)
Nasal Cannulas
Nasal Mask
Simple Oxygen Mask Masks with Gas Reservoirs
gas reservoirs
104
Air-Entraining Venturi Masks Oxygen delivery devices and systems
High FLow nasal Canula

Can warm air (to 37 C) and humidify which
÷
can decrease airway inflammation,maintain
mucociliary function ,mucous clearance and
reduce the caloric expenditure in acute
respiratory failure.
Can deliver between 60 -70 L /min
Can generate PEEP betweeen 4-6 mm Hg
• Decrease Alveolar dead space
•
Disadvantage : less effective in Oxygenation
A- 1114519
Identify the equipment shown in image ?
Order for better oxygenation :

Intubation > NIV > HFNC > O2 Therapy with delivery devices (simple face mask etc)
105
Colour coding of canula
What is Gauge of Pink canula ?

106
Non Invasive Ventilation ( NIV )

Delivery of oxygen via a face mask and therefore eliminating the need of an
: endotracheal airway
Reduces work of breathing and improve gas exchange
NIPPV
Bi PAP CPAP
CPAP
•
Bi level Positive Airway Pressure
• Constant Positive Airway Pressure
Most basic level of support and provides constant fixed positive pressure
: throughput inspiration and expiration,causing the airways to remain open

and reduce the work of breathing
Indications
-Atelectasis
-Rib fractures
-Type I Respiratory failure
-Congestive Heart Failure
-Cardiogenic Pulmonary
-Edema Constant Positive Airway Pressure
-Obstructive Sleep Apnoea
-Pneumonia
Bi PAP
• It can provide different airway pressure
depending on inspiration and expiration.
•
Inspiratory positive airway pressures (iPAP)
is higher than the Expiratory positive airway
pressure (ePAP)
•
Indications:
- Type II Respiratory failure
- Acidotic exacerbation of COPD
- Weaning from tracheal intubation
107
'
AIIMS 17
Calculate GCS ?
108
Miscellaneous
CPR - Cardiopulmonary Resuscitation
AHA Chains of Survival for Adult IHCA and OHCA
(In Hospital )
(Out of Hospital)
Adult Basic Life Support Algorithm
'
AIIMS 17
Correct Sequence of
BLS Algorithm ?
Reference : https://www.ahajournals.org
109
Adult Cardiac Arrest Algorithm ACLS
What is the next step when rhythm is asystole/PEA ?

'
MEET 18 '
AIIMS 20
Alternative drug for cardiac arrest if epinephrine is not effective ? Effective CPR includes?
110
Adult Post–Cardiac Arrest Care Algorithm

111
Recommended approach to multimodal neuroprognostication in

adult patients after cardiac arrest
Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm

112
Major New and Updated Recommendations - ADULT (2020)

Early Initiation of CPR by Lay Rescuers
:
- We recommend that laypersons initiate CPR for presumed cardiac arrest because
the risk of harm to the patient is low if the patient is not in cardiac arrest.
Early Administration of Epinephrine

administer epinephrine as
- cardiac arrest with a nonshockable rhythm soon as feasible.
administer epinephrine after

- cardiac arrest with a shockable rhythm
initial defibrillation attempts
have failed.
Real-Time Audiovisual Feedback
:
- It may be reasonable to use audiovisual feedback devices during CPR for real-time
optimization of CPR performance.
Physiologic Monitoring of CPR Quality
- use physiologic parameters such as arterial blood pressure or ETCO2 when
feasible to monitor and optimize CPR Quality.
Double Sequential Defibrillation Not Supported
:
IV Access Preferred Over IO
- IO access may be considered if attempts at IV access are unsuccessful or
not feasible.
Post–Cardiac Arrest Care and Neuroprognostication
AHA Chains of Survival for pediatric IHCA and OHCA

113
Pediatric Basic Life Support - Single Rescuer
Ratio of Compressions and Breaths when

two rescuer is resuscitating a child ?
114
Pediatric Basic Life Support - 2 or more Rescuer

115
Pediatric Cardiac Arrest Algorithm ACLS

116
Pediatric Bradycardia With a Pulse Algorithm

117
Pediatric Tachycardia With a Pulse Algorithm

118
Major New and Updated Recommendations - Pediatric (2020)

Changes to the Assisted Ventilation Rate: Rescue Breathing
- (PBLS) For infants and children with a pulse but absent or inadequate respiratory
effort, it is reasonable to give 1 breath every 2 to 3 seconds (20-30 breaths/min).
Changes to the Assisted Ventilation Rate: Ventilation Rate During CPR With an
Advanced Airway :
- (PALS) When performing CPR in infants and children with an advanced airway, it
may be reasonable to target a respiratory rate range of 1 breath every 2 to 3
seconds (20-30/min), accounting for age and clinical condition. Rates exceeding
these recommendations may compromise hemodynamics.
Cuffed ETTs
- It is reasonable to choose cuffed ETTs over uncuffed ETTs for intubating
infants and children. When a cuffed ETT is used, attention should be paid to
ETT size, position, and cuff inflation pressure (usually <20-25 cm H2O).
Cricoid Pressure During Intubation
- Routine use of cricoid pressure is not recommended during endotracheal
intubation of pediatric patients.
Emphasis on Early Epinephrine Administration
- For pediatric patients in any setting, it is reasonable to administer the initial dose
of epinephrine within 5 minutes from the start of chest compressions.
• Invasive Blood Pressure Monitoring to Assess CPR Quality

- For patients with continuous invasive arterial blood pressure monitoring in place
at the time of cardiac arrest, it is reasonable for providers to use diastolic blood
pressure to assess CPR quality.
REcommended CPR Technique in infants
2-Finger compressions.
Thumb–encircling hands compressions

119
AED - Automated External Defibrillator

• is a portable electronic device that
automatically diagnoses the life-
threatening cardiac arrhythmias of
ventricular fibrillation (VF) and pulseless
ventricular tachycardia and is able to treat
them through defibrillation, the application
of electricity which stops the arrhythmia,
allowing the heart to re-establish an
effective rhythm.
A- 1114519
Identify the Equipment ?
Head tilt/Chin lift
Is a procedure used to prevent the tongue obstructing the upper airways.
: The maneuver is performed by tilting the head backwards in unconscious

•
patients, often by applying pressure to the forehead and the chin.

The maneuver is used in any patient in whom cervical spine injury is not
a concern
This maneuver and the jaw-thrust maneuver are two of the main tools of
basic airway management.
If cervical spine injury is a concern and/or the patient is immobilized on
a long spine board and/or with cervical collar; the jaw-thrust maneuver
can be used instead.
If the patient is in danger of aspirating; he or she should be placed in
the recovery position or advanced airway management should be used.
The image given below,done for airway management includes :

A. Chin lift
B. In line manual stabilisation
C. Jaw thrust
D. Head extension [NEET 2021]
Reference :
https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Manual%20inline%20stabilisation.pdf
120
Manual In line Stabilisation (MILS)

Provides a degree of stability to the cervical spine prior to the application of a cervical collar.
: Should be used in conjunction with a cervical collar to assist continued spine management while :
- Extricating or moving the patient
- Performing a log roll
- Transferring the patient to and from a stretcher.
1. Kneel behind the patient and

place your hands firmly around the
base of the skull on either side.
2. Support the lower jaw with your index and

long fingers and the head with your palms.
Gently lift the head into a neutral,eyes-
forward position,aligned with the torso.Donot
move the head or neck excessively,forcefully
or rapidly.
3. Continue to support the head manually while

your partner places a rigid cervical collor around
the neck.Maintain manual support until you have
completely secured the patient to a backboard.
121
Jaw Thrust maneuver

The rescuer uses two or three fingers of each
:
hand to lift the jaw upward and outward so that
the lower central incisors are anterior to the
upper central incisors.
In children with traumatic injuries,the cervical
spine must be maintained in a neutral position
during this maneuver

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Anaesthesia

4. Neuromuscular Blocking Drugs 20

8. Anesthesia Delivery system 47

10. Spinal,Epidural Anesthesia 74

11. Peripheral Nerve Blocks 78

12. Patient Positioning and Associated Risks 86

13. Fluid Management 93

14. Special Anesthetic Conditions 98

15. Critical Care Medicine 101

16. Miscellaneous 108

American dentist who pioneered the use

Karl Koller Joseph Priestley

Koller introduced cocaine as a local

Humphry Davy Valerius Cordus

In 1799 he experimented with nitrous oxide,

James young simpson JOHN S. LUNDY

Scottish obstetrician,first physician

William Thomas Green Morton

John Snow August Karl Gustav Bier

Harold Randall Griffith Arthur Ernest Guedel

Henry Edmund Gaskin Boyle

: class II - soft palate, fauces, portion of uvula;

Thyromental distance (TMD) (Patil’s Test)

Cormack and Lehane’s laryngeal grades of the airway

Atlanto-occipital (AO) joint extension

• Grade II: 22 to 34 degrees

• Grade III: 12 to 21 degrees

• Grade IV: <12 degrees

Other ways of assessment include

2.Jaw Protrusion Test or Mandibular Protrusion Test

Guidelines for Food and Fluid Intake Before Elective Surgery in

Medications need to be stopped

Medications for which only morning dose to be omitted

Topical creams and ointments.

Vitamins and iron.

Dose adjustment is needed for

STOP-Bang Questionaire Screening for Sleep Apnea

Difficult Airway Society difficult intubation guidelines

Neuromuscular Blocking Drugs

Depolarizing NMBDs Nondepolarizing NMBDs

mimic the actions of ACh interfere with the actions of ACh.

DEPOLARIZING NEUROMUSCULAR BLOCKING DRUGS

depolarization of the postjunctional membrane.

nondepolarizing NMBDs, predominates when the intravenous

Long acting NON DEpolarizing DEPOLARIZING NEUROMUSCULAR

duration of action of 60 to 90 minutes

selective blockade of cardiac muscarinic receptors

(atropine-like effect), principally in the sinoatrial node.

onset of action of 1 to 2 minutes (Rapid Onset)

duration of action of 20 to 35 minutes

Excreted in bile and urine.

SHORT-ACTING NONDEPOLARIZING NEUROMUSCULAR BLOCKING DRUG

consists of three stereoisomers, with the two most

• active isomers undergoing hydrolysis by plasma

short duration of action of mivacurium.

-unpredictable liver damage

Stages of General Anesthesia

Comparative Characteristics of Inhaled Anesthetics

Factors Decreasing MAC Factors Increasing MAC

-Propofol -Amphetamine (acute use)

Sevoflurane and Desflurane

halogenated exclusively with fluorine

isoflurane was associated with

: utilized for sedation and short-duration general