Anesthesia Concept Book

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Concept Based Learning
Video Companion on Each Chapter
Next Generation
Comprehensive Review Series
“ANESTHESIA”
Active Recall Based
Integrated Edition

Published by Delhi Academy of Medical Sciences (P) Ltd.
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Delhi Academy of Medical Sciences (P.) Ltd.
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ISBN : 978-93-89309-36-2
First Published 1999, Delhi Academy of Medical Sciences
© 2021 DAMS Publication

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Contents
Chapter 1 Preoperative Assessment & Preparation 01 – 19
Chapter 2 Anesthesia Machine, Breathing Circuits &
Airway Equipments 20 – 56
Chapter 3 Induction & Maintenance Anesthetic Agents 57 – 86
Chapter 4 Neuro-muscular Blocking Agents &
Neuro-muscular Monitoring 87 – 106
Chapter 5 Monitoring Under Anesthesia 107 – 128
Chapter 6 Complications Associated with Anesthesia 129 – 150
Chapter 7 Local Anesthetics 151 – 168
Chapter 8 Regional Anesthesia 169 – 202
Chapter 9 Miscellaneous Topics in Anesthesia &
Intensive Care 203 – 238
Chapter 10 Cardiopulmonary Resuscitation 239 – 264
Preoperative Assessment
1 & Preparation
CONCEPTS
Â Concept 1.1 Goals of Pre-Operative Assessment
Â Concept 1.2 Components of Pre-Operative
Assessment
Â Concept 1.3 Pre Opearative-Risk Assessment
Â Concept 1.4 Pre-Operative Preparation
Â Concept 1.5 Premedication
2 | Anesthesia
Concept 1.1: Goals of Pre-Operative Assessment:
LEARNING OBJECTIVE: T
o understand the importance and need of pre-operative
assessment by an anesthesiologist.
Time Needed
st
1 read 15 mins
nd
2 read 10 mins
• Pre-operative assessment is one of the most basic and fundamental aspects of the
conduct of anesthesia.
• A thorough pre-operative assessment is a must requirement for all types of anesthesia
weather it is general anesthesia \ regional anesthesia \ monitored anesthesia care
(procedural sedation).
• It is important for the evaluation to be complete, accurate, and clear, not only to allow
the information to be relayed to others who may care for the patient perioperatively,
but also for medicolegal purposes
• Following are the goal of preoperative assessment: [AIIMS Q]
1. to reduce patient risk and morbidity associated with surgery and coexisting
Diseases
2. promote efficiency and reduce costs
3. prepare the patient medically and psychologically for surgery and anesthesia.
4. a screening tool to anticipate and avoid airway difficulties or problems with
anesthetic drugs.
5. knowledge about contraindications to specific drugs, such as succinylcholine,
nitrous oxide, or volatile agents should be known before starting anesthesia.
6. taking a well-informed, detailed and specific consent for anesthesia and its related
complications.
Points to remember:
• Most basic skill required by an anesthesiologist
• Helps in changing the plan of anesthesia according to clinical status of the patient
• Helps in pre-operative control of comorbidities and diagnosis of previously undiagnosed
conditions
Preoperative Assessment & Preparation | 3
Concept 1.2: Components of Pre-Operative Assessment:
o learn the different components of pre operative assessment
and importance of airway assessment before start of
anesthesia
Time Needed
st
1 read 40 mins
nd
2 read 20 mins
• The preoperative evaluation has several components
• 1ST is to review the available medical records, obtain a history, and perform a physical
examination pertinent to the patient and contemplated surgery.
• Then appropriate laboratory tests and preoperative consultations should be obtained.
• Through these, one needs to determine whether the patient’s preoperative condition
may be improved prior to surgery.
• Finally, the anesthesiologist should choose the appropriate anesthetic and care plan.
TABLE 1: Mechanisms by which preoperative evaluation can help influence and improve perioperative care.
4 | Anesthesia
Concept 1.2.1: History and Physical Examination:
History:
1. classic history of present illness,
2. Current and past medical problems,
3. Previous surgical procedures, types of anesthesia, and any anesthesia-related
complications must be noted.
4. A simple notation of diseases or symptoms such as hypertension, diabetes Mellitus,
coronary artery disease (CAD), shortness of breath, or chest pain.
5. Prescription and over-the-counter medications (including supplements and herbal
medications) should be carefully recorded, along with their dosages and schedules.
6. Patients often claim an “allergy” to a substance when the reaction was an expected
side effect (e.g., nausea or vomiting with narcotics).
7. The patient’s use of tobacco, alcohol, or illicit drugs must be documented.
8. Quantitative documentation of tobacco exposure using pack-years (number of
packs of cigarettes smoked per day, multiplied by the number of years of smoking)
is best
9. A personal or family history of pseudocholinesterase deficiency, malignant
hyperthermia (MH), or a suggestion of MH (hyperthermia or rigidity during
anesthesia) in a patient or family member must be clearly documented
10. airway abnormalities.
11. obstructive sleep apnea [OSA]------ STOP BANG QUESTIONNARE
STOP
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? Yes No
Do you often feel TIRED, fatigued, or sleepy during daytime? Yes No
Has anyone OBSERVED you stop breathing during your sleep? Yes No
Do you have or are you being treated for high blood PRESSURE? Yes No
BANG
BMI more than 35kg/m2? Yes No
Age Over 50 Years Old? Yes No
NECK circumference > 16 inches (40cm)? Yes No
GENDER : Male? Yes No
TOTAL SCORE
High risk of OSA : Yes 5 – 8
Intermediate risk of OSA : Yes 3 – 4
Low risk of OSA : Yes 0 - 2
11: Metabolic equivalents: MET score

• Exercise or work activity can be quantified in metabolic equivalents of the task (METs),
which is a measure of the volume of oxygen consumed during an activity.
• 1 METABOLIC EQUIVALENT is equal to oxygen consumption of 3.5 ml\min\kg in a
40-year-old 70 kg healthy man.
• It determines the status of the patient’s cardiorespiratory fitness or functional
capacity.
• It helps determine whether additional preanesthetic evaluation should be performed
and may predict perioperative outcomes.
• A patient’s self-reported inability to perform average levels of exercise (i.e., 4 to 5
METs) increases the risk of perioperative complications.
METABOLIC EQUIVALENTS OF FUNCTIONAL CAPICITY
METs Equlvalent Level of Exercise
1 Eating, working at computer, or dressing
2 Walking down stairs, Walking in your house, or cooking
3 Walking one or two blocks on level ground
4 Raking leaves or gardening
5 Climbing one Flight oF stair, dancing, or bicycling
6 Playing golf or carrving clubs
7 Playing Singles tennis
8 Rapidly dimbing stairs or slowly jogging
9 Jumping rope slowly or cycling moderately
10 Swimming quickly, running, or fogging briskly
11 Skiing cross country or playing Full court basketball
12 Running rapidly For moderate to long distances
Modifies from jette M, Sidney K, Blumchen G: Metabolic equivalents (METS) in exercise testing, exercise
prescription, and evaluation of functional capacity, Clin Cardoil 13:555-565, 1990.
MET, Matabolic equlvalent (1 MET is equlvalent to oxygen consumption of 305 mL/minute/kg body
weight)
Points to remember:
STOP BANG questionnaire and calculation of MET score is one of the most important predictor
of pre-operative problems and knowing functional status of the patient.
Physical Examination:
• At a minimum, the preanesthetic examination includes vital signs (i.e., arterial blood
pressure [BP], heart rate [HR], respiratory rate, oxygen saturation), height, and
weight.
• Body mass index (BMI) is calculated from the height and weight and is more accurate
than weight in establishing obesity.
• An increased BMI is predictive of difficulties with airway management, both bag-mask
ventilation and endotracheal intubation.
6 | Anesthesia
• In addition, obesity is associated with development of chronic diseases such as heart
disease, cancer, or diabetes
• From the anaesthesiologist’s perspective, inspection of the airway may be the single
most important component of the physical examination
Concept 1.2.2: Airway Assessment:

The role of airway assessment is to identify potential problems with the maintenance of
oxygenation and ventilation during airway management
1: Factors Causing Difficult Bag and Mask Ventilation (BMV) [PGI Q]
Can be remembered by the mnemonic “OBESE“
O: Obese (BMI > 30 kg\m2)
B: Bearded individual
E: edentulous individual ( no teeth)
S: history of Snoring ( Obstructive Sleep Apnea)
E: Elderly (age >55 years)
2: Factors Causing Difficult Laryngoscopy & Intubation

Can be remembered by LEMON:
L = Look externally (facial trauma, large incisors, beard or moustache, large tongue,
high arched palate)
E = Evaluate the 3-3-2 rule
M = Mallampati (Mallampati score > 3). [aiims\neet\pgi q]
O = Obstruction (epiglottitis, peritonsillar abscess, trauma).
N = Neck mobility (limited neck mobility) [neet pg q]
i) E = Evaluate the 3-3-2 rule
This included evaluation of certain distances as a predictor of difficult airway
1: Mouth opening \ interincisor gap: adequate mouth opening for easy laryngoscopy
should be more than 5 cms \ 3 finger breadths (FB) (1 in figure)
2: Hyo-mental distance: distance between hyoid and chin > 3 FB (2 in figure)
3: thyro hyoid distance: should be more than 2 FB (3 in figure)
4: Thyromental distance: Distance between thyroid cartilage (upper border) and chin
(mentum) : patient’s head should be in full extension.
Most common used distance, should be more than 6.5 cms for easy laryngoscopy
[neet pg q]
5: Sternomental distance: most important predictor of difficult airway.[NEET PG Q]
A distance of more than 12.5 cms between the chin and the manubrium sterni is
considered to be an easy airway.
ii) Mallampatti Classification: [most important concept]
• Most common used airway assessment technique.
• Measures the relative size of tongue with respect to oropharynx.
• Patient is instructed to open the mouth wide and protrude tongue but no phonation.
• Classification is based on structures seen and is as follows:
Class I faucial pillar’s, soft palate, uvula, posterior pharyngeal wall
Class II partial view of faucial pillar’s, soft palate, uvula without tip.
Class III soft palate and only base of uvula is visible
Class IV o nly hard palate visible based on this classification we can predict the
difficulty in laryngoscopy class I & II : easy intubation class III & IV :
difficult intubation
• Based on this classification we can predict the difficulty in laryngoscopy
• class I & II : easy intubation
• class III & IV : difficult intubation
8 | Anesthesia
• Class 0 tip of epiglottis is seen (not a part of Mallampati classification) [NEETPGQ]

• A rare entity and no corelation to difficulty in intubation
iii) Cormack and Lehane GRADING [CL Grading] (Direct Laryngoscopic Grading)
I& II: easy intubation

III & IV: difficult intubation
iv) Range of Motion:
• Ideal Position for Intubation is called as Barking Dog \ Sniffing the Morning Air Position
• It involves head extension at atlanto occipital joint and neck flexion at lower cervical
joints.
• During airway assessment an extension of > 85 degrees and an adequate flexion

(chin touching sternum) is considered as adequate
• Components of Airway Examination
• Length of the upper incisors
• Condition of the teeth
• Relationship of the upper (maxillary) incisors to the lower
• (mandibular) incisors
• Ability to advance the lower (mandibular) incisors in front of the upper (maxillary) incisors
• Interincisor or intergum (if edentulous) distance
• Visibility of the uvula
• Presence of heavy facial hair
• Compliance of the mandibular space
• Thyromental distance
• Length of the neck
• Thickness or circumference of the neck
• Range of motion of the head and neck
Points to remember:
• Thyromental and sterno mental distance are important predictor of difficult airway
• Mallampati classification is most used but is a subjective scale
• Class III & IV in both Mallampati and Cormack and lehane classification are suggestive of
difficult airway
• Ideal position of intubation (sniffing position) causes the 3 axes (oropharyngeal,
laryngopharyngeal and visual axis) to come in same line thus making intubation easier.
10 | Anesthesia
Concept 1.3 : Pre Operative Risk Assessment
o learn different classifications used to assess the risk of
morbidity\mortality during anesthesia and post surgery.
Time Needed
st
1 read 30 mins
nd
2 read 15 mins
There are different ways to assess the risk of complications and mortality preoperatively
Concept 1.3.1: Asa Physical Status Classification:

• Most common used way to assess peri operative risk.
• The ASA-PS classification system seeks to describe a patient’s preoperative medical
status, but it does not consider risks inherent to the planned surgical procedure.
• Although not intended to guide estimation of patients’ risks for anesthesia and
surgery, the ASA-PS is often used for this very purpose, especially given its simplicity
of use.
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM
Developed By: Committee on Economics
Last Amended: December 13, 2020 (original approval: October 15, 2014)
• Although pregnancy is not a disease, the parturient’ s physiologic state is significantly
altered from when the woman is not pregnant, hence the assignment of ASA 2 for a
woman with uncomplicated pregnancy.
• **The addition of “E” denotes Emergency surgery: (An emergency is defined as
existing when delay in treatment of the patient would lead to a significant increase in
the threat to life or body part)
CLASS 1 AND 2 ARE LOW RISK OF PERI OPERATIVE MORBIDITY

CLASS 3 AND 4 ARE HIGH RISK
CLASS 5 IS HIGHEST RISK
Draw Backs of ASA Grading

• Does not accommodate asymptomatic pts
• Risk of Surgery and Anesthesia are not taken into account
• Scale is subjective so bias between observers
1.3.2: Risk of Post Operative Pulmonary Complications (POPC)

Postoperative pulmonary complications develop in 5% to 10% of patients undergoing
nonthoracic surgery and in 22% of high-risk patients.
Established risk factors for pulmonary complications include the following:
• History of cigarette use (current or exceeding 40 pack-years) [AIIMSQ]
• ASA-PS scores of 2 or more [AIIMSQ]
• Age 70 years or more [AIIMSQ]
• COPD
• Neck, thoracic, upper abdominal, aortic, or neurologic surgical procedures
• Anticipated prolonged procedures (≥2 hours)[AIIMSQ]
• Planned general anesthesia (especially with endotracheal intubation)
• Albumin concentration less than 35 g/dL
• Inability to walk two blocks on the level or to climb one flight of stairs[AIIMSQ]
• BMI of 30 or more
1.3.3: Risk Stratification in a Cardiac Patient for Non-cardiac Surgery:

Revised Cardiac Risk Index Components and Expected Cardiac Risk
Components of Revised Cardiac Risk Points Assigned
Index
High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal 1
vascular procedure)
Ischemic heart disease (by any diagnostic criteria) 1
History of congestive heart failure 1
History of cerebrovascular disease 1
Diabetes mellitus requiring insulin 1
Creatinine >2.0 mg/dL (176 μmol/L) 1
12 | Anesthesia
Revised Cardiac Risk Index Score Risk of Major Cardiac

Events
0 0.4%
1 1.0%
2 2.4%
>3 5.4%
Step Wise Algorithm for Assessment of a Cardiac Patient for Non-cardiac Surgery
Concept 1.3.4: Risk of Post Operative Nausea & Vomiting (PONV)
• Most common complication following anesthesia
• Risk can be assessed by APFEL criteria:
Simplified Apfel Score
Points to remember:
• ASA PS classification is the most common used classification to assess peri operative risk
from anesthesia & surgery
• Limitation of functional activity (MET score < 4) is both a risk factor for pulmonary &
cardiac complications
• There is very limited role of invasive cardiac testing (coronary angiography) before surgery
14 | Anesthesia
Concept 1.4: Pre-Operative Preparation
o learn methods to prepare the patient’s comorbidities before
surgery by controlling the drug therapy & smoking.
Time Needed
st
1 read 30 mins
nd
2 read 15 mins
Concept 1.4.1: Management of Pre-operative Drug Therapy:

• Each drug that a patient takes for his associated comorbidities has direct \ indirect
anesthetic implications.
• Certain drugs need to be stopped while some need to be continued before surgery.
MEDICATIONS TO BE CONTINUED MEDICATIONS TO BE STOPPED
Antihypertensive medications ACEIs or ARBs ON THE DAY OF SURGERY.
Cardiac medications (e.g., β-blockers, digoxin) Aspirin: MINIMUM 3-4 DAYS
IDEALLY 7 DAYS
Thienopyridines (clopidogrel-7 DAYS ticlopidine-
14 DAYS)
GP 2b\3b #: abciximab (24 to 48 hours)
Eptifibatide and tirofiban (4-8 hours)
ONLY Thiazide diuretics taken for hypertension, Diuretics (REST ALL)
which should be continued on the day of surgery.
Antidepressants, anxiolytics, and other psychiatric LITHIUM (24 TO 48 HOURS)
medications, Monoamine oxidase inhibitors
Thyroid medications HERBAL AND ALTERNATIVE MEDICATIONS
(7 DAYS)
Eye drops Oral hypoglycemic agents AND INSULIN (ON
THE DAY OF SURGERY)
Birth control pills (POP ONLY) ESTROGEN CONTAINING PILLS (4-6 WEEKS)
Statins Sildenafil (Viagra) or similar drugs(36 HOURS)
Steroids (oral and inhaled) NSAIDS (48 HOURS)
Asthma medications
Anticonvulsant medications Warfarin (5 DAYS OR INR <1.5)
Narcotic medications HEPARIN (4-6 HOURS BEFORE SURGERY)
Heartburn or reflux medications LMWH (PROPHYLACTIC DOSE -12 HOURS)
LMWH (THERAPEUTIC DOSE -24 HOURS)
Concept 1.4.2 : Control of Smoking before Surgery
• Smokers are more likely to experience wound infections, respiratory complications
(including oxygen desaturation), and severe coughing.
• Smoking decreases macrophage function, negatively affects coronary flow reserve
and causes vascular endothelial dysfunction, hypertension, and ischemia.
• Smokers require longer hospital stays and often need more postoperative intensive
care than do nonsmokers
Recommendation Duration Effect
Ideal 3-6 Months Patient Reaches Pre Smoking Level
Advised 4-8 Weeks Decreased Airway Reactivity
Less Chances Of Bronchospasm
Minimum 12-24 Hours Improved Oxygenation
Effect Of Nicotine And Carboxy Hb Is Negated
Concept 1.4.3: Fasting Before Surgery

• Keeping the patient NIL BY MOUTH \ NIL PER ORAL \ FASTING is one of the most
important strategies to decrease the risk of aspiration during anesthesia
• This simple act causes the stomach volume to decrease and thereby preventing
aspiration pneumonitis due to regurgitation of gastric contents in lungs
ASA standard fasting period for elective surgical cases is as follows:
1: full meal ( with fat and meat ) : 8 hours
2: light meal ( tea and toast )\ non human milk : 6 hours
3: breast milk : 4 hours
4: clear liquids ( water\ non particulate juices) : 2 hours
Points to remember:
• Drugs affecting coagulation always need to be stopped before surgery
• In practical clinical scenario stopping of smoking for 4-8 weeks before surgery is most
done
• ASA standard fasting guidelines are for both adult and pediatric patients and depend on
the type of food taken by the patient.
16 | Anesthesia
Concept 1.5: Premedication
o learn the drugs used before induction to make the patient
comfortable and decrease the risk of complications.
Time Needed
st
1 read 15 mins
nd
2 read 10 mins
All the drugs given to the patient before the start of anesthesia are considered as
premedication drugs
Concept 1.5.1: Goals of Premedication

1. Relieve anxiety
2. Induce sedation
3. Amnesia
4. decrease the chances of aspiration
5. Provide analgesia
6. Prevent post op. N. & V (nausea & vomiting)
7. Control infection
8. Control of secretions
9. Promote hemodynamic stability
Concept 1.5.2: Drugs used for Premedication

1: BENZODIAZEPINES: used to anxiolytics, sedatives and produces anterograde
amnesia.
Most common used premedicant drug
Midazolam is the agent of choice (fast onset & short duration with no residual effect)
2: PROTON PUMP INHIBITORS & H2 BLOCKERS: Omeprazole and ranitidine
decrease the acid in stomach and decrease the risk of aspiration
3: OPIOIDS: for analgesia and sedation (fentanyl \ morphine)
4: 5HT3 receptor antagonist: ondansetron for prevention & treatment of nausea and
vomiting
5: ANTI CHOLINERGICS: glycopyrrolate is preferred over atropine for control of
secretions before induction
6: ANTIBIOTICS: given according to the type of surgery and local protocol but timing
of administration is 60 mins before incision.
Concept 1.5.3: Advantages and Disadvantages of use of Premedication
Advantages:
1: calm , comfortable & sedated patient. Anesthesia becomes a pleasurable experience
2: less requirement of anesthetics
3: better patient satisfaction
Disadvantages:
1: delayed recovery from anesthesia ( if long acting drugs are used)
2: not suitable for certain age group eg neonates( no anxiety) and old ( risk of post
operative delirium due to benzodiazepines)
Points to remember:
• Pre medications improves patient satisfaction before surgery
• Benzodiazepines are most common used premedicant agents followed by anticholinergic
agents
• Midazolam is the BZD of choice for premedication
• Best time of giving antibiotics is 60 mins before incision
18 | Anesthesia
Worksheet
• MCQ OF “PREOPERATIVE ASSESSMENT & PREPARATION” FROM DQB
• EXTRA POINTS FROM DQB

Important Tables (Active recall)
Active Recall of Important Points:
Class Mallampati Classification Cormack & Lehane Classification
I
II
III
IV
ASA PS CLASS EXAMPLES

CLASS I
CLASS II
CLASS III
CLASS IV
CLASS V
CLASS VI
MOST COMMON PREMEDICATION USED:
• FASTING PERIOD FOR A NEONATE WILL BE ___________ HOURS
• IDEAL TIME FOR ANTIBIOTIC ADMINISTRATION BEFORE SURGERY IS__________
• IDEAL TIME FOR STOPING OF SMOKING BEFORE SURGERY IS__________
• MOST COMMON COMPLICATION AFTER ANESTHESIA IS___________
• ASPIRIN NEEDS TO BE STOPED FOR __________DAYS BEFORE SURGERY

Anesthesia Machine, Breathing
2 Circuits & Airway Equipments
CONCEPTS
Â Concept 2.1: Anesthesia Machine \ Workstation
Â Concept 2.2: Breathing Circuits
Â Concept 2.3: Airway Equipments

Anesthesia Machine, Breathing Circuits & Airway Equipments | 21
Concept 2.1: Anesthesia Machine \ Workstation
LEARNING OBJECTIVE:
• To learn about the anesthesia delivery system.
• To learn the parts of anesthesia machine & safety features in each part.
Time Needed
1 read
st
60 mins
2 read
nd
30 mins
• The basic function of an anesthesia machine is to prepare a gas mixture of precisely

known, but variable composition.
• The gas mixture can then be delivered to a breathing system.
• The machine performs four essential functions:
1. Provides O2,
2. Accurately mixes anaesthetic gases and vapours,
3. Enables patient ventilation and
4. Minimises anesthesia related risks to patients and staff.
History:
• Boyle’s machine was invented by Henry Edmund Gaskin Boyle in 1917.
• His machine was a modification of the American Gwathmey apparatus of 1912 and
soon became the best known early continuous flow anaesthetic machine
Image 1: Basic Boyle’s Machine Image 2: Modern Anesthesia Workstation
Concept 2.1.1: Parts of Anesthesia Machine:

Divided into three parts (based on the pressure of gas they work under):
(a) The high-pressure system: receives gases at cylinder pressure (2000 psi for
oxygen & 760 psi for nitrous oxide)(NEET Q), reduces the pressure and makes it
more constant.
22 | Anesthesia
(b) the intermediate pressure system receives gases from the regulator or hospital
pipeline and delivers them to the flow meters or O 2 flush valve
(c) the low-pressure system: Takes gases from the flow meters to the machine outlet
and contains the vapours of inhaled anesthetic agents.
Concept 2.1.2: The High-Pressure System

The high-pressure system consists of all parts of the machine, which receive gas at
cylinder pressure.
These include the following:
(a) The hanger yoke connects a cylinder to the
Bourdon pressure gauge
machine
(b) the cylinder pressure gauge (BOURDEN’S
GAUGE)(NEET Q): indicates the gas pressure in
the cylinder
(c) the pressure regulator converts a high variable
gas pressure into a lower, more constant pressure,
suitable for use in the machine.
The pressure regulators reduce the pressure of the
O2 cylinders from 2000 PSIG and the N2O cylinders
from 760 PSIG to 45-60 PSIG (NEET Q)
1: GAS CYLINDERS:
• High pressure cylinders are used to store, and transport compressed or liquid medical
gases.
• Originally made from steel, gas cylinders are now constructed of Molybdenum
steel(NEET Q), which is a lightweight, resistant to corrosion and of high tensile
strength
• Aluminium cylinders (NEET Q) are available for use in magnetic resonance imaging
scanners.
PROPERTY OXYGEN NITROUS ENTONOX AIR CO2
OXIDE
Physical state Gas Liquid (NEET Gas Gas Liquid
in cylinder Q)
Critical -118 36 -7 (pseudocritical -141 31
temperature temperature)
Flammability Supports Supports Supports Supports None
combustion combustion combustion combustion
Color coding
Body Black (NEET) Blue Blue Black Grey
Shoulder White Blue Blue \ white Black & white Grey
PIN Index 2, 5 (NEET, 3,5 7 1,5 1,6 (>7.5%)
AIIMS, PGI) 2,6 (<7.5%)
2: PIN Index Safety System (Most Important Concept)
Machines are usually equipped with one or two E type cylinders that hang on specific
hanger yokes.
• The medical gas pin-index safety system ensures that the correct medical gas
cylinder is hung in the correct yoke.(NEETQ)
• The system consists of two pins that are fixed in the yoke, and which fit into two
corresponding holes in the cylinder valve.
• The two pins are in a unique configuration for each gas and should never be removed
from the hanger yoke.
Concept 2.1.3: The Intermediate Pressure System

It includes the components of the machine which receive gases at reduced pressures
usually 37-55 PSIG. (NEETQ)
• This includes
1. O2 failure alarms
2. Flow meter assembly
3. O2 flush (NEETQ)
4. O2 pressure fail safe systems
5. Pipeline inlet connections
6. Pipeline pressure gauges
7. Ventilator power outlets.
24 | Anesthesia
1: O2 Flush
There is a direct tubing connecting the O2 pressure regulator to the O2 flush.
• It gives 35-70 L/min (high flow) of flow with a pressure of 45-60 PSIG(intermediate)
• Its main use is during the mask ventilation with a lot of leak between the mask and
the patient’s face especially in elderly patients and in patients with difficult airways
• When it is operated, even if the vaporisers are turned on, the patient will receive pure
O2 uncontaminated with N2O and volatile agents.
• DISADVANTAGES: Inappropriate use of the O2 flush valve has been associated with
both barotrauma and intraoperative awareness. (NEETQ)
• Barotrauma can occur because the flush valve allows fresh gas to enter the breathing
circuit at high flows.
• Also, if it is accidently turned on and unobserved, patient may not be adequately
anaesthetised.
2: The Flow Meter Assembly

The flow meter assembly controls, measures and indicates the rate of flow of gas passing
through it
• The flow meter assembly consists of flow control valve and flow meter sub-
assembly
Flow control valves
• The flow control valve controls the rate of flow of a gas through its associated flow
meter by manual adjustment of variable orifice.
• These are color coded and different in shape and feel for easy identification.
Physical Principles of Flowmeters
Variable Orifice, Constant Pressure (AIIMSQ)
• The flow meter is of variable orifice type due to the tapering of the tube which has its
lower diameter at the bottom.
• When there is no flow of gas the bobbin rests at the bottom and when the flow control
valve is opened the bobbin moves up as the gas flows in.
• The bobbin floats freely in the tube at an equilibrium position where the downward
force on it due to gravity equals the upward force due to the gas flow.
• The gas flows in the annular opening between the bobbin and the tube. The annular
opening around the bobbin increases with the height.
3: Sequence of Flowmeters (NEET\AIIMSQ)

• The position of the flow meters of individual gases is also important.
• O2 flow meter should be downstream to all other gases to prevent hypoxic mixture
delivered to the patient.
Concept 2.1.4: Low Pressure System

The low-pressure system is the part of the machine downstream of the flow meters in
which the pressure is slightly above the atmosphere.
The components in this system are
(a) Vaporisers mounted on the back bar
(b) Back pressure safety devices
(c) The common gas outlet.
1: Vaporizers:
• A vaporizer (anesthetic agent or vapor delivery device) is a device that changes a
liquid anesthetic agent into its vapor and adds a controlled amount of that vapor to
the fresh gas flow or the breathing system.
26 | Anesthesia
• Up to three vaporizers are commonly attached to an anesthesia machine.
Vaporizer Design
• All vaporizers are called direct-reading, dial-controlled, automatic plenum, percentage-
type, and tec-type vaporizers.
• Vaporizer output is controlled by a single knob or dial that is calibrated in volumes
percent
• They are agent specific and colour coded for easy identification
Red: Halothane (TEC 7)
Yellow: Sevoflurane (TEC 7)
Purple: Isoflurane (TEC 7)
Blue: Desflurane (TEC 6)(NEETQ)
Concept 2.1.5: The Safety Features in an Anesthesia Machine
Incorporation of safety features in anesthesia machines and ensuring that a proper
check of the machine is done before use on a patient ensures patient safety.
• Safety features can be discussed according to parts of machine:
1: High-Pressure System
• The cylinder colour coding and PIN index systems were developed to prevent
wrong attachment of cylinder to machine
Pressure relief device

• Cylinders have exploded because of over-pressure in them either due to over filling
or mis-filling.
• To prevent this, all cylinders to have pressure relief devices, which vent the contents
of the cylinder to the atmosphere should dangerous pressures develop inside the
cylinder.
• They are of two types: Rupture disc (ruptures on high pressure) & the fusible plug
(ruptures on high temperature).
2: Intermediate Pressure System

A: Pipeline attachments: Each terminal unit that connects to the main pipeline
system is equipped with the DISS (Diameter Index Safety System) that prevents
wrong attachment of pipeline to machine.
B: Oxygen pressure failure system
▫ The delivered oxygen concentration at the common gas outlet (CGO) does not
fall below 21%.
▫ The older anesthesia machines employed the Ritchie whistle, which is an
audible alarm and cuts off all other gas supplies
C: Oxygen flush: emergency oxygen supply
3: Low-Pressure System
A: Flow meter assembly: oxygen flowmeter should be most downstream of all
gases
28 | Anesthesia
B: Hypoxia prevention devices
a: Mandatory minimum oxygen flow: a minimum pre-set oxygen flow (50-250 ml\
min), which will automatically start once the machine is powered on.
b: Minimum oxygen ratio: Anesthesia workstation standards require that a device
be provided that protects against a user selection of a gas mixture with an O 2
concentration below 21%.
Points to Remember:
• Boyle’s anesthesia machine is a continuous flow machine
• Modern anesthesia cylinders are made of molybdenum steel.
• Pin index safety system prevents wrong attachment of cylinder to machine
• Every cylinder has a specific colour and pin index system for easy identification
• Diameter index safety system prevents wrong attachment of pipeline to machine
• Oxygen flush is a part of intermediate pressure system
• Principle of working of flowmeter is constant pressure & variable orifice
• Oxygen is kept most downstream of all gas in the arrangement.
• Vaporizers are colour coded, agent specific and concentration calibrated
• Safety features are meant to avoid hypoxic gas mixture being delivered to the patient.
Concept 2.2: Breathing Circuits
LEARNING OBJECTIVE:
• To learn about different types of breathing systems.
• To understand the use of Mapleson circuits and situations where they are useful.
• To understand closed system & nuances of different CO2 absorbers
Time Needed
1 read
st
30 mins
2 read
nd
15 mins
• The function of breathing systems is to deliver oxygen and anaesthetic gases to
patients and eliminate carbon dioxide
• The common components include:
• fresh gas flow, tubing to direct gas flow, an adjustable pressure limiting (
APL) valve to control pressure within the system & allow scavenging of waste gas and
a reservoir bag to store gas and assist with ventilation.
• Modern breathing circuits can be divided into 2 types:
• Semiclosed systems: mapleson circuits
• Closed systems: circle system
Concept 2.2.1: Mapleson Circuits:

• There are 6 types of Mapleson circuits being described.
• Mapleson B&C are obsolete now and not used anymore. (NEETQ)
Type of Circuit Image Circuit of Choice Fresh Gas Remarks
Identification For? Flow Required
to Prevent
Rebreathing
A APL Valve Near Spontaneous = Minute • Coaxial
(Magill’s Circuit) Patient End Respiration Ventilation Variant: Lack’s
Modification
B Obsolete
C (Water’s to and FRO Canister) Obsolete
D APL Valve away Controlled 1-2* MV • MC Used
(Bain’s from Patient Respiration Mapleson
Modification) Circuit
• Coaxial Circuit
E Both Controlled 2-3* Mv • For Pediatric

(Ayre’s T Piece) and Spontaneous Patients (<20
Respiration KGS)
F
• F is better than
(Jackson & Reese
E
Modification)
30 | Anesthesia
Concept 2.2.2: Circle System:
1: Introduction
• A circle system improves the efficiency of anaesthetic gas delivery by recycling gas
that is expired from the patient and thus reducing the amount of fresh gas flow
required.
Image : a typical closed circuit
• The capability to rebreathe exhaled gases is a unique aspect of circle systems as

compared with ICU ventilators.
• Carbon dioxide is efficiently removed to allow safe rebreathing of exhaled gases.
2: Advantages of the circle system

• Economy of anaesthetic consumption
• Warming and humidification of the inspired gases
• Reduced atmospheric pollution
3: Disadvantages
• More prone to leaks and disconnection
• Slow changes in the inspired anaesthetic concentration with low flows and out-of-
circuit vaporiser
Concept 2.2.3:
1: CO2 Absorber \ CO2 Canister

• Circle breathing systems require a means of CO2 removal from the exhaled gases to
avoid rebreathing and hypercapnia.
• Different types of CO2 absorber are traditionally available
a: Sodalime: Oldest and was one of the most commonly used CO2 absorber in the past.
Contents: Ca (OH)2 : 80% (NEETQ)
NaOH : 3%
KOH : 2%
H2O : 16%
• Sodalime reacts with CO2 and absorbs it by a simple exothermic reaction.
• Presence of strong alkali like NaOH & KOH react early with CO2 and then are
regenerated in next step of the reaction
• Regeneration of NaOH & KOH is the limiting step in the reaction.
• CO2 + H2O → H2CO3
• H2CO3 + 2NaOH → Na2CO3 + 2H2O + Heat (a fast reaction)
• Na2CO3 + Ca (OH)2 → CaCO3 + 2NaOH (a slow reaction)
• Absorptive capacity (liters of CO2 /100g granules) : 14–23 (NEETQ)
Interactions:
1: Trilene: formation of dichloroacetylene (neurotoxic affecting cranial nerves) &
phosgene gas ( ARDS)
2: Compound A: a potentially nephrotoxic substance produced because of degradation
of Sevoflurane and seen in rat.(NEETQ)
Have not been proved nephrotoxic in humans.
b: Baralyme: obsolete
Contents:
Ca(OH)2: 73%
Ba(OH)2: 11%
KOH : 5%
H2O: 11-16%
Absorptive capacity (liters of CO2 /100g granules): 9–18
32 | Anesthesia
Interactions:
1: carbon monoxide: on interaction with desflurane.
c: AMSORB:
Newer CO2 absorber.
• Devoid of highly alkaline agents like NaOH & KOH (so no interaction with inhaled
anesthetic agents)
• Contents:
Ca(OH)2: 75%
CaCl2 & CaSO4: < 1%
H2O: 14.5%
Disadvantage: lower absorptive capacity
High cost
2: Indicator:
• A pH indicator dye (eg, ethyl violet) changes colour from white to purple because of
increasing hydrogen ion concentration and absorbent exhaustion.
• Most common used indicator substance is ethyl violet.(AIIMSQ)
Indicator Color when Fresh Color when Exhausted
Ethyl Violet White Purple
Phenolphthalein White Pink
Clayton Yellow Red Yellow
Ethyl Orange Orange Yellow
Mimosa 2 Red White
Points to Remember:
• Most common used Mapleson circuit is Bain’s circuit
• Best Mapleson circuit for spontaneous breathing is Mapleson A
• Jackson & Reese modification \Mapleson F is best for paediatric patients
• CO2 absorber is the most important part of a circle system
• Compound A is a potential nephrotoxic substance, but human toxicity hasn’t been proven
• Desflurane causes maximum production of carbon monoxide with baralyme
• Most common used indicator is ethyl violet
Concept 2.3: Airway Equipments:
LEARNING OBJECTIVE:
• To learn about different types of airway equipment.
• To understand the use of facemask with its advantages & disadvantages
• To learn different types of airways and in detail about laryngeal mask airway
• To learn about laryngoscopes and endotracheal tube with their uses & techniques
Time Needed
1st read 60 mins
2 read
nd
30 mins
Concept 2.3.1: Face Mask

• Most basic and non-invasive mode of airway management.
• Allows gas administration to the patient from the breathing system without introducing
any apparatus into the patient’s mouth.
• The ability to hold the mask and to administer positive pressure ventilation through
the mask is a basic skill that all anesthesia providers must master
Advantages
• Lower incidence of sore throat
• Requires less anesthetic depth than using a supraglottic device or a tracheal tube.
• Muscle relaxants do not need to be used to tolerate the mask
• The face mask may be the most cost-efficient method to manage the airway for short
cases
Disadvantages
• Anesthesia provider’s hands are in continuous use
• Higher fresh gas flows are often needed (inefficient)
• Increased dead space(NEETQ)
34 | Anesthesia
• During remote anesthesia airway access is difficult
• More episodes of oxygen desaturation
• More difficulties in maintaining an airway
• In spontaneously breathing patients, the work of breathing is higher with a face
mask than with a supraglottic airway device or a tracheal tube
Complications
• Skin Problems: Dermatitis due to allergic material of the mask
• Nerve Injury: due to constant pressure of the mask
• Foreign Body Aspiration
• Gastric Inflation: unsecured airway
• Eye Injury: corneal abrasion due to mask inadvertently placed on an open eye
(AIIMSQ)
• Latex Allergy
• Jaw Pain
Concept 2.3.2: Airways

1: Purpose
• A fundamental responsibility of the anesthesia provider is to maintain a patent airway.
• Cervical spine movement does not occur when an airway is inserted unlike chin lift,
jaw thrust, and tracheal intubation.
2: Basic of Working of an Airway:

• Most common cause of airway obstruction under anesthesia: tongue and epiglottis
fall back into the posterior pharynx(NEETQ)
• The purpose of an airway is to lift the tongue and epiglottis away from the posterior pharyngeal
wall and prevent them from obstructing the space above the larynx
• An oral or nasal airway decreases the work of breathing during spontaneous breathing
using a face mask
3: Types
Oropharyngeal Airway Nasopharyngeal Airway
A\K\A Guedel’s airway nasal trumpet
MATERIAL Hard plastic Soft silicon
APPROPRIATE SIZE • Vertical distance between angle of • Tragus to Tip of nose

(NEETQ) mandible & central incisor
OR
• Distance between External Auditory
Meatus to angle of lip
USE • Prevents tongue fall and obstruction • During and after pharyngeal surgery
of airway • to apply continuous positive airway
• prevents biting and occluding of an pressure (CPAP) in infants with
oral tracheal tube Pierre Robin syndrome
• protect from tongue biting • to facilitate suctioning
• facilitate oropharyngeal suctioning • as a guide for a fiberscope
• obtain a better mask fit • as a guide for a nasogastric tube
• provide a pathway for inserting • to dilate the nasal passages in
devices into the esophagus or preparation for nasotracheal
pharynx intubation
• to maintain the airway and
administer anesthesia during dental
surgery
36 | Anesthesia
ADVANTAGES • Easier to insert • Better tolerated than an oral airway

• Less traumatic if the patient has intact airway
• reflexes (semi awake)
• Preferable in loose tooth or poor
condition
• Trauma or pathology of the oral
cavity.
• It can be used when the mouth
cannot be opened
DISADVANTAGES & • Pharyngeal and laryngeal reflexes • Risk of bleeding in patients on

LIMITATIONS should be depressed before an oral anticoagulation
airway is inserted to avoid coughing • a basilar skull fracture
or laryngospasm. • pathology, sepsis, or deformity of
the nose or nasopharynx
• history of nosebleeds requiring
medical treatment
4: Supraglottic Airway Devices (SAD) \ Laryngeal Mask Airway (LMA) \ extraglottic

airway (EAD) devices (MOST IMPORTANT CONCEPT)
• As the name indicates these devices sit outside the trachea but provide a handsfree
means of achieving a gas-tight airway
• They are filling a niche between the face mask and tracheal tube in terms of both
anatomical position and degree of invasiveness.
Advantages of LMA Over Disadvantages of LMA Over
FACEMASK • Better ventilation • More incidence of sore throat
• Hands free operation
• Less OT pollution
• Less user fatigue
• Can be used for longer time
• No jaw pain
ENDOTRACHEAL • No need of muscle relaxation • Doesn’t prevent the risk of
TUBE • Less anesthetic requirement aspiration
• No damage to vocal cords • Not useful in distorted anatomy of
• Useful even in difficult airways upper airway
• Less post-operative sore throat
• Easier to learn and insert
• Smooth Awakening
A: IDEAL POSITION AFTER INSERTION:

• The tip of the mask rests against the upper Esophageal sphincter while the sides face
the piriform fossae
B: The dead space associated with the LMA is less than with a face mask but is
greater than with a tracheal tube
• ORDER OF DEAD SPACE BETWEEN DIFFERENT AIRWAYS:
FACE MASK > LMA > ETT (NEETQ)
C: USE:
• Difficult Face Mask
• Difficult or Failed Intubation
• Ophthalmic Surgery
• Tracheal Procedures
• Ventilatory Support without Tracheal Intubation
• Head and Neck Procedures
• Professional Singers (NEETQ)
• Remote Anesthesia
• Resuscitation
• Out-of-hospital Use
• Laser Surgery
• Neurosurgery
• Unstable Cervical Spine (NEETQ)
D: Complications
• Sore throat: most common complication
• Aspiration of Gastric Contents
• Foreign Body Aspiration
• Airway Obstruction
• Trauma: injuries to the epiglottis, posterior pharyngeal wall, uvula, soft palate, tongue
and tonsils
• Nerve Injury: hypoglossal, recurrent laryngeal, lingual
• Bronchospasm
E: Relative contraindications:
• Situations associated with an increased risk of aspiration
(full stomach, previous gastric surgery, gastroesophageal reflux, diabetic gastroparesis,
over 14 weeks pregnant, dementia, trauma, opiate medications, increased intestinal
pressure)
• Hiatal hernia
• Distorted oral anatomy(tumour, abscess)
F: Laryngeal Mask Airway Family
• Over the years, the LMA family has evolved to include many types of devices based
on new requirements.
38 | Anesthesia
• Classification of LMA:
1st generation (airway tube only) 2nd generation (with additional drain tube)
LMA classic LMA proseal
LMA unique (single use) LMA supreme
LMA flexible (wire reinforced) I Gel
Streamliner of Pharyngeal Airway (SLIPA)
1: LMA-Classic: (standard LMA, Classic LMA, LMA-C, cLMA) (MOST IMPORTANT

CONCEPT)
We need to discuss classic LMA in detail.
Material: silicone and contains no latex
Parts:
1: curved tube (shaft) connected to an elliptical spoon-shaped mask (cup) at a 30°
angle
2: inflatable cuff surrounds the inner rim of the mask
3: An inflation tube and self-sealing pilot balloon are attached to the proximal wider end
of the mask
4: a 15-mm connector at the machine end of the tube
SIZES: available in 8 sizes

• When there is doubt, a larger rather than a smaller size should be chosen for the first
attempt
• Max cuff pressure shouldn’t be more than 60cms of water [NEETQ]
Size of LMA Weight of Patient Max Cuff Inflation Volume

(ML)
1 UPTO 5 KGS 4
1.5 5-10 KGS 7
2 10-20 KGS 10
2.5 20-30 KGS 14
3 30-50 KGS 20
4 (most common size for adult 50-70 KGS 30
female)(neetq)
5 (most common size for adult 70-100 KGS 40
male) (NEETQ)
6 >100 KGS 50
2: LMA-Flexible: (wire-reinforced, reinforced LMA, RLMA, FLMA, flexible LMA)

• it has a flexible, wire-reinforced tube
3: LMA-Fastrach: (intubating LMA, ILMA, ILM, intubating laryngeal mask airway)

• Special type of LMA which is used for tracheal intubation.(aiimsq)
40 | Anesthesia
4: LMA-Pro Seal:
• A 2nd generation LMA with separate drain tube to drain gastric contents.
5: LMA supreme: a preformed (anatomical shape) 2nd generation LMA
6: I GEL: cuffless 2nd generation LMA (AIIMSQ)

Concept 2.3.3: Laryngoscopes
LEARNING OBJECTIVE:
• To learn about different types of laryngoscopes & their uses.
Time Needed
1 read
st
15 mins
2nd read 10 mins
• Laryngoscopes are used to view the larynx and adjacent structures, most commonly
for the purpose of inserting a tube into the tracheobronchial tree (endotracheal
intubation)
Other purposes
• gastric tube insertion
• transoesophageal echo cardiac probe
• foreign body removal
• visualizing and assessing the upper airway
A: Parts of A Scope:
1: Handle: used to hold the laryngoscope for insertion

2: Blade: available in different shapes for use in different types of patients
B: Types:
Based on the shape of the blade they are of two types:
1: Macintosh type blade:
• Curved blade scope
• Most common used blade (neetq)
• Used for adult intubations
42 | Anesthesia
2: Miller’s type blade:

• straight blade scope
• most common used for paediatric intubations
Technique of Use
A: Position: (most important)
• SNIFFING THE MORNING AIR \ BARKING DOG POSITION: approximately
35-degree flexion of the lower cervical spine and an 85-degree to 90-degree head
extension at the atlanto-occipital level
• The lower cervical spine portion can be maintained in a flexed position by using a
pillow under the head.
• Atlanto-occipital joint extension is achieved by pressure on the top of the head and/
or upward traction on the upper teeth or gums.
Other position:
• HELP (Head Elevated Laryngoscopy Position) \ RAMP position (NEETQ)
• In obese patients, considerable shoulders and head elevation may be necessary so
that an imaginary horizontal line connects the patient’s sternal notch with the external
auditory meatus.
• A cushion designed to provide the best possible position has been developed
Technique of Laryngoscopy:
• The laryngoscope handle is held in the gloved left hand (neetq)
• The fingers of the right hand are used to open the mouth and spread the lips.
• The blade is inserted at the right side of the mouth
• Tongue is swept to left side & scope is inserted till the tip reaches the base of tongue
and then handle is moved in forward and upwards direction to lift the base of epiglottis
to visualize the larynx
44 | Anesthesia
Other Manoeuvres
• Even with correct technique, the larynx will not always be visualized.
• Displacing the larynx by external backward, upward, and rightward pressure
(BURP) on the thyroid cartilage may improve visualization of the glottis.
• MOST COMMON INJURED STRUCTURE DURING LARYNGOSCOPY IS UPPER CENTRAL

INCISOR (aiimsq)
Concept 2.3.4: Tracheal Tubes

LEARNING OBJECTIVE:
• To learn about different types of tracheal tubes & their uses.
• To learn different types of cuffs and their advantages and disadvantages.
• To learn how to chose appropriate size and depth of insertion of the ETT
• To know about other special types of tubes.
Time Needed
1 read
st
60 mins
2 read
nd
30 mins
A: Introduction:
• The tracheal tube (endotracheal tube, intratracheal tube, tracheal catheter) is a device
that is inserted through the larynx into the trachea to convey gases and vapours to
and from the lungs.
B: Physiological changes:
• Because the volume of a tracheal tube and its connector is usually less than that of
the natural passages, dead space is normally reduced by intubation.
• In paediatric patients, however, long tubes and connectors may increase the dead
space(neetq)
C: Material:
• Polyvinyl chloride (PVC) is the substance most widely used in disposable tracheal
tubes
• Red rubber
• Silicone
D: Parts:
A typical PVC endotracheal tube has following parts:
1: tip of the tube with a bevel
2: murphy eye
3: cuff with pilot balloon assembly & one-way valve
4: markings on the tube
5: machine end with a 15mm universal connector
1: tip with bevel: a typical ETT has a left sided bevel at the tip.this bevel improves
the visualization of the larynx while inserting the tube.
46 | Anesthesia
2: murphy eye:
• This is a 2nd opening in the wall of ETT just proximal to the tip.
• It acts as a secondary ventilation port incase the main lumen is blocked due to
secretions\carina
• Tube with murphy eye in them are called murphy tubes
• Tube with no murphy eye are called as magill’s tube.
3: Cuff: The cuff is an inflatable sleeve near the patient end of the tube
• Based on presence or absence ,tubes can be cuffed or uncuffed.
• Uncuffed tubes are preferred in paediatric patients less than 8 years old
• Cuffed tubes are used in adults
• The cuff type depends on its construction. The construction largely determines if the
pressure needed to inflate the cuff is high or low
High Pressure, Low Volume Cuff Low Pressure, High Volume Cuff
FEATURE Assumes the shape of a sphere and exerts Assumes the shape of a cylinder and
maximum pressure on tracheal mucosa at the pressure is distributed across entire
the point of contact tracheal mucosa in contact
ADVANTAGE Almost no risk of aspiration Less risk of tracheal mucosal ischemia &
necrosis
DISADVANTAGE High chances of tracheal mucosal Higher risk of aspiration as compared to
ischemia & necrosis high pressure cuff
4: Markings on the tube:
• The word oral or nasal or oral/nasal.

• Tube size in ID (internal diameter) in millimetres. This may also be marked on the
pilot balloon.
48 | Anesthesia
• The OD (outer diameter) for tubes size 6 and smaller.
• The name or trademark of the manufacturer or supplier
• Graduated markings showing the distance in centimetres from the patient end
• A cautionary note such as “Do not reuse” or “Single use only” if the tube is disposable.
• A radiopaque marker at the patient end or along the full length
E: Tube Size
• Current standards designate tracheal tube size by the ID in millimetres.
• Ideal tube in the average adult female is a 7.5-mm-ID and an 8.5-mm-ID tube for
males
• Age is recognized as the most reliable indicator of the appropriate tracheal tube size
for children
• ID = 3 mm for those 3 months of age and younger
• ID = 3.5 mm for those from 3 to 9 months of age
• ID = age in years/4 + 4 or 3.5
F: Depth of Insertion
• In average-size adult patients, securing the tube at the anterior incisors at 23 cm in
males and 21 cm in females
• For nasal intubations, 5 cm should be added to these lengths for positioning at the
nares
• Paediatric Patients: Oral Intubation
• Length in centimetres = age/2 + 12 cm
• Rule of 7-8-9: infants weighing 1 kg are intubated to a depth of 7 cm at the lips, 2-kg
infants to a depth of 8 cm, and 3-kg infants to a length of 9 cm.
• Depth of insertion = 3* ID (mm)
G: Intracuff Pressure
• A high cuff pressure prevents aspiration, ventilatory leaks, and eccentric tube
positioning in the trachea but can cause damage to the trachea.
• A low cuff pressure minimizes tracheal damage and can act to relieve excessive
airway pressure but may result in aspiration, leaks, and eccentric tube positioning.
• It is desirable that the cuff seal the airway without exerting so much pressure on the
trachea that its circulation is compromised or the trachea is dilated.
• Most authors recommend that the pressure on the lateral tracheal wall measured at
end expiration is between 25 and 35 cm H2O (18 to 25 mm Hg) in normotensive
adults
• This is usually achieved by inflating the cuff with 4-8 mls of air
H: Confirmation of placement:
Multiple methods can be used to confirm the placement of ETT in trachea.
1: Direct Visualization: most sensitive sign
2: Feel of the Reservoir Bag
3: Chest Wall Motion
4: Auscultation:
5: Epigastric Distention
6: Moisture Condensation in the Tracheal Tube
7: Gastric Contents in Tracheal Tube
8: Oxygenation
9: Chest X-ray: time consuming
10: Fibreoptic bronchoscopy view: gold standard method
11: Detection of exhaled CO2 (ETCO2): most commonly used technique. Fails in
conditions like severe bronchospasm, cardiac arrest, pulmonary embolism or one
way obstruction of the tube.
I: Inadvertent Bronchial Intubation:
• position of tube in one of the main stem bronchus
• most common in right mainstem bronchus because right bronchus is straighter, wider
& more in line with the trachea.
• The tube will usually move caudally with neck flexion, mouth opening, and change
in position from erect to recumbent
• The distance from the cords to the carina is decreased during laparoscopy and with
the Trendelenburg position
Detection:
• Lung Auscultation: the most commonly used method to detect bronchial intubation
• Symmetrical Chest Expansion: easily performed but is not reliable
• Chest X-ray: reliable but time consuming and expensive
• Fibreoptic bronchoscopy: gold standard
• No role of ETCO2 in detection of endobronchial intubation
J: Position of tip
• In adults, the tube tip should be 3, 5, or 7 cm above the carina with the neck flexed,
neutral, or extended, respectively.
• The tip should lie over the third to fourth thoracic vertebrae in the neutral position or
at the level of the clavicle
50 | Anesthesia
K: Indications for intubation:
• Airway protection
• Maintenance of patent airway
• Pulmonary toilet
• Application of positive pressure ventilation
• Maintenance of adequate oxygenation
• Route for emergency drug during cardiac arrest
L: Nasal Intubation
Indications Advantages Disadvantages Contraindications
Surgical procedures of Securing tube is easy Smaller diameter tube is Coagulopathy
oral cavity\oropharynx\ used
face
Fractured mandible No biting of tube Increased resistance to Mechanical impediment
breathing of the nasotracheal
route, including polyps,
abscesses, foreign
bodies, and possibly
epiglottitis
TMJ ankylosis Less cervical spine Intubation takes longer Base of the skull fracture
movement
Patient’s with neck Severe epistaxis can Weak cribriform plate of
injury occur ethmoid bone
Cervical spine injury
Intraoral pathology Higher incidence of
bacteraemia, sinusitis&
otitis media
Limited \no mouth
opening
M: Complications of laryngoscopy & intubation

DURING INTUBATION WHEN TUBE IN PLACE AFTER EXTUBATION
TRAUMA (MOST COMMON) Endobronchial intubation Sore throat (more common in
Larynx> pharynx> oesophagus females)
Physiological effect of Accidental extubation Hoarseness of voice
laryngoscopy (tachycardia,
hypertension, arrythmias, cardiac
arrest)
Failed intubation Obstruction of tube Recurrent laryngeal nerve palsy
aspiration Tracheal mucosal ischemia
Esophageal intubation Tracheal stenosis
Raised ICP\IOP
O: Specially designed tracheal tubes
1: Oxford tracheal tube
This anatomically L-shaped tracheal tube is used in anesthesia for head and neck surgery
because it is non-kinking
The Oxford tracheal tube, red rubber (left) and plastic (right).
2: Armoured/reinforced tracheal tube

• Armoured tracheal tubes are made of plastic or silicone rubber.
• The walls of the armoured tube contain an embedded spiral of metal wire or tough nylon.
• They are used in anesthesia for head and neck surgery.
• The spiral helps to prevent the kinking and occlusion of the tracheal tube when the
head and/or neck is rotated or flexed.
Armoured cuffed tracheal tube.

52 | Anesthesia
3: Polar and Ring, Adair and Elwyn (RAE) tracheal tubes
• The polar tube is a north- or south-facing preformed nasal cuffed or uncuffed tracheal
tube.
• It is used mainly during anesthesia for maxillofacial surgery as it does not impede
surgical access
Polar and RAE tracheal tubes: (A) cuffed nasal north facing; (B) non-cuffed nasal north facing;
(C) cuffed oral south-facing; and (D) non-cuffed oral north-facing.
4: Laser-resistant tracheal tubes

These tubes are used in anesthesia for laser surgery on the larynx or trachea avoiding
the risk of fire or damage to the tracheal tube
Laser resistant tracheal tubes
5: Micro laryngeal tube

• This tube allows better exposure and surgical access to the larynx.
• It has a small diameter (usually 5-mm ID) with an adult sized cuff.
• The tube is made of ivory PVC to reduce trauma to the nasal mucosa.
Microlaryngeal tracheal tube

54 | Anesthesia
6: double lumen tube (DLT):
Used for one lung ventilation for thoracic surgery, Esophageal surgery & lung isolation
Points to Remember:
• Facemask is simplest and most non invasive airway device
• Nasopharyngeal airway is useful in semi awake patients
• Appropriate size of oropharyngeal airway is by distance between angle of mandible &
central incisor
• LMA is an airway device between facemask and endotracheal tube
• LMA classic is available in 8 sizes
• LMA size 4 is most common used for adult females and 5 for adult males
• Macintosh blade (curved) is the most common used blade of laryngoscope
• Most common injured structure during laryngoscopy is upper central incisor
• Most PVC endotracheal tubes have low-pressure high-volume cuff
• Age is a better criterion for tube size selection in paediatric patients
• Gold standard technique of confirmation of placement of ett is fibreoptic bronchoscopy

Worksheet
• MCQ OF “ANESTHESIA MACHINE, BREATHING CIRCUITS &
AIRWAY EQUIPMENTS” FROM DQB

56 | Anesthesia
ACTIVE RECALL OF IMPORTANT POINTS:
1: modern gas cylinders are made up of __________________
2: colour & pin index of nitrous oxide cylinder is _____________&_________________

respectively.
3: pin index prevents wrong attachment of _____________________________ to

____________________.
4: oxygen flush is a part of _______________________pressure system
5: the colour and type of vaporizer for desflurane is _________________________&

____________________.
6: another name of Mapleson A circuit is____________________ .
7: when ethyl violet is used as an indicator then on exhaustion it changes its colour
from __________________ to _________________________.
8: use of airway prevents fall of _______________________________ on posterior

pharyngeal wall.
9: a LMA used for tracheal intubation is LMA ______________________
10: identify the device
11: this manoeuvre is used to improve visualization of larynx during laryngoscopy:

____________________
12: maximum pressure in the cuff of endotracheal tube is____________________

mmhg.
13: endobronchial intubation is most common in __________________ bronchus.

Induction & Maintenance
3 Anesthetic Agents
CONCEPTS
Â Concept 3.1: Induction Agents
Â Concept 3.2: Maintenance Agents

58 | Anesthesia
Concept 3.1: Induction Agents
LEARNING OBJECTIVE:
• To understand induction of anesthesia
• To learn the classification of induction agents
• To discuss in detail intravenous induction agents
Time Needed
1 read
st
120 mins
2 read
nd
60 mins
Concept 3.1.1: Introduction & Classification

• Induction of anesthesia can be defined as rapid loss of consciousness after
administration of the anesthetic agent.
• General anesthesia began with inhaled agents but now can be induced and Maintenance
with drugs that enter the patient through a wide range of routes.
• The ideal induction anesthetic agent would cause hypnosis and amnesia with a
rapid onset, minimal cardiovascular and respiratory effects, and rapid metabolism.
Classification
INTRAVENOUS AGENTS INHALED AGENTS
GABA AGONIST NMDA ANTAGONIST
• Barbiturates Thiopentone & Methohexitol) • Ketamine • Sevoflurane
• Propofol • Halothane
• Etomidate • Xenon
• Benzodiazepines (Midazolam)
Concept 3.1.2: Barbiturates:

• Barbiturates were the most used IV drugs administered to induce anesthesia before
the introduction of propofol.
• Barbiturates used in clinical anesthesia are of two types:
• Oxybarbiturates: eg methohexital
• Methohexital is unique as it is a proconvulsant agent and so agent of choice in patients
for electroconvulsive therapy. AIIMSQ
• Thiobarbiturates: eg thiopentone & thiamyl
Thiopentone:
• Thiopentone was 1st used in 1934 by Lundy and Waters.
• It is available as a yellow amorphous powder having 6% anhydrous sodium carbonate.
(NEETQ)
• This preparation is high alkaline (pH 10.5-11) so should not be reconstituted in acidic
solution like RL.
• Dose 3-5 mg/kg, adequate induction dose leads to loss of eye lash reflex.
Induction & Maintenance Anesthetic Agents | 59
• In alkaline solution, thiobarbiturates can be stored up to 2 weeks, and methohexital
up to 6 weeks.(IMPORTANT POINT)
A: Mechanism of action
• Barbiturates depress the reticular activating system in the brainstem, which controls
multiple vital functions, including consciousness.
• Barbiturates potentiate the action of GABA-A in increasing the duration of
openings of a chloride specific ion channel.(NEETQ)
B: Pharmacokinetics:
• They are barbituric acid derivatives.
• Replacing oxygen(oxybarbiturate) by sulphur (thiobarbiturate) increases lipid
solubility.
• Onset of action: 15-30 secs (1 arm brain circulation time): due to high lipid
solubility(NEETQ)
• Duration of action: less than 20 mins, after single dose is by rapid redistribution
into highly perfused compartments not by elimination, or metabolism.(NEETQ)
• After an extended infusion of thiopental, accumulation in poorly perfused
compartments and slow elimination play larger pharmacokinetic roles, resulting in a
prolonged context-sensitive half-time and delayed recovery.
• METABOLISM: They are metabolized in liver involving hepatic oxidation.
• EXCRETION: renal
C: Pharmacodynamics:
1: Cardiovascular System:
Decreases in both MAP and cardiac output.
Mechanism: reduction of venous vascular tone → peripheral pooling of venous
blood → decrease in venous return.
Tachycardia : central vagolytic effect and reflex responses to decreases in blood
pressure. (Q)
2: Respiratory System
Decreased ventilatory response to hypoxia & hypercarbia.
Apnea follows induction dose of thiopentone.
Tidal volume & respiratory rate are decreased.
Barbiturates incompletely depress airway reflex responses to laryngoscopy and
intubation, and airway instrumentation may lead to bronchospasm (in asthmatic
patients) or laryngospasm in lightly anesthetized patients.(AIIMSQ)
3: CNS
Decrease cerebral blood flow, cerebral blood volume and ICP (Intra Cranial
Pressure)
Cerebral Perfusion Pressure (CPP) is increased because decrease in ICP is
more than MAP (Mean Arterial Pressure) (CPP= MAP-ICP)
Decreased cerebral oxygen consumption hence neuroprotective.(NEETQ)
Changes in the electroencephalogram (EEG), which progress from low-voltage
fast activity with small doses to high voltage slow activity, burst suppression, and
electrical silence with larger doses.
60 | Anesthesia
They are anti analgesic.
Some patients relate a taste sensation of garlic, onions, or pizza during induction
with thiopental.
Do not cause muscle relaxation and some induce involuntary skeletal muscle
contractions (eg, methohexital)
Thiopentone is a powerful anticonvulsant while methohexitone is a pro
convulsant agent.
4: Renal
Reduced renal blood flow & GFR.
5: Hepatic
Blood flow is decreased.
Induction of hepatic enzymes increases rate of metabolism of other drugs.
Therefore, contraindicated in acute intermittent porphyria (AIP) &
variegate porphyria. (IMPORTANT Q)
Induction of aminolevulinic acid synthetase stimulates porphyrin which can
precipitate an attack of porphyria.
can be safely given in porphyria cutanea tarda.
Important points on barbiturates

Key Pharmacology Key Clinical Uses
• GABA-A receptor agonist • Induction of general anesthesia
• Prolonged context-sensitive half-time • Methohexital used for sedation, premedication,
• CNS depressant, neuroprotective, anticonvulsant, and electroconvulsive therapy
decreases CMRO2, CBF, and IC P • Barbiturate coma (thiopental)
• EEG burst suppression (thiopental) • Thiopental intra-arterial injection can lead to
• Cardiovascular: decreases mean arterial pressure, tissue necrosis
venous vascular tone, and cardiac output
• Pulmonary: Dose-dependent respiratory
depression, does not cause bronchodilation
CMKO2 cerebral metabolic oxygen consumption rate; CBF, cerebral blood flow; ICP, intracranial pressure; EEG,
electroencephalogram.
D: Uses
1) Induction of anesthesia (agent of choice for raised ICP patients)(AIIMSQ)
2) Maintenance of anesthesia (in cases with raised ICP)
3) Sedation
4) premedication (rectal methohexital in paediatric patients)
5) barbiturate coma (for cerebral protection from partial ischemia)
E: Adverse Effects
1. Inadvertent intra-arterial injection of Thiopentone.(NEETQ)
Signs and symptoms: Immediate pain, blanching of hand, loss of radial pulse,
secondary thrombosis.
Treatment: Treatment consists of
Leaving the needle insitu & dilution of the drug by the administration of saline into
the artery
intra-arterial lignocaine to prevent vasospasm.
heparinization to prevent thrombosis
brachial plexus block\ stellate ganglion block: vasodilation & analgesia.
(NEETQ)
intraarterial administration of papaverine
2. extravasation
3. hypersensitivity: anaphylactoid type of reaction.
F: Contraindications
1. Porphyria may be precipitated, or acute attacks may be accentuated by the
administration of thiopental.
2. Severe cardiovascular instability or shock contraindicates barbiturate use.
3. Status asthmaticus is a condition in which airway control and ventilation may be
worsened by thiopental.
Concept 3.1.3: Ketamine (Most Important Agent to Remember)

• It is a phencyclidine derivative.
• Ketamine has been administered by the IV, intramuscular (IM), transcutaneous, oral,
nasal, and rectal routes and as a preservative-free solution epidurally or intrathecally.
• Of the non-volatile agents, ketamine comes closest to being a “complete” anesthetic
as it induces analgesia, amnesia, and unconsciousness.
A: Mechanism of Action:
• Inhibition of NMDA Receptor mediated glutaminergic input to the GABA-ergic
system that leads to changing excitatory activity in the cortex and limbic system that
in the end results in unconsciousness.
• The primary site of CNS action of ketamine seems to be the thalamo-neocortical
projection system.
The drug selectively depresses neuronal function in parts of the cortex (especially
association areas) and thalamus while stimulating parts of the limbic system, including
the hippocampus.
• It dissociates thalamus (reticular activating system) from limbic cortex
• It causes dissociative anesthesia meaning patient appear to be conscious but not
responding to sensory stimulation.
• After ketamine administration, pupils dilate moderately, and nystagmus occurs.
• Lacrimation and salivation are common,
• Increased skeletal muscle tone, often with coordinated but seemingly purposeless
movements of the arms, legs, trunk, and head.
• Corneal, cough, and swallow reflexes all may be present, but they should not be
assumed to be protective.
62 | Anesthesia
• Onset of action within 30 to 60 seconds of administration & duration 10-15 minutes.
• It is more lipid soluble, less protein bound than thiopentone.
• Is metabolized in liver to nor-ketamine (active ) which contains anaesthetic potency
& is excreted via kidney.
• Strongly analgesic
1: CVS
Increase heart rate, blood pressure, cardiac output
They occur due to central stimulation of sympathetic system & inhibition of
reuptake of nor epinephrine from nerve endings
Should be avoided in IHD, hypertension, aortic aneurysm (direct myocardial
depressant action)
Choice for hypovolemic shock patients(acute shock)
2: Respiratory system
Minimal effect on respiratory drive on routine induction doses.
but rapid injection can cause apnea which can be treated by positive pressure
ventilation.
Potent bronchodilator hence preferred in asthmatic patients
Ketamine is as effective as halothane in preventing bronchospasm
Maintains upper airway reflexes hence agent of choice for full stomach patients.
Can be used in status asthmaticus patients when conventional therapy fails.
Causes increased salivation which can be treated with anticholinergic agents.
3: CNS
Increase cerebral oxygen consumption, ICP, cerebral blood flow
C/I in SOL, head injury
Causes Emergence reactions on waking up: The common manifestations of
these reactions, are vivid dreaming, extracorporeal experiences (sense of floating
out of body), and illusions (misinterpretation of a real, external sensory experience)
decreased by administration of benzodiazepines
Causes increase in Intra Ocular Pressure therefore c/I in glaucoma
action of NDMR are potentiated by ketamine
Is used in children for short surgical procedures, for burn dressings and for field
anesthesia.
• NMDA receptor antagonist • Anesthesia—intravenous and intramuscular
• Cardiovascular stability; increases heart rate and induction
blood pressure • Analgesia
• Mild respiratory depression • Chronic pain
• Side effects: Emergence delirium, hallucinations, • Depression
nystagmus, increased salivation • Bronchodilator
• Trance-like cataleptic unconscious state • Procedural sedation, especially in pediatric and
("dissociative anesthesia") burn patients
D: Uses:
1. Induction and Maintenance of Anesthesia
DOC for unstable cardiovascular patients suffering from hypovolemia,
haemorrhagic shock, or cardiovascular depression in sepsis.
DOC for patients with reactive airway disease (bronchodilation and profound
analgesia).
rapid sequence anesthesia induction with ketamine: Patients who have
sustained trauma with extensive blood loss.
DOC: Patients with septic shock, cardiac tamponade, and restrictive
pericarditis
DOC: congenital cyanotic heart disease, especially patients with right-to-left
shunting. (increased systemic vascular resistance causes decreased left to right
shunt and thus improves oxygenation).
Ketamine has been successfully used in a patient susceptible to malignant
hyperthermia
The use of propofol in combination with small dose ketamine also has gained
increasing popularity as a total IV anesthesia technique for patients undergoing
noncardiac surgical procedures
2. Premedication: along with benzodiazepines and anticholinergic
3. Pain management: Ketamine may be effective in the treatment of cancer pain,
chronic peripheral and central neuropathic pain, phantom and ischemic limb pain,
fibromyalgia, complex regional pain syndrome, visceral pain, and migraine.
4. Sedation: especially in children for outside operating room anesthesia e.g., MRI
suites, CT guided biopsy etc.
5. Depression: Ketamine has been evaluated as a possible treatment for major
depression
E: Contraindications:
1) Head injury, raised ICP
2) Open eye injury
3) IHD and Vascular aneurysms
4) Psychiatric diseases like schizophrenia
Concept 3.1.4: Propofol

• Propofol (2,6-diisopropylphenol) has become one of the most frequently used
intravenous anesthetics on the market today
• Its pharmacokinetic profile presents a desirable rapid onset, a predictable context-
sensitive half-time, and a rapid emergence from anesthesia.
• Additionally, a favorable side-effect profile and antiemetic property allow for a
wide spectrum of uses, including induction and maintenance of general anesthesia,
intensive care unit (ICU) sedation, and as a sedative-hypnotic in a variety of outpatient
procedures.
64 | Anesthesia
Poorly understood but believed to be Primarily via enhancement of GABA inhibitory
pathways.
1: Preparation: available as a 1% propofol (oil in water emulsion) that appears milky
white in colour & contains:
10% soybean oil
2.25% glycerol
1.2% egg phospholipid emulsifier
It can act as a good culture medium for bacterial growth hence an open vial should
be discarded after 6 hrs (EDTA is added to prevent bacterial growth )
Causes pain on injection.
Pain can reduced by
Administration of lignocaine before giving propofol.
Choosing a wider vein
Mixing some amount of blood before injecting propofol
2: Onset of action: 1 arm brain circulation time (15-30 secs)
3: Duration of action: rapid(<10mins) & clear-headed recovery (no residual effect of
the drug).
4: Metabolism: extra hepatic ( more important) & hepatic ( less important).
5: Excretion: renal
1: CVS
The hemodynamic effects of propofol are dose-dependent and more significant
after an induction dose than during a continuous infusion.
There is a characteristic drop in systolic and diastolic blood pressure without the
expected increase in heart rate(direct inhibition of the baroreceptor response).
The fall in blood pressure is due to decrease in cardiac output, stroke volume,
and systemic vascular resistance (SVR).
Propofol decreases sympathetic activity and leads to indirect arterial vasodilation
and venodilation.
2: Respiratory System
Causes ventilatory depression, may cause apnea.
Depress hypoxic ventilatory drive.
Causes maximum upper airway depression of reflexes hence doc for LMA insertion.
3: CNS
Neuroprotective action: by decreasing CMRO2 & ICP which happens because of
overall decrease in cerebral blood flow.
Is an antiemetic, and antipruritic
The effect of propofol on the EEG, an initial increase in alpha rhythm followed by
a shift to gamma and theta frequency.
Rapid infusion rates produce burst suppression
Propofol has a dose-dependent anticonvulsant action.
Propofol has even been used to treat epileptic seizures.
However, propofol can cause grand mal seizures and has been used for cortical
mapping of epileptogenic foci
Decreases IOP
Is antioxidant
Doesnot potentiate the actions of NDMR
• Primary mechanism: GABA-A receptor agonist • General anesthesia induction and maintenance
• Predictable context-sensitive half-time across • Commonly used for TWA
various comorbidities • Conscious and deep sedation, including out-of-
• CNS depressant, neuroprotective, anticonvulsant, operative-room settings
decreases • Intensive care unit sedation
• CMRO2, CBF, and ICP • Postoperative nausea and vomiting prophylaxis
• Can be used for EEG burst suppression • Safe for use In patients with malignant
• Cardiovascular significant decreases in systemic hyperthermia
vascular resistance, stroke volume, and cardiac
output Pulmonary: respiratory depressant and
potent bronchodilator
• Addiction potential: may elicit feelings of well-
being or euphoria during emergence
• Side effects: associated pain with injection,
propofol Infusion syndrome
CMRO2 cerebral metabolic oxygen consumption rate; CBE, cerebral blood flow; ICP, intracranial pressure; EEG,
electroencephalogram; TIVA, total intravenous anesthesia.
D: Uses:
1: Most common induction agent used nowadays
2: agent of choice for patients with malignant hyperthermia, open eye injury,
neurosurgery, hepatic disease\failure, office based procedures, rigid bronchoscopy.
3: best agent for Total IntraVenous Anesthesia (TIVA) along with a short acting opioid.
4: used for procedural & ICU sedation.
E: Side Effects:
1: pain on injection.
2: Hallucinations, sexual fantasies, and opisthotonos occur after propofol administration.
3: green coloured urine after prolonged infusion.
4: Propofol infusion syndrome (PRIS)
Extremely rare and potentially lethal complication of prolonged infusion of propofol
Was 1st seen in children & later in adults who were kept on prolonged propofol
infusion in ICU.
Is seen when propofol is used in doses >4mg\kg\hour for more than 48 hours
66 | Anesthesia
Mechanism: mitochondrial toxicity and uncoupling of the intracellular respiration
chain, along with inhibition of fatty acid oxidation have been suggested
The clinical features of propofol infusion syndrome are acute refractory
bradycardia leading to asystole in the presence of one or more of the following:
metabolic acidosis (base deficit >10 mmol/L), rhabdomyolysis,
hyperlipidemia, and enlarged or fatty liver.
Other features include cardiomyopathy with acute cardiac failure, skeletal
myopathy, hyperkalemia, hepatomegaly,and lipemia
Treatment is conservative & CPR in case of cardiac arrest.
Concept 3.1.5: Etomidate:

• Etomidate contains a carboxylated imidazole and is structurally unrelated to other
anesthetic agents.
• The imidazole ring provides water solubility in acidic solutions and lipid solubility at
physiological pH.
• etomidate is dissolved in propylene glycol for injection. (NEETQ)
• Milky white in appearance
• This solution often causes pain on injection(NEETQ) that can be lessened by a
prior intravenous injection of lidocaine.
• It gained much popularity because of its safe hemodynamic profile however,
it lost some proponents with increased reports of adrenal suppression, pain
on injection, thrombophlebitis, PONV, myoclonus, and hiccups
• Etomidate depresses the reticular activating system and mimics the inhibitory
effects of GABA
• Unlike barbiturates, etomidate may have disinhibitory effects on the parts of the
nervous system that control extrapyramidal motor activity.
• This disinhibition offers a potential explanation for the 30–60% incidence of
myoclonus with etomidate induction of anesthesia.
• Etomidate is available only for intravenous administration and is used primarily for
induction of general anesthesia.
• Redistribution is responsible for decreasing the plasma concentration to awakening
levels.
• Hepatic microsomal enzymes and plasma esterases (NEETQ)rapidly hydrolyse
etomidate to an inactive metabolite
• The end products of etomidate hydrolysis are primarily excreted in the urine.
1: CVS:
Etomidate has a minimal or nonexistent effect on MAP, pulmonary artery (PA)
pressure, pulmonary artery wedge pressure, central venous pressure (CVP), stroke
volume, cardiac index, SVR, and pulmonary vascular resistance (PVR).(AIIMSQ)
Etomidate is frequently used for induction of anesthesia in cardiac operating
rooms.
Etomidate is also used for trauma patients who are hemodynamically unstable and
are often hypovolemic.
2: RS:
etomidate depresses airway reflexes less than propofol.
3: CNS:
Etomidate decreases cerebral metabolic rate, cerebral blood flow, and
intracranial pressure.
Because of minimal cardiovascular effects, CPP is well maintained.
Although changes on EEG resemble those associated with barbiturates, etomidate
increases the amplitude of somatosensory evoked potentials.
However, despite its neurodepressant properties at high doses, etomidate is often
associated with epileptogenic activity (excitatory spikes) on EEG. This alone
may render etomidate an undesirable induction agent for patients undergoing
neurosurgical procedures
Postoperative nausea and vomiting are more common following etomidate
than following propofol induction.
Etomidate is used frequently for electroconvulsive therapy(JIPMERQ). Unlike
the barbiturates (except methohexital), etomidate is proconvulsant and lowers
the seizure threshold.
Etomidate lacks analgesic properties.
• GABA-A receptor agonist • Hemodynamically stable induction
• Hemodynamically stable • Cardiac, trauma, and hypovolemic patients
• Adrenocortical suppression
• Postoperative nausea and vomiting
D: Uses:
1: agent of choice for cardiac patients with low cardiac reserve.(NEETQ)
2: 2nd best agent of choice for electroconvulsive therapy.(JIPMERQ)
E: Side Effects:
• Adrenocortical suppression (NEETQ)may be the most significant adverse effect of
etomidate.
• Etomidate inhibits the activity of the enzyme 11β-hydroxylase and prevents the
conversion of cholesterol to cortisol.
• Maximum incidence of post-operative nausea & vomiting among iv induction agents
& hiccups & myoclonus.
Concept 3.1.6: Benzodiazepines

• Benzodiazepines—midazolam in particular—are frequently used by anesthesiologist
to produce several clinically desirable effects: anxiolysis, anterograde amnesia,
sedation, and hypnosis.
• They can also be used as muscle relaxants and anticonvulsants.
• Benzodiazepines have a favourable safety profile and can be reversed by flumazenil
to manage excessive sedation or respiratory depression.
68 | Anesthesia
Important Pharmacokinetic Property of BZDs (Most Important)
Duration of Duration of Hepatic Induction Half-life Preparation &
action action (min) clearance dose (mg\ (min) lipid solubility
kg)
Midazolam Short 15-20 High 0.1-0.3 7-15 Water Soluble
(No Pain)
Diazepam Intermediate 15-30 slow 0.3-0.6 10-15 Lipid Soluble
(Pain)
Lorazepam long 60-120 intermediate 0.03-0.1 3-10 Lipid Soluble
(Pain)
• Benzodiazepines augments the effect of the GABA-A receptor/chloride channel
coupling, resulting in increased frequency of chloride channel opening.
• The resultant hyperpolarization of the cell ultimately leads to neural inhibition.
B: Pharmacodynamics
1: CVS:
Benzodiazepines given alone decrease arterial blood pressure, cardiac
output, and peripheral vascular resistance slightly, and sometimes increase
heart rate.
Intravenous midazolam tends to reduce blood pressure and peripheral vascular
resistance more than diazepam.
Changes in heart rate variability during midazolam sedation suggest decreased
vagal tone (ie, drug-induced vagolysis).
2: RS:
Benzodiazepines can also have a profound effect on the respiratory system.
Upper airway reflexes may be decreased, and central respiratory drive is depressed.
3: CNS:
Benzodiazepines reduce cerebral oxygen consumption, cerebral blood flow, and
intracranial pressure but not to the extent the barbiturates do.
They are effective in preventing and controlling grand mal seizures.
Oral sedative doses often produce Anterograde amnesia, a useful premedication
property.
The mild muscle-relaxing property of these drugs is mediated at the spinal
cord level, not at the neuromuscular junction.
The antianxiety, amnestic, and sedative effects seen at lower doses progress
to stupor and unconsciousness at induction doses.
Benzodiazepines have no direct analgesic properties
• GABA-A receptor agonist • Anxiolysis
• Minimal respiratory depression • Anterograde amnesia
• Minimal cardiovascular depression • Sedation
• Large therapeutic window • Induction of anesthesia, hemoclynamically stable
• Reversible with flumazenil • Anticonvulsant
C: Use:
1: primarily used as premedication agents.
2: can be used for induction at high doses but is always associated with prolonged
recovery times.
D: Side Effects
1: most common side effect is respiratory depression.
It can be treated by either supporting respiration or use of specific antagonist in the
form of Flumazenil.
2: pain on injection with diazepam & lorazepam (due to propylene glycol used as a
solvent)
70 | Anesthesia
Concept 3.2: Maintenance Agents:
LEARNING OBJECTIVE:
• To understand maintenance of anesthesia
• To learn the classification of inhaled anesthetic agents
• To discuss the pharmacokinetics of inhaled anesthetic agents
• To discuss in detail about individual inhaled agents along with their clinical use.
Time Needed
1st read 120 mins
2 read
nd
60 mins
• These agents are used in the maintenance phase of anesthesia.

• Predominantly inhaled anesthetic agents are used for maintenance phase.
• When IV induction agents are used for maintenance then this type of anesthesia is
called as Total Intravenous Anesthesia (TIVA).
Inhalational Agents
• Inhalation anesthetics are the most common drugs used for the provision of general
anesthesia.
• Adding only a fraction of a volatile anesthetic to the inspired oxygen results in a state
of unconsciousness and amnesia
• Ether was the 1st anesthetic agent to be used clinically and that moment marked the
advent of clinical anesthesia.
• Arthur guedal studied the physiological changes that happen under ether anesthesia
which are described as stages of anesthesia and are still often quoted for reference.
Concept 3.2.1: Guedels Stages of ether Anesthesia

Stage of Respiration Tidal Pupils Eye Eyeball Reflexes abolished
anesthesia volume position movement
Stage 1 (stage of Irregular Small Constricted Divergent + Nil
analgesia)
Stage 2 (stage of Irregular Large Partially Divergent +++ (max) Eyelash (1st reflex
excitement) Dilated Roving lost)(NEETQ)
eyeballs
Stage 3 (stage of surgical anesthesia) divided in 4 planes.
Plane 1 Regular Medium constricted Fixed absent Conjunctival
centrally Skin
Pharyngeal
Plane 2 Regular Medium ½ dilated Fixed Absent Corneal
centrally
Plane 3 Regular Small ¾ dilated Fixed Absent Laryngeal
centrally (NEETQ)
Plane 4 Jerky Small Fully dilated Fixed Absent Carinal & Anal
centrally sphincter (last
reflexes to get
abolished)
Stage 4 Apnea (medullary paralysis & death)
Concept 3.2.2: Classification of Inhaled Anesthetic Agents:

PURE GASES VOLATILE LIQUIDS
OLD AGENTS NEW AGENTS
• Xenon • Ether • Halothane
• Nitrous Oxide • Ethyl Chloride • Isoflurane
• Chloroform • Desflurane
• Cyclopropane • Sevoflurane
Concept 3.2.3 Mechanism of Action of Inhaled Anesthetic Agents

1) NMDA receptor antagonism (nitrous oxide and xenon)
2) Gaba receptor agonism
3) Depresses excitatory neurotransmitters in brain and spinal cord.
2 hypotheses for the same:
1) Meyer Overton hypothesis: it states that the potency of an inhaled anesthetic
agent is directly proportional to its lipid solubility.
2) Critical volume hypothesis (PGIQ): anesthetic binding to hydrophobic sites in
phospholipid bilayer beyond critical amount can alter membrane function. This is a
more acceptable hypothesis and explains the mechanism of action better.
Concept 3.2.4: Pharmackinetics: General Points

1. Inhaled anesthetics are gases rapidly transferred bidirectionally via the lungs to and
from the bloodstream and subsequently to and from CNS tissues as partial pressures
equilibrate.
2. Plasma and tissues have a low capacity to absorb the inhaled anesthetics relative
to the amount we can deliver to the lungs, allowing us to quickly establish or
abolish anesthetizing concentrations of anesthetic in the bloodstream and
ultimately the CNS.
3. Metabolism, excretion, and redistribution of the inhaled anesthetics are minimal
relative to the rate at which they are delivered or removed from the lungs. This
permits easy maintenance of blood and CNS concentrations.
4. Inhaled anesthetics equilibrate based on their partial pressures in each tissue (or
tissue compartment) not based on their concentrations.
5. The partial pressure of a gas in solution is defined by the partial pressure in the gas
phase with which it is in equilibrium. Where there is no gas phase the partial pressure
reflects a force to move out of solution.
72 | Anesthesia
6. The concentration of anesthetic in a tissue depends on its partial pressure and the
tissue solubility of the anesthetic.
Figure: Inhalation anesthetic agents must pass through many barriers

between the anesthesia machine and the brain.
A: Blood Gas Partition Coefficient (ʎ B: G)(Most Important Concept)

• It is defined as the ratio of concentration of anesthetic agent in blood to alveolar
gas at steady state at 37 degree Celsius.
• ʎ B:G ∝ solubility ∝ 1\ rate of rise of FA\FI ∝ 1\ rate of induction and recovery
• The higher the blood/gas coefficient, the greater the anesthetic’s solubility and the
greater its uptake by the pulmonary circulation.
• Because of this increased solubility, alveolar partial pressure rises more slowly, and
induction is prolonged.
• Speed of onset and recovery [ increasing order of B:G partition coefficient
and blood solubility]
Desflurane (0.42) [fastest onset & recovery] > N2O (0.47) > sevoflurane (0.69) >
isoflurane (1.38) > enflurane ( 1.8) > halothane (2.4) > ether (12) > methoxyflurane
(15) [slowest onset & recovery]
B: MAC: Minimum Alveolar Concentration
Minimum Alveolar Concentration is defined as alveolar concentration of inhaled
anesthetic agent that prevents movement in 50% of patients in response to a standard
stimulus ( eg surgical incision) at 1 atmosphere pressure.(MOST IMPORTANT CONCEPT)
Properties of MAC:
1) Best measure of potency of inhaled agents.
2) Also denotes the Oil Gas Partition (λ O:G) coefficient
3) It is equal to ED50 of a drug
4) MAC is additive.
Order of potency (increasing order of MAC values)
Methoxyflurane (0.16) [most potent]> halothane (0.74)> > isoflurane (1.15) >
enflurane (1.68) > ether (1.92) > sevoflurane (2.0) > desflurane (6.6) > > xenon (70)
> N2O (104) [least potent]
• Most potent inhalational anesthetic: methoxyflurane
• Least potent inhalational anesthetic: nitrous oxide
• Least potent halogenated anesthetic agent: desflurane
Factors Affecting MAC (NEETQ\AIIMSQ\PGIQ)

Factor Decrease in MAC Increase in MAC
(↑ Potency) (↓ Potency)
1: Temperature Hypothermia Hyperthermia (>42 Deg)

Hyperthermia
2: Age (NEETQ) Elderly Young (Max at 6 Months of Age)
3: Alcohol Acute Chronic
4: Amphetamine Chronic Acute
5: Electrolyte Hyponatremia Hypernatremia

Hypercalcemia Hypocalcemia
6: Pregnancy (NEETQ) √
7: Local Anesthetics All Except Cocaine
8: Thyroid Hormone No Effect No Effect
C: Oil Gas Partition Coefficient:

• It measures the lipid solubility of the agent.
• Higher oil gas partition coefficient, higher is lipid solubility and thus higher potency.
D: Metabolism:
• METHOXYFLURANE: 70% (HIGHEST): maximum fluoride release on metabolism
causing vasopressin resistant high output renal failure.(NEETQ)
• HALOTHANE: 25% (maximum hepatotoxicity)
• SEVOFLURANE: 5%
• ISOFLURANE: 0.2%
• DESFLURANE: 0.02%
• NITROUS OXIDE: NIL
74 | Anesthesia
E: Pharmacodynamics: General Points: (Most Important Q)
(1) All Agents are Myocardial Depressants Except Nitrous Oxide
(2) All Agents Increase Respiratory Rate and Decrease Tidal Volume (Short and Fast
Respiration)
(3) All Agent Increase ICP (Cerebral Vasodilators)
(4) All Agents Decrease CMRO2 Except Nitrous Oxide
(5) All Agents Cause Muscle Relaxation Except Nitrous Oxide
(6) All Agents Trigger Malignant Hyperthermia Except Nitrous Oxide
F: Environmental Effects (NEETQ)
Ozone depletion Greenhouse effect
Potential Halothane Desflurane
Overall impact Nitrous oxide Nitrous oxide
G: Maximum limit of concentration of volatile agent in OT:

1: when only nitrous oxide is used: 25ppm.
2: only volatile anesthetic agent: 2 ppm
3: volatile anesthetic agent used along with nitrous oxide: 0.5ppm
H: Physiochemical Properties of Inhaled Anesthetic Agents
Property Halothane Enflurane Isoflurane Desflurane Sevoflurane N2O
Boiling point 50 57 49 24 59 –88
B:G coefficient 2.5 1.9 1.46 0.42 0.69 0.46
MAC 0.75 1.63 1.17 6.6 2 104
Preservative Thymol No No No No No
Stable in CO2 No Yes Yes Yes No yes
absorber
% metabolism 20 2.4 0.2 0.02 2-5 none
Concept 3.2.5: Individual Inhaled Anesthetic Agents:
1: Xenon:
• Pure inert gas.
• Closest to being an ideal anesthetic agent.
• Extracted from the air
• Not approved for use clinically.
Advantages Disadvantages
Fastest Onset And Recovery (Bg:0.15) High Cost
Inert Low Potency (Mac 70%)
Analgesic (Nmda Antagonist)
Neuro & Cardio Protective

No Metabolism
No Malignant Hyperthermia
No Environmental Pollution
2: Nitrous Oxide: (Laughing Gas)

A: Physical Properties:
• colourless and odourless gas.
• non-flammable but, like O2, supports combustion.
• gas at room temp and ambient pressure but liquid under pressure (in a cylinder)
• MAC 104 (least potent)
• Analgesic
B: Pharmacodynamics:
1: Cardiovascular
direct myocardial depressant effect balanced by sympathetic nervous system
stimulation so BP and PR stable
myocardial depression may be unmasked by
▫ CAD
▫ hypovolemia
pulmonary vasoconstriction -> increased PVR (caution in patients with pulmonary
hypertension)
2: Respiratory
tachypnea + decreased VT = stable VE and paCO2
BEWARE: inhibits carotid body hypoxic drive
3: CNS
mildly increases CBF, CBV and ICP
increases CMRO2
analgesia
▫ concentration effect N2O rapid uptake into blood allows more N2O to enter the
blood thereby shortening induction time.
▫ Second gas effect
▫ Avoided in neurosurgery
4: Neuromuscular
No muscle relaxation
Doesn’t trigger malignant hyperthermia
5: GI
Increased risk of PONV by activation of CTZ in medulla
C: Biotransformation and Toxicity
• eliminated by exhalation.
• least metabolized in body [safest anesthetic]
76 | Anesthesia
• irreversibly oxidizes cobalt atom of vitamin B12, inhibiting B12-dependent enzymes:
(NEETQ)
methionine synthetase (myelin formation)
thymidylate synthetase (DNA synthesis)
• so prolonged exposure can lead to
bone marrow depression (megaloblastic anemia)
peripheral neuropathy
pernicious anemia
• controversial:
teratogenic (maybe not, but not necessary in early pregnancy, so usually avoided)
D: Effects of Nitrous Oxide (Most Important Concept)
2nd gas effect Diffusion hypoxia Expansion of Air Filled
Cavity
Timing Seen at Induction Seen During Recovery During the use of Nitrous
(1st 5-10 Mins) Oxide
Property of N2O Causing High Concentration & Fast Diffusion of Large Relatively Faster
this Pehnomenon Fast Uptake in Blood Amount of N2O from Diffusion of N 20
Leads to Contraction of Blood to Alveoli Leads (30 Times More) As
Alveoli to Dilution of Other Compared to N2 Leads
Alveolar Gases to Increased Volume of
Cavity
#Anshuldiwakar
Effect Faster Induction of 2nd Decreases Alveolar PP

Agent (Eg Halthane of O2 (Hypoxia) and CO2
when used with N2O (Hypocapnea) Causing
Depressed Ventilatory
Drivepressure On
Surrounding Structures
Clinical Significance Faster Induction with Hypoxia at the end of Increased Complications
N2O Surgery in Conditions with
Closed Air Filled Cavity
Intervention Done to None Giving 100% O2 Before Avoid N2O in

Avoid Complication the end of Surgery • Pneumothorax
• Pulmonary Air Cyst
• Airt Embolism
• Intraocular Air
Bubble
• Middle Ear Surgery
• Pneumocephalus
• Bowel Obstruction
E: Contraindications (NEETQ)
• 35 times more soluble in blood than nitrogen, N2
• so fills and expands any air-containing cavities:
air embolism (venous or arterial)
pneumothorax
acute intestinal obstruction with bowel distension
intracranial air (pneumocephalus during Dural closure )
pulmonary air cysts
intraocular air bubbles
tympanic membrane grafts
endotracheal tube cuff (monitor and reduce pressure periodically)
• may exacerbate pulmonary hypertension.
F: Use:
1: used primarily as a carrier gas in anesthesia.
2: ENTONOX: combination of 50% oxygen+ 50% nitrous oxide in a cylinder: as a sole
analgesic agent for dental extraction
3: can be used for labour analgesia.
3: Halothane:
A: Physical Properties
• It is a halogenated ethane (not an ether)
• non-flammable and non-explosive
• it is a sweet-smelling liquid.
• spontaneous oxidative decomposition retarded by
thymol preservative (0.01%)
amber-coloured bottle
• MAC: 0.75
1: Cardiovascular
direct myocardial depressant and coronary artery vasodilator
▫ interferes with Na-Ca exchange and intracellular Ca utilization.
▫ depresses cardiac output and lowers arterial BP
▫ depresses myocardial O2 demand so that myocardial O2 delivery is adequate.
depresses SA-node function.
▫ bradycardia (NEETQ)
▫ AV nodal rhythm (junctional rhythm)
depresses baroreflex.
enhances myocardial sensitivity to the arrhythmogenic effects of epinephrine.
Reacts with metal in vaporizers.
78 | Anesthesia
2: Respiratory
fast, shallow breathing, with increased paCO2 (during spontaneous ventilation)
that partly reverses cardiovascular depression
severe depression of hypoxic ventilatory drive (even at 0.1 MAC)
potent bronchodilator (inhibits intracellular Ca mobilization) (AIIMSQ)
depresses mucocilliary function.
3: CNS
general anesthesia, MAC = 0.75
cerebral vasodilator therefore increases CBF
blunts cerebrovascular autoregulation
hyperventilation prior to halothane may prevent the expected rise in ICP
does not provide pain relief
Halothane shakes. Can sometimes cause shivering.
4: Uterus:
It is a powerful uterine relaxant hence used for manual removal of placenta and
external\internal version during late pregnancy(NEETQ)
Contraindicated during labour : can cause PPH
C: Biotransformation and Toxicity

• oxidized in liver by cytochrome P-450 2EI to trifluoracetic acid.
• Maximally metabolized >20%
• hepatotoxic reduction products may arise.
D: Halothane & Liver (Most Important)

(1) Maximum decrease in hepatic blood flow
(2) Hepatic artery vasospasm
(3) Halothane hepatitis: an immune mediated destruction of hepatocytes after exposure
to halothane
Factors that increase risk:
• multiple exposures to halothane over a short interval
• middle-aged, obese women
• familial predisposition
• Personal history of autoimmune diseases
Pathophysiology:
centrilobular necrosis
antibody that binds to halothane-exposed hepatocytes may be isolated
• A hallmark clinical presentation is a mixture of a high fever, tender hepatomegaly,
and jaundice starting two to three days post halothane exposure.
Two types of hepatitis seen:
Mild Form (type 1) Fulminant Form (type 2)
Incidence, 1: 5 Incidence, 1:10,000
Repeat exposure not necessary Multiple exposures
Mild elevation of ALT, AST Marked elevation of ALT, AST, bilirubin, alkaline phosphatase
Focal necrosis Massive hepatic necrosis
Self-limited Mortality rate, 50%
Antibodies to halothane-altered protein antigens
Supportive therapy consists of:
• Fluid and electrolyte balance
• Correcting coagulation alterations
• Managing hypoglycaemia
• Supporting ventilation
• Supporting hemodynamic
• Oral lactulose/restricting protein intake.
E: Contraindications/Precautions
• malignant hyperthermia susceptibility
• Not to be used in patients with PPH.
• unexplained liver dysfunction after previous halothane exposure
• intracranial mass lesion
• adrenaline use > 1.5 mcg\kg
• hypovolemia
• aortic stenosis
• pheochromocytoma: with aminophylline has been associated with severe ventricular
dysrhythmias
F: Uses:
1: agent of choice for patients with bronchial asthma.
2: 2nd best agent for paediatric inductions.
3: agent of choice for manual removal of placenta
4: Isoflurane, Desflurane, & Sevoflurane (Most Important)

A: Physical & Chemical Properties:
Isoflurane Desflurane Sevoflurane
Odour Pungent Pungent(Max) Sweet Smelling
MAC 1.2 6.6 2
Vaporizer (type) TEC 7 TEC 6 (low BP & high TEC 7

Vapour pressure)
80 | Anesthesia
Vaporizer (colour) Purple Blue Yellow
Lowest B: G coefficient
Fastest onset & recovery
Least solubility
1) CVS
HR ↑ ↑↑↑ (transient sympathetic ↔

stimulation)
BP ↓ ↑ ↓
CO ↔ (max preserved) ↓ ↓
OTHER Coronary steal phenomenon

(theoretical concern)
2) RS
Rate ↑ ↑ ↑
Tidal Vol ↓ ↓ ↓
Response of Airway PUNGENT Airway irritation Non pungent

Coughing No reaction
Bronchospasm
↑ salivation
Laryngospasm
3) CNS
ICP ↑ ↑ ↑(MIN)
CMRO2 ↓ ↓ ↓(MAX)
CBF ↑ ↑ ↑
4) Other
Risk of Hepatitis + + NO (no protein adducts

formation)
Rection with CO2 NONE CO Compound A

Absorber
C: Use
AOC cardiac surgery Elderly Most common used inhaled agent
Liver disease\liver transplant Morbidly obese Day care surgery
Hypotensive anesthesia Neurosurgery & raised icp patients
AOC for patients with K\

C\O halothane hepatitis
Paediatric inductions
5: Old Inhaled Anesthetic Agents:

A: Ether (diethyl ether)
• Pungent smelling
• WTG Morton demonstrated 1st public demonstration of anesthesia using ether
anesthesia on 16th October 1846 (WORLD ANESTHESIA DAY)
• Decomposes in presence of light, so stored in amber coloured bottles
• Highly inflammable and explosive, should not be used with cautery (also
cyclopropane)
• Maximum muscle relaxation
• High chances of laryngospasm at induction, slow induction
• Good analgesic, muscle relaxant, complete anaesthetic agent
• Does not depress myocardium
• Does not depress respiration, potent bronchodilator, preserves ciliary activity
• Markedly increases secretions
• High nausea and vomiting
• Crosses placental barrier, causes hyperglycaemia
B: Trilene
• Maximum analgesic action
• Reacts with soda lime to form phosgene gas (causes ARDS )and dichloroacetylene
neurotoxicity (5th cranial nerve)
• Contraindicated with sodalime in closed circuit
• Used in labor analgesia
C: Cyclopropane
• Stimulates sympathetic system
• Was used as an agent of choice for shock patients.
• Orange cylinder
• Causes hyper glycemia
82 | Anesthesia
D: Chloroform
• Very toxic, high incidence of vomiting
• Can cause ventricular fibrillation and death
• Hepatotoxic
• Profound hyperglycaemia
• Highly emetic
E: Methoxyflurane
• Highly soluble in rubber tubing, another inhalational agent is halothane.
• Most potent, boiling point more than that of water
• Hepatotoxic
• Causes vasopressin resistant high output renal failure (max fluoride release on
metabolism)
Worksheet
• MCQ OF “INDUCTION & MAINTENANCE ANESTHETIC AGENTS” FROM DQB

84 | Anesthesia
1: AGENTS THAT ACT BY INHIBITION OF NMDA RECEPTOR ARE _________________,

_________________ &________________
2: INHALED ANESTHETIC AGENTS THAT ARE USED FOR INDUCTION OF ANESTHESIA
ARE:
3: TERMINATION OF ACTION AFTER A SINGLE DOSE OF THIOPENTONE IS BY
________________
4: MAXIMUM DECREASE IN ICP AMONG INDUCTION AGENTS IS BY: ___________
_________________
5: AGENT OF CHOICE FOR ELECTROCONVULSIVE THERAPY IS: _________________
_____________________
6: AGENT OF CHOICE FOR HEMODYNAMIC UNSTABLE PATIENTS IS:_________________
7: SITE OF ACTION OF KETAMINE IS:_________________
8: USE OF FOLLOWING AGENTS ARE:
AGENTS USE
THIOPENTONE
KETAMINE
PROPOFOL
ETOMIDATE
SEVOFLURANE
HALOTHANE
ISOFLURANE
9: LIST THE SIDE EFFECTS OF USE OF ETOMIDATE: ___________________________

______________
10: FILL IN THE COLUMNS:
PROPERTY OF INHALED AGENTS CLINICAL IMPLICATION
B: G COEFFICIENT
MAC
CONCENTRATION EFFECT
2ND GAS EFFECT
DIFFUSION HYPOXIA
86 | Anesthesia
11:
INHALED AGENT PROPERTY NAME
MAX METABOLISM
MAX GREENHOUSE EFFECT
MAX OZONE DEPLETION
MAX HEPATOTOXICITY
MAX NEPHROTOXICITY
MAX MAC
MAX CONCENTRATION IN OT (SOLE)
MAX CONCENTRATION IN OT ( WITH N20)
MAX AIRWAY IRRITATION

4 Neuro-muscular Blocking Agents
& Neuro-muscular Monitoring
CONCEPTS
Â Concept 4.1: Neuro Muscular Blocking Agents
Â Concept 4.2: Depolarising Muscle Relaxant (DMR)
Â Concept 4.3: Non-Depolarising Muscle Relaxant

(NDMR)
Â Concept 4.4: Neuromuscular Monitoring &

Reversal of Block
88 | Anesthesia
Concept 4.1: Neuro Muscular Blocking Agents
LEARNING OBJECTIVE:
• To revisit in brief about the physiology of neuromuscular transmission
• To understand the need and importance of muscle relaxation during anesthesia
• To learn the classification of neuromuscular blocking agents based on their mechanism
of action.
Time Needed
1st read 15 mins
2 read
nd
05 mins
• The neuromuscular junction (NMJ) is one of the most comprehensively studied models
of neural function.
• Neuromuscular blocking agents (NMBAs), also called “muscle relaxants” or “paralytics,”
have been used in the clinical setting for almost 75 years.
• Neuromuscular blocking agents (NMBAs) improve conditions for tracheal intubation
and protect against vocal cord damage, improve surgical conditions, and facilitate
mechanical ventilation in the operating room and intensive care unit.
Concept 4.1.1: Physiology of Neuromuscular Transmission:

Neuro-muscular Blocking Agents & Monitoring | 89
Concept 4.1.2: Classification (NEETQ)
Depolarising Muscle Relaxant (DMR) Non-Depolarising Muscle Relaxants (NDMR)
Succinylcholine\Suxamethonium\Scoline Benzylisoq-Uinoleum Aminosteroid
Doxacurium Vecuronium
Atracurium Pancuronium
Cisatracurium Pipecuronium
Mivacurium Rocuronium
90 | Anesthesia
Concept 4.2: Depolarising Muscle Relaxant (DMR)
(Most Important Concept)
LEARNING OBJECTIVE:
• To understand the mechanism of action of scoline
• To learn the pharmacokinetics, side effects & uses of scoline under different clinical
situation.
Time Needed
1 read
st
40 mins
2nd read 20 mins
Concept 4.2.1: Mechanism of Action

• Succinylcholine—also called diacetyl choline or Suxamethonium—consists of two
joined ACh molecules.
• Succinylcholine \ Suxamethonium \ scoline is the only depolarizing NMBA available
clinically.
• It has the fastest onset, the shortest duration, and greatest reliability (i.e., narrowest
onset variability around the mean) of any NMBA. (aiimsq,neetq,pgiq)
• Depolarizing muscle relaxants very closely resemble ACh and readily bind to ACh
receptors, generating a muscle action potential.
• Unlike ACh, however, these drugs are not metabolized by acetylcholinesterase, and
their concentration in the synaptic cleft does not fall as rapidly, resulting in a prolonged
depolarization of the muscle end-plate.
• Continuous end-plate depolarization causes muscle relaxation because opening of
perijunctional sodium channels is time limited (sodium channels rapidly “inactivate”
with continuing depolarization)
• After the initial excitation and opening, these sodium channels inactivate and cannot
reopen until the end-plate repolarizes.
• The endplate cannot repolarize as long as the depolarizing muscle relaxant continues
to bind to ACh receptors; this is called a phase I block. (aiimsq)_
• After a period of time, prolonged end-plate depolarization can cause poorly understood
changes in the ACh receptor that result in a phase II block,(aiimsq) which clinically
resembles that of nondepolarizing muscle relaxants.
Concept 4.2.2: Pharmacokinetics

Property Scoline
Onset of Action (Secs) 30-60 Secs (Fastest) [NEETQ]
Duration Of Action (Mins) 3-10 Mins (Shortest) [NEETQ]
Intubating Dose 1-1.5 Mg\Kg
Metabolism Pseudocholinestrase\Butrylcholinestrase\Plasma Cholinestrase [AIIMSQ]
Active Metabolite None
Excretion Renal
Concept 4.2.3: Factors Responsible for Increased duration of Action
of Scoline
• The most favourable and preferred property of scoline for its clinical use is its ultrashort
duration of action.
• Therefore, it is important to know the factors that will cause prolonged duration of
action of scoline:
I. Alteration in Metabolism:
1: HYPOTHERMIA: Decreased rate of hydrolysis of the molecule
2: DECREASE IN PSEUDOCHOLINESTRASE ENZYME (20 mins): Pregnancy, liver
disease, renal failure and certain drugs.
Drugs causing decrease in pseudocholinesterase enzyme

Echothiophate Organophosphate use for glaucoma
Neostigmine Cholinesterase inhibitors
Pyridostigmine
Phenelzine Monoamine oxidase inhibitor
Cyclophosphamide Antineoplastic agent
Metoclopramide Antiemetic/prokinetic agent
Pancuronium Nondepolarizing muscle relaxant
Oral contraceptives Various agents
Esmolol β-Blocker
3: GENETIC ALTERATION IN THE ENZYME: There can be genetic alteration in the
enzyme function that can lead to reduced affinity towards scoline and thus prolonged
duration of action.
2 Types have been recognised:
A: Heterozygous atypical pseudocholinesterase:
▫ One normal and one abnormal gene coding the enzyme.
▫ Duration of scoline is prolonged to 20-30 mins.
B: homozygous atypical pseudocholinesterase:
▫ patients have two copies of the most prevalent abnormal gene (homozygous
atypical) that produce an enzyme with little or no affinity for succinylcholine.
▫ Duration of action can be prolonged to 4-8 hours.
DIAGNOSIS : DIBUCAINE NUMBER : [most important point]
The percentage of inhibition of pseudocholinesterase activity is termed the dibucaine
number
• Dibucaine, a local anesthetic, inhibits normal pseudocholinesterase activity by 80%,
but inhibits atypical enzyme activity by only 20%.
• A patient with normal pseudocholinesterase has a dibucaine number of 80.
• Serum from an individual who is heterozygous for the atypical enzyme is characterized
by an intermediate 40% to 60% inhibition.
92 | Anesthesia
• A homozygote for the most common abnormal allele will have a dibucaine number
of 20.
• The dibucaine number measures pseudocholinesterase function, not the amount of
enzyme.
• Therefore, adequacy of pseudocholinesterase can be determined in the laboratory
quantitatively in units per liter (a minor factor) and qualitatively by dibucaine number
(the major factor).
Treatment:
• Continued mechanical ventilation and sedation until muscle function returns to normal
by clinical signs.
• Administration of Fresh Frozen Plasma can be done to replace plasma enzymes but is
tried as a last resort and not a 1st line management.
II. PHASE II BLOCK:

• It occurs after repeated boluses (>7mg\kg ) or a prolonged infusion(>60mins) of
succinylcholine
• In patients with atypical plasma cholinesterase, Phase II block can develop after a
single dose of the drug.
• The block is characterized by fade of the train-of-four (TOF) twitch response, tetanic
fade and post-tetanic potentiation, which are all features of competitive block.
Concept 4.2.4: Adverse Drug Reactions (AIIMSQ)

Effect Reason Prevention\Treatment
Bradycardia, ventricular ectopy Muscarinic stimulation of SA Atropine
node
Fasciculations Rapid depolarization Self-taming with small dose
of NDMR or deep inhalational
anesthesia
Myalgia Uncoordinated muscle NSAIDS, Opioids, lignocaine
contractions
Raised ICP\IOP\intragastric Tonic contraction of muscles Self-taming with NDMR
pressure
Bronchospasm\urticaria Histamine release Avoid in asthamtics

Malignant hyperthermia Trigger agent
Masseter spasm Tonic contraction of masseter Increase dose of scoline
muscles
Phase II block Large dose & prolonged infusion Mechanical ventilation
hyperkalemia Prolonged depolarization Rapid and transient rise.
No treatment required under
normal patients
HYPERKALEMIA: Scoline administration induces a mild elevation in the plasma level
of potassium of 0.5 mEq/L, however, severe hyperkalemia with attendant cardiac arrest
has been reported in cases in which there is proliferation of immature nAChRs.
Conditions causing susceptibility to succinylcholine-induced hyperkalemia. (most
important concept)
• Burn injury(safe in 1st 24 hours and then unsafe upto 2 years post burns)
• Massive trauma
• Severe intraabdominal infection
• Spinal cord injury
• Encephalitis
• Stroke
• Guillain-Barré syndrome
• Severe Parkinson’s disease
• Tetanus
• Prolonged total body immobilization
• Ruptured cerebral aneurysm.
• Polyneuropathy
• Closed head injury.
• Haemorrhagic shock with metabolic acidosis
• Myopathies (eg, Duchenne’s dystrophy)
Treatment : hyperventilation, IV calcium chloride, and glucose/insulin to shift potassium
intracellularly.
Concept 4.2.5: Indications

Scoline is indicated for rapid attainment of optimal intubating conditions and prevention
of regurgitation and pulmonary aspiration of gastric contents in patients at risk (those
unfasted, with gastroparesis or gastrointestinal obstruction) in the “rapid sequence
induction and intubation” (RSII) scenario.
Concept 4.2.6: Contraindications

1) Hyperkalemia
2) Head injury with raised icp
3) Open eye injury \ glaucoma
4) All trigger for phase II block
5) Myotonica dystrophica(causes severe muscle rigidity, preventing resp. and intubation)
6) Known case of malignant hyperthermia.
7) Children below 8 years of age: potential to induce acute rhabdomyolysis and
hyperkalemia followed by ventricular dysrhythmias, cardiac arrest and death
after administration to pediatric patients who were subsequently found to have
undiagnosed skeletal muscle myopathy, most frequently Duchenne’s.
94 | Anesthesia
Concept 4.3: Non-Depolarising Muscle Relaxant (NDMR)
LEARNING OBJECTIVE:
• To learn the mechanism of action of NDMR and their characteristics.
• To learn the pharmacokinetics and dynamics of NDMR.
Time Needed
1st read 60 mins
2 read
nd
45 mins
Concept 4.3.1: Mechanism of Action (NEETQ)

• Also known as CURARES as they were originally derived from a south American arrow
poison extracted from the bark of a tree.
• Non-depolarizing NMBDs antagonize the action of ACh in a competitive manner at the
postsynaptic nicotinic receptor.
• Binding to one or both α-subunits prevents access by ACh to depolarize the receptor.
• With antagonist block, there is a gradual reduction in end-plate potential until it fails
to reach the threshold to fire off a propagating action potential to produce muscle
contraction causing flaccid paralysis.
Concept 4.3.2: Classification (AIIMSQ)

Class Long Duration Intermediate Duration Short Duration
Aminosteroid Pancuronium Vecuronium
Pipecuronium Rocuronium
Benzylisoquinoleum Doxacurium (Longest) Atracurium Gantacurium (Shortest)
DTC Cisatracurium Mivacurium
Concept 4.3.3: Pharmacokinetics

Relaxant Metabolism Excretion Onset Duration Histamine Vagolytic
Release Effect
Atracurium *Non-specific ester -------- Moderately Intermediate ++++ -
hydrolysis (75%) rapid (<25mins)
*Hoffman’s elimination (3-5mins)
(25%)(AIIMSQ)
Cisatracurium Only Hoffman’s ------ Moderately Intermediate ----- ------
elimination (AIIMSQ) rapid (<25mins)
(3-5mins)
Vecuronium Hepatic Renal Moderately Intermediate ------- -------
rapid (<25mins)
(3-5mins)
Rocuronium No metabolism Bile Fast onset Intermediate ------ +
(60-90secs) (<25mins)
Pancuronium Hepatic Renal Slow onset Long ------- ++++

duration
Mivacurium Pseudocholinesterase ---- Moderately Short +++ -------
rapid duration
(3-5mins) (<20mins)
Concept 4.3.4: Drug Interactions

Increased Potency Decreased Potency
• Antibiotics: streptomycin & neomycin • Chronic anti-epileptic therapy
• Dantrolene • Calcium
• Inhaled Anesthetic Agents: • Anti-cholinesterase drugs
• Desflurane > sevoflurane > isoflurane > halothane
> nitrous oxide
• Hypermagnesemia, Hypokalaemia, Acidosis,
Hypercarbia
• Hypothermia: decreases receptor sensitivity and
ACh mobilization
• decreases the force of muscle contraction
• reducing renal and hepatic metabolism, and the
Hoffman degradation pathway
• Aging
Concept 4.3.5: Indications

1: For Intubation: Rocuronium is a good choice because of fastest onset of action (60-
90 secs)
2: For Maintenance of muscle relaxation: Atracurium & Cisatracurium is be better
choice because of non-organ dependant metabolism.
3: Precurarization \ self-taming: Administration of 1\10th dose of NDMR before
giving scoline to reduce fasciculations & post op myalgia due to scoline.
Preferred agent for this is also rocuronium because similar onset time as compared to
scoline.
Concept 4.3.6: Individual Agents
1: Atracurium & Cisatracurium:

• INTERMEDIATE ACTING BENZYLISOQUINOLEUM DERIVATIVES
• ONSET: MODERATELY RAPID (3-5MINS)
• METABOLISM & ELIMINATION: by two non organ dependant processes:
A: Nonspecific ester hydrolysis in plasma
B: Hoffman’s elimination: non enzymatic spontaneous degradation of the molecule
under physiological ph. and temperature
96 | Anesthesia
Atracurium Cisatracurium
• Racemix mixture of isomers of atracurium • Pure cis isomer of atracurium
• Metabolism by non-specific hydrolysis (75%) & • Only Hoffman’s elimination

Hoffman’s elimination (25%)
• Releases histamine on fast administration(avoided • No histamine release

in asthamatics)
• Less potent than Cisatracurium • 4 times more potent than atracurium
• Risk of laudonosine toxicity (seizure potential) • No risk of laudonosine toxicity
2: Use:
Both are preferred agents in:
• Extremes of age: neonate & elderly
• Patients with known history of neostigmine hypersensitivity
• Patients with organ dysfunction (renal and hepatic failure)
3: Mivacurium:
• Only NDMR which is metabolized by pseudocholinesterase enzyme.
• Therefore, doesn’t need reversal with anti-cholinesterase agents (AOC for Day Care
surgery patients)
• Shortest acting NDMR available for use
• Releases histamine
4: Vecuronium & Rocuronium

Vecuronium Rocuronium
Onset Moderate Fastest (60-90sec)
Duration Intermediate Intermediate
Accumulationn in Renal\ Significant Negligible

Hepatic Failure
Hemodynamic Changes None Slight vagolytic
Pain On Injection None Present
Use Most used agent for maintenance Agent of choice for intubation
phase of muscle relaxation esp. in RSII
Reversal Agent Anticholinesterase & Anticholinesterase &

sugammadex sugammadex
5: D Tubocurarne:
• 1st muscle relaxant to be used clinically
• Associated with histamine release
• Blocked autonomic ganglion as well
6: Doxacurium:
• Longest acting NDMR
• Highly potent
• Exclusive renal excretion
98 | Anesthesia
Concept 4.4: Neuromuscular Monitoring
LEARNING OBJECTIVE:
• To learn the concept of neuromuscular monitoring and its importance in conduct of
anesthesia.
• To learn the pattens of stimulation and their use.
• To learn drugs needed for reversal of muscle relaxation.
• To remember the sensitivity of different muscle groups to the action of muscle
relaxants.
Time Needed
1st read 60 mins
2 read
nd
45 mins
Why do we need to monitor the action of neuromuscular blocking agents?

• Neuromuscular monitoring (NMT) is good guidance to significantly improve the quality
of intubation and reduce airway injury.
• To identify the residual neuromuscular block which is defined by the presence of
signs or symptoms of muscular weakness after administration of NMBAs, even when
neuromuscular blockade is reversed in the operating room.
• Residual neuromuscular block is a frequent occurrence and is associated with serious
complications such as: pharyngeal dysfunction, increased risk for aspiration and
pneumonia, acute respiratory events (hypoxemia, airway obstruction), need of
tracheal intubation, discomfort for patients and surgeons, increased length of stay in
the Post Anesthesia Care Unit (PACU).
• NMT is also useful in choosing the antagonist strategy. When using anticholinesterases
or sugammadex, the choice of the reversal agent must be guided by neuromuscular
monitoring (NMT). Antagonism dosage and injection time can also be optimized by
the proper monitoring of the neuromuscular blockade’s depth.
The degree of neuromuscular block can be assessed by applying a supramaximal stimulus
to a peripheral motor nerve, and then measuring the associated muscular response.
Nerve stimulators (also named peripheral nerve stimulators [PNSs] are generally
battery-operated, handheld units (image) that provide the stimulus via wires connected
to surface (skin) electrodes.
Conditions where neuromuscular monitoring is essential:

• After prolonged infusions of neuromuscular blocking drugs or when long-acting drugs are used
• When surgery or anesthesia is prolonged
• When inadequate reversal may have devastating effects, for example, severe respiratory disease, morbid
obesity.
• In conditions where administration of a reversal agent may cause harm for example, tachyarrhythmias,
cardiac failure.
• Liver or renal dysfunction, when pharmacokinetics of muscular relaxants may be altered.
• Neuromuscular disorders such as myasthenia gravis or Eaton–Lambert syndrome
Image: a TOF watch peripheral nerve stimulator
Image: position of electrodes and movement of adductor pollicis muscle.

100 | Anesthesia
Concept 4.4.1: Stimulator Characteristics & Nerve Muscle
Combination Used
A: Measuring Evoked Muscle Responses:

Assessing muscle responses by visual or tactile means is difficult.
There are several methods for detecting and measuring these evoked responses more
accurately.
• mechanomyography [MMG]: GOLD STANDARD (NEETQ)
• acceleromyograph (AMG): MOST COMMONLY USED
• electromyography [EMG]
B: Nerve and Muscle Combination Used:

The nerve chosen to be stimulated must fulfil a number of criteria.
1. It must have a motor element
2. Second, it must be close to the skin
3. Contraction in the muscle or muscle group which the nerve supplies must be visible
or accessible to evoked response monitoring.
MOST COMMON USED: Ulnar nerve & adductor pollicis muscle (NEETQ)
2nd most common used: facial nerve & orbicularis oculi muscle (NEETQ)
Other nerves used: common peroneal nerve.
Concept 4.4.2: Patterns of Stimulation

• MAXIMAL STIMULUS: The current which generates a response through all nerve
fibres and hence a maximal muscle contraction is termed a maximal stimulus.
• SUPRAMAXIMAL STIMULUS: a current of 25% above the maximal stimulus is
applied when stimulating a peripheral nerve.
A: Single Twitch:
• A single square wave supramaximal stimulus is applied to a peripheral nerve for a
period of about 0.2 ms, at regular intervals.
• Frequency: 1 hz( 1 per sec) or 0.1 hz( 1 per 10 secs)
• Uses: to determine the supramaximal strength of stimulus
• To determine onset of block ( when using 0.1 hz stimulation)
• To elicit post tetanic count
• Limitation: unable to differentiate between depolarising and non-depolarising type of
block.
B: Train of Four:
Application of four supramaximal stimulus over 2 seconds (most important
concept)
• Frequency of stimulations: 2 hz
• Duration between 2 stimuli: 0.5 sec (500 ms)
• Frequency of TOF: 1 every 10 seconds
• Advantages: most common used pattern
• Doesn’t require a control twitch response to compare.
• The motor movement are visible and can be compared easily.
• Less painful than tetany
• Two concepts are useful in TOF: TOF ratio & TOF count. ( discussed later)
C: Tetany:
• Tetanic stimulation uses a high frequency (50–200 Hz) with a supramaximal stimulus
for a set time: normally 5 s.
• This pattern of stimulation is very sensitive and can elicit minor degrees of
neuromuscular block, which is potentially useful in the postoperative recovery room.
• Also used to measure the Post Tetanic Count (PTC)
• However, its use is limited by the fact that tetanic stimulation is extremely painful.
102 | Anesthesia
D: Double Burst Stimulation (DBS):
• Two short bursts of tetanus at 50 Hz at a supramaximal current are applied to a nerve.
• Typically, each burst will have three impulses lasting 0.2 ms.
• Each impulse is delivered every 20 ms and the two bursts are separated by 750 ms
• Advantage is small degrees of residual block may be easier to appreciate with DBS
Concept 4.4.3: C
haracteristics of DMR & NDMR Types of Blocks (NEETQ)
Depolarising Agents Non-Depolarising Agents \ Phase
II of DMR
Fasiculations Present Absent
Single Twitch Response Depression of twitch height Depression of twitch height
Tof Response No fade Fade
Tetanic Response No fade Fade
Post Tetanic Response Not applicable Facilitation
Effect Of Anti Cholinestrase Increase block Decrease block
Repeated Dosing Phase II block No change in character
Evoked responses during depolarizing (phase I and phase II) and

nondepolarizing block.
Concept 4.4.4: M
onitoring and Reversal of Muscle Relaxation [NEETQ]
Knowledge of time course for onset, duration, and recovery of neuromuscular block of
NMBAs is important for optimal patient care.
1: For onset of block: we need laryngeal muscle paralysis for safe intubation.
Single twitch : 75% depression of twitch height is a good parameter to assess
laryngeal muscle paralysis
TOF count: these are number of twitches observed in TOF stimulation.
Normal TOF count : 4
For intubation: tof count needed is 0 or 1.
2: For maintenance phase of relaxation:
It depends on the type of surgery and requirement of relaxation.
For intense block:
TOC count 0 & Post Tetanic Count(PTC) also 0
For moderate block
TOC count 1 or 2 & PTC >1
3: For recovery from NM blockade:
TOF count : 4
TOF ratio: ratio of strength of muscle contraction of 4th response to 1st response.
Normal TOF ratio : 1
Under NDMR: fading is seen so TOF ratio always <1
For administration of reversal agent : TOF ratio 0.7
For safe extubation: TOF ratio >0.9
Correlation between the depth of NM blockade and patterns of stimulation

Depth of Block Post Tetanic Count TOF Count TOF Ratio
(PTC)
Intense Block 0 0 0
Deep Block >1 0 0
Moderate Block Na 1-3 0
Light Block Na 4 0.1-0.4
Minimal Block Na 4 >0.4 But <0.9
Full Recovery Na 4 >0.9 -1.0
104 | Anesthesia
Subjective Monitoring:
Clinical Signs of Recovery:[NEETQ]
1) Sustained Head Lift (>5secs)
2) Sustained Leg Lift (>5secs)
3) Sustained Hand Grip (>5secs)
4) Positive Tongue Depressor Test
5) Negative Inspiratory Pressure of -40 to -50 Cms of Water
Reversal of Muscle Relaxation:

There are two ways of Reversing the Neuromuscular Blockade by NMDR:
1: Increased availabilty of Acetylcholine at the NMJ: Anti Cholinestrase Drugs
[NEETQ]
Blocking or inhibiting the breakdown of ACh at the NMJ results in an increase in the
available pool of ACh at the synaptic cleft and better chances of competing with
the nondepolarizing NMBA for binding to the receptor’s α- subunit; this binding of
ACh to nAChR results in normal transmission.
There are three clinically available acetylcholinesterase inhibitors (anticholinesterase
agents) in clinical use today: neostigmine, edrophonium, and pyridostigmine.
These cholinesterase inhibitors are quaternary compounds and do not cross the
blood–brain barrier in sufficient concentrations to have central effects.
Neostigmine is the most frequently used anticholinesterase agent today.
Because acetylcholinesterase is blocked at all cholinergic synapses, all
cholinesterase inhibitors have significant parasympathomimetic effects.
For this reason, they are generally coadministered with either glycopyrrolate
(which has a slower onset of action like neostigmine) or atropine (which has a
more rapid onset of action similar to edrophonium)
2: Direct Reversal by Neutralising the NMDR Molecule: Sugammadex
Selective Relaxant Binding Agents Sugammadex [AIIMSQ]
Sugammadex is an FDA-approved gamma-cyclodextrin that has been developed
as an selective relaxant binding agent (SRBA).
It is an eight-membered ring with a central cavity that perfectly encapsulates the
steroid nucleus of steroidal intermediate-acting NMBAs (rocuronium>vecuronium
>>pancuronium/pipecuronium) but has no affinity for any of the other depolarizing
or nondepolarizing NMBAs.
USE: Reversal in Patients with Neuromuscular Disorders & reversal of Intense
(Profound) Neuromuscular Block
Concept 4.4.5: Sensitivity of Different Muscles to Relaxants

Most Resistant: (Last to get Blocked)
• Diaphragm > Corrugater Supercilli > Laryngeal Adductors
• Diaphragm is last Muscle to get Blocked and 1st Muscle to Recover.
• Muscle used for Monitoring Laryngeal Adductors: Corrugater Supercilli
Most Sensitive: (Last to Recover)
• Geniohyoid, Masseter, and upper Airway Muscles.
• Muscle used for Monitoring Recovery: Adductor Pollicis
Worksheet
• MCQ OF “NEURO-MUSCULAR BLOCKING AGENTS & MONITORING” FROM DQB

106 | Anesthesia
1: NAME A DEPOLARISING MUSCLE RELAXANT: ____________________________.
2: ONSET AND DURATION OF ACTION OF SCOLINE IS: ___________&____________.
3: DIBUCAINE NUMBER IS __________________________TYPE OF ASSESSMENT

OF ENZYME FUNCTION.
4: SCOLINE IS CONTRAINDICATED IN A BURNS PATIENTS FOR HOW LONG AFTER

THE INJURY: ____________________
5: FASTEST. LONGEST & SHORTEST ACTING NDMR ARE: ______________, _______

_________&_______________________.
6: WHICH PROCESS CONTRIBUTES MAXIMUM TO METABOLISM OF ATRACURIUM:

_______________________
7: MUSCLE RELAXANTS METABOLIZED BY PSEUDOCHOLINESTRASE ARE: ________

____________________________________
8: MOST COMMON NERVE MUSCLE COMBINATION USED TO MONITER NM JUNCTION

IS: _____________________________________
9: MOST COMMON USED PATTERN OF STIMULATION USED FOR NM MONITORING IS:

__________________.
10: LAST MUSCLE TO GET RECOVERED FROM ACTION OF NM BLOCKING AGENTS IS:
_____________________
5 Monitoring Under Anesthesia
CONCEPTS
Â Concept 5.1 Introduction & Classification of Intra
Operative Monitors
Â Concept 5.2 Cardiac Monitors
Â Concept 5.3 Non-Cardiac Monitors
https://t.me/usmle_study_materials_2
108 | Anesthesia
Concept 5.1: Introduction & Classification of Intra Operative Monitors
LEARNING OBJECTIVE:
• To understand the importance & basic standards of monitoring under anesthesia.
• To classify different types of monitoring
Time Needed
1 read
st
10 mins
2 read
nd
05 mins
Image: a typical monitor used intraoperatively
Standards for Basic Anesthetic Monitoring:

ASA has defined certain minimum standards of anesthesia monitoring for all patients
taken up for anesthesia. They apply to all general anesthetics, regional anesthetics and
monitored anesthesia care.
This set of standards addresses only the issue of basic anesthetic monitoring, which is
one component of anesthesia care.
Standard I: Qualified anesthesia personnel shall be present in the room throughout the
conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.
Standard II (“VOTC”): During all anesthetics, the patient’s ventilation, oxygenation,
temperature, circulation and shall be continually evaluated.
• Ventilation: ETCO2, inspired anesthetic gases
• Oxygenation: SpO2 and inspired O2 (oxygen analyser with a low oxygen concentration
limit alarm in use.)
Monitoring Under Anesthesia | 109
• Temperature
• Circulation: Heart Rate & Blood Pressure [every 5 mins], continuous
Electrocardiography
Classification of Intra Operative Monitors

Cardiac Monitors Non-Cardiac Monitors
Invasive arterial blood pressure monitoring Depth of anesthesia monitoring
Electrocardiography Pulse oximetry
Central venous catheterization Capnography
Swan Ganz catheter (pulmonary artery catheter) Temperature monitoring
Cardiac output monitoring
110 | Anesthesia
Concept 5.2: Cardiac Monitors
LEARNING OBJECTIVE:
• To learn cardiac monitoring techniques
• To apply the knowledge of the monitoring technique in conduct of safe anesthesia
• To learn and understand the nuances of each technique and their details.
Time Needed
1 read
st
120 mins
2 read
nd
60 mins
1: Invasive Arterial Blood Pressure Monitoring: monitoring of beat-to-

beat blood pressure by catheterization of an artery.
Indications
• induced, current or anticipated hypotension.
• wide blood pressure deviations
• end-organ disease necessitating precise beat-to-beat blood pressure regulation,
• need for multiple arterial blood gas measurements. [most common in icu]
Contraindications
• smaller end arteries with inadequate collateral blood flow
• suspicion of pre-existing vascular insufficiency.
Selection of Artery for Cannulation:
• Several arteries are available for percutaneous catheterization.
• Allen’s test is a simple, but not reliable, method for assessing the safety of radial
artery cannulation. (NEETQ)
• Alternatively, blood flow distal to the radial artery occlusion can be detected by
palpation, Doppler probe, plethysmography, or pulse oximetry.
• Unlike Allen’s test, these methods of determining the adequacy of collateral circulation
do not require patient cooperation.
Arterial Cannulation Site Clinical Points of Interest
Radial artery Preferred site for monitoring Nontapered catheters
preferred
Ulnar artery Complication similar to radial Primary source of
hand blood flow
Brachial artery Insertion site medial to biceps tendon
Median nerve damage is potential hazard
Can accommodate 18-gauge cannula
Axillary artery Insertion site at junction of pectoralis and deltoid
muscles
Specialized kits available
Femoral artery Easy access in low-flow states Potential for local and
retroperitoneal hemorrhage
Longer catheters preferred
Dorsalis pedis artery Collateral circulation = posterior tibial artery
Higher systolic pressure estimates
Complications
• hematoma
• bleeding (particularly with catheter tubing disconnections)
• vasospasm(NEETQ)
• arterial thrombosis
• embolization of air bubbles or thrombi
• pseudoaneurysm formation
• necrosis of skin overlying the catheter
• nerve damage
• infection
• necrosis of extremities or digits
• unintentional intraarterial drug injection
Image: technique of arterial cannulation

112 | Anesthesia
2: Electrocardiography
Indications & Contraindications
• All patients should have intraoperative monitoring of their electrocardiogram (ECG).
There are no contraindications.
Clinical Considerations
• The ECG is a recording of the electrical potentials.
• generated by myocardial cells.
• Its routine use allows arrhythmias, myocardial ischemia, conduction abnormalities,
pacemaker malfunction, and electrolyte disturbances to be detected.
• Lead V5 alone will detect 75% of ischemic episodes in men 40 – 60 years of age
adding lead V4 increases this to 90%, and the combination of leads II, V4, and V5
(AIIMSQ)add up to a 96% detection rate.
• For ischemia: lead V
• For Arrhythmias: lead II
3: Central Venous Catheterization

Indications (AIIMSQ) Contraindications
1. Monitoring central venous pressure (CVP) 1. Tumours, clots, or tricuspid valve vegetations
that could be dislodged or embolized during
cannulation.
2. Administration of fluid to treat hypovolemia and 2.
Subclavian vein cannulation is relatively
shock. contraindicated in patients who are receiving
anticoagulants (due to the inability to provide
direct compression in the event of an accidental
arterial puncture)
3. Infusion of caustic drugs 3. Cannulation on the side of a previous carotid
endarterectomy
4. Total parenteral nutrition 4. The presence of other central catheters or
pacemaker
5. Aspiration of air emboli
6. Insertion of transcutaneous pacing leads
7. Continuous monitoring of central venous oxygen
saturation
8. Gaining venous access in patients with poor
peripheral veins
Techniques
• Central venous cannulation involves introducing a catheter into a vein so that the
catheter’s tip lies with the venous system within the thorax.
• Generally, the optimal location of the catheter tip is just superior to or at the junction
of the superior vena cava and the right atrium.
• Measurement of CVP is made with a water column (cm H 2 O), or, preferably, an
electronic transducer (mm Hg).
Various sites can be used for cannulation:
1) Basilic vein
2) Internal jugular vein (best combination of ease of insertion, safety, long term
complications)(AIIMSQ)
3) External jugular vein
4) Subclavian vein
5) Femoral vein
Complications:
• line infection
• blood stream infection
• air or thrombus embolism
• arrhythmias (indicating that the catheter tip is in the right atrium or ventricle)
• hematoma
• pneumothorax (Maximum with Subclavian Vein Cannulation) [NEETQ]
• haemothorax
• hydrothorax
• chylothorax
• cardiac perforation
• cardiac tamponade
• trauma to nearby nerves and arteries
• Thrombosis.
4: Swan Ganz Catheter (Pulmonary Artery Catheter) [AIIMSQ, PGIQ,

NEETQ]
114 | Anesthesia
Technique and placement:
• The most popular design integrates five lumens into a 7.5 FR catheter, 110-cm long,
(Q) with a polyvinylchloride body.
The lumens house the following:
• Wiring to connect the thermistor near the catheter tip to a thermodilution Cardiac
Output computer
• an air channel for inflation of the balloon
• a proximal port 30 cm from the tip for infusions, CO injections, and measurements
of right atrial pressures
• a ventricular port at 20 cm for infusion of drugs
• a distal port for aspiration of mixed venous blood samples and measurements
of PA pressure.
• The PA catheter is advanced through the introducer and into the internal jugular vein.
• At approximately 15 cm, the distal tip should enter the right atrium, and a central
venous tracing that varies with respiration confirms an intrathoracic position.
• The balloon is then inflated with air according to the manufacturer’s recommendations
(usually 1.5 mL) to allow the right ventricle’s CO to direct the catheter forward.
• The balloon is always deflated during withdrawal.
• A sudden increase in the systolic pressure on the distal tracing indicates a right
ventricular location of the catheter tip.
• Entry into the pulmonary artery normally occurs by 35–45 cm and is heralded by a
sudden increase in diastolic pressure.
Use of the pulmonary artery catheter.
• Assessment of volume status where CVP unreliable.
• Core body temperature monitoring ( gold standard)[NEETQ]
• Sampling of mixed venous blood to calculate shunt fraction.
• Measurement of cardiac output using thermodilution.[AIIMSQ]
• Derivation of other cardiovascular indices, such as the pulmonary vascular resistance,
oxygen delivery and uptake
Indications for insertion
In normal individuals, CVP correlates with filling pressures of both right and left atria,
this is not true in the following disease states:
• Left ventricular failure with pulmonary oedema
• Interstitial pulmonary oedema
• Chronic pulmonary disease
• Valvular heart disease
Complications
• Arrhythmias on insertion (most common)[PGIQ]
• Knotting of catheter in right ventricle
• Balloon rupture ( most common due to over inflation of balloon)
• Pulmonary infarction
• Infection
Table of Impportant Points: Cardiac Monitoring

1. RADIAL ARTERY: most common used artery for invasive arterial monitoring
2. ALLEN’S TEST: to check the patency of collateral circulation of hand.
3. LEAD II, V4 & V5: best combination of ECG leads for intraoperative myocardial ischemia monitoring.
4. Ideal position of tip of central venous catheter is at the junction of superior vena cava (SVC) & right
atrium (RA)
5. PA catheter measures Pulmonary Capillary Wedge Pressure (PCWP) which is the best indicator of Left
Ventricular End Diastolic Pressure (LVEDP)
6. Gold standard technique to monitor core body temperature is PA catheter.
5: Techniques of Cardiac Output Monitoring:

Classified based on invasiveness:
Invasive techniques:
1.
Pulmonary artery catheter (thermodilution and continuous cardiac output
measurement) [AIIMSQ]
Less invasive techniques:
1. Transpulmonary thermodilution
2. Ultrasound flow dilution
3. Pulse contour and pulse pressure analysis
116 | Anesthesia
4. Respiratory derived cardiac output monitoring system: partial CO2-rebreathing
5. Transoesophageal echocardiography [AIIMSQ]
6. Esophageal Doppler
Non-invasive techniques
1. Transthoracic echocardiography [AIIMSQ]
2. Non-invasive pulse contour systems
3. Bioimpedance
4. Estimated continuous cardiac output
5. Ultrasonic cardiac output monitoring
Concept 5.3: Non-Cardiac Monitors
LEARNING OBJECTIVE:
• To learn about non cardiac monitors
• To know how to assess the depth of anesthesia using eeg based indices.
• To understand the principle, working & importance of pulse oximetry
• To learn different capnography waveforms and their clinical implications
Time Needed
1st read 60 mins
2 read
nd
30 mins
1: Depth of Anesthesia Monitoring

• Depth of anesthesia or depth of hypnosis refers to a continuum of progressive central
nervous system depression and decreased responsiveness to stimulation.
• Depth of anesthesia monitoring is used to avoid 2 complications.
• Very deep anesthesia leading to delayed emergence and cardiovascular
complications.
• Light anesthesia leading to post traumatic stress disorder.
Methods of monitoring depth of anesthesia
A. Clinical techniques and conventional monitoring:
I. Clinical signs:
The most used scoring system incorporates the PRST or Evan›s score
This assesses autonomic activity related to P (systolic blood Pressure), R (heart Rate),
S (Sweating) and T (Tears)
II. Isolated forearm technique: A tourniquet is applied to the patient’s upper arm,
inflated above systolic blood pressure before the administration of muscle relaxants.
Movement of the arm either spontaneously or to command indicated wakefulness,
although not necessarily explicit awareness.
B. Brain electrical activity monitoring:
Most of the devices designed to monitor brain electrical activity for the purpose of
assessing anaesthetic effect record EEG activity from electrodes placed on the forehead.
I: Spontaneous EEG activity monitors:[neetq]
• Bispectral Index
• Entropy
• Narcotrend
• Patient state analyser
II: Evoked brain electrical activity monitors
• Somatosensory evoked potentials (SSEP)
• Visual evoked potentials (VEP)
• Auditory evoked potential (AEP): Gold standard
118 | Anesthesia
Bispectral Index [AIIMSQ]
• BIS is a proprietary algorithm (Aspect Medical Systems, Natick, MA) that converts a
single channel of frontal EEG into an index of hypnotic level (BIS).
• BISpectral Index (BIS) is a frontal processed EEG which is used to monitor the depth
of anesthesia.
• The BIS monitor generates a dimensionless number on a continuous scale of 0-100,
with 100 representing normal cortical electrical activity and 0 indicating cortical
electrical silence.
• It ranges from values 0 to 100 where 100 represents awake patient while 0 is complete
iso electric eeg.
Evoked Brain Electrical Activity Monitors:[AIIMSQ]
• They measure electrical activity in certain areas of the brain in response to stimulation
of specific sensory nerve pathways.
Indications: surgical procedures associated with possible neurological injury
• Spinal fusion with instrumentation
• spine and spinal cord tumour resection
• brachial plexus repair
• thoracoabdominal aortic aneurysm repair
• epilepsy surgery
• cerebral tumour resection.
• Auditory EPs have also been used to assess the effects of general anesthesia on the
brain.
• The middle latency auditory EP may be a more sensitive indicator than BIS
regarding anesthetic depth. [AIIMSQ]
• The amplitude and latency of this signal following an auditory stimulus is influenced
by anesthetics.
• In general, balanced anesthetic techniques (nitrous oxide, neuromuscular
blocking agents, and opioids) cause minimal changes, whereas volatile agents
(halothane, sevoflurane, desflurane, and isoflurane) are best avoided or used
at a constant low dose [NEETQ]
(i) Somatosensory evoked potentials (SSEP):
▫ A supramaximal stimulus is applied to peripheral nerves while a recording scalp
electrode is placed over the appropriate sensory area.
▫ It is most commonly used evoked potential monitor during surgery.
(ii) Visual evoked potentials (VEP):
▫ Light-emitting diodes are incorporated into specialized goggles and the optic
nerve is stimulated at 2 Hz.
▫ This is most affected by the anesthetic agents used.
(iii) Auditory evoked potential (AEP):
▫ The AEP is defined as the passage of electrical activity from the cochlea to the
cortex.
The waveform can be divided into three parts:
• Brainstem Auditory Evoked Potential (BAEP)
• Middle Latency Auditory Evoked Potential (MLAEP): best indicator of depth of
anesthesia
• Long Latency Auditory Evoked Potential (LLAEP).
It is the natural choice for measuring patient consciousness under anaesthetic because
hearing is the last retained sense during anesthesia and the first to be regained prior to
waking.
2: Pulse Oximetry\Plethesmography [AIIMSQ, PGIQ,NEETQ]

• It is one of the most widely used monitors during peri operative period & offers
a unique advantage of non-invasive & continuous monitoring of saturation of
haemoglobin with oxygen,
120 | Anesthesia
• By virtue of its ability to quickly detect hypoxaemia, it has become the standard of
care during anesthesia as well as in the recovery room and intensive care unit.
Pulse oximetry is thus based upon two physical principles:

a) The light absorbance of oxygenated haemoglobin is different from that of reduced
haemoglobin, at the oximeter’s two wavelengths, which include red and near infrared
light
b) The absorbance of both wavelengths has a pulsatile component, which is due to the
fluctuations in the volume of arterial blood between the source and the detector.
Given these two facts, clever engineering techniques have produced an invaluable
monitor.
• Detection of oxygen saturation of haemoglobin by spectrophotometry is based on
Beer-Lambert law, which relates the concentration of a solute to the intensity of
light transmitted through a solution.
• Two wavelengths of light are used: 660 nanometres (red) and 940 nanometres (near
infrared).
• At 660nm, reduced haemoglobin absorbs about ten times as much light as
oxyhaemoglobin.
• At the infrared wavelength, (940nm), the absorption coefficient of oxyhaemoglobin is
greater than that of reduced haemoglobin.
Factors Affecting Pulse Oximeter Readings [Most Important Concept]

False Low Reading False High Reading No Change in Reading
Methemoglobinemia (85%) Carboxyhaemoglobin (COhb) Skin pigmentation
[NEETQ]
Methylene blue dye (65%) SULPH-HB
Indocyanine green dye HB- F\H\S

Peripheral vasoconstriction Jaundice
(shock, hypotension)[NEETQ]
Shivering Fluorescein
Badly positioned probe\ motion Acrylic fingernails
Nail paints (dark blue – max Henna (mehndi)
Purple \ black)[NEETQ]
Anaemia Polycythaemia
3: Capnography: [Most Important Concept]

• Capnometry is the measurement and numeric representation of the CO2 concentration
during inspiration and expiration.
• A capnogram is a continuous concentration–time display of the CO2 concentration
sampled at a patient’s airway during ventilation.
• If the PACO2– PaCO2 gradient is constant and small, capnography provides a non-
invasive, continuous, real-time reflection of ventilation.
• NORMAL VALUE OF CAPNOGRAM IS 35-45 MMHG
Normal Capnogram
122 | Anesthesia
The capnogram is divided into four distinct phases,
• The first phase (A–B) represents the initial stage of expiration. Gas sampled
during this phase occupies the anatomic dead space and is normally devoid of CO2.
• At point B, CO2-containing gas presents itself at the sampling site and a sharp
upstroke (B–C) is seen in the capnogram.
• Phase C–D represents the alveolar or expiratory plateau. At this phase of the
capnogram, alveolar gas is being sampled. Normally, this part of the waveform is
almost horizontal.
• Point D is the highest CO2 value and is called the end-tidal CO2 (ETCO2). ETCO2 is
the best reflection of the alveolar CO2 (PACO2).
• As the patient begins to inspire, fresh gas is entrained and there is a steep
downstroke (D–E) back to baseline. Unless rebreathing of CO2 occurs, the baseline
approaches zero.
Causes of Changes in Partial Pressure of EDN-Tidal Carbon Dioxide
↑Pet CO2 ↓Pet CO2
↑CO2 Production and Delivery to the Lungs ↓CO2 Production and Delivery to the Lungs
Increased metabolic rate Hypothermia

Fever Pulmonary hypoperfusion
Sepsis Cardiac arrest
Seizures Pulmonary embolism
Malignant hyperthermia Hemorrhage
Thyrotoxicosis Hypotension
Increased cardiac output (e.g., during CPR)
Bicarbonate administration
↓Alveolar Ventilation ↑Alveolar Ventilation
Hypoventilation Hyperventilation
Respiratory center depression
Partial muscular paralysis
Neuromuscular disease
High spinal anesthesia
COPD
Equipment Malfunction Equipment Malfunction
Rebreathing Ventilator disconnect

Exhausted CO2 absorber Esophageal intubation
Leak in ventilator circuit Complete airway obstruction
Faulty inspiratory/expiratory valve Poor sampling
Leak around endotracheal tube cuff
Different Types of Capnographic Waveforms
A : normal in controlled mechanical ventilation

B : normal during spontaneous breathing
C : bronchospasm (asthma, COPD) / partially obstructed ET tube or breathing circuit

D:c ardiogenic oscillation at the end of exhalation as flow decreases and the beating
heart causes emptying the different lung regions and back-and-forth motion between
exhaled and fresh gas
E:s pontaneous breathing effort during controlled mechanical ventilation (CURARE

NOTCH)
F : Esophageal intubation
124 | Anesthesia
G : r ebreathing of CO2, as may occur with faulty expiratory valve or exhausted absorber
system
H : faulty inspiratory valve
I : single lung transplant
J : faulty inspiratory valve
K : abrupt onset of a ruptured or leaking ET tube cuff

L : leak in a side stream sample line
FLAT CAPNOGRAM: Sudden and abrupt fall of etco2 to zero

Can be seen in:
• Accidental extubation (most common)
• Disconnection of CO2 transducer
• Sudden cardiac arrest
• Massive pulmonary embolism
126 | Anesthesia
Worksheet
• MCQ OF “MONITORING UNDER ANESTHESIA” FROM DQB

1: THIS TEST IS USED TO CHECK THE PATENCY OF COLLATERAL CIRCULATION OF

HAND: ___________________
2: BEST ECG LEADS TO DIAGNOSE INTRAOPERATIVE ISCHEMIA:_________________
3: IDEAL LOCATION OF TIP OF CVC IS:____________________________
4: PNEUMOTHORAX IS A COMPLICATION OF WHICH CENTRAL VEIN CANNULATION:

__________________
5: LENGTH IS PA CATHETER IS:___________________CMS
6: MOST COMMON COMPLICATION OF PA CATHETER INSERTION IS:_______________
7: MOST COMMON NON INVASIVE WAY TO ASSESS CARDIAC OUTPUT IS

BY:____________________
8: MOST COMMON DEPTH OF ANESTHESIA MONITOR:_____________________
9: BEST MONITOR FOR DEPTH OF ANETHESIA :___________________________
10: IDENTIFY THE CAPNOGRAM AND THE CLINICAL CONDITION IT IS SEEN IN:______
_____________________
128 | Anesthesia
6 Complications Associated
with Anesthesia
CONCEPTS
Â Concept 6.1 Classification of Complications
Â Concept 6.2 Complications Seen During Induction
Â Concept 6.3 Complications Seen During The Conduct
of Anesthesia (Intraoperative)
Â Concept 6.4 Complications Seen Post Operatively
130 | Anesthesia
Concept 6.1: Classification of Complications
LEARNING OBJECTIVE:
• To know different types of complications seen during anesthesia
• To classify them based on the time during the anesthesia when they appear during
the course of anesthesia.
Time Needed
1 read
st
15 mins
2nd read 05 mins
AT INDUCTION INTRA OPERATIVELY POST OPERATIVELY

Aspiration pneumonitis Hypothermia Post-operative nausea & vomiting
(PONV)
Laryngospasm Malignant hyperthermia Post-operative cognitive dysfunction
(POCD)
Bronchospasm Complications due to position of the Delayed recovery from anesthesia
patient
Anaphylaxis Bronchospasm
Anaphylaxis
Complications Associated with Anesthesia | 131
Concept 6.2: Complications Seen During Induction
LEARNING OBJECTIVE:
• To know the complications seen during induction of anesthesia
• To learn in detail about the incidence, pathophysiology, clinical presentation and
management of aspiration pneumonitis, bronchospasm, anaphylaxis & laryngospasm
Time Needed
1 read
st
60 mins
2nd read 30 mins
Concept 6.2.1: Aspiration Pneumonitis \ Mendelson Syndrome

• Aspiration can be defined as the inhalation of material into the airway below the
level of the true vocal cords.
• It is linked with a range of clinical outcomes, being asymptomatic in some instances
and resulting in severe pneumonitis and ARDS in others.
This usually occurs in two phases.
• First: desquamation of the bronchial epithelium causing increased alveolar permeability
resulting in interstitial oedema, reduced compliance and VQ mismatch.
• Second: occurs after 2 to 3 hours, is due to an acute inflammatory response, mediated
by proinflammatory cytokines such as tumour necrosis factor alpha and interleukin 8
and reactive oxygen products.
• Clinically, this may be asymptomatic, or present as tachypnoea, bronchospasm,
wheeze, cyanosis, and respiratory insufficiency. [NEETQ]
Predisposing Factors: [AIIMSQ]

Traditionally two risk factors had been identified i.e., increased gastric volume
(>25ml or 0.4 ml\kg) and\or low pH (<2.5).
PATIENT FACTORS OPERATION FACTORS ANAESTHETIC FACTORS
Increased gastric content. Procedure Airway
• Intestinal obstruction • Emergency • Difficult intubation
• Non-fasted • Laparoscopic • Gas insufflation
• Drugs
• Delayed gastric emptying
Lower oesophageal sphincter Position: Lithotomy Maintenance: Inadequate depth
incompetence
• Hiatus hernia
• Gastro-oesophageal reflux
• Pregnancy
• Morbid obesity
• Neuromuscular disease
Decreased laryngeal reflexes.
• Head injury
• Bulbar palsy
132 | Anesthesia
Prevention:
A: Preoperative fasting: [AIIMSQ]
one of the most common ways of decreasing residual gastric volume is by adequate
fasting before surgery.
ASA guidelines for pre-operative fasting are as follows: [most important concept]
TYPE OF FOOD HOURS OF FASTING
Clear liquid\non pulpy juices 2 hours
Breast milk 4 hours
Light meal \ tea with milk\toast 6 hours
Heavy meal 8 hours
B: Reducing gastric acidity
Histamine (H2) antagonists and proton pump inhibitors (PPIs) are commonly used
to increase gastric pH, although they do not affect the pH of fluid already in the
stomach.
Oral sodium citrate solution reliably elevates gastric pH above 2.5, but it increases
gastric volume, and is associated with nausea and vomiting.
C: Rapid Sequence Induction (RSI): [AIIMSQ\pgiq\NEETQ]
RSI is a method of achieving rapid control of the airway whilst minimising the risk
of regurgitation and aspiration of gastric contents.
Intravenous induction of anesthesia, with the application of cricoid pressure, is
swiftly followed by the placement of an endotracheal tube (ETT).
(i) Indications for RSI
f Unfasted patient or unknown fasting status e.g., trauma patients, emergency
surgery, resuscitation situations and in patients with a reduced conscious
level
f Known gastro-oesophageal reflux such as due to hiatus hernia.
f Conditions leading to delayed gastric emptying e.g., autonomic gastroparesis
(diabetes, Parkinson’s disease), history of gastric banding surgery, patient in
severe pain or with recent administration of opioids.
f Pregnancy (from the second trimester onwards)
(ii) RSI was originally described in 1961 by Sellick as:
f Emptying of the stomach via a gastric tube which is then removed.
f Pre-oxygenation
f Positioning the patient supine with a head-down tilt
f Induction of anesthesia with a barbiturate (e.g., thiopentone) or volatile, and
a rapid-acting muscle relaxant (e.g., suxamethonium)
f Application of cricoid pressure (Sellick’s manoeuvre)
f Laryngoscopy and intubation of the trachea with a cuffed tube immediately
following fasciculations.
(iii) ‘MODIFIED RSI’: In current clinical practice, several modifications have been
made to the traditional RSI technique. The term is sometimes used to describe
such variations, but this term lacks a commonly accepted definition.[AIIMSQ]
Common modifications
f Omitting the placement of an oesophageal tube
f Supine or ramped positioning
f Titrating the dose of induction agent to loss of consciousness
f Use of propofol, ketamine, midazolam, or etomidate to induce anesthesia.
f Use of high dose rocuronium as a neuromuscular blocking agent.
f Omitting cricoid pressure
(iv) Cricoid Pressure [AIIMSQ]
f Cricoid pressure is the application of force to the cricoid cartilage of the
patient.
f The rationale is that the upper oesophagus is occluded by being compressed

between the trachea and the cervical vertebrae, preventing passive reflux of
gastric contents and subsequent development of aspiration pneumonitis.
f 10 Newtons of force is applied by the thumb and index finger of an assistant
increasing to 30N once consciousness is lost.
f This pressure is maintained until endotracheal tube placement is confirmed.
D: Airway device
cuffed endotracheal tube is considered the gold standard device used for airway
protection
E: Emergence:
Care should be taken to ensure that their airway reflexes have fully returned
before extubation occurs.
Management
• Head down tilt [NEETQ] • Oropharyngeal suction
• 100% oxygen • Apply cricoid pressure and ventilate.
• Deepen anesthesia/perform RSI. • Intubate trachea.
• Release cricoid once airway secured. • Tracheal suction
• Consider bronchoscopy. • Bronchodilators if necessary
NO ROLE OF PROPHYLACTIC STEROID & ANTIBIOTICS [AIIMSQ]
134 | Anesthesia
Concept 6.2:2: Bronchospasm & Anaphylaxis
1: Bronchospasm:
• Bronchospasm and wheeze are common features of reactive airways disease.
• Patients with bronchial asthma and some with chronic obstructive pulmonary disease
(COPD) show hyperreactive airway responses to mechanical and chemical
irritants.
• In these groups there is a combination of constriction of bronchial smooth muscle,
mucosal oedema and mucous hypersecretion with plugging.
• Exposure to tobacco smoke, history of atopy and viral upper respiratory tract infection
(URTI) all increase the risk of bronchospasm during anesthesia.
Etiology:
A: Inadequate depth of anesthesia
Manipulation of the airway or surgical stimulation under light anesthesia increases
the risk of bronchospasm(EG: anal or cervical dilatation, stripping of the long
saphenous vein during varicose vein surgery and traction on the peritoneum)
B: Pharmacological[NEETQ]
Pungent volatile anaesthetic agents (isoflurane, desflurane)
IV agents beta-blockers, prostaglandin inhibitors (NSAIDs) and cholinesterase
inhibitors (neostigmine)
Histamine release (thiopentone, atracurium, mivacurium, morphine, meperidine,
d-tubocurarine)
Recognition of Bronchospasm
• Prolonged expiration
• Expiratory wheeze may be auscultated in the chest
• Breath sounds may be reduced or absent
• With IPPV, peak airway pressures are increased, tidal volumes reduced, or both
• With capnography, narrowed airways and prolonged expiration result in a delayed rise
in end-tidal carbon dioxide, producing a characteristic ‘sharkfin’ appearance (Figure
1). [NEETQ]
Fig.: The characteristic ‘Shark-fin’ capnograph suggestive of airway obstruction
Prevention of Bronchospasm
• Known case of asthma: encouraged to continue their medication until the time
of surgery. Preoperative bronchodilators, inhaled or oral corticosteroids, chest
physiotherapy and referral to a respiratory physician
• drug sensitivities: NSAID-induced bronchospasm
• stop smoking preoperatively (Six to eight weeks of abstinence before surgery)
• URTI in children postpone surgery (approximately 2 weeks).
• Pre-treatment with an inhaled/nebulised beta agonist, 30 minutes prior to surgery,
induction of anesthesia with propofol and adequate depth of anesthesia before airway
instrumentation
• The use of an LMA (in suitable patients) has been shown to reduce the incidence of
bronchospasm compared to tracheal intubation.[AIIMSQ]
• Regional techniques where appropriate can also avoid the need for general anesthesia
and intubation.
Management
A: On suspecting bronchospasm
Switch to 100% oxygen
Ventilate by hand
Stop stimulation / surgery
Consider allergy / anaphylaxis; stop administration of suspected drugs / colloid /
blood products
B: Immediate management; prevent hypoxia & reverse bronchoconstriction.
Deepen anesthesia: DOC propofol[AIIMSQ]
If ventilation through ETT difficult/impossible, check tube position and exclude
blocked/misplaced tube.
DRUG THERAPY: DOC: inhaled nebulized salbutamol
Other drugs: ipratropium bromide, magnesium sulphate, hydrocortisone, ketamine,
nebulized \ iv adrenaline
C: Secondary management
Optimise mechanical ventilation
Reconsider allergy/anaphylaxis - expose and examine the patient, review medications
Request & review chest X-ray
Consider transfer to a critical care area for ongoing investigations and therapy
2: Anaphylaxis
• Anaphylaxis is a life-threatening allergic reaction mediated by the release of histamine
and other substances from mast cells after exposure to certain antigens.
• There is a lack of consistent clinical manifestations and hence there is a wide range
of possible clinical presentations.
• In addition, the timing of the reaction in relation to exposure to the triggering agent
can vary.
• Both these facts mean diagnosis can be difficult and a high index of suspicion is
required.
A: Common triggering agents in anesthesia include:
ANTIBIOTICS [MOST COMMON] [AIIMSQ]
Muscle relaxants
136 | Anesthesia
Latex
Antibiotics
Colloids
B: The most common presentations include:
Cardiovascular collapse (88%)[NEETQ]
Erythema (48%)
Bronchospasm (40%)
Angioedema (24%)
Cutaneous rash (13%)
Urticaria (8%)
C: It has been classified clinically into 5 grades:
I. Cutaneous reaction only: urticiaria, erythema, angio-oedema
II. As above but also hypotension, tachycardia or bronchospasm
III. As II but more severe: collapse, arrythmias
IV. Cardiac and/or respiratory arrest
V. Death
D: Immediate management:
STOP triggering agent (if known or suspected)
Call for HELP
Deliver 100% OXYGEN
Exclude airway or breathing circuit obstruction, intubate trachea if not already
done
Give ADRENALINE (epinephrine), either intravenously (IV) or intramuscularly
(IM).
IM adrenaline is less likely to provoke potentially life-threatening arrhythmias, but
may be poorly absorbed if perfusion is compromised, such that the dose may be
ineffective.
IV adrenaline should be carefully titrated to effect and only administered by
anaesthetists familiar with its use.
IV ADRENALINE (1:10000) 50MCG[AIIMSQ]
IM ADRENALINE (1:1000): 500MCG[AIIMSQ]
Give a FLUID bolus of 20ml/kg of crystalloid.
E: Subsequent management
IV Chlorphenamine
IV Hydrocortisone
Bronchodilators such as salbutamol if persistent wheeze
F: Intramuscular versus intravenous route for adrenaline
The IM route is the most appropriate way of administering adrenaline for most
healthcare professionals treating anaphylaxis, in both adults and children.
There is a greater margin of safety, it does not require intravenous access and is
easier to learn.
Concept 6.2.3: Laryngospasm:

• Laryngospasm is a reflex closure of the upper airway caused by adduction of the vocal
cords due to glottic muscular spasm.
• This narrowing of the laryngeal aperture results in partial or complete airway
obstruction.
• If the spasm is sustained, it can result in morbidity such as hypoxia, gastric aspiration,
arrhythmia, pulmonary oedema and cardiac arrest
A: Pathophysiology
the presence of local, mechanical, chemical, or thermal stimuli, which ascend
through the superior laryngeal nerve [AIIMSQ] via sensory fibres of the vagus
nerve.
B: Risk factors for laryngospasm can be divided into three categories:
ANAESTHETIC FACTORS LOCAL STIMULATION OF EXTERNAL FACTORS

THE LARYNX
Inadequate depth of anesthesia Saliva Surgical stimulation

[AIIMSQ]
Irritant volatile agents Blood Moving / transferring patient
Inexperienced anaesthetist Vomitus Anal / cervical stimulation (the

Brewer-Luckhardt reflex)
Foreign bodies
Instruments: including
laryngoscope, laryngeal mask
airways (LMAs) and suction
catheters
C: Differential diagnosis
Bronchospasm
Inhaled foreign body
Laryngeal oedema or trauma
Recurrent laryngeal nerve damage
D: Clinical Features:
Stridor: a harsh high-pitched noise usually heard on inspiration
Use of accessory muscles causing tracheal tug, intercostal and subcostal
recession
Paradoxical respiratory pattern
Decreased tidal volumes
Difficulty in ventilating patient through facemask or LMA
Desaturation and cyanosis
Bradycardia
138 | Anesthesia
E: Management
1: Prevention:
1. recognition of all risk factors already discussed.
2. use of inhalational anesthetic with low pungency.
3. gradual induction technique
4. pre-treatment with fentanyl\morphine
5. use of propofol to blunt laryngeal reflexes.
6. use of lignocaine 1.5mg\kg before intubation & extubation.
7. magnesium sulphate 15mg\kg is preventive.
8. removing secretions or blood, until you are sure that the larynx stays
completely clean.
9. extubation in either deep plane of anesthesia (laryngeal reflexes haven’t
returned back) or completely awake (complete return of reflexes) but never
in light planes of anesthesia
2: Treatment: [most important concept]
▫ Early recognition and prompt treatment is key as oxygen desaturation
occurs quickly in children.
▫ The aim is to maintain oxygenation until the laryngospasm resolves.
▫ It is important to call for help early as the clinical picture can progress rapidly
from mild laryngospasm to complete airway obstruction and cyanosis.
▫ Eliminate the cause if easily identifiable
▫ Ask surgeon to stop
▫ Deepen anesthesia
▫ Remove blood/secretions from airway
▫ Switch to 100% oxygen via an anaesthetic breathing circuit
▫ Open the airway with a firm jaw thrust (this may break the laryngospasm due
to a combination of airway opening and stimulation)[LARSON’S MANEUVER]
▫ Deliver Continuous Positive Airway Pressure (CPAP) if possible by closing the
APL valve.
▫ Attempt gentle bag mask ventilation, ensuring that the stomach is not inflated
in the process, as this will further obstruct ventilation and increase the risk of
regurgitation
▫ If laryngospasm fails to break with above methods give Suxamethonium (up to
2mg/kg IV). An alternative is propofol 0.5mg/kg IV.
▫ Intubation of the trachea may be necessary
▫ Beware hypoxic bradycardia: this may resolve with re-oxygenation, however
one should always have atropine (20mcg/kg) to hand
▫ Once the laryngospasm has resolved, consider inserting a nasogastric tube to
decompress the stomach
Concept 6.3: Complications seen during the Conduct of Anesthesia
(Intraoperative)
LEARNING OBJECTIVE:
• To understand temperature monitoring & intraoperative hypothermia
• To learn in detail about malignant hyperthermia
• To learn and understand the nuances of problems of positioning.
• Pathophysiology & management of venous air embolism.
Time Needed
1 read
st
60 mins
2 read
nd
30 mins
Concept 6.3.1: Temperature Related Complications during Anesthesia:

1: Perioperative Hypothermia And Temperature Monitoring:
• Normal core body temperature is approximately 36.5 – 37.5 degrees celcius
• temperature control is tightly regulated by the body to within 0.2 °C. This is referred
to as the interthreshold range. Within this range, active methods of heating or
cooling are not triggered.
• Temperature signals from the skin, spinal cord, deep abdominal/thoracic tissue, and
other parts of the brain coalesce mainly within the anterior spinal cord and travel to
the primary area of temperature regulation, the hypothalamus.
• The hypothalamus then activates both behavioural and autonomic responses to
temperature changes.
A: Causes of Perioperative Hypothermia
There are many behavioural and autonomic controls of maintaining body
temperature.
Anesthesia disrupts these homeostatic mechanisms EXCEPT SWEATING
(PRESERVED UNDER ANESTHESIA)
The human body loses heat to the atmosphere in four ways:
Radiation: infrared transfer of heat. The most significant heat loss, approximately
60%, occurs by radiation.
Conduction: heat transfer through physical contact with an object (i.e., operating
room table)
Convection: movement of heat based on air flow (i.e., cold air blowing over body)
Evaporation: loss of heat through sweat from skin or fluid loss from exposure of
organs to the open atmosphere
B: Consequences of Perioperative Hypothermia
Blood loss: hypothermia-induced platelet dysfunction and coagulation cascade
enzyme dysfunction
Surgical wound infection
Increased Length of hospital stay and PACU recovery time.
140 | Anesthesia
Decreased drug metabolism: Mild hypothermia impairs temperature-sensitive
enzymes that metabolize and clear anesthetic drugs, thus increasing their duration
of action.
Post anesthesia shivering and thermal discomfort: prevented by:
▫ Doc: meperidine [NEETQ]
▫ Other drugs: magnesium sulphate, clonidine, ketanserin
C: Hypothermia Prevention and Treatment
Passive warming methods: passive insulation, environmental warming, and
closed or semi-closed anesthesia systems.
Active warming requires heat transfer to the patient through warmed fluids,
circuit humidification, radiant heaters, forced or convective air warmers,
infrared lights or circulating hot water system.
Concept 6.3.2: Malignant Hyperthermia [Most Important Concept]

• Malignant hyperthermia (MH) is a rare genetic hypermetabolic muscle disease
• The characteristic phenotypical signs and symptoms of which most commonly appear
with exposure to inhaled general anaesthetics (except nitrous oxide) or
succinylcholine (triggering agents).
• MH may occasionally present more than an hour after emergence from an anaesthetic,
and rarely may occur without exposure to known triggering agents.
A: Drugs known to trigger malignant hyperthermia.[NEETQ]
Inhaled general anaesthetics.
1. Ether
2. Halothane
3. Methoxyflurane
4. Enflurane
5. Isoflurane
6. Desflurane
7. Sevoflurane
Nondepolarizing muscle relaxants
1. Succinylcholine
B: Pathophysiology
The mechanisms of MH has been the gene for the ryanodine (Ryr 1) receptor,
located on chromosome 19. [AIIMSQ]
Ryr 1 is an ion channel responsible for calcium release from the sarcoplasmic
reticulum and it plays an important role in muscle depolarization.
Biochemical causes of MH reveal an uncontrolled increase in intracellular
calcium in skeletal muscle.
The sudden release of calcium from sarcoplasmic reticulum removes the inhibition
of troponin, resulting in sustained muscle contraction.
Markedly increased adenosine triphosphatase activity results in an uncontrolled
increase in aerobic and anaerobic metabolism.
The hypermetabolic state markedly increases oxygen consumption and CO 2
production, producing severe lactic acidosis and hyperthermia.
C: Clinical Manifestations [NEETQ]
Markedly increased Increased Muscle damage Hyperthermia

metabolism sympathetic activity
• Increased CO2 • Tachycardia • Masseter spasm • Fever

production • Hypertension • Generalized rigidity • Sweating
• Increased oxygen • Arrhythmias • Increased serum
consumption creatine kinase
• Reduced mixed venous • Hyperkalaemia
oxygen tension • Hypernatremia
• Metabolic acidosis • Hyperphosphatemia
• Cyanosis • Myoglobinuria
• Mottling • Myoglobinuria
Other complications:
• Acute kidney failure disseminated intravascular coagulation (DIC), cerebral edema
with seizures and hepatic failure.
• Most MH deaths are due to DIC and organ failure due to delayed or no treatment
with dantrolene. [JIPMERQ]
D: Diagnosis:
PREOPERATIVE DIAGNOSIS INTRAOPERATIVE
Gold standard test: halothane caffeine contracture Premonitory sign: masseter spasm after scoline
test [AIIMSQ] administration [AIIMSQ]
Order of appearance of symptoms are: hypercarbia

(30.7%), masseter spasm (24.8%), and sinus
tachycardia (21.1%).
Most sensitive indicator of MH: sudden and abrupt

and massive rise in etco2 [AIIMSQ]
Late sign: hyperthermia
E: Protocol for Immediate Treatment of Malignant Hyperthermia.

1. Discontinue volatile anaesthetic and succinylcholine. Notify the surgeon. Call for
help.
2. Mix Dantrolene sodium with sterile distilled water and administer: BOLUS: 2.5
mg/kg intravenously UPTO 10mg\kg followed by an INFUSION of 1mg \ kg over 6
hours for a minimum of 24 to 48 hours.[NEETQ]
3. Administer bicarbonate for metabolic acidosis
4. Institute cooling measures (lavage, cooling blanket, cold intravenous solutions).
142 | Anesthesia
5. Treat severe hyperkalaemia with dextrose, 25–50 g intravenously, and regular
insulin, 10–20 units Intravenously (adult dose).
6. Administer antiarrhythmic agents if needed despite correction of hyperkalaemia
and acidosis except CCBS (increase hyperkalaemia)
7. Monitor end-tidal CO2 tension, electrolytes blood gases, creatine kinase, serum
myoglobin, core temperature, urinary output, and colour, coagulation status
F: Associations: Duchenne’s and other muscular dystrophies, nonspecific myopathies,
heat stroke, and osteogenesis imperfecta have been associated with MH-like
symptoms.
Differential diagnosis of hyperthermia in the intraoperative and immediate
postoperative periods.
Malignant hyperthermia
Neuroleptic malignant syndrome
Thyroid storm
Pheochromocytoma
Drug-induced hyperthermia
Serotonin syndrome
Iatrogenic hyperthermia
Brainstem/hypothalamic injury
Sepsis
Transfusion reaction
G: Masseter Spasm and Malignant Hyperthermia:
MASSETER SPASM, or trismus, is a forceful contraction of the jaw musculature
that prevents full mouth opening.
The masseter and lateral pterygoid muscles contain slow tonic fibers that can
respond to depolarizing neuromuscular blockers with a contractur
Occurrence of MASSETER SPASM after full dose of Scoline can be a premonitory sign
of malignant hyperthermia and in that case immediately trigger free anesthesia
should be instituted.
Concept 6.3.3: Complications due to Position of the Patient

1: Venous Air Embolism [Very Very Very Important for INICET]
• Any gas can result in embolization if present in the vasculature.
• Its characteristics, mainly its solubility and volume will determine the clinical sequelae.
• Air is the commonest cause for this predominantly iatrogenic complication.
The following are basic definitions of different types of embolism.
• Venous air embolism: air in the venous circulation occluding or impeding distal
flow.
• Arterial air embolism: air in the arterial circulation, occluding arterioles with
resultant distal hypoxaemia.
• Paradoxical air embolism: air crosses from venous to systemic circulation either
via a congenital defect (e.g., a patent foramen ovale, PFO) or via the pulmonary
circulation into the left heart.
A: Risk Factors
Any procedure where the operative site is higher than the right atrium and where the
vasculature is exposed in a surgical field carries a risk of air embolism.
SURGICAL FACTORS ANESTHETIC PATIENT FACTORS

FACTORS
VENOUS AIR • Sitting craniotomy • Central venous access • Trauma: blunt and
EMBOLISM • Posterior fossa • Pressurised infusions penetrating
surgery • Non-primed giving sets • Hypovolaemia
• Spinal surgery • Unrecognised epidural
• Shoulder surgery vein cannulation
• Laparoscopic surgery
(CO2 embolism)
• Caesarean section
• Exteriorisation of the
uterus
B: Clinical Manifestation
Cardiovascular
• An awake patient may experience chest pain and palpitations associated with
arrhythmias, both brady- and tachyarrhythmias are possible.
• Ischaemic ECG changes may be found.
• gradual elevation in pulmonary artery pressure
• right ventricle (RV) outflow tract obstruction and acute right sided heart failure
• compromised left ventricular preload leading to cardiovascular collapse.
Respiratory [AIIMSQ]
• A sudden drop in end tidal carbon dioxide is observed due to the dead space
ventilation caused by air in the pulmonary circulation.
• The degree of ventilation-perfusion mismatch will be revealed as hypoxaemia and
hypercarbia on arterial blood gas analysis.
• Air embolism can also trigger an inflammatory cascade, resulting in an acute lung
injury and non-cardiogenic pulmonary oedema.
• In an awake patient, sudden shortness of breath and pleuritic sub-sternal
chest pain can occur with a dry cough.
• Haemoptysis is a relatively late sign.
Central nervous system
• In an awake patient, there may be sudden onset of confusion, dysarthria, hemiparesis
and seizure.
144 | Anesthesia
C: Monitoring
MODALITY ADVANTAGE DISADVANTAGE
NON-INVASIVE End tidal carbon dioxide • Readily available • Not specific to air
level • Fairly sensitive • Affected by perfusion
pressures and
respiratory pathology
Precordial Doppler • Sensitive and specific • Affected by obesity
[Most Sensitive Non • Easy to position • Interference from
Invasive Modality] diathermy
[Aiimsq] • No indication of
volume of entrainment
• Potentially obscured by
ambient noise, requires
more vigilance
Physiological signs • Routinely monitored. • Poor sensitivity and
• No additional cost specificity
required • Late manifestations
INVASIVE Transoesophageal • Excellent sensitivity • Difficult to differentiate
Echocardiography and can quantify size air from fat/clot
[Most Sensitive Invasive of embolus • Limited availability
Modality] [Aiimsq] • Gold standard for and training
detection of PFO • Expensive
• Equipment in/near
operative field
• Risk of oesophageal
injury
Pulmonary Artery Catheter • Widely available and • Limited specificity for
• reasonably sensitive venous air embolism
• Risk associated with
insertion
• Not conducive to
aspirating air
• Expensive
Central Venous Pressure • Cheap and readily • Complications of
available insertion
• May assist in • Risk of air embolism
management by on insertion and
aspirating air from removal
right atrium.
• administration of
inotropes
D: Clinical Management [AIIMSQ]
To Stop the Furthur Entrapment of Air To Remove Already Entrapped Air
1: inform the surgeon & flood the field with normal 1: aspiration of air through CVC
saline
2: bilateral jugular venous pressure 2: stop nitrous oxide and give 100% oxygen
3: lower the head end of the patient 3: fluid, inotropes & vasopressors to maintain
perfusion
2: Nerve Injuries
• The most injured peripheral nerve is the ulnar nerve.
• Risk factors are male gender, hospital stay greater than 14 days, and very thin or
obese body habitus.
• Most injured peripheral nerve in lower limb is common peroneal nerve which gets
injured during lithotomy \ lateral decubitus position.
Ophthalmic injury during anesthesia:
• Most common: corneal abrasion due to facemask or dryness of cornea
• Most common cause of post-operative vision loss (POVL) is ischemic optic
neuropathy which is seen during prone position & sustained hypotension during
surgery.
146 | Anesthesia
Concept 6.4: Complications Seen Post Operatively
LEARNING OBJECTIVE:
• To understand post-operative nausea and vomiting
• To learn the methods of post-operative recovery and the scales used in it its
assessment.
Time Needed
1 read
st
60 mins
2nd read 30 mins
Concept 6.4:1: Post-Operative Nausea & Vomiting

• Postoperative nausea and vomiting (PONV) is defined as any nausea, retching, or
vomiting occurring during the first 24–48 h after surgery in inpatients.
• PONV is one of the most common causes of patient dissatisfaction after anesthesia,
with reported incidences of 30% in all post-surgical patients and up to 80% in high-
risk patients.
Physiology of Nausea & Vomiting

• Vomiting centres are different structures in brain. They include the chemoreceptor
trigger zone (CRTZ), located at the caudal end of the fourth ventricle in the area
postrema, and the nucleus tractus solitarius (NTS), located in the area postrema and
lower pons.
• The CRTZ receives input from vagal afferents in the gastrointestinal tract, and it can
also detect emetogenic toxins, metabolites, and drugs circulating in the blood and
cerebrospinal fluid due to its lack of the blood–brain barrier
Risk Factors: [AIIMSQ]

APFEL criteria: 4 risk factors have been described.
1: female gender
2: history of PONV and/or motion sickness
3: non-smoking status
4: postoperative use of opioids: Opioids reduce muscle tone and peristaltic activity,
thereby delaying gastric emptying, inducing distension, and triggering the vomiting
reflex.
Surgery related risk:

• gynaecological, ophthalmological, ontological, and thyroid surgery can each increase
the risk of PONV.
• in children, strabismus surgery was identified as an independent risk factor for POV.
Prevention:
• Incidence of PONV is lower following regional rather than general anesthesia especially
with decreased use of opioids.
• The use of nonopioid analgesics may reduce the frequency of emesis while providing
adequate pain control.
• Induction agents such as propofol and barbiturates are associated with reduced
incidence compared to etomidate and ketamine.
• A total intravenous anesthetic (TIVA) technique with propofol greatly reduces PONV
incidence compared to a pure inhalation anesthetic. There is little significant difference
among inhalation agents, although sevoflurane and desflurane might generate slightly
higher rates of nausea.
Antiemetic drugs
First-line antiemetic interventions [AIIMSQ]
1: serotonin antagonists (e.g. ondansetron)[ DRUG OF CHOICE]
2: corticosteroids (e.g. dexamethasone)
3: dopamine antagonists (e.g. droperidol)
4: Neurokinin-1 receptor antagonists[APREPITANT] are a promising new class of
antiemetics that were originally developed and approved for chemotherapy-induced
nausea and vomiting
Second-line antiemetic interventions
1: Metoclopramide
2: Haloperidol is a butyrophenone similar to Droperidol
3: Dimenhydrinate is an antihistamine like promethazine and cyclizine.
4: Transdermal scopolamine is a cholinergic antagonist typically used to treat motion
sickness.
Concept 6.4:2: Postoperative Cognitive Dysfunction [AIIMSQ]

• the term postoperative cognitive dysfunction (POCD), which reflected an objectively
measured decline in cognitive function that typically persists beyond the period
expected for normal recovery from the physiological and pharmacological effects of
anesthesia and surgery
• RISK FACTORS: benzodiazepines, anticholinergics, and meperidine, Pain,
anticholinergics
• Presence of preexisting dementia, cognitive abnormalities, organic brain syndrome,
or hearing and visual impairment predicts postoperative delirium, as does evidence
of physical infirmity such as high ASA physical status or lack of stress response to
surgery.
Concept 6.4:3: Persistent Sedation/Delayed Emergence

• Recovery from anesthesia may be defined as a state of consciousness of an individual
when he is awake or easily arousable and aware of his surroundings and identity.
The entire process of recovery after anesthesia is divided into three phases.
Immediate Recovery
This consists of return of consciousness, recovery of protective airway reflexes, and
resumption of motor activity. This stage usually lasts for a short time.
148 | Anesthesia
Intermediate recovery
During this stage, the patient regains his power of coordination and the feeling of
dizziness disappears. This stage usually lasts for 1 h after short anesthetic. Outpatient
may be considered fit for discharge with a responsible escort.
Long-term recovery
There is a full recovery of coordination and higher intellectual function. It may last for
hours or even days.
Delayed Awakening or Emergence from General Anesthesia

• It is medically defined as a state of unresponsiveness from which the patient cannot
be aroused.
• Risk factors responsible for delayed emergence from anesthesia
Concept 6.4.4: Recovery Protocol after Anesthesia:

Worksheet
• MCQ OF “COMPLICATIONS ASSOCIATED WITH ANESTHESIA” FROM DQB

150 | Anesthesia
1: RISK FACTORS CAUSING ASPIRATION ARE ____________ & _____________.
2: NUMBER OF HOURS OF FASTING FOR A 2 YEAR OLD INFANT ON BREAST MILK IS:
_________________
3: 1ST STEP IN AN EVENT OF APIRATION PNEUMONITIS IS:

_________________________
4: TYPE OF CAPNOGRAM SEEN IN BRONCHOSPASM IS: ________________________
5: MOST COMMON CAUSATIVE AGENT FOR INTRAOPERATIVE ANAPHYLAXIS IS:

_______________________
6: DOSE OF ADRENALINE FOR TREATMENT OF ANAPHYLAXIS IS __________________

IV & ___________________ IM.
7: MOST COMMON ROUTE OF LOSS OF HEAT INTRAOPERATIVELY IS :

______________________
8: DRUG OF CHOICE FOR POST ANESTHESIA SHIVERING IS __________________
9: MOST SENSITIVE INDICATOR OF MALIGNANT HYPERTHERMIA IS

____________________
10: DOSE OF DANTROLENE FOR MANAGEMENT OF MH IS __________________
11: MOST SENSITIVE NON INVASIVE MODALITY FOR DIAGNOSIS OF VAE :

_________________
12: MOST SENSITIVE INVASIVE MODALITY FOR DIAGNOSIS OF VAE: ______________
13: MOST COMMON NERVE INJURED DURING ANESTHESIA IS: ________________
14: DRUG OF CHOICE FOR PONV IS _______________________

7 Local Anesthetics
CONCEPTS
Â Concept 7.1
Anatomy and Physiology of Nerve
Conduction
Â Concept 7.2
Mechanism of Action of Local
Anesthetics
Â Concept 7.3 Structure & Classification (Important
Concept)
Â Concept 7.4 Pharmacokinectics:
Â Concept 7.5 Side Effects & Toxicity
Â Concept 7.6 Important Local Anesthetics and use
152 | Anesthesia
Concept 7.1: Anatomy and Physiology of Nerve Conduction
LEARNING OBJECTIVE:
• To understand the anatomy of a nerve
• To learn the physiology of nerve transmission and important points about the action
of a voltage gated sodium channel
Time Needed
1 read
st
15 mins
2nd read 05 mins
Local and regional anesthesia and analgesia techniques depend on a group of drugs—local anesthetics—that
transiently inhibit sensory, motor, or autonomic nerve function, or a combination of these functions, when
the drugs are injected or applied near neural tissue.
Concept 7.1.1: Anatomy Of Nerves

• Local anesthetics are used to block nerves in the peripheral nervous system (PNS)
and central nervous system (CNS).
• In the PNS, nerves contain both afferent and efferent fibres, which are bundled into
one or more fascicles and organized within three tissue layers.
• Individual nerve fibres within each fascicle are surrounded by the endoneurium, a
loose connective tissue containing glial cells, fibroblasts, and blood capillaries.
• A dense layer of collagenous connective tissue called the perineurium surrounds
each fascicle.
• A final layer of dense connective tissue, the epineurium, encases groups of fascicles
into a cylindrical sheath.
• These layers of tissue offer protection to the surrounded nerve fibres and act as
barriers to passive diffusion of local anesthetics.
• Nerves in both the CNS and PNS are differentiated by the presence or absence of
myelin sheath. Myelinated nerve fibres are surrounded by Schwann cells in the PNS
and by oligodendrocytes in the CNS.
• The cells form a concentrically wrapped lipid bilayer sheath around the axons that
cover the length of the nerve.
• The myelin sheath is interrupted at short regular intervals by specialized regions
called nodes of Ranvier, which contain densely clustered protein elements essential
for transmission of neuronal signals.
• As electrical signals are renewed at each node, nerve impulses move in myelinated
fibers by saltatory conduction.
• In contrast, there are no nodes of Ranvier in nonmyelinated nerve fibers.
• Although these nerve fibers are similarly encased in Schwann cells, the plasma
membrane does not wrap around the axons concentrically.
Local Anesthetics | 153
Fig.: Schematic cross-section of a typical peripheral nerve
Concept 7.1.2: Electrophysiology of Neural Conduction and Voltage-

gated Sodium Channels
• Transmission of electrical impulses along the cell membrane forms the basis of signal
transduction along nerve fibres.
• Neurons at rest are more permeable to potassium ions than sodium ions because
of potassium leak channels.
• Electrical impulses are conducted along nerve fibres as ACTION POTENTIALS.
• They are brief, localized spikes of positive charge, or depolarizations, on the cell
membrane caused by rapid influx of sodium ions down its electrochemical gradient.
• An action potential is initiated by local membrane depolarization.
• The spike in membrane potential peaks around +50 mV, at which point the influx
of sodium is replaced with an efflux of potassium, causing a reversal of membrane
potential, or repolarization.
154 | Anesthesia
Concept 7.2: Mechanism of Action of Local Anesthetics
LEARNING OBJECTIVE:
• To understand the mechanism & site of action of local anesthetics.
• To know the sensitivity of different nerve fibres to local anesthetics.
Time Needed
1 read
st
30 mins
2 read
nd
15 mins
Concept 7.2.1: Site of Action: (Most Important Concept)

• Na channels are membrane-bound proteins that are composed of one large α
subunit, through which Na ions pass, and one or two smaller β subunits.
• Voltage-gated Na channels exist in (at least) three states—resting (nonconducting),
open (conducting), and inactivated (nonconducting) (Figure). (AIIMSQ)
Fig.: Voltage-gated sodium (Na) channels exist in (at least) three states—resting, activated (open),
and inactivated.
Note that local anesthetics bind and inhibit the voltage-gated Na channel from
a site that is not directly accessible from outside the cell, interfering with the
large transient Na influx associated with membrane depolarization.
Concept 7.2.2: Mechanism of Action:

• Local anesthetics bind a specific region of the α subunit and inhibit voltage-gated
Na channels, preventing channel activation and inhibiting the Na influx associated
with membrane depolarization. (AIIMSQ\NEETQ)
156 | Anesthesia
• With increasing local anesthetic concentrations, an increasing fraction of the Na
channels in the membrane bind a local anesthetic molecule and cannot conduct Na
ions as consequence, impulse conduction slows, the rate of rise and the magnitude of
the action potential decrease, and the threshold for excitation and impulse conduction
increases progressively.
• At high enough local anesthetic concentrations and with a sufficient fraction of local
anesthetic-bound Na channels, an action potential can no longer be generated, and
impulse propagation is abolished.
• Local anesthetics have a greater affinity for the channel in the open or
inactivated state than in the resting state. (AIIMSQ)
• Local anesthetic binding to Na channels does not alter the resting membrane
potential. (NEETQ)
Concept 7.3: Structure & Classification (Important Concept)
LEARNING OBJECTIVE:
• To know the basic chemical structure of local anesthetic.
• To learn the classification of local anesthetics based on their chemical structure.
Time Needed
1 read
st
15 mins
2 read
nd
05 mins
• Local anesthetics consist of a lipophilic group (usually an aromatic benzene ring)

separated from a hydrophilic group (usually a tertiary amine) by an intermediate
chain.
• Local anesthetics are weak bases that usually carry a positive charge at the tertiary
amine group at physiological ph.
• The nature of the intermediate chain is the basis of the classification of local anesthetics
as either esters or amides.
Concept 7.3.1: Classification based on Chemical Structure of

Intermediate Chain: (NEETQ\AIIMSQ\PGIQ)
AMINO-ESTERS AMINO-AMIDES
INTERMEDIATE CHAIN Ester Amide
METABOLISM Pseudocholinesterase enzyme Liver
(exception cocaine: by liver) (exception articaine: by
pseudocholinesterase enzyme)
DURATION OF ACTION Shorter acting Longer acting
ALLERGIC POTENTIAL High [due to metabolism into Less
para-amino benzoic acid (PABA)]
EXAMPLES Procaine Lignocaine
Chloroprocaine Bupivacaine
Benzocaine Levo-bupivacaine
Cocaine Ropivacaine
158 | Anesthesia
Concept 7.4: Pharmacokinectics:
LEARNING OBJECTIVE:
• To understand in detail the factors affecting the pharmacokinetics of local anesthetics.
• To classify local anesthetics based on their potency and duration of action.
• To understand how the knowledge of pharmacokinetics can be used to change the
onset and duration of action of local anesthetics.
Time Needed
1 read
st
30 mins
2 read
nd
15 mins
Concept 7.4.1: Potency:

• Correlates with octanol solubility, which in turn reflects the ability of the local
anesthetic molecule to permeate lipid membranes.(AIIMSQ)
• There is no measurement of local anesthetic potency that is analogous to the minimum
alveolar concentration (MAC) of inhalation anesthetics.
• In general, the more lipid soluble an agent is, more is its potency and so longer will
be the duration of action.
Classification Based on duration of Action

Long Acting Intermediate Acting Short Acting
• Dibucaine(longest) • Lignocaine • Procaine (shortest)

• Bupivacaine • Prilocaine • Chloroprocaine
• Levo bupivacaine • Mepivacaine
• Ropivacaine
Increasing the Duration of Action:

Addition of Vasoconstrictor (NEETQ)
• Addition of epinephrine or less commonly phenylephrine causes vasoconstriction at
the site of administration.
• The consequent decreased absorption reduces the peak local anesthetic concentration
in blood, facilitates neuronal uptake, enhances the quality of analgesia, prolongs the
duration of action, and limits toxic side effects.
• Vasoconstrictors have more pronounced effects on shorter-acting than longer-acting
agents.
• Most common vasoconstrictor added is epinephrine which is added as 1:200000
concentration (5 mcg \ml)
• Epinephrine-containing drugs should not be injected intracutaneously or into tissues
supplied by end arteries (fingers, tip of nose, pinna, penis) because the resulting
vasoconstriction can produce ischemia and even gangrene.
Concept 7.4.2: Onset of Local Anesthetic: (NEETQ)
• Onset of action depends on many factors, including lipid solubility and the relative
concentration of the nonionized lipid soluble form (B) and the ionized water-
soluble form (BH +), expressed by the p K a .
• The pKa is the pH at which the fraction of ionized and nonionized drug is equal.
• Less potent, less lipid-soluble agents generally have a faster onset than more potent,
more lipid soluble agents.
• Local anesthetics with a pKa closest to physiological pH will have (at physiological
pH) a greater fraction of nonionized base that more readily permeates the nerve cell
membrane, generally facilitating a more rapid onset of action.
• It is the lipid-soluble form that more readily diff uses across the neural sheath
(epineurium) and passes through the nerve membrane.
• Curiously, once the local anesthetic molecule gains access to the cytoplasmic side of
the Na channel, it is the charged cation (rather than the nonionized base) that more
avidly binds the Na channel.
• For instance, the p K a of lidocaine exceeds physiological ph. Thus, at physiological
Ph (7.40) more than half the lidocaine will exist as the charged cation form (BH +)
• in fact, the agent of fastest onset (2-chloroprocaine) has the greatest p K a of all
clinically used agents , this can be explained by low potency of the drug causing use
in high concentrations and thus more available molecules for diffusion to occur.
Carbonization Of The Drug: (NEETQ)

• Addition of sodium bicarbonate (eg, 1 mL 8.4% sodium bicarbonate per 10 mL local
anesthetic) speeds the onset and improves the quality of the block by increasing the
amount of free base available.
• Interestingly, alkalinization also decreases pain during subcutaneous infiltration.
Concept 7.4.3: Absorption:

Systemic absorption of injected local anesthetics depends on blood flow, which is
determined by the following factors.
1. Site of injection: the rate of systemic absorption is related to the vascularity of
the site of injection: intravenous (or intraarterial) > tracheal > intercostal nerve
block> intrapleural nerve block > caudal epidural> paracervical nerve block > lumbar
epidural > brachial plexus block > sciatic nerve block > subcutaneous infiltration.
(AIIMSQ)
2. Presence of vasoconstrictors: presence of vasoconstrictor decreases the systemic
absorption of local anesthetics and thus decreases the risk of toxicity.
160 | Anesthesia
Concept 7.5: Side Effects & Toxicity
LEARNING OBJECTIVE:
• To know about the local and systemic toxicity of use of local anesthetics.
• To learn the management of local anesthetic systemic toxicity in great detail.
Time Needed
1 read
st
30 mins
2 read
nd
15 mins
Concept 7.5.1: Methmoglobenemia:

• Both benzocaine and prilocaine on metabolism get converted to o toludine which
converts the normal haemoglobin to methaemoglobin.
Concept 7.5.2: Allergic Reactions:

• p-Aminobenzoic acid is one of the metabolites of ester-type compounds that can
induce allergic-type reactions in a small percentage of patients.
Concept 7.5.3: Local Anesthetic Systemic Toxicity (Last):

• Local anaesthetics cause symptoms and signs of toxicity after reaching a toxic level
in the blood and start affecting the CNS followed by CVS.
• The reason for toxicity can be either excessive dose administration or inadvertent
intravascular injection of large amounts of local anaesthetics.
• In general, the CNS is more susceptible to the actions of systemic local anaesthetics
than the cardiovascular system is, and thus the dose or blood level of local anaesthetic
required to produce CNS toxicity is usually lower than that resulting in circulatory
collapse.
(i) CNS toxicity:
▫ Appears before CVS toxicity and always requires lesser dose to develop.
▫ Excitatory symptoms are seen 1st due to inhibition of inhibitory neurons in
frontal cortex.
▫ Later depressive symptoms ensue, rapidly leading to respiratory depression and
death.
▫ Prodromal symptom: circumoral numbness (AIIMSQ)
▫ 1st symptom: light headedness and dizziness followed by auditory and visual
disturbances (tinnitus) followed by finally disorientation and drowsiness.
▫ Signs: tremors, muscular twitching and shivering followed by generalized tonic
clonic seizures eventually leading to respiratory depression and death.
Treatment:
f The mainstay of treatment is termination of seizure using small dose of short
acting benzodiazepine (midazolam) or barbiturate. (AIIMSQ)
f Maintain airway and avoid hypoxia and hypercarbia.
(ii) CVS toxicity:
▫ All local anaesthetics exert dose-dependent negative inotropic action on cardiac
muscle.
▫ Local anaesthetics may depress myocardial contractility by affecting calcium
influx and triggered release from the sarcoplasmic reticulum, as well as by
inhibiting cardiac sarcolemma Ca2+ currents and Na+ currents.
ECG changes:
f Increase in the PR interval and duration of the QRS complex.
f Extremely high concentrations of local anaesthetics depress spontaneous
pacemaker activity in the sinus node, thereby resulting in sinus bradycardia
and sinus arrest.
f The depression of cardiac contractility is roughly proportional to conduction
blocking potency. Thus, bupivacaine and tetracaine are more potent cardio
depressants.
f Cardiac resuscitation is more difficult after bupivacaine- induced cardiovascular
collapse, and acidosis and hypoxia markedly potentiate the cardiotoxicity of
bupivacaine.
Treatment:
f Drug Of Choice: 20% Intralipid (lipid emulsion) [AIIMSQ] given as a
bolus of 1.5 ml \kg followed by an infusion of 0.25 ml \kg\min. max dose of
12 ml \kg can be given safely.
f Many resuscitation drugs, including atropine, epinephrine, bretylium, lidocaine,
amrinone, and phenytoin, have been used but beyond the established uses
of low-dose epinephrine and amiodarone in their designated steps in ACLS
protocol and beyond the use of lipid emulsions there is no established role
for antiarrhythmic drugs or other traditional cardiac resuscitation drugs in the
setting of bupivacaine-induced cardiac arrest.
f Basic CPR should be started immediately, and defibrillation should be
performed as indicated according to advanced cardiac life support (ACLS)
algorithms.
f Rapid institution of extracorporeal cardiopulmonary support and/ or
cardiopulmonary bypass has been lifesaving.
162 | Anesthesia
Concept 7.6: Important Local Anesthetics and use
LEARNING OBJECTIVE:
• To learn the different applications of local anesthetics and relevant doses.
• To learn in brief about different individual local anesthetic agents and their important
uses.
Time Needed
1 read
st
20 mins
2nd read 10 mins
Concept 7.6.1: Uses of Local Anesthetics:

Regional Anesthesia
Regional anesthesia is classified according to the following six sites of placement of the
local anesthetic solution:
(a) topical or surface anesthesia
(b) local infiltration
(c) peripheral nerve block
(d) intra venous regional anesthesia (Bier block)
(e) epidural anesthesia
(f) spinal (subarachnoid) anesthesia.
A: Topical Anesthesia
Local anesthetics are used to produce topical anesthesia by placement on the
mucous membranes of the nose, mouth, tracheobronchial tree, esophagus, or
genitourinary tract.
Nebulized lidocaine is used to produce surface anesthesia of the upper and
lower respiratory tract before fiberoptic laryngoscopy and/or bronchoscopy. Local
anesthetics are absorbed into the systemic circulation after topical application to
mucous membranes.
Eutectic Mixtures of Local Anesthetics(EMLA) which is a mixture of 2.5% lidocaine
base and 2.5% prilocaine base.[AIIMSQ]
This preparation must be applied under an occlusive bandage for 45 to 60 minutes
to obtain effective cutaneous anesthesia.
It is effective in relieving the pain of venepuncture, arterial cannulation, lumbar
puncture, and myringotomy in children and adults.
EMLA cream is not recommended for use on mucous membranes because lidocaine
and prilocaine is absorbed faster through mucous membranes than through intact
skin.
Other Topically Effective Local Anesthetics:
Benzocaine
Cocaine (not used anymore)
Cyclomine
Lignocaine
Tetracaine
EMLA
Proparacaine (duration of anesthesia 15-20 mins): used for topical anesthesia
for ophthalmic surgery. [NEETQ]
B: Local Infiltration Anesthesia
Local infiltration anesthesia involves the extravascular placement of local anesthetic
in the area to be anesthetized.
Lidocaine is the local anesthetic most often selected for infiltration anesthesia.
C: Peripheral Nerve Block Anesthesia
Peripheral nerve block anesthesia is achieved through the injection of local
anesthetic solutions into tissues surrounding individual peripheral nerves or nerve
plexuses, such as the brachial plexus.
When local anesthetic solutions are deposited in the vicinity of a peripheral nerve,
they diffuse from the outer surface (mantle) toward the center (core) of the nerve
along a concentration gradient.
D: Intravenous Regional Anesthesia (Bier Block) [NEETQ]
The intravenous injection of a local anesthetic solution into an extremity isolated
from the rest of the systemic circulation by a tourniquet produces a rapid onset of
anesthesia and skeletal muscle relaxation.
The duration of anesthesia is independent of the specific local anesthetic and is
determined by how long the tourniquet is kept inflated.
Bupivacaine is not recommended for intravenous regional anesthesia, considering
its greater likelihood than other local anesthetics for producing cardiotoxicity when
the tourniquet is deflated at the conclusion of the anesthetic
Drug of choice for bier’s block is prilocaine followed by lignocaine( preservative
free)
E: Epidural Anesthesia
Local anesthetic solutions placed in the epidural or sacral caudal space produce
epidural anesthesia by diffusion across the dura to act on nerve roots and passage
into the paravertebral area through the intervertebral foramina, thus producing
multiple paravertebral nerve blocks.
F: Spinal Anesthesia
Spinal anesthesia is produced by the injection of local anesthetic solutions into the
lumbar subarachnoid space.
Local anesthetic solutions placed into lumbar cerebrospinal fluid act on superficial
layers of the spinal cord, but the principal site of action is the preganglionic fibers
as they leave the spinal cord in the anterior rami.
G: Tumescent Liposuction
The tumescent technique for liposuction characterizes the subcutaneous infiltration
of large volumes (5 or more liters) of solution containing highly diluted lidocaine
(0.05% to 0.10%) with epinephrine (1:100,000).
When highly diluted lidocaine solutions are administered for tumescent liposuction,
the dose of lidocaine may range from 35 mg/kg to 55 mg/kg (“mega-dose
lidocaine”). [AIIMSQ]
164 | Anesthesia
Cocaine
• Extracted from leaves of Erythroxylon Coca (naturally occurring)
• 1st Local anesthetic to be used clinically by Carl Koller who did first eye surgery in
humans using cocaine as local anesthetic.
• Causes vasoconstriction therefore not to be used with adrenaline or IV
• Effects: CNS-stimulation
Eye-mydriasis
• Used as 4% strength for surface analgesia.
• Only ester LA not metabolized by pseudocholinesterase. [NEETQ]
Procaine
• 1-2% concentration is used for nerve blocks.
• Metabolized by pseudocholinesterase.
• LA of choice in patients with history of malignant hyperthermia.
Chloroprocaine
• Contains preservatives in the preparation and so not used for spinal anesthesia
(causes neurotoxicity)
• Shortest acting despite of Highest pKa because of high concentrations of use.
• Most acidic of all LAs
Lignocaine : [Most Important LA]

• Most used LA, pKa-7.8
• Anti-arrhythmic property
Concentration of lignocaine used:

• 4%-Surface (topical) analgesia
• 1%-Nerve blocks
• 0.5%-intravenous regional anesthesia
• 1-2%-Extradural
• 5% heavy -Spinal
• 2%-Jelly for urethral procedures
• Other uses: Used for ventricular arrhythmias (As xylocard 2% 2mg/kg)

• To blunt cardiovascular response to laryngoscopy and intubation
• not to be used in patient with H/O malignant hyperthermia (it releases Ca2+ from
sarcoplasmic reticulum)
• Administration of 5% lidocaine has been associated with neurotoxicity (cauda equina
syndrome) following infusion through small-bore catheters used in continuous spinal
anesthesia.
• This may be due to pooling of drug around the cauda equina, resulting in high
concentrations and permanent neuronal damage.
• neurotoxicity following repeat intrathecal injection is lidocaine = tetracaine >
bupivacaine > ropivacaine.
• Transient neurological symptoms, which consist of dysesthesia, burning pain,
and aching in the lower extremities and buttocks, have been reported following spinal
anesthesia after use of lidocaine for outpatient spinal anesthesia in men undergoing
surgery in the lithotomy position
Bupivacaine
• 2nd most used LA
• Long-acting LA
• Most cardiotoxic LA
• 8 times more potent than xylocaine
Concentration of bupivacaine used:

• Infiltration \nerve blocks\epidural anesthesia: 0.25 % - 0.5 %
• Spinal anesthesia: 0.5 % & 0.75 %
• Labour analgesia: 0.0625 & to 0.125 % [AIIMSQ]
• Cardiotoxic potential is much higher than Xylocaine

• Cardiotoxicity increases in
Pregnancy
hypoxia
hypercapnia
• Not to be used in intravenous regional anesthesia ( risk of cardiovascular toxicity)
Adjuvants
• Adjuvants are used to influence the activity of the local anaesthetic, prolonging, or
enhancing its action.
• Those in clinical use include adrenaline, clonidine, opioids, ketamine,
dexamethasone, dexmedetomidine and midazolam.
• Other than adrenaline, there is a weak evidence base for adding adjuvants to
peripherally administered local anaesthetics.
MAX SAFE DOSE Without adrenaline With adrenaline
LIGNOCAINE 4.5 mg\kg (300 mg) 7mg\kg(500mg)
BUPIVACAINE 2mg\kg (175 mg) 3 mg\kg(225mg)
166 | Anesthesia
Worksheet
• MCQ OF “LOCAL ANESTHETICS” FROM DQB

168 | Anesthesia
1: SITE OF ACTION OF LOCAL ANESTHETICS IS ___________________________
2: ACTIVE FORM OF LOCAL ANESTHETIC IS IONIZED\ UNIONIZED FORM ???
3: FORM OF LOCAL ANESTHETIC RESPONSIBLE FOR ONSET OF ACTION

IS__________________??
4: NERVE FIBRE MOST SUSCEPTIBLE TO THE ACTION OF LOCAL ANESTHETIC

IS___________??
5: METABOLISM OF ESTER LOCAL ANESTHETICS IS BY______________________??
6: LONGEST ACTING LOCAL ANESTHETIC IS______________________??
7: ADDING SODABICARBONATE CAUSES _________________________ TO THE

ACTION OF LOCAL ANESTHETIC?
8: _________________ & _______________ CAN CAUSE METHHEMOGLOBINEMIA

ON LARGE DOSE USE?
9: DRUG OF CHOICE FOR TREATMENT OF CARDIOVASCULAR TOXICITY OF LOCAL

ANESTHETICS IS______________________?
10: EMLA IS A MIXTURE OF __________________&_______________________?
11: MAXIMUM DOSE OF LIGNOCAINE USED FOR TUMESCENT ANESTHESIA

IS_____________________MG\KG?
8 Regional Anesthesia
CONCEPTS
Â Concept 8.1 Types of Regional Anesthesia
Â Concept 8.2 Central Neuraxial Blockade
Â Concept 8.3 Upper & Lower Limb Blocks
Â Concept 8.4 Head & Neck Blocks & Trunkal Blocks
Â Concept 8.5 Ocular Anesthesia
170 | Anesthesia
Concept 8.1: Types of Regional Anesthesia
LEARNING OBJECTIVE:
• To understand different types of regional anesthetic techniques
• To classify different regional anesthetic techniques.
Time Needed
1 read
st
10 mins
2 read
nd
05 mins
CENTRAL NEURAXIAL BLOCK PERIPHERAL NERVE BLOCKS

1: Subarachnoid block 1: Upper limb blocks
2: Epidural block 2: Lower limb blocks
3: Head & neck blocks
4: Truncal blocks
5: Ocular anesthesia
Regional Anesthesia | 171
Concept 8.2: Central Neuraxial Blockade
LEARNING OBJECTIVE:
• To understand relevant anatomy of vertebral column and spinal cord.
• To understand the basic mechanism and physiological changes associated with
conduct of central neuraxial blockade.
• To learn the specifics of procedure and technique of CNB.
• To understand the different complications associated with use of these techniques
along with their use.
• To learn in brief about caudal epidural anesthesia.
Time Needed
1 read
st
90 mins
2 read
nd
45 mins
• Central Neuraxial anesthesia is a type of regional anesthesia that involves injection

of anesthetic medication in the fatty tissue that surround the nerve roots as they exist
the spine (also known as an epidural) or into the cerebrospinal fluid which surrounds
the spinal cord (also known as a spinal).
• This numbs the patient from the abdomen to the toes and often eliminates the need
for general anesthesia.
• James Leonard Corning, a neurologist in New York City, in 1885,1st described the
use of cocaine for spinal anesthesia into a dog.
• Augustus Karl Gustav Bier, a German surgeon, used cocaine intrathecally in 1898
on six patients for lower extremity surgery.
Advantages:
Neuraxial blocks may reduce the incidence of:
• Venous thrombosis and pulmonary embolism.
• Cardiac complications in high-risk patients
• Bleeding and transfusion requirements
• Vascular graft occlusion
• Pneumonia and respiratory depression following upper abdominal or thoracic surgery
in patients with chronic lung disease.
• Neuraxial blocks may also allow earlier return of gastrointestinal function following
surgery.
Proposed mechanisms (in addition to avoidance of larger doses of anesthetics
and opioids) include:
• Amelioration of the hypercoagulable state associated with surgery.
• Sympathectomy mediated increases in tissue blood flow
• Improved oxygenation from decreased splinting
• Enhanced peristalsis, and suppression of the neuroendocrine stress response
to surgery.
172 | Anesthesia
• Postoperative epidural analgesia may also significantly reduce both the time until
extubation and the need for mechanical ventilation after major abdominal or thoracic
surgery.
Concept 8.2.1: Anatomy of Vertebral Column and Spinal Cord.

A: THE VERTEBRAL COLUMN
The spine is composed of the vertebral bones and intervertebral disks.
There are 7 cervical (C), 12 thoracic (T), and 5 lumbar (L) vertebrae.
The sacrum is a fusion of 5 sacral (S) vertebrae, and there are small rudimentary
coccygeal vertebrae.
The spine provides structural support for the body and protection for the spinal
cord and nerves and allows a degree of mobility in several spatial planes.
At each vertebral level, paired spinal nerves exit the central nervous system.
Ventrally, the vertebral bodies and intervertebral disks are connected and
supported by the anterior and posterior longitudinal ligaments.
Dorsally, the ligamentum flavum, interspinous ligament, and supraspinous
ligament provide additional stability.
Using the midline approach, a needle passes through these three dorsal ligaments
and through an oval space between the bony lamina and spinous processes of
adjacent vertebra.
Fig: Anatomy of Spine

Fig: Structures encountered while performing central neuraxial block.
Fig: Surface landmarks useful for conduct of central neuraxial block.

174 | Anesthesia
B: THE SPINAL CORD
The spinal canal contains the spinal cord with its coverings (the meninges), fatty
tissue, and a venous plexus.
The meninges are composed of three layers: the pia mater, the arachnoid mater,
and the dura mater; all are contiguous with their cranial counterparts.
The pia mater is closely adherent to the spinal cord, whereas the arachnoid
mater is usually closely adherent to the thicker and denser dura mater.
Cerebrospinal fluid (CSF) is contained between the pia and arachnoid maters
in the subarachnoid space.
The epidural space is a better-defined potential space within the spinal canal
that is bounded by the dura and the ligamentum flavum.
C: EXTENT:
The spinal cord normally extends from the foramen magnum to the level of lower
border of L1 in adults & In children, the spinal cord ends at upper border L3
and moves up with age. [AIIMSQ]
Terminal end of the spinal cord is called conus medullaris.
Filum terminale: An extension of the pia mater that is attached to the coccygeal
segments.
Bunch of nerve roots distal to conus medullaris is present. These lower spinal
nerves form the cauda equina (“horse’s tail”)
Concept 8.2.2: Mechanism of Action [AIIMSQ]

The principal site of action for neuraxial blockade is believed to be the nerve root.
Local anesthetic is injected into CSF (spinal anesthesia) or the epidural space
(epidural and caudal anesthesia) and bathes the nerve root in the subarachnoid
space or epidural space, respectively.
Direct injection of local anesthetic into CSF for spinal anesthesia allows a relatively
small dose and volume of local anesthetic to achieve dense sensory and
motor blockade.
In contrast, the same local anesthetic concentration is achieved within nerve roots
only with much larger volumes and quantities of local anesthetic molecules
during epidural and caudal anesthesia.
Sympathetic outflow from the spinal cord may be described as thoracolumbar,
whereas parasympathetic outflow is craniosacral.
Neuraxial anesthesia does not block the vagus nerve (tenth cranial nerve).
[NEETQ]
The physiological responses of neuraxial blockade therefore result from decreased
sympathetic tone and/or unopposed parasympathetic tone.
Concept 8.2.3: Systemic Manifestations

A: CARDIOVASCULAR SYSTEM: [Most Important Concept]
Neuraxial blocks produce variable decreases in blood pressure that may be
accompanied by a decrease in heart rate. [NEETQ]
These effects are generally proportional to the dermatomal level and extent of
sympathectomy.
Vasomotor tone is primarily determined by sympathetic fibres arising from T5–
L1, innervating arterial and venous smooth muscle.
Blocking these nerves causes vasodilation of the venous capacitance vessels and
pooling of blood in the viscera and lower extremities, thereby decreasing the
effective circulating blood volume and venous return to the heart.
High sympathetic block not only prevents compensatory vasoconstriction but may
also block the sympathetic cardiac accelerator fibres that arise at T1–T4. [NEETQ]
Profound hypotension may result from arterial dilation and venous pooling
combined with bradycardia. [HIGH SPINAL ANESTHESIA]
Unopposed vagal tone may explain the sudden cardiac arrest sometimes seen
with spinal anesthesia.[AIIMSQ]
Management: [Most Important Concept]

PROPHYLAXIS TREATMENT
Preloading with colloid solution [AIIMSQ] 1: 15-degree head low
2: pregnant female: left uterine displacement
3: crystalloid bolus: 500ml to 1500 ml
4: vasopressors:[AIIMSQ]
Drug of choice in non-pregnant: ephedrine
Drug of choice in pregnant female: phenylephrine
Other agents: atropine, adrenaline,
mephentermine, dopamine, noradrenaline
B: PULMONARY MANIFESTATIONS:
Alterations in pulmonary physiology are usually minimal with neuraxial blocks
because the diaphragm is innervated by the phrenic nerve, with fibers originating
from C3–C5.
High levels of block impair accessory muscles of respiration (intercostal and
abdominal muscles) which can affect patients with severe chronic lung disease.
However rare, respiratory arrest associated with spinal anesthesia is often
unrelated to phrenic or inspiratory dysfunction but rather to hypoperfusion of
the respiratory centers in the brainstem[AIIMSQ]. [total spinal anesthesia]
C: GASTROINTESTINAL MANIFESTATIONS
Neuraxial block-induced sympathectomy allows vagal tone dominance and results
in a small, contracted gut with active peristalsis.
This can improve operative conditions during laparoscopy when used as an adjunct
to general anesthesia.
Hyperperistalsis of bowel is responsible for nausea and vomiting under neuraxial
anesthesia.
Postoperative epidural analgesia with local anesthetics and minimal systemic
opioids hastens the return of gastrointestinal function after open abdominal
procedures.
176 | Anesthesia
D: URINARY TRACT MANIFESTATIONS
Neuraxial anesthesia at the lumbar and sacral levels blocks both sympathetic and
parasympathetic control of bladder function.[AIIMSQ]
Loss of autonomic bladder control results in urinary retention until the block wears
off.
E: METABOLIC & ENDOCRINE MANIFESTATIONS
Neuraxial blockade can partially suppress (during major invasive surgery) or totally
block (during lower extremity surgery) the neuroendocrine stress response.
Neuroendocrine stress response:
▫ Surgical trauma produces a systemic neuroendocrine response via activation of
somatic and visceral afferent nerve fibres, in addition to a localized inflammatory
response.
▫ This systemic response includes increased concentrations of adrenocorticotropic
hormone, cortisol, epinephrine, norepinephrine, and vasopressin levels, as well
as activation of the renin–angiotensin–aldosterone system.
▫ Clinical manifestations include intraoperative and postoperative hypertension,
tachycardia, hyperglycaemia, protein catabolism, suppressed immune responses,
and altered renal function.
Concept 8.2.4: Indications & Contraindications

A: Indications
NEURAXIAL ANESTHESIA NEURAXIAL ANALGESIA
PROCEDURES INVOLVING • intraoperative analgesia
• lower extremities • acute postsurgical pain
• perineum • severe chronic pain associated with malignancy.
• pelvic girdle
• lower abdomen
• intrathecal and/or epidural opioids (alone or in
combination with local anesthetics)
• labour and delivery
• during and after hip or knee replacement
• laparotomy
• thoracotomy
B: Contraindications
ABSOLUTE RELATIVE
Patient refusal Neurologic:
• Myelopathy or Peripheral Neuropathy.
• Spinal Stenosis
• Spine Surgery
• Multiple Sclerosis
• Spina Bifida
Localized sepsis Cardiac:

• Aortic Stenosis or Fixed Cardiac Output
• Hypovolemia
Allergy to any of the drugs Hematologic: [risk of spinal\epidural hematoma]
• Thromboprophylaxis
• Inherited Coagulopathy: [AIIMSQ] haemophilia,
von Willebrand disease, or idiopathic
thrombocytopenic purpura
Patient’s inability to maintain stillness during needle Infection
puncture,
Raised intracranial pressure (risk of brainstem
herniation)
Concept 8.2.5: Technique of the Block

1: Needles:
A: spinal needles: [most important concept]
Needles of different diameters and shapes have been developed for spinal anesthesia.
DURA CUTTING NEEDLES DURA SPLITING NEEDLES

(pencil point needles)
Examples Quinke Sprotte

pitkin Whitacre
Description sharp point with a medium length cutting rounded, noncutting bevel with a solid tip
needle,
Advantages Better feel of structures while inserting Less traumatic so less chances of PDPH
Disadvantages More traumatic so more chances of PDPH High failure rate

[NEETQ]
Dura cutting needles.

178 | Anesthesia
Dura splitting needles.
B: epidural needle:
Most common epidural needle used is touhy’s needle.
These needles are usually 16- to 18-g in size and have a 15- to 30-degree curved,
blunt “Huber” tip designed to both reduce the risk of accidental dural puncture and
guide the catheter cephalad.
The needle shaft is marked in 1-cm intervals so that depth of insertion can be
identified.
The catheter is made of a flexible, calibrated, durable, radiopaque plastic with

either a single end hole or multiple side orifices near the tip.
2: Surface Anatomy & Position of the Patient

• Spinous processes are generally palpable and help to define the midline.
• A line drawn between the highest points of both iliac crests (Tuffier’s line) usually
crosses either the body of L4 or the L4–L5 interspace [AIIMSQ]
• A line connecting the posterior superior iliac spine crosses the S2 posterior Foramina
180 | Anesthesia
Patient Positioning
A. Sitting Position
The anatomic midline is often easier to appreciate when the patient is sitting than
when the patient is in the lateral decubitus position.
Flexion of the spine (arching the back “like a mad cat” maximizes the “target” area
between adjacent spinous processes and brings the spine closer to the skin surface
B. Lateral Decubitus
Patients lie on their side with their knees flexed and pulled high against the
abdomen or chest, assuming a “fetal position.”
C. Buie’s (Jackknife) Position
This position may be used for anorectal procedures utilizing an isobaric or hypobaric
anesthetic solution.
The advantage is that the block is done in the same position as the operative
procedure, so that the patient does not have to be moved following the block.
3: Preparation & Puncture

A: Preparation.
Informed consent must be obtained, with adequate documentation of the
discussion of risk.
Resuscitation equipment must always be readily available whenever a spinal
anesthetic procedure is performed.
The patient should have adequate intravenous access and be monitored with pulse
oximetry, noninvasive arterial blood pressure, and electrocardiogram.
Sterility is an issue of utmost importance.
One of the most common organisms responsible for postspinal bacterial
meningitis is Streptococcus viridans, which is an oral commensal, emphasizing
the purpose of wearing a mask as part of a full aseptic technique.
Chlorhexidine and alcohol together have been concluded to be most effective
antiseptic used to prepare the part of the patient.
B: PUNCTURE
Subarachnoid Block
Since the spinal cord ends at the level of L1-L2 and so needle insertion above this
level should be avoided.
Usually at the L2-L3, L3-L4, or the L4-L5 space [aiims\NEETQ]
The intercristal line is the line drawn between the two iliac crests and traditionally
corresponds to the level of the L4 vertebral body or the L4-L5 interspace.
Structures pierced during sub arachnoid block(using midline technique) [most
important concept]
From outside to inside:
1. Skin
2. Subcutaneous tissues
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Dura (“click” or “pop” sensation) [AIIMSQ]
7. Arachnoid
Dermatomal Level Required for Various Common Surgical Procedures [NEETQ]
Type of Surgery Dermatomal Level
Upper abdominal surgery T4
Cesarean delivery[AIIMSQ] T4
Transurethral resection of prostate T10
Hip surgery T10
Foot and ankle surgery T2
182 | Anesthesia
Epidural Block:
• Patient preparation, consent, position, and approach are usually the same as
subarachnoid block.
• Epidural block can be performed on any level depending on the requirement of surgery.
Suggested Epidural Insertion Sites for Common Surgical Procedures
Nature of Surgery Suggested Level of Insertion
• Hip surgery • Lumbar (L2-L5)
• Lower extremity
• Obstetric analgesia
• Colectomy, anterior resection • Lower thoracic (T6-T8)
• Upper abdominal surgery
• Thoracic • T2-T6
• Difference is in identification of the epidural space and use of touhy’s needle for
epidural catheter insertion.
• Methods to identify epidural space: [most important concept]
1. Loss of resistance to air\saline (most common used)
2. Hanging drop method
3. Ultrasonography
C: SALIENT FEATURES OF EPIDURAL ANESTHESIA:
The epidural space surrounds the dura mater posteriorly, laterally, and anteriorly.
Nerve roots travel in this space as they exit laterally through the foramen and
course outward to become peripheral nerves.
Other contents of the lumbar epidural space include fatty connective tissue,
lymphatics, and a rich venous (Batson’s) plexus.
Epidural anesthesia is slower in onset (10–20 min) and may not be as dense
as spinal anesthesia. [AIIMSQ]
This can be manifested as a more pronounced differential block or a segmental
block, a feature that can be useful clinically.
Differential block: using relatively dilute concentrations of a local anesthetic
combined with an opioid, an epidural provides analgesia without motor block. This
is commonly employed for labour and postoperative analgesia.[AIIMSQ]
Segmental block: characterized by a well-defined band of anesthesia at certain
nerve roots; leaving nerve roots above and below unblocked.
This can be seen with a thoracic epidural that provides upper abdominal anesthesia
while sparing cervical and lumbar nerve roots.
D: BLOCK MONITORING
Assessment of sensory block:
Loss of sensation to cold usually occurs first, verified using an ethyl chloride spray,
ice, or alcohol, followed by the loss of sensation to pinprick, verified using a needle
that does not pierce the skin.
Assessment of Motor block:
the modified Bromage scale is most commonly used, although this represents only
lumbosacral motor fibres.
Modified Bromage Scale
0: No motor block
1: Inability to raise extended leg; able to move knees and feet.
2: Inability to raise extended leg and move knee; able to move feet
3: Complete block of motor limb
4: Factors Affecting the Level of the Block [Most Important Concept]

SPINAL ANESTHESIA EPIDURAL ANESTHESIA
DRUG FACTORS Dose Volume

Baricity Dose
PATIENT FACTORS Csf volume Elderly age

Elderly age Pregnancy
Pregnancy
PROCEDURE FACTORS Patient position Level of injection
A: BARICITY: [AIIMSQ\NEETQ]
Baricity is the ratio of the density of a local anesthetic solution to the density of
CSF.
Local anesthetic solutions that have the same density as CSF are termed isobaric,
those that have a higher density than CSF are termed hyperbaric, and those with
a lower density than CSF are termed hypobaric.
The clinical importance of baricity is the ability to influence the distribution of local
anesthetic spread based on gravity.
The spread of hyperbaric solutions is more predictable & will preferentially spread
to the dependent regions of the spinal canal.
Dextrose and sterile water are commonly added to render local anesthetic solutions
either hyperbaric or hypobaric, respectively.
Isobaric solutions tend not to be influenced by gravitational forces.
Clinical use of Hyperbaric Local Anesthetic Solution: [Most Important

Concept]
• The level of anesthesia is then dependent on the patient’s position during and
immediately following the injection.
• In the sitting position, “SADDLE BLOCK” can be achieved by keeping the patient
sitting for 3–5 min following injection, so that only the lower lumbar nerves and sacral
nerves are blocked.
• UNILATERAL SPINAL ANESTHESIA: The patient is placed laterally, with the
extremity to be operated on in a dependent position.
• If the patient is kept in this position for about 5 min following injection, the block will
tend to be denser and achieve a higher level on the operative dependent side.
184 | Anesthesia
Concept 8.2.6: Caudal Epidural Anesthesia [Most Important Concept]
• Caudal epidural anesthesia is a common regional technique in paediatric patients. It
may also be used for anorectal surgery in adults.
A: INDICATIONS:
In children, caudal anesthesia is typically combined with general anesthesia for
intraoperative supplementation and postoperative analgesia.
It is commonly used for procedures below the diaphragm, including urogenital,
rectal, inguinal, and lower extremity surgery.
B: SURFACE ANATOMY:
The caudal space is the sacral portion of the epidural space.
The patient is placed in the lateral or prone position with one or both hips flexed,
and the sacral hiatus is palpated.
The sacral hiatus may be felt as a groove or notch above the coccyx and between
two bony prominences, the sacral cornua.
The posterior superior iliac spines and the sacral hiatus define an equilateral
triangle.
Caudal anesthesia involves needle and/or catheter penetration of the
sacrococcygeal ligament covering the sacral hiatus that is created by the
unfused S4 and S5 laminae.
Calcification of the sacrococcygeal ligament may make caudal anesthesia difficult
or impossible in older adults. [more than 8 years age]
C: DOSE OF LOCAL ANESTHETIC:

ARMITAGE FORMULA: [most important concept]
This formula is used to calculate the dose of 0.25% bupivacaine that is used for
caudal anesthesia.
BLOCK HEIGHT VOLUME OF BUPIVACAINE (ML\KG)
Lumbosacral 0.5 ml\kg
thoracolumbar 1ml\kg (most common)
Mid thoracic 1.25 ml\kg
Concept 8.2.7: Complications

Complications of neuraxial anesthesia can be classified as follows:
Adverse or exaggerated Complications related to needle/ Drug toxicity
physiological responses catheter placement
Urinary retention Backache Systemic local anesthetic toxicity
Shivering
Nausea & vomiting
High block Dural puncture/leak Transient neurological symptoms
• Postdural puncture headache
• Diplopia
• Tinnitus
186 | Anesthesia
Total spinal anesthesia Neural injury Cauda equina syndrome

• Nerve root damage
• Spinal cord damage
• Cauda equina syndrome
Cardiac arrest Bleeding
• Intraspinal/epidural hematoma
Anterior spinal artery Misplacement
syndrome • No effect/inadequate anesthesia
• Subdural block
• Inadvertent subarachnoid block
• Inadvertent intravascular injection
Horner’s syndrome Catheter shearing/retention
Inflammation
• Arachnoiditis
Infection
• Meningitis
• Epidural abscess
A: URINARY RETENTION
Local anesthetic blockade of the S2, S3, and S4 nerve roots inhibits urinary
function as the detrusor muscle is weakened.
Neuraxial opioids can further complicate urinary function by suppressing detrusor
contractility and reducing the sensation of urge.
B: PRURITUS [most important concept]
It is the most common side effect related to the intrathecal administration of
opioids, with rates between 30% and 100%.
Pruritus occurs more commonly after intrathecal opioid administration than after
intravenous opioid administration and is not dependent on the type or dose of
opioid administered. [AIIMSQ]
The mechanism of pruritus is unclear but is likely related to the central opioid
receptor activation.
C: NAUSEA AND VOMITING
There are multiple possible mechanisms:
direct exposure of the chemoreceptive trigger zone in the brain to emetogenic
drugs (e.g., opioids)
hypotension associated with generalized vasodilation.
gastrointestinal hyperperistalsis secondary to unopposed parasympathetic activity
Among the opioids, morphine administration has the most frequent risk of nausea
or vomiting, whereas fentanyl and sufentanil carry the least frequent risk.
D: HIGH SPINAL & TOTAL SPINAL ANESTHESIA: [most important concept]
HIGH SPINAL: Hypotension associated with profound bradycardia is seen
when the level of block extends to T1 (blocking cardi accelerator fibres).
Unconsciousness, apnea, and hypotension along with the block extending to
cranial nerves is termed as a “total spinal.”
These conditions can also occur following attempted epidural/caudal anesthesia if
there is accidental intrathecal injection.
Apnea is more often the result of severe sustained hypotension and medullary
hypoperfusion than a response to phrenic nerve paralysis from anesthesia of C3–
C5 roots.
Treatment of an excessively high neuraxial block involves:
maintaining an adequate airway and ventilation and supporting the circulation.
When respiratory insufficiency becomes evident, in addition to supplemental
oxygen, assisted ventilation, intubation, and mechanical ventilation may be
necessary.
Hypotension can be treated with rapid administration of intravenous fluids, a
head-down position, and intravenous vasopressors.
Bradycardia can be treated early with atropine.
Ephedrine or epinephrine can also increase heart rate and arterial blood pressure.
E: POST–DURAL PUNCTURE HEADACHE [Most Important Concept]
A relatively common complication of neuraxial anesthesia is post–dural puncture
headache.
As the name implies, post–dural puncture headache is believed to result from
unintentional or intentional puncture of the dura membrane in the setting of
neuraxial anesthesia or after myelography and diagnostic lumbar puncture.
I) Mechanism: There are two possible explanations for the cause of the headache.
▫ First, the loss of CSF through the dura is proposed to cause traction on pain-
sensitive intracranial structures as the brain loses support and sags.
▫ Alternatively, the loss of CSF initiates compensatory yet painful intracerebral
vasodilation to offset the reduction in intracranial pressure.
II) Clinical Features:
▫ Cardinal symptom is headache: frontal or occipital headache.
▫ worsens with the upright or seated posture.
▫ relieved by lying supine.
Associated symptoms:
f nausea, vomiting
f neck pain
f dizziness
f tinnitus
f diplopia
f hearing loss
f cortical blindness
f cranial nerve palsies, and even seizures.
III) ONSET: within 3 days of the procedure
IV) Spontaneous resolution: usually occurs within 7 days in the majority & almost
all by 6 months.
▫ Post–dural puncture headache can occur in the setting of either spinal or epidural
anesthesia.
▫ The latter associated with unintentional puncture of the dura by advancing the
Tuohy needle.
188 | Anesthesia
V) RISK FACTORS FOR PDPH [Most Important Concept]
Factors that Increase Incidence of PDPH
I. AGE Young > old age
II. SEX Females > males
III. NEEDLE SIZE Larger > smaller
IV. NEEDLE BEVEL Less when the needle bevel is placed in the long axis
of the neuraxis
V. PREGNANCY More when pregnant
VI. DURAL PUNCTURES More with multiple punctures
VI) MANAGEMENT: [most important concept]
Conservative management:
▫ supine positioning
▫ hydration
▫ caffeine
▫ oral analgesics
▫ Sumatriptan has also been used with varying effect but is not without side
effects.
Definitive Treatment \ Treatment of Choice \ Best Treatment:

• Epidural blood patch is the definitive therapy for post–dural puncture headache[AIIMSQ]
• Epidural blood patch is ideally performed 24 hours after dural puncture and after the
development of classic symptoms.
• It involves injection of 20 ml of patient own blood into the epidural space.
• Coagulation of blood seals the dural hole and thus decreases the leak of csf and so
the symptoms of pdph.
F: SPINAL OR EPIDURAL HEMATOMA
Clinically significant spinal hematoma can occur following spinal or epidural
anesthesia, particularly in the presence of abnormal coagulation or a bleeding
disorder.
The onset of symptoms is typically more sudden than with epidural abscess.
Symptoms include sharp back and leg pain with a motor weakness and/or sphincter
dysfunction.
Recovery is good in patients who have undergone surgical decompression within
8–12 hr.
G: INFECTION
Bacterial meningitis and epidural abscess are rare, but potentially catastrophic,
infectious complications of all neuraxial techniques.
Staphylococcal infections arising from the patient’s skin are one of the most
common epidural-related infections.
whereas oral bacteria such as Streptococcus viridans are a common cause of
infection after spinal anesthesia
Concept 8.3: Upper & Lower Limb Blocks
LEARNING OBJECTIVE:
• To understand relevant anatomy of brachial plexus and different approaches to
brachial plexus block.
• To understand the basic anatomy of lumbar plexus and the nerves coming off it.
• To understand different approaches to blocking nerves in lower limbs.
Time Needed
1 read
st
45 mins
2 read
nd
30 mins
Block Techniques
1: Field Block Technique
A field block is a local anesthetic injection that targets terminal cutaneous nerves
Field blocks are used commonly by surgeons to minimize incisional pain and may
be used as a supplementary technique or as a sole anesthetic for minor, superficial
procedures
Eg: superficial cervical plexus for procedures involving the neck or shoulder.
the intercostobrachial nerve for surgery involving the medial upper extremity
proximal to the elbow (in combination with a brachial plexus nerve block)
the saphenous nerve for surgery involving the medial leg or ankle joint
2: Paraesthesia Technique
Using known anatomic relationships and surface landmarks as a guide, a block
needle is placed in proximity to the target nerve or plexus.
3: Nerve Stimulation Technique
For this technique, an insulated needle concentrates electrical current at the
needle tip.
When the insulated needle is placed in proximity to a motor nerve, muscle
contractions are induced, and local anesthetic is injected.
4: Ultrasound Technique
Visualizing the nerves\plexus under ultrasonographic guidance and then depositing
the local anesthetic in its proximity.
Considered to be the best and safest mode of performing nerve blocks
Contraindications to all types of blocks:

1: patient refusal
2: severe coagulopathy
3: infection at the site of needle insertion
4: local anesthetic allergy
190 | Anesthesia
Concept 8.3.1: Upper Extremity Peripheral Nerve Blocks
[Most Important Concept]
• Brachial plexus is most blocked for upper extremity surgery.
• There are different approaches to brachial plexus black depending on the site of
injection and the level at which the plexus is blocked.
• Brachial plexus is formed from the anterior primary rami of cervical nerves C5 to C8
and 1st thoracic nerve.
• It is formed in the neck and descends into the arm via axilla.
• Functionally it is divided into roots, trunks, cords and terminal nerves.
Interscalene Supraclavicular Infraclavicular Axillary Approach

Approach Approach Approach
Part Of Plexus Trunks Trunks & cords Cords Terminal

Blocked Nerves(radial,
median,ulnar)
Anatomical Between anterior Lateral to subclavian Medial & inferior to Around axillary
Landmark & middle scalene artery coracoid process artery
(interscalene
groove)
Area Of Analgesia Shoulder & Everything below mid Everything below mid Everything below
proximal humerus humeral level humeral level mid humeral level
Sparing Ulnar None None Musculocutaneous

nerve(C8-T1) nerve
Axillary &
medial brachial
cutaneous nerve
Indications Shoulder & upper Below elbow surgery Below elbow surgery Below elbow
arm surgery surgery
Complications Most common: Most common: phrenic Arterial puncture Axillary artery
phrenic nerve block nerve block (60%) pneumothorax puncture
(100%) Most specific:
Others: pneumothorax
Vertebral artery
injection
Carotid puncture
Epidural injection
Horner’s syndrome
• In all approaches to brachial plexus block, Intercostobrachial nerve[T2]

(supplying medial side of arm) is spared.
Fig: Different approaches to brachial plexus block
Concept 8.3.2 Lower Extremity Peripheral Nerve Blocks

A: ANATOMY:
The lumbosacral plexus divides into four nerves (femoral, lateral femoral
cutaneous, obturator, and sciatic), which entirely innervate the lower extremity.
The femoral nerve provides sensation and motor function to the anterior thigh.
It continues as the saphenous nerve to provide sensation to the medial leg, foot,
and great toe.
The lateral femoral cutaneous nerve supplies sensation in the lateral thigh.
The obturator nerve supplies sensory to the medial thigh and motor to the thigh
adductors.
Five nerves provide sensory and motor to the foot:
Saphenous nerve supplies sensation to the medial foot and a portion of the
great toe
Deep peroneal supplies the web space between the great toe and the second toe
Superficial peroneal nerve supplies the majority of the dorsum of the foot and
toes
Sural nerve supplies the lateral foot and a portion of the fifth toe
Posterior tibial nerve divides into the medial and lateral plantar nerves, and
supplies the sole and plantar surface of the toes.
B: INDICATION:
Lower extremity blocks are useful in providing targeted anesthesia to the hip,
knee, ankle, or foot.
Particularly in patients for whom general or neuraxial anesthesia are contraindicated,
local blocks may be a useful alternative to provide adequate analgesia.
C : Femoral Nerve Block:
The term 3-in-1 block refers to anesthetizing the femoral, lateral femoral cutaneous,
and obturator nerves with a single injection below the inguinal ligament;
192 | Anesthesia
The femoral nerve can be blocked deep to the fascia iliaca just caudad and medial
to the anterior superior iliac spine (fascia iliaca compartment) or at the femoral
crease
Femoral Nerve Block
D: ADDUCTOR CANAL BLOCK:

The saphenous nerve can be blocked
at the mid-shaft femur (adductor
canal) or with a field block at the
tibial plateau
E: SCIATIC NERVE BLOCK:
The sciatic nerve is blocked in the
gluteal region (classical approach)
between the greater trochanter and
ischial tuberosity, just deep to the
gluteus muscles and superficial to
the quadratus femoris
Sciatic Nerve Block (Classic Approach)

F: ANKLE BLOCK:
A complete block of the foot can be accomplished at the ankle with five injections.
The saphenous nerve is blocked anterior to the medial malleolus.
The deep peroneal nerve is blocked at the anterior ankle between the extensor
hallucis longus and extensor digitorum longus.
The superficial peroneal nerve is blocked anterior to the lateral malleolus.
The sural nerve is blocked between the lateral malleolus and the Achilles tendon.
The posterior tibial nerve is blocked posterior to the medial malleolus.
Ankle Block
G: PUDENDAL NERVE BLOCK [most important concept][AIIMSQ]

Blocking the pudendal nerve (transvaginal)
The sensory and motor innervation of the perineum: pudendal nerve( S2-S4)
Target:
• pudendal nerve trunk as it enters the lesser sciatic foramen, (1 cm inferior and medial
to the attachment of the sacrospinous ligament to the ischial spine)
• Here, the nerve is medial to the internal pudendal vessels.
Indications:
• Analgesia for the second stage of labor
• Repair of an episiotomy or perineal laceration
• Outlet instrument delivery (to assist with pelvic floor relaxation)
• Minor surgeries of the lower vagina and perineum
Equipments:
• Iowa trumpet or similar guide (eg, Kobak) to facilitate the placement of the needle
• Needle, usually 6 in, 20-22 gauge
• Syringe with finger ring, 10 mL
• Local anesthetics (eg, lidocaine 1%)
194 | Anesthesia
POSITION: lithotomy
Block:
• The single injection is done nearly 1 cm through the sacrospinous ligament medial
and posterior to the ischial spine.
Concept 8.4: Head & Neck Blocks & Trunkal Blocks
LEARNING OBJECTIVE:
• To understand relevant anatomy of nerves in head and neck and block technique for
superficial cervical plexus block.
• To learn about different truncal blocks and their use.
Time Needed
1 read
st
45 mins
2nd read 30 mins
A: Superficial Cervical Plexus Block
The superficial cervical plexus block provides cutaneous analgesia for surgical
procedures on the neck, anterior shoulder, and clavicle.
It is helpful to identify and avoid the external jugular vein.
The cervical plexus is formed from the anterior rami of C1–4, which emerge from
the platysma muscle posterior to the sternocleidomastoid.
It supplies sensation to the jaw, neck, occiput, and areas of the chest and shoulder.
Fig: superficial cervical plexus block injection
B: INTERCOSTAL NERVE BLOCK [most important concept][AIIMSQ]

Anatomy: Intercostal nerve T1-T11 nerve roots
Branches
Posterior cutaneous branch : supplies paravertebral muscles and skin
196 | Anesthesia
Lateral cutaneous branch : supplies skin of lateral aspect of chest
Anterior cutaneous branch : supplies breasts and anterior chest and abdominal
wall
Neurovascular bundle lies immediately inferior to rib and consists of vein, artery
and nerve from superior to inferior
Indications
▫ Anesthesia
f Chest drain insertion, gastrostomy insertion
f Other minor thoracic or abdominal procedures
▫ Analgesia
f Fractured ribs
f Thoracotomy or laparotomy as adjuvant technique
Needle placement
• Sitting, lateral or prone positions
• Identify line of lateral margin of paravertebral muscles (6-8 cm lateral to midline)
• Posterior axillary line can be used in some patients

• Count ribs to identify correct level
• insert needle over rib and walk needle off inferior edge of rib
• Blockade of the two dermatomes above and the two below the level of surgical incision
is required
Local anaesthetic
• Long-acting agent with adrenaline
• 2-5 ml of solution per nerve
• Care with total dose as absorption is rapid
Complications
Pneumothorax
• Rare despite risks of entering pleura as the needle used is small
• Managed conservatively
Local anaesthetic toxicity
• Minimize with adrenaline-containing solution
• Very short duration of action due to high vascularity
C: Paravertebral Block
Paravertebral block is a technique where local anaesthetic is injected into the
space adjacent to the vertebrae to block the spinal nerves as they emerge from the
intervertebral foramen.
Here the spinal nerves are devoid of covering fascia making them sensitive to the action
of local anaesthetic.
Anatomy:
The Thoracic paravertebral space is a wedge shaped space adjacent to the Thoracic
vertebral column. The boundaries of the space are:
• Medial – the vertebral body and intervertebral foramen.
• Antero-lateral – Pleura.
• Posterior – Costo-transverse ligament and the internal intercostal membrane laterally.
These two structures are continuous with one another.
198 | Anesthesia
Complications:
• Inadvertent vascular puncture
• Hypotension
• epidural or intrathecal spread
• pleural puncture
• pneumothorax
D: Transversus Abdominis Plane Block
The transversus abdominis plane (TAP) block is most often used to provide
surgical anesthesia for minor, superficial procedures on the lower abdominal wall,
or postoperative analgesia for procedures below the umbilicus.
The subcostal (T12), ilioinguinal (L1), and iliohypogastric (L1) nerves are targeted
in the TAP block, providing anesthesia to the ipsilateral lower abdomen below the
umbilicus
Fig.: Diagram of transverse section of abdominal wall during landmark TAP block performance
(N. needle; ST, subcutaneous tissue; EO, External oblique muscle; IO, internal oblique; TA, transversus
abdominis; LD latissumis dorsi; QL, quadraus lumborum)
Concept 8.5: Ocular Anesthesia [Most Important Concept]
LEARNING OBJECTIVE:
• To understand different types of ophthalmic blocks and their use and complications.
• To know about a common complication encountered during ocular surgery i.e OCULO
CARDIAC REFLEX.
Time Needed
1 read
st
15 mins
2nd read 10 mins
Ocular Anesthesia
TOPICAL SUB TENONS PERIBULBAR RETROBULBAR
ANESTHESIA (Episcleral) BLOCK BLOCK BLOCK
(EXTRACONAL) (INTRACONAL)
• Instillation of LA • Tenon’s fascia • Extra-conal • Local anesthetic
eye drops provides surrounds the globe injection of local is injected behind
corneal anesthesia and extraocular anaesthetic the eye into the
• Quick and simple to muscles. • 2-point injection cone formed by the
perform • Local anesthetic technique is used extraocular muscles
• Lack of akinesia injected beneath the • Advantages less risk • Facial nerve &
and intraocular tenon’s capsule of penetration of the trochlear nerve
pressure control • Spread: circularly globe, optic nerve, (superior oblique) :
around the sclera and and artery, and less SPARED
to the extraocular pain on injection. • Hyaluronidase
muscle sheaths • Disadvantages (3–7 U/mL), added
slower onset and an to enhance the
increased likelihood retrobulbar spread
of ecchymosis of LA
• Safer as compared to • Highest risk of
retrobulbar block complications among
all blocks.
TOPICAL LOCAL Safest of the 3 types of Complications

ANESTHETIC: blocks Retrobulbar hemorrhage
PROPARACAINE: Most common used Subconjunctival edema
Duration of action: 15- block now for ocular (chemosis)
20 mins (aiims) surgeries Perforation of the globe
Optic nerve atrophy
Intravascular injection
with resultant convulsion
Central spread of local
anesthetic
Oculocardiac reflex
200 | Anesthesia
Oculocardiac Reflex: [Most Important Concept]
• The Oculocardiac reflex, also known as Aschner phenomenon, Aschner reflex,
or Aschner–Dagnini reflex, is a decrease in pulse rate associated with traction
applied to extraocular muscles and/or compression of the eyeball.
• It can elicit a wide variety of cardiac dysrhythmias ranging from bradycardia and
ventricular ectopy to sinus arrest or ventricular fibrillation.
• This reflex consists of a trigeminal (V1) afferent and a vagal efferent pathway.
• The oculocardiac reflex is most encountered in pediatric patients undergoing
strabismus surgery, although it can be evoked in all age groups and during a variety of
ocular procedures, including cataract extraction, enucleation, and retinal detachment
repair.
• This reflex consists of a trigeminal (V1) afferent and a vagal efferent pathway.
• Intravenous anticholinergic medication is often helpful in preventing the oculocardiac
reflex.
• Management of the oculocardiac reflex when it occurs includes:
1. immediate notification of the surgeon and temporary cessation of surgical
stimulation until heart rate increases
2. confirmation of adequate ventilation, oxygenation, and depth of anesthesia
3. administration of intravenous atropine (10 mcg/kg) if bradycardia persists
• The reflex eventually fatigues (self- extinguishes) with repeated traction on the
extraocular muscles.
Worksheet
• MCQ OF “REGIONAL ANESTHESIA” FROM DQB

202 | Anesthesia
1: TUFFIER’S LINE CROSSES WHICH PART OF THE VERTEBRAL CANAL:___________

_________________
2: SPINAL CORD ENDS AT ____________________ LEVEL IN CHILDREN.
3: SITE OF ACTION OF SPINAL\EPIDURAL BLOCK :__________________________
4: HIGH SPINAL ANESTHESIA IS ASSOCIATED WITH :_______________________
5: TOTAL SPINAL ANESTHESIA IS ASSOCIATED WITH : _______________________
6: DRUG OF CHOICE FOR SPINAL INDUCED HYPOTENSION IN PREGNANT FEMALE

IS:____________________
7: EPIDUAL NEEDLE MOST COMMONLY USED IS: ________________________
8: DERMATOMAL LEVEL OF BLOCK REQUIRED FOR TURP SURGERY IS:

____________________
9: MOST COMMON METHOD USED TO IDENTIFY EPIDURAL SPACE IS:

_____________________
10: VOLUME OF BUPIVACAINE USED FOR CAUDAL EPIDURAL ANALGESIA IN A 3 YEAR

OLD 15 KG CHILD WILL BE:
11: TREATMENT OF CHOICE FOR POST DURAL PUNCTURE HEADACHE IS:
12: MOST COMMON COMPLICATION OF INTERSCALENE APPROACH TO BRACHIAL

PLEXUS BLOCK :____________________
13: PNEUMOTHORAX IS SEEN MOST COMMONLY WITH WHICH APPROACH TO

BRACHIAL PLEXUS BLOCK:_____________________
14: 1ST STEP IN THE MANAGEMENT OF OCULOCARDIAC REFLEX IS: ______________

____________________
9 Miscellaneous Topics in
Anesthesia & Intensive Care
CONCEPTS
Â Concept 9.1 Opioids in Anesthesia
Â Concept 9.2 Perioperative Fluid Therapy
Â Concept 9.3 Pain Management
Â Concept 9.4 Anesthetic Considerations In
Special Situations
Â Concept 9.5 Mechanical Ventilation & Oxygen
Therapy
204 | Anesthesia
Concept 9.1: Opioids in Anesthesia
LEARNING OBJECTIVE:
• To learn the pharmacology of commonly used opioids
• To understand specific use of opioids in anesthesia.
Time Needed
1 read
st
45 mins
2 read
nd
30 mins
• Opioids are the most potent painkillers available in modern medicine.

• Traditionally opioids are used in perioperative care by anesthesiologists to attenuate
autonomic responses to noxious (surgical) stimulation and treat acute postoperative
pain.
Concept 9.1.1: Mechanism of Action

• Opioids produce their actions at a cellular level by activating opioid receptors.
• These receptors are distributed throughout the central nervous system (CNS) with
high concentrations in the nuclei of tractus solitarius, peri-aqueductal grey area (PAG),
cerebral cortex, thalamus and the substantia gelatinosa (SG) of the spinal cord.
• Opioid receptors are coupled with inhibitory G-proteins and their activation has a
number of actions including closing of voltage sensitive calcium channels; stimulation
of potassium efflux leading to hyperpolarization and reduced cyclic adenosine
monophosphate production.
• Overall, the effect is a reduction in neuronal cell excitability that in turn results in
reduced transmission of nociceptive impulses.
Concept 9.1.2: Opioid Receptor & Classification of Opioids

A: OPIOID RECEPTOR
The following is the current nomenclature for identification of the opioid receptors,
approved by the International Union of Pharmacology.
• MOP - μ (mu) opioid peptide receptor
• KOP - κ (kappa) opioid peptide receptor
• DOP - δ (delta) opioid peptide receptor
• NOP (nociceptin orphanin FQ peptide receptor)
B: CLASSIFICATION OF OPIOIDS: [Most Important Concept]
TRADITIONAL ORIGIN FUNCTION
STRONG: NATURALLY OCCURING PURE AGONISTS
• morphine • Morphine • Morphine
• pethidine • Codeine • fentanyl
• fentanyl • Papaverine • alfentanil
• alfentanil • thebaine • remifentanil
• remifentanil • sufentanil
• sufentanil
Miscellaneous Topics in Anesthesia & Intensive Care | 205
INTERMEDIATE SEMISYNTHETIC PARTIAL AGONISTS

• Buprenorphine • diamorphine • buprenorphine
• Pentazocine • dihydrocodeine
• Butorphanol • buprenorphine
• nalbuphine
WEAK SYNTHETIC AGONIST- ANTAGONIST
• codeine • Phenylpyperidines: codeine • pentazocine
pethidine, fentanyl, alfentanil, • nalbuphine
sufentanil • nalorphine
• Diphenylpropylamines: methadone,
dextropropoxyphene
• Morphinans: butorphanol,
levorphanol
• Benzomorphans: pentazocine
PURE ANTAGONISTS
• Naloxone
• naltrexone
Concept 9.1.3: Pharmacokinetics & Pharmacodynamics of Opioid

A: PHARMACOKINETICS
MORPHINE PETHIDINE FENTANYL ALFENTANIL REMIFENTANIL
Relative lipid 1 28 580 (max) 90 50
solubility
Metabolism Liver\kidney Liver Liver Liver RBC & tissue
estrases
B: PHARMACODYNAMICS:
CENTRAL NERVOUS CARDIOVASCULAR RESPIRATORY OTHER
SYSTEM SYSTEM SYSTEM
Analgesia Mild bradycardia Respiratory depression Nausea & vomiting
sedation Peripheral vasodilatation Cough suppression Meiosis (pupillary
constriction)
Euphoria & dysphoria Histamine release &
itching
Hallucinations Muscle rigidity
Tolerance & Depressed immunity
dependence
Neonatal respiratory
depression
206 | Anesthesia
Concept 9.1.4: Anesthetic Techniques Using Opioids [Most Important
Concept]
1: ANALGESIA: for perioperative analgesia and as an adjuvant for regional anesthesia
2: SEDATION: Morphine, fentanyl, and sufentanil are frequently used intravenous
analgesic agents in the ICU.
3: BALANCED ANESTHESIA
Inclusion of an opioid as a component of balanced anesthesia can reduce preoperative
pain and anxiety, decrease somatic and autonomic responses to airway manipulations,
improve hemodynamic stability, lower requirements for inhaled anesthetics, and
provide immediate postoperative analgesia.
4: TOTAL INTRAVENOUS ANESTHESIA
5:
Concept 9.1.5: Some Important Opioids

1: MORPHINE
Strong natural opioid agonist
Routes: iv\im\oral\rectal\intrathecal\epidural\subcutaneous
Least lipid soluble
Metabolism: liver: M3G (morphine 3 glucuronide) & M6G (active)
Excretion: renal
Effects
▫ The main effects are mediated through MOP receptors.
▫ It is a potent analgesic with good sedative and anxiolytic properties.
▫ It may cause euphoria, dysphoria and hallucination.
▫ It produces respiratory depression and cough suppression.
▫ It has minimal effect on cardiovascular system and may produce bradycardia
and hypotension.
▫ Nausea and vomiting are common side-effects.
▫ Histamine release may lead to rash, itching and bronchospasm (in susceptible
patients).
▫ Meiosis is common.
▫ Tolerance and dependence may develop.
2: FENTANYL
Most potent: 100 times more potent than morphine.
Highly lipid soluble: 500 times more lipid soluble than morphine
Most commonly used opioid.
All routes of administration: iv\im\oral\rectal\intrathecal\epidural\subcutaneous
Chest wall rigidity (fast and high dose administration)
Fentanyl is also available as a transdermal patch for chronic pain conditions and
as a lollipop to premedicate children.
Large doses (50- 100 microgram/kg) have been used for cardiac surgery to
obtund metabolic stress response. At such high doses, sedation is profound, and
unconsciousness may occur [STRESS FREE ANESTHESIA]
In addition, muscular rigidity of the chest wall may affect ventilation.
3: ALFENTANIL
Alfentanil is a synthetic phenylpiperidine derivative structurally related to fentanyl
it has 10-20% of its potency.
useful for short term analgesia and attenuation of the cardiovascular response to
intubation
lower lipid solubility than fentanyl
onset of action is more rapid.
Effects
Most effects of alfentanil are similar to fentanyl but with quicker onset and shorter
duration of action.
4: REMIFENTANIL
It is a synthetic phenylpiperidine derivative of fentanyl with similar potency but is
ultra-short-acting.
Pharmacokinetics
▫ Remifentanil is rapidly broken down by non-specific RBC and tissue estrases
resulting in a short elimination half-life (3-10 minutes).
▫ It is context insensitive, in that the half-life, clearance and distribution are
independent of duration and strength of infusion.
Effects
▫ ADVANTAGES: rapid onset, rapid offset, organ independent metabolism and
lack of accumulation make it suitable for use during various surgical procedures.
DISADVANTAGES: it should be used cautiously at higher rates of infusion
as serious side effects for example bradycardia, hypotension, apnoea and
muscle rigidity may occur.
208 | Anesthesia
▫ Since there is no residual effect, alternative postoperative analgesic regimen
should be established before infusion is terminated.
5: TRAMADOL
Tramadol is phenylpiperidine analogue of codeine.
It is weak agonist at all opioid receptors.
It inhibits neuronal reuptake of norepinephrine.
It potentiates release of serotonin and causes descending inhibition of
nociception [AIIMSQ].
In equi-analgesic dose to morphine, tramadol produces less respiratory and
cardiovascular depression than morphine.
Constipation is less common.
Tramadol is contra-indicated in patients on MAOI or with a history of epilepsy.
6: BUPRENORPHINE
Buprenorphine is 30 times more potent than morphine.
It is highly lipid soluble and is well absorbed sublingually.
As buprenorphine has extremely high affinity for MOP receptors, its effects are not
completely reversed by naloxone.
Nausea and vomiting are severe and prolonged.
7: PENTAZOCINE
Pentazocine has 25% of the analgesic potency of morphine.
It is not very effective in relieving severe pain, and this may be partly because of
absence of euphoriant effect.
It produces an increase in heart rate and blood pressure.
Nausea, vomiting, bizarre dreams and hallucinations are more common than
morphine.
8: MEPERIDINE\ PETHIDINE- UNIQUE OPIOID
Synthetic, strong, pure opioid agonist
Anti-muscarinic property (tachycardia, drying of secretions)
Local anesthetic properties
Metabolism in liver (ester hydrolysis) produce norpethidine (active, more potent
than pethidine)
Norpethidine excretion renal
Accumulation in renal failure (seizures)
Histamine release (bronchospasm\ urticaria)
Contraindicated with mao inhibitors causes cheese reaction.
Doc for prevention &treatment of post-operative shivering
Opioid Antagonists
Naloxone and its longer acting derivative naltrexone occupy opioid receptors, but
they have essentially no intrinsic activity at these receptors
Naloxone
Naloxone is a pure opioid agonist and will reverse opioid effects at
MOP, KOP and DOP receptors, although its affinity is highest at
MOP receptors.
It is the drug of choice for the treatment of opioid induced respiratory depression.
The usual dose is 200-400mcg intravenously, titrated to effect.
Smaller doses (0.5-1.0mcg.kg-1) may be titrated to reverse undesirable effects
of opioids, for example itching associated with the intrathecal or epidural
administration of opioids, without significantly affecting the level of analgesia.
The duration of effective antagonism is limited to around 30 minutes and therefore
longer acting agonists will outlast this effect and further bolus doses or an infusion
(5-10mcg.kg-1.h-1) will be required to maintain reversal
Caution must be used in opioid addicts as giving naloxone may cause an acute
withdrawal state with hypertension, pulmonary oedema and cardiac arrhythmias
210 | Anesthesia
Concept 9.2: Perioperative Fluid Therapy
LEARNING OBJECTIVE:
• To understand the fluid physiology in the body
• To classify different types of fluids and their importance
• To learn about colloids and crystalloids.
Time Needed
1 read
st
30 mins
2 read
nd
10 mins
Goal:
• Provide the appropriate amount of parenteral fluid to maintain intravascular volume
and cardiac preload, oxygen-carrying capacity, coagulation status, acid-base
homeostasis, and electrolyte balance.
• To make up for surgical losses like blood loss, evaporative loss, third spacing.
Types of IV Fluids:
Intravenous fluid therapy may consist of infusions of crystalloids, colloids, or a
combination of both.
1. Crystalloids:
aqueous solutions of ions (salts) with or without glucose
crystalloid solutions rapidly equilibrate with and distribute throughout the entire
extracellular fluid space and for the most part remain intravascular
half-life of a crystalloid solution is 20–30 min eg: 0.9% normal saline, ringers
lactate solution(RL) , plasmalyte, 5% dextrose, dextrose normal saline( DNS)
HYPOTONIC FLUIDS ISOTONIC HYPERTONIC
D5W NS D5 1\2 NS
1\2 NS D5 1\4NS D5NS
RL D5 LR
PLASMALYTE HYPERTONIC SALINE ( 3%, 7%, 11.5%)
2. Colloids:
high-molecular-weight substances such as proteins or large glucose polymers
Colloid solutions help maintain plasma colloid oncotic pressure
most colloid solutions have intravascular half-lives between 3 and 6 h
CRYSTALLOIDS COLLOIDS
INTRAVASCULAR VOLUME EXPANSION BETTER
INTERSTITIAL VOLUME EXPANSION BETTER
PULMONARY EDEMA SIMILAR POTENTIAL SIMILAR POTENTIAL
PERIPHERAL EDEMA COMMON UNCOMMON
ALLERGIC REACTIONS RARE COMMON
COST CHEAP EXPENSIVE
Several generalizations can be made:
1. Crystalloids, when given in sufficient amounts, are just as effective as colloids in
restoring intravascular volume.
2. Replacing an intravascular volume deficit with crystalloids generally requires three to
four times the volume needed when using colloids.
3. Surgical patients may have an extracellular fluid deficit that exceeds the intravascular
deficit.
4. Severe intravascular fluid deficits can be more rapidly corrected using colloid solutions.
5. The rapid administration of large amounts of crystalloids (>4 5 L) is more frequently
associated with tissue edema.
Crystalloid Solutions
Crystalloids are usually considered as the initial resuscitation fluid in patients with
hemorrhagic and septic shock, in burn patients, in patients with head injury (to maintain
cerebral perfusion pressure), and in patients undergoing plasmapheresis and hepatic
resection.
Choice of fluid is according to the type of fluid loss being replaced.
1. For losses primarily involving water, replacement is with hypotonic solutions, also
called maintenance-type solutions.
hypotonic solutions must be administered slowly to avoid inducing hemolysis.
Five percent dextrose in water (D 5 W) is used for replacement of pure water
deficits and as a maintenance fluid for patients on sodium restriction.
Glucose is provided in some solutions to maintain tonicity or prevent ketosis and
hypoglycemia due to fasting.
Children are prone to developing hypoglycaemia (<50 mg/dL) following 4- to 8-h
fasts.
Dextrose containing fluids have to be avoided in head injury patients as they
increase cerebral edema and worsen outcome.
2. If losses involve both water and electrolytes, replacement is with isotonic electrolyte
solutions, also called replacement-type solutions.
Because most intraoperative fluid losses are isotonic, replacement-type solutions
are generally used.
A. Lactated Ringer’s solution: The most commonly used fluid for replacement.
f Slightly hypotonic
f Providing approximately 100 mL of free water per liter and tending to lower
serum sodium
f Least effect on extracellular fluid composition
f Most physiological solution when large volumes are necessary.
f The lactate in this solution is converted by the liver into bicarbonate.
B. 0.9% Normal Saline: isotonic fluid
f high sodium and chloride content (154 mEq/L). When given in large volumes,
normal saline produces a dilutional hyperchloremic acidosis.
f Normal saline is the preferred solution for hypochloremic metabolic alkalosis
and for diluting packed red blood cells prior to transfusion.
C. Hypertonic 3% saline: therapy of severe symptomatic hyponatremia
212 | Anesthesia
Colloid Solutions
• The osmotic activity of the high-molecular-weight substances in colloids tends to
maintain these solutions intravascularly.
• It should be noted that colloid solutions are prepared in normal saline (Cl − 145 154
mEq/L) and thus can also cause hyperchloremic metabolic acidosis
Indications for Colloids:

1. Fluid resuscitation in patients with severe intravascular fluid deficits (eg, hemorrhagic
shock) prior to the arrival of blood for transfusion
2. Fluid resuscitation in the presence of severe hypoalbuminemia or conditions associated
with large protein losses such as burns.
3. Blood loss be replaced on a milliliter-per-milliliter basis with colloid solutions (including
blood products).
Several colloid solutions are generally available.
I) NATURAL:
1) ALBUMIN (5% and 25% solutions):
Blood-derived
heated to 60°C for at least 10 h to minimize the risk of transmitting hepatitis and
other viral diseases.
Occasionally resulted in allergic hypotensive reactions.
II) SYNTHETIC:
1. Gelatins are associated with histamine mediated allergic reactions and are not
available in the United States.
2. Dextran is available as dextran 70 & dextran 40, which have average molecular
weights of 70,000 and 40,000, respectively
Although dextran 70 is a better volume expander than dextran 40, the latter
also improves blood flow through the microcirculation, presumably by decreasing
blood viscosity.
Antiplatelet effects are also described for dextrans
Infusions exceeding 20 mL/kg per day can interfere with blood typing, may prolong
bleeding time, and have been associated with kidney failure.
Dextrans can also be antigenic, and both mild and severe anaphylactoid and
anaphylactic reactions are described.
3. Hetastarch (hydroxyethyl starch)
a) The starch molecules are derived from plants
b) Hetastarch is highly effective as a plasma expander and is less expensive than
albumin
c) hetastarch is nonantigenic, and anaphylactoid reactions are rare.
d) Coagulation studies and bleeding times are generally not significantly affected
following infusions of older, higher molecular weight formulations up to 1.0 L in
adults.
Newer, lower molecular weight formulations can safely be given in larger volumes.
Concept 9.3: Pain Management
LEARNING OBJECTIVE:
• To know the definition of pain
• To understand pain pathway and different types of pain
• To know about pain assessment in children
• To learn who cancer ladder of pain.
• To learn about the pharmacology in pain.
Time Needed
1 read
st
45 mins
2nd read 15 mins
Concept 9.3.1:Definition of Pain:

The current International Association for the Study of Pain (IASP) definition
of pain as:
• “An unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue damage.”
Concept 9.3.2: Different types of Pain

Classification Based on Time:
• Acute pain: Pain lasts for less than 3 months or which is directly related to tissue
damage.
• Example: postoperative pain, pain because of a cut on the finger.
• Chronic pain: IASP defines it to be a pain persisting for more than 3 months.
Classification Based on Mechanism:
• Nociceptive pain: Pain that arises from actual or threatened damage to non-neural
tissue and is due to the activation of nociceptors.
• Neuropathic pain: Pain caused by a lesion or disease of the somatosensory nervous
system
Concept 9.3.3: Different Terminologies of Pain [AIIMSQ]

Term Description
Allodynia Perception of an ordinarily nonnoxious stimulus as pain
Analgesia Absence of pain perception
Anesthesia Absence of all sensation
Anesthesia Dolorosa Pain in an area that lacks sensation
Dysesthesia Unpleasant or abnormal sensation with or without a stimulus
Hypalgesia (hypoalgesia) Diminished response to noxious stimulation (eg, pinprick)
Hyperalgesia Increased response to noxious stimulation
Hyperesthesia Increased response to mild stimulation
214 | Anesthesia
Hperpathia Presence of hyperesthesia, allodynia, and hyperalgesia usually associated

with overreaction, and persistence of the sensation after the stimulus
Hyperpathia (hypoesthesia) Reduced cutaneous sensation (eg, light touch, pressure, or temperature)
Neuralgia Pain in the distribution of a nerve or a group of nerves
Paresthesia Abnormal sensation perceived without an apparent stimulus
Radiculopathy Functional abnormality of one or more nerve roots
Pharmacotherapy of Pain
Drugs used in pain management can be categorized under two broad headings:
• Analgesics
• Co-analgesics
Analgesics are
• Non-steroidal anti-inflammatory drugs:
Nonselective or Selective COX-2 inhibitors.
• Acetaminophen/Paracetamol
• Opioids.
Co-analgesics or adjuvant group includes
• Anticonvulsants
• Antidepressants
Concept 9.3.4: Pain Pathway: [AIIMSQ]
• Pain is produced by the noxious stimuli perceived by specific sensory receptors called
nociceptors which are there at the free nerve endings of primary afferent terminals
of A delta and C fibres.
• An action potential is generated at this nociceptor (transduction) which are then
further carried by the A delta and C fibres towards the higher centre (transmission)
and make us feel pain (perception).
• Pain is a unique sensory signal as it is maximally changed on its way towards the
higher cortical centres (modulation)
Some of the modulation systems are described below:
a. Endogenous pain modulation system:
Endogenous opioids like endorphins,
enkephalins and dynorphins act on the opioid receptors present in the dorsal horn
and results in presynaptic inhibition.
b. Segmental inhibition:
Local inhibition in the dorsal horn is mediated by the release of inhibitory
neurotransmitters like glycine and GABA.
c. Gate control theory of pain:
It states that activating the larger diameter A beta fibres leads to inhibition of pain
signals transmitted via smaller diameter A delta and C fibres.
An inhibitory interneuron acts as a physiological gate which is closed by stimulation
of A beta fibres.
Transcutaneous electrical nerve stimulation (TENS), spinal cord
stimulation, peripheral nerve stimulation was established based on this
principle.
d. Descending inhibitory pathways:

Periaqueductal grey (PAG) and the rostral ventromedial medulla in the midbrain
send descending fibres which project into the dorsal horn of the same side of
tissue damage.
These inhibitory neurons are activated by serotonin (SHT) and norepinephrine
(NE).
They send an inhibitory signal in the dorsal horn and reduce the intensity of the
signal which is transmitted from first order neuron to the second order neuron.
Antidepressant medications activate this system and increase the level of SHT and
NE and help in reducing the intensity of pain.
216 | Anesthesia
Concept 9.3.5: Pain Assessment in Children: [AIIMSQ]
PAIN SCALE REMARKS AGE

SELF REPORT SCALES Horizontal line with “no pain at one end to “worst 3-ADULTS
1: VAS possible pain at the other
2: Wong-Baker Faces Pain SIx line-drawn faces range from no pain to worst 3-18 YRS
Rating Scale pain
3: Faces Pain Scale-Revised Six cartoon faces range from neutral to high pain 4-16 YEARS
(FPS-R) expression
4: Poker chip tool Number of poker chips representing the intensity 4-7 YEARS
of the pain
OBSERVATIONAL SCALES facial expression; leg movement; activity; cry; 2 MO- 7 YRS
1: FLACC Pain Assessment Tool and consolability
2: Procedure Behaviour Checklist Observational measure of pain and anxiety during 3-18 years
(PBCL). invasive medical procedures
3: Children’s Hospital of Eastern Observational measure of postoperative pain in 1-12 yeas
Ontario Pain Scale(CHEOPS). children.
Assesses sIx behaviours: CTy, facial, child verbal,
torso, touch and legs
4: COMFORT Scale Use in intensive care 0-18 years
5: Premature Infant Pain Profile (PIPP) Physiological (heart rate, 28 weeks till adult
oxygen saturation) behavioural dimensions (facial
expression, eye squeeze, brow bulge, nasolabial
furrow, and crying)
Concept 9.3.6: Cancer Pain – Who Ladder

• The World Health Organization has developed a 3-step ladder for pain management
in adult cancer patients.
• This three-step approach of administering the right drug in the right dose at the right
time is inexpensive and 80-90% effective.
Keys to remember.
• The Oral route is preferred for all steps of pain ladder (however, parenteral therapy
may be required in cases of refractory pain or inability to take P.O.)
• Cancer pain is continuous. Analgesics should be scheduled at regular intervals as
opposed to on a PRN basis.
• Adjuvant drug therapy is used to decrease the anxiety and fear associated with
chronic pain. These adjuvants include antidepressants, anticonvulsants, etc.
Concept 9.3.7: Pharmacotherapy in Pain:

Drugs used in pain management can be categorized under two broad headings:
ANALGESICS CO-ANALGESICS
• Non-steroidal anti-inflammatory drugs: • Anticonvulsants
Nonselective or Selective COX-2 inhibitors.
• Opioids. • Antidepressants
• Acetaminophen/Paracetamol • Local anesthetics
• Steroids
• Muscle relaxants
• Botulinum toxins
• NMDA receptor antagonists
• Others like a 2 agonist, calcium channel blockers,
vitamins and nutri supplements, etc
218 | Anesthesia
Commonly Used Nsaids:
Drug Name Dose (mg)- oral dose Special points
range (max) in mg
Ibuprofen 200-800 (1200) 8-12 h Interferes with platelet aggregation and clot formation,
avoid use in patients with bleeding diathesis. To be used
with caution in patients with asthma.
Diclofenac sodium 25-75 (200) 12 h Acumulates in synovial fluid, useful in OA, RA. Should
be avoided in children, pregnant and nursing women.
Nimesulide 100 12 h COX-2 preferential inhibitor, lesser GI irritation
Ketoprofen 300-600 6-8h One high potency drug with fast elimination
Naproxen 250-500 (1375) 8-12 h Favorable GI profile plasma half-life is 13 h, twice a day
dose is enough
Piroxicam 20 (40) 12-24 h Long half-life thus to be used with caution in elderly.
Takes as long as 1 week to achieve steady concentration
Etoricoxib 60-120 (180) 24 h COX-2 specific inhibitors. In patients with cardiac risk
should be used with caution and low dose aspirin to be
added.
Mefenamic acid 500 8-12 h Common side effect is diarrhea. May cause severe
pancytopenia.
Anti Convulsants
Drug name Dose Mechanism Side effects
Gabapentin Starting dose 100-300 HS Membrane stabilizer by Dizziness, somnolence,
Usual dose 900-3600 mg in binding at α2δ subunit of fatigue peripheral edema
3 divided doses Max dose L-type calcium channel
4800/day
Pregabalin Starting dose is 75 mg HS Membrane stabilizer by Dizziness, somnolence,
Usual dose 450-600 mg in binding at α2δ subunit of fatigue peripheral edema,
two divided doses. L-type calcium channel ataxia
Carbamazepine Starting dose 100 mg/day Sodium channel blocker. Aplastic anemia,
Max dose 300-1000 mg/ Inhibit pain via central and agranulocytosis,
day peripheral mechanism. leukopenia, sedation, gait
alteration
Oxcarbazepine Starting dose 300 mg/day May be by modulating Risk of hyponatremia in
Max dose 1200-2400 mg/ voltage activated calcium first few months
day current
Topiramate Starting dose 50 mg/day Enhances action of Sedation, may predispose
Max dose 200 mg/day GABA, inhibt AMPA type glaucoma and renal calculi
glutamate
Lamotrigine Starting dose 20-50 mg/day Prevent release of Rash, drug should be
Max dose 300-500 mg/day glutamate slowly tapered off
Anti Depressants
Drug Name Oral dose in mg / Clinical consideration
duration
Amitriptyline 10-25/12-24 h Caution in elderly male Urinary retention
Nortriptyline 10-25/12-24 h Better tolerated than amitriptyline
Duloxetine 20-60/12-24 h DOC in diabetic peripheral neuropathy and
fibromyalgia (FDA approved)
Milnacipran 50-100/ 12-24 h FDA approved drug for fibromyalgia
Venlafaxine 37.5-112.5/12-2h r SNRI better tolerated
Desipramine 10-25/24 h Better tolerated TCA in elderly
Fluoxetine 10-60/ 12-24 h Agitation, weight loss, rashes
Summary-Medication Classes Useful In Chronic Pain

Drug class Pain treated
Opitates (oxycodone, tramadol, hydrocodone, Used for nocieptive pain; helpful with appropriate
morphine methadone) adjuvants for neuropathic pain.
NSAIDS (aspirin, naproxen, ibuprofer, celecoxib) Mainly useful for nociceptive pain; the COX-2
inhibitors have increased the variety of clinical
settings where they can be used reduced GI
discomfort.
TCAS (amitriptyline, nortriptylin, doxepin Neuropathic pain, can improve sleep mood.
imipramine)
SNRIs (duloxetine, venlafaxine) Act on both serotonergic as well as noradrenergic
pathways. Lesser side effect than TCA
SSRIs (citalopram, luoxetine, fluvoxamine, Some studies have suggested that these might be
paroxetine, sertraline) helpful in neuropathic pain syndromes They are
helpful for depression, which is common in chronic
pain
Anticonvulsants (gabapentin, pregabalin, tegretol Primarily used for neuropathic pain syndromes; s can
valproic acid, valium, topiramate, levetiracetam, be useful as adjuvant for opiates and improvement in
zonisamide, lamotrigine) quality of sleep.
NMDA receptor antagonists (ketamine, memantine Useful as opiate adjuvants, might help to improve
Dextromethorphan) responsiveness of neuropathic pain to opiates might
be helpful to manage opiate tolerance
Muscle relaxants (baclofen Valium, cyclobenzaprine) Myofascial pain form muscle spasms and headaches
µ-2 agonists (tizanidine, clonicdine) Useful for opiate withdrawal can be helpful for
neuropathic pain division line
Topical medications (lidocaine patch, capsaicin) Localized neuropathic pain or dysesthesias
220 | Anesthesia
Stellate Ganglion Block
Anatomy Indications Contraindications
Formed on each side of the neck Chronic pain conditions • Recent myocardial infarction
by the fusion of the inferior • CRPS 1 and 2 • Anti-coagulated patients or
cervical ganglion with the first, • Herpes zoster affecting the face those with coagulopathy
and occasionally second thoracic and neck • Glaucoma
ganglion
• Refractory chest pain or Angina • Pre-existing contralateral
• Phantom limb pain phrenic nerve palsy (may
Vascular Disorders of upper limb precipitate respiratory
distress)
• Raynaud’s phenomenon
• Obliterative vascular disease
• Vasopasm
• Frost bites
Technique
The needle introduced between the trachea and the carotid sheath at the level of the
cricoids cartilage and Chassaigne’s tubercle (C6) to avoid any potential injury to the
pleura
Confirmatory Sign
1) Horner’s syndrome: sympathetic blockade on the ipsilateral side of the face causes:
Drooping of the eyelid (ptosis)
Constriction of the pupil (meiosis)
Decreased sweating of the face on
the same side (anhydrosis)
Redness of the conjunctiva of the
eye
Impression of an apparently
sunken eyeball (enophthalmos)
2) Guttmann’s sign: nasal stuffness
3) Mueller’s sign: warmth of face &
injection of tympanic membrane
Complications
• Hoarseness & dysphagia (most common)
• Pulmonary injury, pneumothorax
• Chylothorax (thoracic duct injury)
• Oesophageal perforation
• Vagus nerve injury
• Brachial plexus root injury
Concept 9.4: Anesthetic Considerations in Special Situations
LEARNING OBJECTIVE:
• To understand anesthesia concerns in neurosurgery
• To understand anesthesia concerns in renal & hepatic failure
• To understand anesthesia concerns in day care surgery
• To understand anesthesia concerns in obstetric patients.
Time Needed
1st read 45 mins
2 read
nd
15 mins
Concept 9.4.1: Neuroanesthesia:
1: Effect of Anaesthetic Agents on Cerebral Physiology:

INCREASE DECREASE
Cerebral Metabolic Rate • Nitrous oxide • Rest all inhaled anaesthetic
• ketamine agents.
• Thiopentone
• Propofol
• Etomidate
• benzodiazepine
Cerebral Blood Flow\ ICP • All inhaled anaesthetic agents • Thiopentone
• ketamine • Propofol
• Etomidate
• BZD
2: Neurosurgery & Anesthesia

• Induction of choice in neurosurgery: intravenous (propofol > thiopentone) >
inhalational
• Maintenance: propofol> thiopentone
• Inhalational: sevoflurane
• Raised ICP: thiopentone
3: Epilepsy and Anesthesia

• Several commonly used anesthetics have some epileptogenic potential, particularly
in predisposed individuals.
• A concern is that seizure activity may go unrecognized in an anesthetized and paralyzed
patient and may result in neuronal injury if substrate demand (CMR) exceeds supply
for a prolonged period.
• A second concern is that the epileptogenic effect will persist in the postanesthesia
period when seizures may occur in less well-controlled circumstances than those that
exist in the surgical unit.
222 | Anesthesia
Agents Proconvulsant Anticonvulsant

Inhaled Anesthetic Agents • Enflurane • Isoflurane
• Sevoflurane (supra mac levels) • Desflurane
• Halothane
IV Induction Agents • Methohexital (max) • Thiopentone
• Etomidate • Benzodiazepines
• Ketamine • Propofol
Opioids • Meperidine(pethidine) • Rest all
Atracurium:
• Metabolism of Atracurium produces a metabolite called as LAUDONOSINE which is
excreted renally.
• So when this metabolite gets accumulated in prolonged infusions in renal failure
patients then it can precipitate seizures in predisposed individuals.
4: Electroconvulsive Therapy & Anesthesia

• Electroconvulsive therapy (ECT), introduced by Cerlitti and Bini in 1937, is the
induction of a generalised seizure by electrical stimulation of one or both cerebral
hemispheres.
• The anaesthetic requirements for ECT include control of haemodynamic changes
and related complications, together with the primary requirements of amnesia and
muscle relaxation.
• Although these are essential, the level of anesthesia should not be so deep as to
overly suppress the seizure activity which is the goal of the treatment.
• Drugs used in ECT are:
• Premedication: glycopyrrolate, esmolol, dexmedetomidine, clonidine
• Induction agents: methohexital (gold standard) > etomidate (max decrease in
seizure threshold) > ketamine (anti-depressant) > thiopentone > propofol
• Muscle relaxant: Scoline > Mivacurium
• Opioids: Remifentanil > Alfentanil
• Airway technique: Laryngeal Mask Airway
• Drugs to avoid: Anticonvulsant agents, midazolam, lithium, fentanyl.
Concept 9.4.2: Renal Failure and Anesthesia

Drugs To be Avoided Safe
i) Opioids Morphine, Meperidien, Hydromorphone Fentanyl, Sufentanil, Alfentanil,
Remifentanil
ii) Inhaled Anesthetic Agents: Methoxyflurane, Sevoflurane Isoflurane, Desflurane, Halothane
iii) IV Agents: Barbiturates, Diazepam Propofol, Etomidate
iv) Muscle Relaxants: Pancuronium, Vecuronium, Rocuronium, Cisatracurium & Atracurium
Mivacurium, Scoline (Only if
Hyperkalemia)
v) Cholinestrase Inhibtors: Neostigmine, Edrophonium, Pyridostigmine
(Prolonged Duration of Action)
Concept 9.4.3: Liver Failure and Anesthesia
Drugs To be Avoided Safe
i) Opioids Morphine, Meperidine, Alfentanil Fentanyl, Sufentanil, Remifentanil
ii) Inhaled Anesthetic Agents: Halothane, Enflurane Xenon, Sevoflurane, Isoflurane,
Desflurane
iii) Iv Agents: Midazolam, Diazepam, Propofol, Etomidate
Dexmedetomidine
iv) Muscle Relaxants: Pancuronium, Vecuronium,
Rocuronium, Mivacurium, Scoline
Cistracurium & Atracturium
Drugs Causing Spasm of Sphinter of Oddi: Fentanyl, Morphine, Meperidine
Agent of Choice for Liver Transplant: Isoflurane
Agent of Choice for Patients with Previous Hisotry of Halthane /Autoimmune
Hepatitis: Sevoflurane (No Hepatotocity)
Concept 9.4.4: Day Care Surgery & Anesthesia

• Day-care surgery, that is, the patient being discharged from the hospital on the same
day of surgical procedure, has become immensely popular modality of treatment
throughout the globe.
• Anesthesia for day-care (ambulatory anesthesia) surgeries may require administration
of general, regional, and local anesthesia or monitored anesthesia care supplemented
with sedation.
Choice of Agent / Technique
1. Anxiolytic Premedication Oral\Iv Midazolam
2. Analgesic premedication NSAIDs
3. Anti emetic premedication Dexamethasone
4. Choice of technique: General > Central Neuraxial Blcok
5. Induction Intravenous > Inhalational
6. Intravenous agent Propofol
7. Maintenance TIVA> Inhalational
8. Inhalational agent Sevoflurane > Desflurane
9. Opioids Remifentanil > Alfentanil > Fentanyl
10. Neuromuscular blocking agents Mivacurium > Rocuronium
11. Airway management: LMA (Proseal) > ETT
12. Central neuraxial block Low dose Bupivacaine > 2 Chloro Procaine
13. Complications Drowsiness> Aches And Sore Throat>Headache>
Dizziness>Nausea and Vomiting
224 | Anesthesia
Concept 9.4.5: Obstetric Anesthesia

• All patients entering the obstetric suite potentially require anesthesia services,
whether planned or emergent for labor or cesarean section.
• Regardless of the time of last oral intake, all patients are considered to have a full
stomach and to be at risk for pulmonary aspiration.
• Because the duration of labor is often prolonged, guidelines usually allow small
amounts of oral clear liquid for uncomplicated labor.
• The supine position should be avoided unless a left uterine displacement device (>15°
wedge) is placed under the right hip.
1: Pain Pathways During Labor

• The pain of labor arises from contraction of the myometrium against the resistance of
the cervix and perineum, progressive dilation of the cervix and lower uterine segment,
and stretching and compression of pelvic and perineal structures.
• Pain during the first stage of labor is primarily visceral pain resulting from uterine
contractions and cervical dilation.
• It is usually initially confined to the T11–T12 dermatomes during the latent phase, but
eventually involves the T10–L1 dermatomes as labor enters the active phase.
• The onset of perineal pain at the end of the first stage signals the beginning of fetal
descent and the second stage of labor.
• Stretching and compression of pelvic and perineal structures intensifies the pain.
• Sensory innervation of the perineum is provided by the pudendal nerve (S2–4) so
pain during the second stage of labor involves the T10–S4 dermatomes.
2: Methods of Labour Analgesia:
Nonpharmacological Pharmacological
Systemic Regional
• Continuous emotional support Inhalational methods Neuraxial techniques
• Entonox • Lumbar epidural analgesia
• Volatile anesthetic agents: (MOST COMMON)
sevoflurane, isoflurane, • CSEA
• desflurane, enflurane • Single shot spinal analgesia
• TENS Systemic analgesics Maintenance of LA
• Opioids: pethidine, • Intermittent top ups
meperidine, morphine, • Continuous epidural infusion
diamorphine • PCEA
• fentanyl, sufentanil
remifentanil, alfentanil
Hypnosis Nonopioid analgesics Alternative regional anesthetic
• Relaxation/breathing • Agonist‑antagonist analgesics techniques
techniques. (nalbuphine, buprenorphine, • Lumbar sympathetic block
• Acupuncture/acupressure butorphanol) • Pudendal block
• Miscellaneous: aromatherapy, • Sedatives, tranquillizers • Paracervical block
music, massage, therapeutic (barbiturates, benzodiazepines,
use of heat and cold phenothiazine derivatives)
• Dissociative or amnesic drugs
(ketamine)
Lumbar epidural analgesia:

• Most common & effective modality of labour analgesia.
• Lumbar epidural analgesia aims to produce a selective sensory block from T10 to L1
while at the same time sparing the motor supply to the lower limbs (L2–L5), and it is
called the “mobile epidural or walking epidural.”
• Decreasing the concentration of local anesthetics by addition of opioid, most commonly
fentanyl (2 μg/mL) with epidural bupivacaine (0.0625%–0.125%), results in sparing
of motor fibers.
• Bupivacaine is most common used local anesthetic used.
• Concentration of bupivacaine used for labour analgesia: 0.0625% - 0.125% with or
without opioids.
3: Possible Indications for General Anesthesia during Vaginal Delivery.

• Fetal distress during the second stage
• Tetanic uterine contractions
• Breech extraction
• Version and extraction
• Manual removal of a retained placenta
• Replacement of an inverted uterus
226 | Anesthesia
4: Heart Disease in Pregnancy
Cardiac Disease Hemodynamic Goals Choice of Labour Choice of Anesthesia
Analgesia
Coarctation of Aorta • Maintain BP Epidural Epidural
MR \ AR • Avoid Bradycardia Epidural Epidural Spinal
• Avoid Increase in
SVR
• Maintain Euvolemia
Left to Right Shunts • Maintain SVR Epidural Epidural
(ASD, VSD, PDA) • Maintain PVR
Mild / Mod MS or AS • Avoid Tachycardia Epidural Epidural
• Maintain SVR
• Avoid Fluid Overload
Severe AS \ MS • Same as above Epidural General Anesthesia
TOF • Avoid Decrease in • IV Opioids General Anesthesia
SVR • Entonox
• Maintain PVR • Pudendal, Nerve
Block
Aortic Disection / • Avoid Tachycardia Epidural General Anesthesia
Marfan Syndrome
Eisenmenger’s • Avoid Decrease in Epidural General Anesthesia
Syndrome SVR
• Avoid Hypotension
5: Anesthetic Drugs with Non-organ based Metabolism:

• Metabolism of drugs used in anesthesia is of special significance.
• Especially when we use it in context of certain organ failure patients.
• Most drugs are metabolised by liver.
• Certain drugs are metabolised by enzymes based in plasma.
• Here is a list of those drugs in anesthesia.
Non-organ based Metabolism
Plasma Cholinestrase\ Rbc & Tissue Non-Specific Hoffmans
Pseudocholinestrerase Estrase Estrase Elimination
Scoline Remifentanil Etomidate Atracurium (33%)
Mivacurium Esmolol Atracurium (66%) Cisatracurium
Amino Ester Local Anesthetics
Except Cocaine
Concept 9.5: Mechanical Ventilation & Oxygen Therapy
LEARNING OBJECTIVE:
• To understand different modes of mechanical ventilation
• To learn the indications of mechanical ventilation
• To learn the criteria of initiating mechanical ventilation
• To learn about weaning criteria.
Time Needed
1st read 30 mins
2 read
nd
15 mins
Definition:
• Invasive mechanical ventilation is defined as the delivery of positive pressure to the
lungs via an endotracheal or tracheostomy tube.
• Non-invasive ventilation (NIV) is delivered through an alternative interface, usually
a face mask.
Indications:
• Invasive mechanical ventilation is most often used to fully or partially replace the
functions of spontaneous breathing by performing the work of breathing and gas
exchange in patients with respiratory failure.
Examples of Conditions often Requiring Mechanical Ventilation

PATHOLOGY EXAMPLES
Alveolar filling processes • Pneumonitis - infectious, aspiration
• Noncardiogenic pulmonary edema/ARDS (eg, due to infection,
inhalation injury, near drowning, transfusion, contusion, high altitude)
• Cardiogenic pulmonary edema
• Pulmonary hemorrhage
• Tumor (eg, choriocarcinoma)
• Alveolar proteinosis
Pulmonary vascular disease • Pulmonary thromboembolism
• Amniotic fluid embolism, tumor emboli
Diseases causing airways • Tumor
obstruction: central • Laryngeal angioedema
• Tracheal stenosis
Diseases causing airways • Acute exacerbation of chronic obstructive pulmonary disease
obstruction: distal • Acute, severe asthma
Hypoventilation: decreased • General anesthesia
central drive • Drug overdose
228 | Anesthesia
Hypoventilation: peripheral • Amyotrophic lateral sclerosis

nervous system/respiratory • Cervical quadriplegia
muscle dysfunction • Guillain-Barré syndrome
• Myasthenia gravis
• Tetanus, tick bite, ciguatera poisoning
• Toxins (eg, strychnine)
• Muscular dystrophy, myotonic dystrophy, myositis
Hypoventilation: chest wall • Kyphoscoliosis
and pleural disease • Trauma (eg, flail chest)
• Massive pleural effusion
• Pneumothorax
Increased ventilatory demand • Severe sepsis
• Septic shock
• Severe metabolic acidosis
Miscellaneous • Airway protection
Modes of Mechanical Ventilation:

A) CMV = Conventional controlled ventilation, without allowances for spontaneous
breathing. Many anesthesia ventilators operate in this way.
B) Assist-Control = Where assisted breaths are facsimiles of controlled breaths.
C) Intermittent Mandatory Ventilation = which mixes controlled breaths and
spontaneous breaths. Breaths may also be synchronized to prevent “stacking”.
D) Pressure Support = Where the patient has control over all aspects of his/her breath
except the pressure limit.
E) High Frequency Ventilation = where mean airway pressure is maintained at a
constant and hundreds of tiny breaths are delivered per minute.
Goals of the Volume Control mode and the Pressure Control mode.
Common Modes of Ventilation:
• Volume-limited assist control ventilation
• Pressure-limited assist control ventilation
• Synchronized intermittent mandatory ventilation with pressure support ventilation
(SIMV-PSV)
• Pressure support ventilation (PSV) alone is uncommonly used as an initial mode of
ventilation but commonly used during weaning.
Initial Ventilator Settings:

(A) mode of ventilation
Assist-Control Ventilation
1. Select assist-control as the initial mode of ventilation.
2. It may be necessary to switch to synchronized IMV in patients who are breathing too
rapidly in the assist-control mode.
Volume vs. Pressure Control
1. The use of volume control or pressure control is largely a matter of personal preference,
although some patients breathe more comfortably with pressure control.
(B) Tidal Volume
The following recommendations are from the lung protective ventilation protocol
1. Select an initial tidal volume of 8 mL/kg using predicted body weight.
2. Reduce the tidal volume to 6 mL/kg over the next 2 hours, if possible.
3. Monitor the peak alveolar pressure and keep it ≤30 cm H2O (to limit the risk of
volutrauma).
Inspiratory Flow Rate
1. Select an inspiratory flow rate of 60 L/min if the patient is breathing quietly or has no
spontaneous respirations.
2. Use higher inspiratory flow rates (e.g., ≥80 L/min) for patients with respiratory
distress or a high minute ventilation (≥10 L/min).
I: E Ratio
1. The I:E ratio should be ≥1:2.
2. If the I:E ratio is <1:2, the options for increasing the I:E ratio include:
(a) increasing the inspiratory flow rate
(b) decreasing the tidal volume
(c) decreasing the respiratory rate, if possible.
(C) Respiratory Rate
1. If the patient has no spontaneous respirations, set the respiratory rate to achieve
your estimate of the patient’s minute ventilation just prior to intubation, but do not
exceed 35 breaths/minute.
2. If the patient is triggering each ventilator breath, set the machine rate just below the
patient’s spontaneous respiratory rate.
3. After 30 minutes, check the arterial PCO2, and adjust the respiratory rate, if necessary,
to achieve the desired PCO2.
4. For patients who are breathing rapidly and have an acute respiratory alkalosis or
evidence of occult PEEP, consider switching to synchronized IMV (SIMV) as the mode
ofventilation.
230 | Anesthesia
(D) PEEP
1. Set the initial PEEP to 5 cm H2O to prevent the collapse of distal airspaces at end
expiration.
2. Further increases in PEEP may be required if either of the following conditions is
present: (a) a toxic level of inhaled oxygen (>60%) is required to maintain adequate
oxygenation (SaO2 ≥90%), or (b) hypoxemia is refractory to oxygen therapy.
Weaning:
• Weaning is the process of decreasing the degree of ventilator support and allowing
the patient to assume a greater proportion of their own ventilation (eg, spontaneous
breathing trials or a gradual reduction in ventilator support)
Weaning Criteria
Common Weaning Criteria
Category Example Note
Clinical criteria Resolution of acute phase of disease

Adequate cough Absence of excessive
secretions Cardiovascular and
hemodynamic stability
Ventilatory criteria Spontaneous breathing trial Tolerates 20 to 30 min

PaCO2 <50 mm Hg with normal pH
Vital capacity >10 mL/kg
Spontaneous V1 >5 mL/kg
Spontaneous f <35/min
f/V1 <100 breaths/min/L*
Minute ventilation <10 L with satisfactory ABG
Oxygenation criteria PaO2 without PEEP >60 mm hg at FiO2 upto 0.4

PaO2 with PEEP (<8 cm H2O) SaO2 >100 mm Hg at FiO2 up to 0.4
PaO2 / FiO2 (P/F) >90% at FiO2 up to 0.4
Q5 / Qr >150 mm Hg
P(A–a)O2 <20%
<350 mm Hg at FiO2 of 1.0
Pulmonary reserve Vital capacity >10 mL/kg

Max. insp. Pressure >–30 H2O in 20 sec
Rapid Shallow Breathing Index (RSBI)

• Rapid shallow breathing is quantified as the f (number of breaths per minute) divided
by the VT in litres
• This breathing pattern induces inefficient, dead space ventilation.
• When the RSBI or f/VT index is greater than 100 breaths/min/L it correlates with
weaning failure.
• Absence of rapid shallow breathing (f/VT ratio <100 breaths/min/L), is an accurate
predictor of weaning success
• Weaning from mechanical ventilation describes the transition between full ventilatory
support and spontaneous breathing, and the removal of any artificial airway.
• The most common mode of ventilation for weaning is pressure-support ventilation.
• Weaning may start with the patient on BIPAP, with reduction in ventilatory pressures,
cardiovascular support and sedation as the patient’s condition improves.
• This facilitates a switch to spontaneous ventilation with gradually reducing pressure
support as the patient takes over the work of breathing.
• T-piece trials may then also be used, although there is little evidence that they are
superior to simply reducing the pressure support the patient is receiving.
• Continuous positive airway pressure (CPAP) is the natural end-point of PSV weaning
and may be the last step prior to extubation.
• Non-invasive ventilation is generally used in patients with chronic obstructive
pulmonary disease (COPD), where it may bridge the gap between ventilation and
spontaneous breathing in patients with poor respiratory reserve.
Oxygen Delivery Systems

Oxygen delivery systems are classified as
• low-flow systems: nasal prongs
• reservoir systems: face masks and face masks with reservoir bags
• high flow systems: air-entrainment masks or heated, humidified O2 delivered through
nasal prongs.
The features of different oxygen delivery systems are summarized in Table

System of Device Oxygen Flow Reservoir FiO2
Rates volume
Range Variability
Low-Flow Nasal O2 1–6 L/min — 24–40% Variable
Standard Face Mask 5–10 L/min 100–200 mL 35–50% Variable
Partial Rebreather Mask >10 L/min 600–1000 mL 40–70% Variable
Nonrebreather Mask > 10 L/min 600–1000 mL 60–80% Variable
Air-Entrainment Mask > 60 L/min 100–200 mL 24–50% Constant
High-Flow Nasal O2 ≤ 40 L/min — 21–100% Variable
1: Low-Flow Nasal O2
The standard device for low-flow O2 therapy is the nasal cannula or nasal prongs,
which deliver oxygen into the nasopharynx at flow rates of 1 to 6 L/min.
A large fraction of the inspired volume is drawn from room air, which means that
low-flow nasal O2 does not achieve high concentrations of inhaled oxygen.
The FiO2 range during quiet breathing is 24% O2 (at 1 L/min) up to 40% O2
(at 6 L/min)
232 | Anesthesia
Advantages and Disadvantages

The major advantages of nasal prongs are simplicity of use and patient acceptance,
including the ability for patients to eat and converse.
The major disadvantage is the inability to achieve high concentrations of inhaled
O2, particularly in patients with increased ventilatory demands.
2: Standard Face Masks
Face masks are considered a reservoir system because the mask encloses a
volume of 100 to 200 mL.
Standard face masks deliver oxygen at flow rates between 5 and 10 L/min
A minimum flow rate of 5 L/min is needed to clear exhaled gas from the mask.
Exhalation ports on the side of the face mask also allow room air to be inhaled.
This system can achieve a maximum FiO2 of about 60% during quiet breathing.
Standard face masks can provide a slightly higher maximum FiO2 than low-flow
nasal prongs, but like nasal prongs, the FiO2 varies with the ventilatory demands
of the patient.
Face masks are more confining than nasal prongs, and they do not permit oral
feeding.
3: Masks with Reservoir Bags
The addition of a reservoir bag to a standard face mask increases the capacity of the
oxygen reservoir by 600 to 1000 mL (depending on the size of the bag).
If the reservoir bag is kept inflated, the patient will draw primarily from the gas in the
bag.
There are two types of reservoir bag devices:
Partial rebreathers and Non-rebreathers.
Partial Rebreather
This device allows the gas exhaled in the initial phase of expiration to return to
the reservoir bag.
As exhalation proceeds, the expiratory flow rate declines, and when the expiratory
flow rate falls below the oxygen flow rate, exhaled gas can no longer return to the
reservoir bag.
The initial part of expiration contains gas from the upper airways (anatomic dead
space), so the gas that is rebreathed is rich in oxygen and largely devoid of CO2.
The patient can inhale room air through the exhalation ports on the mask, but
the gas in the reservoir bag is under positive pressure, and inhalation will draw
primarily from the gas in the bag.
Partial rebreather devices can achieve a maximum FiO2 of about 70%.
234 | Anesthesia
Nonrebreather
The expiratory ports on the mask are covered with flaps that allow exhaled gas to
escape but prevent inhalation of room air gas.
There is also a one-way valve between the reservoir bag and the mask that allows
inhalation of gas from the bag but prevents exhaled gas from entering the bag (to
prevent rebreathing of exhaled gas).
Nonrebreather devices can theoretically achieve an FiO2 of 100%, but in reality
the maximum FiO2 is closer to 80% (because of leaks around the mask).
The principal advantage of the reservoir bags is the ability to deliver higher
concentrations of inhaled oxygen.
The disadvantages are the same as described for face masks.
4: Air Entrainment Device
Air entrainment devices are high-flow systems that deliver a constant FiO2.
The end of the oxygen inlet port is narrowed, and this creates a high-velocity
stream of gas (analogous to the nozzle on a garden hose). This creates a shearing
force known as viscous drag that pulls room air into the device through air-
entrainment ports.
The greater the flow of O2 into the mask, the greater the volume of air that is
entrained, and this keeps the FiO2 constant.
The final flow created by the device is in excess of 60 L/min, which exceeds the
inspiratory flow rate in most cases of respiratory distress.
The FiO2 can be varied by varying the size of the air entrainment port on the
device.
The FiO2 range of these devices is 24 to 50%.
Venturi valve
Colour FiO2 O2 Flow
Blue 24% 2 L/min
White 28% 4 L/min
Orange 31% 6 L/min
Yellow 35% 8 L/min
Red 40% 10 L/min
Green 60% 15 L/min

The major advantage of air-entrainment devices is the ability to deliver a constant
FiO2.
This is desirable in patients with chronic CO2 retention, where an inadvertent
increase in FiO2 can lead to further increases in arterial PCO2.
The major disadvantage of these devices is inability to deliver high concentrations
of inhaled O2.
5: High-Flow Nasal Cannula (HFNC)
The newest technique of O2 delivery (in adults) is high-flow nasal O2 using heated
and humidified gas.
236 | Anesthesia
Using oxygen that is heated to body temperature and supersaturated with water
(to a relative humidity of 99%), O2 flow rates up to 40–60 L/min can be delivered
through wide nasal prongs without discomfort and mucosal injury.
A commercially available product for high-flow nasal O2 allows adjustments for

flow rate (1–40 L/min), FiO2 (21–100%), and temperature (usually at 37°C).
Physiological dead space washout of waste gasses including carbon dioxide (CO2):
displacement of excess CO2 with excess O2.
Decrease work of breathing by decreasing airway resistance through the application
of a positive pressure.
Decreased respiratory rate.
Positive end-expiratory pressure
Increased tidal volume.
Advantages
• Enhanced comfort as well as compliance with therapy
• An alternative intervention for patients who cannot tolerate non-invasive mechanical
ventilation.
Disadvantages
• Expense for care.
• Increased complexity and training to initiate care.
• Decreased mobility.
• Risk for ineffective sealing of the passageways leading to leaking of air.
• Loss of the positive airway pressure effect.
• Potential to delay intubation.
Worksheet
• MCQ OF “MISCELLANEOUS TOPICS IN ANESTHESIA &
INTENSIVE CARE” FROM DQB

238 | Anesthesia
1: NEUROLEPT ANESTHESIA INVOLVES USED OF _______________, ____________

& _____________.
2: MOST POTENT OPIOID USED IN ANESTHESIA IS:________________________
3: MECHANISM OF ACTION OF TRAMADOL IS:_____________________________
4: SHORTEST HALF LIFE IS OF THIS OPIOID:______________________________
5: MOST COMMON USED FLUID FOR REPLACEMENT IS_______________________
6: COMMON EXAMPLE OF A MODALITY USING GATE CONTROL THEORY OF PAIN

IS_____________________
7: STEP 2 IN WHO LADDER OF PAIN IS:__________________________
8: CONFIRMATORY SIGN OF STELLATE GANGLION BLOCK IS:__________________
9: AGENT OF CHOICE FOR INDUCTION IN A PATIENT WITH BRAIN TUMOR WITH

RAISED ICP IS:______________________
10: AGENT OF CHOICE FOR INDUCTION IN ECT THERAPY IS:____________________

11: CONCENTRATION OF BUPIVACAINE USED FOR LABOUR ANALGESIA IS:
________________________
12: METABOLISM OF REMIFENTANIL IS BY:___________________________
13: MOST COMMON WEANING MODE OF VENTILATION IS:_____________________
14: A HIGH FLOW FIXED RATE OXYGEN DELIVERY DEVICE IS:__________________
15: FLOW RATE OF OXYGEN IN HIGH FLOW NASAL CANNULA IS:_________________

10 Cardiopulmonary Resuscitation
CONCEPTS
Â Concept 10.1 Introduction & Goals of CPR
Â Concept 10.2 Adult & Pediatric Chain of Survival
Â Concept 10.3 Overview of CPR
Â Concept 10.4 Basic Life Support (BLS) & Adult
Cardiac Life Support (ACLS)
Â Concept 10.5 Post Cardiac Arrest Care
Â Concept 10.6 Summary of Key Changes in 2020
CPR Update
https://t.me/usmle_study_materials_2
240 | Anesthesia
Concept 10.1: Introduction & Goals Of CPR
LEARNING OBJECTIVE:
• To understand the science behind cardiopulmonary resuscitation
• To learn the goals of CPR
Time Needed
1 read
st
10 mins
2 read
nd
05 mins
Introduction:
• Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the
chance of survival following cardiac arrest.
• Sudden cardiac arrest remains a leading cause of death in the United States.
The science of CPR

• One fact about CPR and other post–cardiac arrest treatments that is certain, is that
no amount of defibrillation will impact outcomes if there is no perfusion to the heart
and brain.
• Re-establishing blood flow to the vital organs is the single most important
factor for successful resuscitation.
• Establishing circulation with CPR at a level fast enough and deep enough to
achieve an effective CPP(coronary perfusion pressure) is therefore the goal
of CPR compressions.
• This was clearly the goal of the changes since 2010 AHA guidelines for CPR where
more importance was given to compressions and early defibrillation over ventilation.
• For adult victims it is critical that the Adult Cardiac Arrest Chain of Survival is
initiated quickly and performed at a high level of quality.
• The Adult Cardiac Arrest Chain of Survival has been updated to include a different
response whether the cardiac arrest takes place inside or outside of the hospital.
Goals [NEETQ]
1. Maintain oxygen and blood supply to vital organs during cardiac arrest.
2. Restore spontaneous circulation (Cardiac output during CPR with effective,
uninterrupted chest compression is at best 25% to 30% of the normal spontaneous
circulation.
3. Minimize post resuscitation organ injury
4. Improve the patient’s survival and neurologic outcome.
Cardiopulmonary Resuscitation | 241
Concept 10.2: Adult & Pediatric Chain of Survival
LEARNING OBJECTIVE:
• To learn the key steps in the chain of survival for both outside and inside hospital
cardiac arrest for adult and paediatric patients.
• The term Chain of Survival provides a useful metaphor for the elements of the ECC
systems concept.
• The chain of survival refers to a series of actions that, properly executed, reduce the
mortality associated with sudden cardiac arrest.
Time Needed
1 read
st
20 mins
2 read
nd
10 mins
Adult Chain of Survival [Most Important Concept]
The 6 links in the adult out-of-hospital Chain of Survival are:

• Recognition of cardiac arrest and activation of the emergency response system
• Early cardiopulmonary resuscitation (CPR) with an emphasis on chest
compressions
• Rapid defibrillation
• Advanced resuscitation by Emergency Medical Services and other healthcare providers
• Post-cardiac arrest care
• Recovery (including additional treatment, observation, rehabilitation, and
psychological support)
A strong Chain of Survival can improve chances of survival and recovery for victims of
cardiac arrest.
242 | Anesthesia
Pediatric Chain of Survival
Concept 10.3: Overview of CPR
LEARNING OBJECTIVE:
• To understand the components of CPR as described as compressions, airway, breathing
& defibrillation.
• To learn all components of high-quality CPR.
• To understand how and which airway access to be taken during BLS & ACLS
• To learn the concept of rescue breaths and compression to ventilation ratio in CPR.
• To understand the principles of defibrillation and the know different types of
defibrillators used.
• To learn the difference between adult and paediatric CPR.
Time Needed
1st read 60 mins
2 read
nd
30 mins
CPR is as easy as CAB
Age & Site of Pulse Check in CPR

Category Age Site For Pulse Check
Neonate 1st 30 Days After Birth Precordial Auscultation\ 3 Lead Ecg
Infant 30 Days To 1 Year After Birth Brachial Artery
Child 1year To Puberty Femoral\ Carotid Artery
Adult \ Adolocent After Puberty Carotid Artery
• Puberty: Female: Breast Development +
Male: Axillary Hair +
244 | Anesthesia
Concept 10.3.1: Chest Compression

Physiology of Circulation during Closed-chest Compression
Two theories of the mechanism of blood flow during closed-chest compression have
been suggested.
1: Cardiac Pump Mechanism:
According to this theory, pressure on the chest compresses the heart between the
sternum and the spine.
Compression raises the pressure in the ventricular chambers, closing the
atrioventricular valves and ejecting blood into the lungs and aorta.
During the relaxation phase of closed-chest compression, expansion of the thoracic
cage causes a sub atmospheric intrathoracic pressure, facilitating blood return.
2: Thoracic Pump Mechanism:
According to this theory, blood flows into the thorax during the relaxation phase
of chest compressions in the same manner as that described for the cardiac pump
mechanism.
During the compression phase, all intrathoracic structures are compressed equally
by the rise in intrathoracic pressure caused by sternal depression, forcing blood
out of the chest.
BLS Dos and Don’ts of Adult High-Quality CPR

Rescuers Should Rescuers Should Not
Perform chest compressions at a rate of 110-120/min Compress at a rate slower than 100/min or faster
than 120/min
Compress to a depth of at least 2 inches (5 cm) Compress to a depth of less than 2 inches (5 cm) or
greater than 2.4 inches (6 cm)
Allow full recoil after each compression Lean on the chest between compression
Minimize pauses in compressions Interrupt compressions for greater than 10 seconds
Ventilate adequately (2 breaths after 30 compression, Provide excessive ventilation (i.e, too many breaths
each breath delivered over 1 second, each causing or breaths with excessive force)
chest rise)
Complications of chest compressions:

1: Chest injuries related to chest compressions were classified as follows:
Rib fracture (most common 3,4,5); sternal fracture; and other uncommon
complications, such as lung contusion, lung haemorrhage, pneumothorax,
haemothorax, retrosternal haematoma, and mediastinal haematoma.
2: Other extrathoracic complications secondary to chest compression were classified as
follows:
Pneumoperitoneum, haemoperitoneum, scapula fractures, and vertebral fractures.
Summary of High-Quality CPR Components For BLS Providers
[Most Important Concept]
Component Adults and adolescents Children Infants
(age 1 year to puberty) (age less than 1 year,
excluding newborns)
Verifying scene safety Make sure the environment is safe for rescuers and victim
Recognizing cardiac Check for responsiveness
arrest No breathing or only gasping (i.e, no normal breathing)
No definite pulse felt within 10 seconds
(breathing and pulse check can be performed simultaneously
in less than 10 seconds)
Activating emergency If a mobile device is available, phone emergency services (9-1-1)
response system
If your are alone with Witnessed collapse
no mobile phone, leave Follow steps for adults and adolescents on the left
the victim to activate
Unwitnessed collapse
the emergency response
system and get the AED Give 2 minutes of CPR
before beginning CPR Leave the victim to activate the emergency response
Otherwise, send system and get the AED
someone and begin CPR Return to the child or infant and resume CPR;
immediately; use the AED Used the AED as soon as it is available
as soon as it is available
Compression-ventilation 1or 2 rescuers 30:2 1 rescuer 30:2
ratio without advanced 2 or more rescuers 15:2
airway
Compression-ventilation Continuous compression Continuous compressions at a rate of 100-120/min
ratio with advanced at a rate of 100-120/min Give 1 breath every 2-3 seconds
airway Give 1 breath every 6 (20-30 breaths/min)
seconds
(10 breaths/min)
Compression rate 100-120/min
Compression depth At least 2 inches (5 cm) At least one third At least one third
AP diameter of chest AP diameter of chest
Approximately 2 inches Approximately 1 ½ inches
(5 cm) (4 cm)
Hand placement 2 hands on the lower 2 hands or 1 hand 1 rescuer 2 fingers or
half of the breastbone (optional for very small 2 thumbs in the center
(sternum) child) on the lower half of of the chest, just below
the breastbone (sternum) the nipple line 2 or
more rescuers 2 thumb-
encircling hands in the
center of the chest, just
below the nipple line If
the rescuer is unable to
achieve the recommended
depth, it may be
reasonable to use the hell
of one hand
246 | Anesthesia
Chest recoil Allow complete recoil of chest after each compression;

do not lean on the chest after each compression
Minimizing interruptions Limit interruptions in chest compressions to less than 10 seconds
with a CCF goal of 80%
*Compression depth should be no more than 2.4 inches (6 cm).

Abbreviations: AED, automated external defibrillator; AP, anteroposterior: CCF, chest compression fraction:
CPR, cardiopulmonary resuscitation.
Concept 10.3.2: Airway

Unsecured Airway:
• Bag-mask ventilation with a head tilt–chin lift or head tilt–jaw thrust manoeuvre
is recommended for initial airway control in most circumstances.
• Triple manoeuvre: head tilt- chin lift, mouth open, jaw thrust. [AIIMSQ]
• These manoeuvres open up the upper airway by preventing fall of tongue posteriorly
and helps in providing mouth to mouth OR mask to mouth breathing.
Secured Airway\Advanced Airway

• Depending on the level of expertise of the cpr provider
• Endotracheal tube
• Laryngeal mask airway
• Combitube
• “Under no circumstances should the insertion of advanced airway compromise the
chest compressions”
Concept 10.3.3: Breathing

victim with pulse:
• This is seen in cases of respiratory arrest like in opioid overdose.
• The rescuer is supposed to give only rescue breaths and wait for the help to arrive.
• The rescuer must provide 1 breath every 6 secs i.e., 10 breaths \min.
248 | Anesthesia
Victim without pulse (cardiac arrest algorithm) [AIIMSQ\PGIQ\NEETQ]
WITHOUT ADVANCED AIRWAY WITH ADVANCED AIRWAY
(compression to ventilation ratio)
ADULT 30:2 1 breath every 6 secs (10 breaths\min)
PEDIATRIC Single rescuer: 30:2 1 breath every 2-3 seconds (20-30 breaths
2 rescuers: 15:2 per min)
Concept 10.3.4: Defibrillation

Cardiac arrest is associated with one of the following rhythms:
SHOCKABLE RHYTHMS NON-SHOCKABLE RHYTHMS
Asystole: Often called cardiac standstill or flat Ventricular fibrillation (VF): Characterized by
line and is the absence of all evidence of electrical chaotic electrical activity on the monitor, a victim
activity on the ECG. There are no complexes visible with VF will have no palpable pulses.
on the monitor. Asystole will not respond to shocks.
It is now the most common cardiac arrest rhythm
in both adults and paediatric patients.
Pulseless electrical activity (PEA): When there Pulseless ventricular tachycardia (VT): Is usually
are visible complexes on the cardiac monitor, but seen as very wide QRS complexes on the ECG. The
no pulses can be felt, the rhythm is PEA. The goal victim will be pulseless with this rhythm. Without
of treatment for PEA is to identify and treat the treatment, VT can quickly deteriorate into VF;
underlying cause of the rhythm using the H’s and consequently, the treatment is the same as for VF.
T’s. PEA will not respond to shocks.
• Defibrillation is the delivery of an electrical current through the myocardium to
interrupt disorganized cardiac activity by causing simultaneous depolarization of the
myofibrils and restore an organized cardiac rhythm.
• The most important controllable determinant of failure to resuscitate a patient with
VF is the duration of fibrillation.
• Defibrillation is effective only when there is some electrical activity present in the
heart.
• Defibrillation is only consistently effective treatment for shockable type of cardiac
arrest rhythms i.e., pulseless VT & ventricular fibrillation.
Defibrillator
• Is a device that delivers current of a specified energy to the myocardium.
• Defibrillators are classified by the current waveform delivered: monophasic (current
flows in one direction between electrodes) or biphasic (current reverses direction
between electrodes during the shock).
• Monophasic defibrillator: a single 360 joule (J) shock is delivered. (old – not used
anymore)
• All defibrillators currently on the market, including AEDs, deliver current in a truncated
exponential (BTE), rectilinear (RLB), or pulsed biphasic waveform.
1: AED (AUTOMATED EXTERNAL DEFIBRILLATOR) [most important concept]
The AED is a device that monitors the ECG, recognizes VF, charges automatically,
and gives a defibrillatory shock.
It has allowed the introduction of defibrillation into first-responder EMS networks
and public access defibrillation because minimally trained individuals can
incorporate defibrillation into BLS skills, improving survival in out-of-hospital
arrest by reducing time to delivery of the first shock.
250 | Anesthesia
Automated External Defibrillator (Basic Life Support)
2: MANUAL DEFIBRILLATOR:
This device is used to analyse rhythm and then use appropriate amount of energy
to be used to defibrillate the patient.
It’s a rescuer based device and is used in ACLS algorithm.
Biphasic defibrillator :(120-200 J) is usually sufficient to terminate the
arrhythmia (new & better)
If the rescuer is unfamiliar: maximal available energy should be used as the
default energy.
Pediatric patients: 1st shock: 2-4 J\kg---subsequent shocks 4 J\kg ( MAX 10J\
kg)
Manual Defibrillator (Advanced Cardiac Life Support)

Placement of Electrodes:
ADULT:
• Upper right sternal border, just below the clavicle
• Lateral to the left nipple.
Child or Infant: Anterior and Posterior.
Concept 10.3.5: Monitoring during CPR

• The adequacy of closed-chest compression is frequently judged by palpation of a
pulse in the carotid or femoral vessels.
• Quantitative waveform capnography is the most accurate measure of the quality
of CPR and airway management during resuscitation.
• If the PETCO2 measured by capnography goes below 10 mm Hg during CPR, the
team member doing compressions should be directed to increase the depth and rate
of compressions.
• A PETCO2 <10 mm Hg indicates that the prognosis for ROSC [Return Of Spontaneous
Circulation] is poor.
• Return of the PETCO2 to 35-40 mm Hg indicates ROSC.
Concept 10.3.6: Difference Between Adult & Pediatric CPR
Difference in Adult And Pediatric CPR [Most Important Concept]

POINT OF DIFFERENCE ADULTS CHILDREN\ INFANT
1: Activation of Emergency 1st: Activate ERS & get AED Witnessed collapse: same as adult.
Response System 2nd: Start CPR. Unwitnessed collapse:
1st: 2 mins of CPR
2nd: leave the victim to active ERS.
2: Compression to Ventilation Always 30:2 1 rescuer: 30:2
Ratio without Advanced 2 rescuers: 15:2
Airway
3: Compression to Ventilation 1 breath every 6 secs (10 breaths\ 1 breath every 2-3 secs (20-30
Ratio with Advanced Airway min) breaths \mins)
4: Depth of Compression 2 to 2.4 inches Children: about 2 inches
Infants: about 1.5 inches
5: Hand Placement Lower half of sternum Infants: 1 rescuer: 1 finger technique
2 rescuers: thumb encircling
technique
252 | Anesthesia
Concept 10.4: Basic Life Support (BLS) & Adult Cardiac Life Support
(ACLS)
LEARNING OBJECTIVE:
• To understand the difference between BLS & ACLS.
• To learn BLS algorithm and its specifics.
• To learn the ACLS algorithm and its specifics
• To learn the drug therapy in CPR along with routes of administration of drugs.
Time Needed
1 read
st
60 mins
2 read
nd
30 mins
Concept 10.4.1: Difference Between BLS & ACLS

BASIC LIFE SUPPORT ADVANCED CARDIAC LIFE SUPPORT
• CAN BE PERFORMED BY ANYONE • TRAINED MEDICAL \ PARAMEDICAL STAFF
• RHYTHM IDENTIFICATION BY AED • RHYTHM IDENTIFICATION BY RESUSICATOR
• AED FOR DEFIBRILLATION • MANUAL DEFIBRILLATOR
• NO IV LINE \ DRUG USE • IV LINE AND DRUG MANAGEMENT
• NO ADVANCED AIRWAY • ADVANCED AIRWAY USE
• NO OXYGEN SUPPORT • OXYGEN SUPPORT

Concept 10.4.2: Basic Life Support Algorithm

254 | Anesthesia
Concept 10.4.3: Advanced Cardiac Life Support Algorithm

• ADVANCED LIFE SUPPORT is a teamwork and involves a minimum of 6 trained
individuals and a maximum of 10.
• Comprises of doctors, trained paramedical staff, nurses.
1: Advanced life support includes:
Determination of whether the cardiac rhythm is shockable.
Provision of vascular access for drug administration (see Routes of Access for
Medication Administration)
Defibrillation
Medication therapy
Advanced airway management (although an ET tube is preferred, efficient bag-
mask ventilations can be just as effective for short resuscitation efforts).
2: The structure of team is as follows:
1 Team Leader
1 Compressor & 1 Ventilator (Change Roles Every 2 Mins)
1 Defibrillator
1 Intravenous Drug Delivery
1 Time-Keeper
256 | Anesthesia
3: Salient Features of ACLS Algorithm
CPR Quality
• Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil.
• Minimize interruptions in compressions.
• Avoid excessive ventilation.
• Change compressor every 2 minutes, or sooner if fatigued.
• If no advanced airway, 30:2 compression-ventilation ratio.
• Quantitative waveform Capnography
– If PETCO2 is low or decreasing. reassess CPR quality.
Drug Therapy
• Epinephrine IV/IO dose: 1 mg every 3-5 minutes
• Amiodarone IV/IO dose: First dose: 300 mg bolus. Second dose: 150 mg
or
Lidocaine IV/IO dose: First dose: 1-1.5 mg/kg. Second dose: 0.5-0.75 mg/kg
Return of Spontaneous Circulation (ROSC)

• Pulse and blood pressure
• Abrupt sustained increase in PETCO2, (typically ≥ 40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial monitoring
Shock Energy for Defibrillation

• Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum
available. Second and subsequent doses should be equivalent, and higher doses may he considered
• Monophasic: 360 J
Advanced Airway
• Endotracheal intubation or supraglottic advanced airway
• Waveform capnography or capnometry to confirm and monitor ET tube placement
• Once advanced airway in place. give 1 breath every 6 seconds (10 breaths/min) with continuous chest
compressions
4: Routes of Access
INTRAVENOUS ROUTE INTRAOSSEOUS ROUTE ENDOTRACHEAL ROUTE
MOST PREFERRED 2 ONLY IF IV ACCESS IS least preferred
ND
NOT AVAILABLE
Intravenously push bolus injection Most common: lower end of
femur or upper end of tibia
258 | Anesthesia
Flush with 20 mL of fluid or saline Dose is 2-2.5 times the iv dose

Raise extremity for 10 to 20 5 drugs:( NAVAL)
seconds to enhance delivery of Naloxone
drug to circulation Adrenaline
Vasopressin
Atropine
Lignocaine
5: Drug Therapy in CPR [Most Important Concept]
DRUG ADULT PEDIATRIC
ADRENALINE\ 1mg (1:10000) bolus every 3-5 mins 0.01Mg\kg (0.1ml\kg of 1:10000
EPINEPHRINE Endotracheal: 2-2.5 times dose (1:1000) concentration)
diluted in 10 ml normal saline Max dose:1 mg
Repeat every 3-5mins.
Endotracheal: 0.1 mg\kg (0.1 ml\kg of
1:1000 concentration)
AMIODARONE 1st dose: 300mg 5 mg\kg bolus during cardiac arrest.
2nd dose: 150 mg May repeat 3 doses for refractory VF\
pulseless VT
LIGNOCAINE 1st dose: 1-1.5mg\kg 1mg\kg bolus dose
2nd dose: 0.5-0.75 mg\kg
6: Critical Variables Associated with Successful Resuscitation
VARIABLE AMOUNT
Myocardial blood flow (ml\min\100g) >15-20
Aortic diastolic pressure (mmhg) >40
Coronary perfusion pressure (mmhg) >15-20
End tidal CO2 (mmhg) >10
Concept 10.5: Post Cardiac Arrest Care
LEARNING OBJECTIVE:
• To learn the goals of post cardiac arrest care and how to achieve them.
Time Needed
1 read
st
20 mins
2nd read 10 mins
260 | Anesthesia
Initial Stabilization Phase

Resuscitation is ongoing during the post-ROSC phase, and many of these activities can occur concurrentiy.
However, if prioritization is necessary, follow these steps:
• Airway management: Waveform capnography or capnometry to confirm and monitor endotracheal tube
placement
• Manage respiratory parameters: Titrate FIO2 for SpO2 92% – 98%, start at 10 breaths/min titrate to
PaCO2 of 35-45 mm Hg
• Manage hemodynamic parameters: Administer crystalloid and/or vasopressor or inotrope for goal
systolic blood pressure > 90 mm Hg or mean arterial pressure > 65 mm Hg
Continued Management and Additional Emergent Activities

These evaluations should be done concurrently so that decisions on targeted temperature management
(TTM) receive high priority as cardiac interventions.
• Emergent cardiac intervention: Early evaluation of 12-lead electrocardiogram (ECG) consider
hemodynamics for decision on cardiac intervention
• TTM: If patient is not following commands, start TTM as soon as possible; at 32-36°C for 24 hours by
using a cooling device with feedback loop
• Other critical care management
– Continuously monitor core temperature (esophageal rectal, bladder)
– Maintain normoxia, normocapnia, euglycemia
– Provide continuous or intermittent electroencephalogram (EEG) monitoring
– Provide lung-protective ventilation
When to Terminate Resuscitation Efforts

If the victim fails to respond to ACLS interventions, the team leader must consider
terminating treatment. Factors to consider when making the decision to terminate
resuscitation efforts include:
• Failure to respond to ACLS interventions.
• Amount of time after collapse before CPR and defibrillation began.
• Any other comorbid disease or conditions.
• Discovery of a “Do Not Resuscitate” order for the victim.
• Length of the resuscitation effort; increased time generally results in poor outcomes.
• Policies of the healthcare facility.
• Low end-tidal carbon dioxide (ETCO2) after 20 minutes of CPR in intubated victims
(e.g., <10 mm Hg by quantitative waveform capnography) along with other items
listed above
Concept 10.6: Summary of Key Changes in 2020 CPR Update
LEARNING OBJECTIVE:
• To learn the key changes in the 2020 CPR update.
Time Needed
1 read
st
20 mins
2nd read 10 mins
HIGHLIGHTS of Key changes in 2020 CPR guidelines below in charts:
BLS
1. A sixth link, recovery added to all 4 chains of survival.
2. Emphasis on early epinephrine administration (within 5 minutes of cardiac
arrest), repeat doses every 4 minutes to coincide with alternate pulse check.
3. Separate algorithm for pregnant women (for perimortem c/s if no ROSC in
4 minutes changed to 5 minutes) and Opioid related arrests (give rather than
consider naloxone)
4. EEG, neurological imaging introduced as part of post resuscitation care.
5. Rate of breaths in paediatric age group increased to 1 breath every 2 to 3 seconds
(20-30 bpm). 30 in children <1 year, 25 for> 1 year.
6. Advised to consider a cuffed ETT in paediatric age group
7. New algorithm for paediatric tachycardia with pulse (QRS duration 0.09 sec)
8. Umbilical vein catheterization to be considered.
9. 2 thumb encircling compression in infants is better than 2 fingers compression.
10. FAS (facial drop, arm drift, speech difficulties) changed to FAST(time to call
emergency number) for stroke
11. Aspirin intake advised for all non-traumatic chest pain before arrival of EMS unless
contraindicated.
12. Fetal monitoring not advised during maternal resuscitation. Post ROSC, yes. Rolling
over on left post ROSC
13. Ventilation rate in adults 1 breath every 6 seconds rather than 5-6 seconds
14. Use of waveform capnography recommended during bag mask ventilation too.
15. Use of mobile technology reasonable
ACLS
1. Amiodarone and lidocaine are now considered equivalent as antiarrhythmic in
cardiac arrest scenarios.
2. For adult symptomatic bradycardia, atropine dose changed to 1 mg from 0.5
mg. Dopamine dose for this changed from 2-20 mcg/kg/minute to 5-20 mcg/kg/
minute.
3. Emphasis on prevention of hyperoxia, hypoxemia and hypotension
4. Initial stabilisation split in to manage airway, manage respiratory parameters and
manage hemodynamic parameters.
262 | Anesthesia
5. For adult tachycardia IV access and ECG moved earlier in the algorithm.
6. Updated ACS algorithm contact to balloon inflation goal less than or equal to 90
minutes
7. Target SpO2 >94% for stroke and general care; 92-98% for post cardiac arrest
care
8. During CPR, 15 seconds before pausing compressions, high performance team
should check for pulse, precharge defibrillator, and prepare to deliver shock in 10
seconds or less to increase CCF>80% as 10% rise in CCF leads to 11% rise in
survival
9. Feedback devices or metronomes(can be downloaded on mobiles too)
10. IV preferred over IO
11. New diagram to guide neuroprognostication
Newly introduced concepts

1. CPR coach to help team leader. CPR coach ensures high quality BLS, while team
leader focuses on other aspects like ACLS.
2. Double sequential defibrillation
3. In Situ training
4. Booster training
5. Spaced learning approach
Worksheet
• MCQ OF “CARDIOPULMONARY RESUSCITATION” FROM DQB

264 | Anesthesia
1: WHICH IS THE NEW STEP ADDED IN THE CHAIN OF SURVIVAL ACCORDING TO

2020 UPDATE ON CPR:____________________
2: WHAT IS THE ORDER OF STEPS TO BE DONE IN CPR:______________________
3: PREFERRED SITE FOR PULSE CHECK IN AN INFANT IS______________________
4: MOST COMMON RIBS FRACTURED DURING CHEST COMPRESSIONS IS

______________________
5: WHAT IS THE RATE OF BREATHS GIVEN IN A 4 YEAR OLD CHILD UNDERGOING

CPR WITH AN ENDOTRACHEAL TUBE IN PLACE:___________________
6: MOST COMMON CARDIAC ARREST RHYTHM IN A CHILD IS:_________________
7: FULL FORM OF AED:_______________________________
8: MAX ENERGY USED IN A BIPHASIC DEFIBRILLATOR IS:________________________
9: BEST MEASUREMENT OF QUALITY OF CPR IS DONE BY:_______________________
10: IF A PATIENT IS UNRESPONSIVE THEN WHAT IS THE NEXT STEP IN THE

MANAGEMENT:_______________________
11: DRUG OF CHOICE, DOSE, DILUTION & ROUTE OF ADMINISTRATION IN CPR IS __

_______________________________________________________________
12: WHAT RANGE OF TEMPERATURE IS MAINTAINED DURING TTM IN POST CARDIAC

ARREST CARE:______________________
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First Published 1999, Delhi Academy of Medical Sciences

© 2021 DAMS Publication

11: Metabolic equivalents: MET score

Concept 1.2.2: Airway Assessment:

2: Factors Causing Difficult Laryngoscopy & Intubation

• Class 0 tip of epiglottis is seen (not a part of Mallampati classification) [NEETPGQ]

I& II: easy intubation

• During airway assessment an extension of > 85 degrees and an adequate flexion

Concept 1.3.1: Asa Physical Status Classification:

CLASS 1 AND 2 ARE LOW RISK OF PERI OPERATIVE MORBIDITY

Draw Backs of ASA Grading

1.3.2: Risk of Post Operative Pulmonary Complications (POPC)

1.3.3: Risk Stratification in a Cardiac Patient for Non-cardiac Surgery:

Revised Cardiac Risk Index Score Risk of Major Cardiac

Simplified Apfel Score

Concept 1.4.1: Management of Pre-operative Drug Therapy:

Concept 1.4.3: Fasting Before Surgery

Concept 1.5.1: Goals of Premedication

Concept 1.5.2: Drugs used for Premedication

• EXTRA POINTS FROM DQB

ASA PS CLASS EXAMPLES

MOST COMMON PREMEDICATION USED:

• FASTING PERIOD FOR A NEONATE WILL BE ___________ HOURS

• IDEAL TIME FOR ANTIBIOTIC ADMINISTRATION BEFORE SURGERY IS__________

• IDEAL TIME FOR STOPING OF SMOKING BEFORE SURGERY IS__________

• MOST COMMON COMPLICATION AFTER ANESTHESIA IS___________

• ASPIRIN NEEDS TO BE STOPED FOR __________DAYS BEFORE SURGERY

Â Concept 2.2: Breathing Circuits

Â Concept 2.3: Airway Equipments

• The basic function of an anesthesia machine is to prepare a gas mixture of precisely

Image 1: Basic Boyle’s Machine Image 2: Modern Anesthesia Workstation

Concept 2.1.1: Parts of Anesthesia Machine:

Concept 2.1.2: The High-Pressure System

Concept 2.1.3: The Intermediate Pressure System

2: The Flow Meter Assembly

3: Sequence of Flowmeters (NEET\AIIMSQ)

Concept 2.1.4: Low Pressure System

Pressure relief device

2: Intermediate Pressure System

Concept 2.2.1: Mapleson Circuits:

E Both Controlled 2-3* Mv • For Pediatric

Image : a typical closed circuit

• The capability to rebreathe exhaled gases is a unique aspect of circle systems as

2: Advantages of the circle system

1: CO2 Absorber \ CO2 Canister

Indicator Color when Fresh Color when Exhausted

Ethyl Violet White Purple

Phenolphthalein White Pink

Clayton Yellow Red Yellow

Ethyl Orange Orange Yellow

Mimosa 2 Red White

Concept 2.3.1: Face Mask

Concept 2.3.2: Airways

2: Basic of Working of an Airway:

A\K\A Guedel’s airway nasal trumpet

MATERIAL Hard plastic Soft silicon

1: LMA-Classic: (standard LMA, Classic LMA, LMA-C, cLMA) (MOST IMPORTANT

2: colour & pin index of nitrous oxide cylinder is _&_____