ANESTHESIA

ASA GRADING
I. Normal healthy patient
II. Mild systemic disease with no functional limitations
III. Moderate systemic disease with functional limitations
IV. Severe systemic disease which is constant threat to life
V. Moribund patient who is not expected to survive for more than 24 hrs.
VI. Brain dead patient
Draw backs of ASA grading
Does not accommodate asymptomatic pts
Risk of surgery and anaesthesia is not taken into account

Mallampati scoring for airway assessment

Class 0 tip of epiglottis is seen
Class I faucial pillar’s, soft palate, uvula, posterior phyrngeal wall
Class II faucial pillar’s, soft palate, uvula without tip.
Class III only soft palate
Class IV no soft palate
Other tests include : thyromental distance > 6.5 cm, sternomental distance > 12.5 cm, mouth opening
at least 3 fingers

Management of preexisting drug therapy

• Patient on MAO inhibitors discontinued before 3 weeks
• Levodopa-should be continued
• Oral hypoglycemics-for minor surgery (<20 min) continue, omit morning dose
• For major surgery-switch over to insulin 48 hrs. before surgery ,omit morning dose of insulin
• Oral anticoagulants- To be stopped 1 week before and switch over to low mol. Wt heparin, which is
stopped one day before surgery.
• Oral contraceptives- Estrogen pills to be continued
• Only progesterone pills need not be stopped
• Antihypertensives: to be continued and morning dose to be taken, Beta blockers are preffered to be
given on morning of surgery.
• Antianginal-to be continued (except aspirin)
• Antithyroid drugs: to be continued
• Lithium: To be stopped 48-72 hrs. before surgery
• Steroid: if patient has taken steroid for more than 1 wk in last 1 year intra-operative steroid
replacements is necessary
• Smoking : to be stopped 6 wks before
• Smoking stopped 12 hrs before surgery leads to fall in carboxy Hb levels, nicotine effects are decreased
• Muco ciliary activity returns in 6-8 weeks
• Aspirin: to be stopped 5 days before surgery
• Antitubercular drugs: To be continued but assessment of liver function tests is mandatory

CYLINDERS
Cylinders are made up of special alloy known as Mo steel so that it can withstand high pressures ,
cylinders used in mri are made up of aluminium.
• O2 cylinders
• Pressure-2000 psi(or 137 kg/cm2)
 ANESTHESIA DFX - WORKBOOK 2023
• Colour-Black body with white shoulders
• Available in sizes from AA to H
• Most commonly used cylinder on anaesthesia machine is Type E
• Testing to be done every 5 years
• -Acceptable purity 99%

N2O cylinders
Pressure-760 psi
Colour-blue
Filled as liquid, because critical temp. of N2O 36.5(above room temp)

Yoke of machine to be fitted corresponding holes of cylinder valve

This pin index system is to prevent wrong fitting of cylinders
Central Supply of O2 & H2O
• O2 & N2Oare supplied at 60 psi through central supply.
Liquid O2
Special supply reservoirs are used
Advantages
Can be used away from hospital e.g. in wars,
• Liquid O2 must be stored below its critical temperature of -1190C
• 1 ml of liquid oxygen releases 840ml of gas.

GAS PRESSURE PSI COLOR PIN INDEX

OXYGEN 2000 BLACK WITH WHITE SHOULDERS 2,5

AIR GREY BODY WITH BLACK AND WHITE 1,5

SHOULDERS

NITROUS OXIDE 750 FRENCH BLUE 3,5

CO2 GREY 2,6

CYCLOPROPANE 60 ORANGE 3,6

ENTONOX BLUE BODY WITH BLUE & WHITE SHOULDERS 7

Breathing Systems

Open Semiclosed Closed

Open_ By putting mask or gauge piece directly over nose & mouth, previously used for ether, chloroform.
A special mask schimmel busch mask is used for ether.

Semiclosed- Described by Mapleson

Airways
Most commonly used airway- Guedel
Length of airway =Distance between tip of nose & tragus + 1 inch

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Laryngeal mask airway
Available in sizes 1 - 5
Advantages:
— Easy to insert
— Can be used in cervical stability
— No laryngoscopy required
— No muscle relaxants required
— Can be used in awake pat
— Even paramedical staff can insert
Disadvantages:- Does not prevent aspiration, so not to be used in full stomach pts

TYPES OF LMA
 CLASSICAL LMA
 FLEXO METALLIC LMA
 FAST TRAC LMA
 PROSEAL LMA

Laryngoscope : Commonly used laryngoscope → Macintosh

Head & neck position for laryngoscope → extension at Atlanto-occipital joint & flexion at cervical spine, sniffing the
morning air position or barking dog position.
Teeth most vulnerable to damage → upper incisors

Endotracheal tubes
ET tubes ↓ the dead space (by 70 ml) in adults but ↑ in children
Bevel < 380+-8
Radius of curvature 14-16 cm

Red rubber PVC

Reusable Disposable

Expensive Cheap

High tendency Less tendency to kink

Absent Murphy eye present

Cuff low volume high pressure cuff high volume low pressure

best for small surgeries suitable for long duration

↑ chances of tracheal injury ↓ chances of tracheal injury

Non transparent transparent

Radiolucent radiopaque

less incidence of sore throat ↑ sore throat

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Mapleson A System
also K/a Magill circuit
Best for spontaneous respiration
Fresh gas flow should be Equal to minute volume to prevent rebreathing when patient is on spontaneous
respiration.
It is twice the minute volume when patient is on controlled ventilation.
Lack circuit modification of type A system
It has inner expiratory tube and outer inspiratory tube

Type B -Obsolete circuit, no more used

Type C -Obsolete circuit, no more used

Type D
— Most commonly used circuit is Bain’s modification of Mapleson D system
— Length of tubing is 1.5-1.8 meters
— Bain’s circuit is best for controlled ventilation
— Fresh gas flow should be 1.6 times of minute’s volume to prevent re breathing in Bain’s circuit, on
controlled ventilation.
It is 2.5 times of minute’s volume when patient is on spontaneous ventilation.

Mapleson E (Also K/a Ayre T piece)

Mapleson F

It is Jackson Rees modification of T piece (mapleson E) system

Used for children usually <6 yrs. of age or < 20 kg

CLOSED CIRCUIT- It is the circle system in which CO2 is absorbed by soda time from exhaled gases &
exhaled gases can be reused.

Soda lime composition

Ca(OH)2 - 94%
Na OH - 5%
KOH - 1%

Indicator
Silica is added to make it hard so that minimum powered dust is formed
Indicator color changes
Fresh Exhausted
Phenolphthalein White Pink
Ethyl violet White Purple
Mimosa Z Red White

Size of soda lime granules 4-8mesh size.

— Air space in canister-53%
— Max amount of CO2 that can be absorbed by 100 grams of sodalime is 26 L
— 13,700 calories are produced for 1 mole of CO2 absorbed

BARYLIME Ca (OH)2 -80%

Ba (OH)2 -20%
Barylime is less caustic

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Airways
Most commonly used airway- Guedel
Length of airway =Distance between tip of nose & tragus + 1 inch

PROPOFOL (2,6 di isopropylphenol)

• Comes as 1%,2% emulsion
• It contains soyabean oil, glycerol, egg lecithin
• Causes pain on injection
• It is good culture medium for bacterial growth hence should be used in 6 hrs
• May contain EDTA
• For iv use only
• Recovery from propofol is rapid & clear doc for day care surgery
• Is metabolized hepatic as well as extra hepatic clearance

Systemic effects
 CVS
Decrease in blood pressure, fall in SVR, cardiac contractility, preload
More hypotension
May cause bradycardia
 Resp
Causes ventilatory depression, may cause apnea
Depress hypoxic ventilatory drive
Causes maximum upper airway depression of reflexes hence doc for LMA insertion
 CNS
Decreases cerebral blood flow, ICP
Is antiemetics, and antipruritic
Doesnot have anticonvulsant properties may cause involuntary movements
Decreases IOP
 Is antioxidant
 Doc in hepatic disease
Potentiates NDMR, fentanyl
 Propofol infusion syndrome
Lethal syndrome
Triad of metabolic acidosis, skeletal myopathy, acute cardiomyopathy
Occurs on prolonged infusion( >48hrs) high dose mainly in children
Occurs due to failure of metabolism of free fatty acids

Nitrous Oxide, N2O (“Lauging Gas”)

Physical Properties
• colorless
• odorless
• nonflammable but, like O2, supports combustion
• gas in room temp and ambient pressure; liquid under pressure
• is prepared by heating ammonium nitrate at 245-2700C

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Organ System Effects
Cardiovascular
• direct myocardial depressant effect balanced by
• sympathetic nervous system stimulation
• so BP and PR stable
• myocardial depression may be unmasked by
o CAD
o hypovolemia
• pulmonary vasoconstriction -> increased PVR

Respiratory
• tachypnea + decreased VT = stable VE and paCO2
• BEWARE: inhibits carotid body hypoxic drive

CNS
• mildly increases CBF, CBV and ICP
• increases CMRO2
• analgesia

Biotransformation and Toxicity

• eliminated by exhalation
• irreversibly oxidizes cobalt atom of vitamin B12, inhibiting B12-dependent enzymes:
o methionine synthetase (myelin formation)
o thymidylate synthetase (DNA synthesis)
• so prolonged exposure can lead to
o bone marrow depression (megaloblastic anemia)
o peripheral neuropathy
o pernicious anemia
• controversial:
o emetogenic? (not especially)
o teratogenic (maybe not, but not necessary in early pregnancy, so usually avoided)

Contraindications
• 35 times more soluble in blood than nitrogen, N2
• so fills and expands any air-containing cavities:
o air embolism
o pneumothorax
o intracranial air
o lung cysts
o intraocular air bubbles
o tympanoplasty
o endotracheal tube cuff (monitor and reduce pressure periodically)
• may exacerbate pulmonary hypertension
• Diffusion Hypoxia
• Concentration effect & second gas effect

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Sevoflurane, (CF3)2-cH-O-CF2H
Relatively low solubility and nonpungency make it an excellent choice for inhalational induction in
children.

Physical Properties
• vapor pressure = 160 mmHg at 20 deg C
• low solubility (lambdablood:gas = 0.65)
• moderate vapor pressure (160 mmHg at 20 degrees C)

Organ System Effects

Cardiovascular
• mild negative inotrope
• little or no tachycardia
• so cardiac output not as well maintained as with isoflurane or desflurane
• may prolong the QT interval

Respiratory
• depresses respiration
• bronchodilator

CNS
• general anesthesia, MAC = 2.0
• slightly increases CBF and ICP
• decreases CMRO2

Biotransformation and Toxicity

• rate of metabolism = 5% (ten times that of isoflurane)
• inorganic fluoride is a metabolic product soda lime (NOT calcium hydroxide) degrades sevoflurane to compound
A
o nephrotoxic in rats
o accumulation of compound A increases with
 increased respiratory gas temperature
 low-flow anesthesia
 dry barium hydroxide absorbent
 high sevoflurane concentrations
 time
• some recommend minimum total fresh gas flows of 2 L/min and
• avoid if preexisting renal dysfunction
• metal and environmental impurities can degrade sevoflurane to hydrogen fluoride
o can produce acid burn of respiratory mucosa
o degradation minimized by adding water during manufacture and packaging in special plastic containers

Contraindications
• malignant hyperthermia susceptibility
• hypovolemia

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 ANESTHESIA DFX - WORKBOOK 2023
Musle relaxants are divided into 2
 Non depolarizing agents or tachycurares
 Depolarizing agents or leptocurares

Mech. of action
Depolarizing or non-competitive block, drug occupies α subunit of receptor to produce depolarization,
and remain attached for longer than Ach, rendering receptor insensitive to further stimulation
Non-Depolarizing or competitive block , the drug competes with Ach to occupy the receptor binding site
but doesnot produce any intial stimulation or depolarization.

Depolarizing neuromascular block

Only succinylcholine is available.
Features of block include
 Cause muscle fasciculation
 Fast dissociation at receptors
 Not reversed by neostigmine
 No fade or post titanic stimulation seen
 Potentiated by isoflurane,resp. alkolosis,hypothermia and Mg
 Antagonized by acidosis and NDMR
 Repeated use causes phase II block.

Onset within 30 seconds and lasts 10-12 min

It is redistributed and hydrolysed
Causes bradycardia in children esp. after 2nd dose
B.P and ICP and IOP are and intra gastric pressure ↑ed
Dibucaine number the % inhibition of plasma cholinesterase by dibucaine. Normal is 75-85%
Homozygotes have only 30%.
Cholinesterase def may occur in liver disease, malnutrition, carcinomatosis, pregnancy, uremia,
hypothyroidism.

Side effects
 Hyperkalemia rises up to .5 mmol/L, more after burns,spinal cord injury,stroke, cerebral palsy due to extrajuctional
receptors. Scoline should be avoided 48 hrs to 9 months after acute injury.
 Intraocular pressure rises 7-8mmhg
 Muscles pain decreases by NDMR,scoline,lignocaine
 Malignant hyperpyrexia most common drug implicated
 Allergy realeases histamine
 Dystrophica myotonica causes severe muscle rigidity, preventing resp. and intubation.

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FMGE PYQS

Q1: Before Laparoscopic surgery, what

advise should be given to the patient
by surgeon?
a. NPO 8 - 12 hours before OT
b. NPO 24 hours before OT
c. On the table hair removal by razor
d. None of the above

Q2: Which of the inhalational anesthetic

uses special vaporizer? D:
a. Desflurane
b. Sevoflurane Q4.: halothane causes malignant
c. Isoflurane hyperthermia by affecting which
d: Halothane channels?
A: potassium B: calcium
Q3: there is a sick patient in ward who C: sodium D: magnesium
needs supplemental oxygen. It will
be given from which of the following Q5: How long should you check for
cylinder? breathing while performing CPR?*
A. Do not check for breathing,
B. continue chest compressions
C. 2 seconds
D. No longer than 10 seconds

Q6: Hallucinations are seen with?

A. Propofol B. Sevoflurane
C. Ketamine D. Isoflurane
A:
Q7: Succinylcholine causes?
A. Severe hyperkalemia
B. Paaraplegia
C. Liver failure
D. Renal failure

Q8: Mendelson’s syndrome is due to?

A. Hypersensitivity reaction to anesthetic agent
B. Gastric contents aspiration
C. Faulty intubation
B:
D. Asphyxia due to tracheal stenosis

Q9: Mallampati classification in which

tonsillar pillars, uvula is not seen?
A. Class I B. Class II
C. Class III D. Class IV

Q10. Most efficient Mapelson circuit for

spontaneous ventilation?
A. Mapelson A B. Mapelson B
C. Mapelson C D. Mapelson D
C: