Anesthesia

1. Preanesthetic checkup
2. Monitoring
3. Airway Management
4. Anesthesia machine
5. Breathing systems
6. Regional anesthesia
7. Local anesthesia
8. Muscle relaxants
9. IV anesthetics
10. Inhalational anesthetics
11. Oxygen therapy
12. Mechanical ventilation
13. Daycare anesthesia
14. CPR
 Pre anesthetic checkup
condition concern

HTN continue all except ACE inhibitors & ARBs [for r/o severe
hypotension]

DM target RBS : 120-200 mg/dL

skip OHAs & insulin on day of Sx
long acting insulin reduced to 1/3rd
SGLT 2 inhibitors stopped 24 hrs prior [r/o euglycemic
ketoacidosis]

epilepsy continue antiepileptics

avoid enflurane, methohexitone [seizure provoking]

thyroid disorders continue thyroid supplements & anti thyroid drugs

psychiatry MAO inhibitors stopped 3-4 wks prior [r/o hypertensive crisis]
Li or Mg interact & prolong muscle relaxation - continue
depending on pt. condition

past h/o MI low dose aspirin (60-75 mg) : continue

high dose aspirin (150-300 mg) : stop 3 days prior
clopidogrel, warfarin : stop 5-7 days prior
after stopping other anticoagulants, bridge c̅ LMW heparin
▪︎ prophylactic : stop 12 hrs prior
▪︎ therapeutic : stop 24 hrs prior
▪︎ regular : stop 6 hrs prior
Ticlopidine : stop 10 days prior
all other cardiac drugs : continue

OCPs estrogen containing pills

high risk category : stop 4 wks prior
low risk : continue

steroids continue

herbal medicine if LFT deranged : wait for 1-2 wks

NSAIDs stop 24-48 hrs prior

 Sildenafil stop 24-48 hrs prior [r/p intractable hypotension]

diuretics except thiazide, stop all drugs

monitor S.electrolytes

Personal history

condition concern

smoking stop 6-8 wks prior

bronchospasm → wheeze → salbutamol
laryngospasm → stridor, desaturation → 100% O2,
propofol, Sch

alcohol stop 24-48 hrs prior, check LFT

tobacco difficult intubation

chewing

Allergy h/o :-
h/o anaphylactic shock
causes : antibiotics, latex, muscle relaxants, local anesthetics
pathophysiology : histamine release
features :
sudden unexplained tachycardia
hypotension
↑ airway resistance
edema
wheeze
Rx : adrenaline (1 ml of 1 : 1 lakh IV)

Family h/o :-
h/o malignant hyperthermia
severe mortality under GA
cause : all inhalational anesthetics, Sch
pathophysiology : mutation of Ryanodine receptors @ sarcoplasmic reticulum
features :
sudden unexplained tachycardia
HTN
↑ body temperature
↑ ET CO2
ventricular fibrillation
sudden cardiac arrest
Rx :
stop inhalational agents
100% O2
dantrolene sodium
calcium gluconate, salbutamol, insulin + dextrose
Post op complication : AKI

ASA grading :-
i : normal healthy pt.
ii : mild disease c̅ no functional limitation (asthma)
iii : moderate disease c̅ functional limitation (CKD, CLD)
iv : severe life threatening disease
v : moribund pt.; not expected to survive >24 hrs
vi : brain dead pt.

Investigations :-
Hb (min. acceptable) : 8 gm/dL
Platelets
invasive procedure : 50,000
surgery : 80,000 - 1,00,000
ECG
CXR

Risk stratification :-
high risk surgery
h/o ischemic heart disease
h/o CHF
h/o CVA
DM requiring insulin
S. creatinine >2
coronary stenting
bare metal stent : >30 days
drug eluting stents : 6 months
URTI : wait for 6 wks

Pre operative instructions :-

• Anxiolytics : short acting benzodiazepines
• Anticholinergics : atropine/ glycopyrrolate
• Antiemetics :
females
h/o motion sickness
laparoscopy
middle ear surgery
ophthalmic surgery
analgesics
antibiotics

MAO/TCA inhibitors : 3 weeks

Clopidogrel : stop 7 days prior
Warfarin : 5 days
Lithium : 48 hrs
LMW heparin : 12-24 hrs
Unfractionated heparin : 4 hrs
ACE #/ARBs/OHAs/insulin : omit morning dose
 Monitoring
CNS monitoring
Bispectral index : to assess depth of anesthesia by analyzing EEG waveforms
target value : 40-60

CVS monitoring
1. PR
2. NIBP
3. ECG
lead 2 to detect arrhythmia
lead V3, V4, V5 to detect ischemia, infarction
4. IBP
m/c site : radial artery
Allens test to check adequate collateral circulation
5. CVP monitoring
normal CVP : 0-5 cm
m/c site : IJV
to detect Rt. side heart function & fluid status
low CVP + low BP → hypovolemia
high CVP + low BP → Rt. heart failure
not used for rapid resuscitation
6. PCWP
Lt. side heart function
normal : 12-16 cm
invasive
complication : pulmonary artery rupture
7. 2D ECHO

Core temperature monitoring

site surgery

nasopharynx, tympanic membrane CNS surgery

pulmonary capillary temp. CABG

mid esophageal temp. GI surgery

 rectal intermediate b/w core & surface
temp.

Respiratory monitoring
Pulse oximeter :-
Beer Lambert’s law
red light → reduced Hb
infrared light → oxygenated Hb
falsely elevated values → CO poisoning
falsely low values → Methemoglobin, dye, henna on hand, jaundice, thick skin

Capnography :- monitor exhaled CO2

Normal • Respiratory baseline
• Expiratory upstroke
• expiratory plateau
• inspiratory downstroke
• ET-CO2 : 30-45 mmHg

Shark fin plateau bronchospasm, COPD

Hypoventilation low RR c̅ high ET-CO2

Hyperventilation high RR c̅ low ET-CO2

Rebreathing circuit baseline increasing

• problem c̅ soda lime

Curare cleft • dips in expiratory plateau

• spontaneous breaths
• need for NM blockers

Adequate chest compressions ET-CO2 >20 mmHg

Malignant hyperthermia sudden ↑se in ET-CO2 (earliest)

Sudden loss of waveform • circuit disconnection

• cardiac arrest
• air embolism
- h/o sitting position (neuroSx)
- Best : Transesophageal 2D echo
- Mx : Durant’s position
[Trendelenburg + Lt lateral]
 Gradual ↓se in ET-CO2 Esophageal intubation

Neuromuscular monitoring
m/c used : ulnar nerve >> facial nerve
1. Single twitch stimulation : no differentiation b/w DMR & NDMR
2. Train of four ratio : 4 supramaximal stimulus @ every 0.5 sec
Train of four ratio = 4th amplitude/ 1st amplitude

if ratio > 0.9 → safe for extubation

3. Tetanic stimulation : to monitor deeper blocks
4. Double burst stimulation (less painful)
 Airway management
Predictors for difficult intubation :-
• Obesity
• Beard
• Elderly
• Snoring
• Edentulous
• Pregnant lady
• Mouth opening : finger breath technique < 3 fingers (normal = 3 fingers)
• Atlanto-occipital movement < 12° (normal : 12-35°)
• Angle made by forehead < 80° (from flexion to extension)
• Neck circumference > 43 cm
• Thyro-mental distance < 6 cm (normal = 6.5 cm)
• Sterno-mental distance < 12 cm

Mallampati scoring :-
i : uvula hanging freely
ii : tip of uvula not visible
iii : half of uvula not visible
iv : only hard palate visible

Intubation :-
Preoxygenation → Induction agents → Muscle relaxants → attenuate response →
Extubate
1. Preoxygenation
100% O2 for 3 mins → apnea period can be extended to 10 mins
C&E technique c̅ pressure <25 cm H2O
emergency intubation : 8 > 4 vital capacity breaths
triple maneuver : head tilt, chin lift, jaw thrust
2. Induction agents
3. Muscle relaxants
rapid sequence intubation → Sch
if Sch contraindicated → Rocuronium
4. Attenuate response
to attenuate sympathetic response as a result of laryngoscopy
drugs :
preservative free lignocaine or
nitroglycerine or
opioids (Fentanil) or
short acting beta blocker (esmolol)

Equipment :-
1. Anatomical face mask
2. Guedel's oropharyngeal airway
• prevents tongue fall back
• disadvantage : stimulates gag reflex - used in unconscious patients
• size : angle of mouth to tragus/ mandible
3. Nasopharyngeal airway
prevents collapse of pharynx
no gag reflex stimulation - used in conscious patients
4. Laryngoscope

Mc intosh curved blade Millers straight

blade

use adults children

method hold laryngoscope in Lt. hand inserted from

↓ center of oral cavity
insert from Rt. corner of mouth c̅ include epiglottis
forwards & upwards pressure
↓
push tongue to side till blade reaches its
base
↓
on visualizing epiglottis, lift hand

Mc-coy blade : curved blade + lever

C-Mac : Video laryngoscopy
ATLS recommended in trauma pt./difficult intubation
4. ET tube

• PVC cuffed ETT

low pressure high volume cuff
prevents aspiration
• uncuffed ETT
used in children
• microcuff ETT
used in children
• south oral Ring-Adair-Elwyn ET tube : nasal, ophthalmic surgeries
Size of ETT :
<6 yrs = age/3 + 3.75
>6 yrs = age/4 + 4.5
length = age/2 + 12

adult males : 8.0/ 8.5/ 9.0

adult females : 7.0/ 7.5/ 8.0
preterm child : 2.5
term baby : 3.0
1 yr : 3.5

Position : Sniffing position - flexion of C-spine & extension @ atlanto-occipital joint

Signs of correct placement :
B/L & equal chest lift
mist formation
B/L equal air entry on auscultation
capnography
fiber optic bronchoscopy
CXR
Accessory gadgets : stylet, magills forceps, bougie
Modifications :
1. Flexometallic tube
no kinking
prone position surgeries - spine/ head & neck surgeries
2. RAE (preformed) ET tubes :
nasal (north pole) : for oral/dental Sx
oral (south pole) : Nose/PNS Sx

3. Double lumen ETT :

selective/single lung ventilation
intrathoracic surgeries (pneumonectomy/lobectomy)

Modern gadgets : air traque, video laryngoscope, tru scope, ambu scope
Supraglottic airway devices :-
1. Classic Laryngeal mask airway
• 1 tube + inflation port
• easy to use, r/o aspiration
2. Proseal LMA
• 2 tubes + inflation port
• drain tube sucks out secretions
• less r/o aspiration
3. LMA supreme
• made up of PVC - disposable
• high sealing pressure
• gastric port +
4. AMBU/ Intubating LMA
• inflation cuff +nt
• no gastric port
5. I-gel/ 2nd generation airway
• pilot balloon absent
• silicon rubber grips pharynx
• gastric drain port +nt
6. SLIPA
Size :
Child = 3
Female = 4
Male = 5

Modifications :-
Normal : flexion @ lower cervical spine, extension @ atlanto-occipital joint
Obese : RAMP position/ reverse trendelenburg position
Spine surgery : prone position
Oral surgery : nasal intubation
contraindications - children (adenoid hypertrophy), # base of skull, coagulopathy
Emergency intubation : rapid sequence intubation

RSI modified RSI

preoxygenation no mask ventilation gentle mask ventilation

induction agents thiopentone sodium propofol

muscle relaxant Sch Sch/ rocuronium

 method Selick’s maneuver (cricoid pressure) → ET
tube placement → inflate cuff → release
cricoid pressure

Intubation after RTA :

protect C-spine - manual in line stabilization
in pneumothorax - insert ICD (endotracheal intubation)

Difficult airway Mx :-
laryngoscopy
↓
plan A
facemask ventilation & tracheal intubation
↓
plan B
maintain oxygenation & supraglottic airway device insertion
↓
plan C
final attempt @ facemask ventilation & waking pt.
↓
plan D
emergency front of neck access (cricothyroidotomy)
 Anesthesia machine
inventor : Sir Henry Edmund Gaskin Boyle
purpose : provide O2 & anesthesia
types :

continuous flow intermittent flow

gas flow throughout pt. has to draw inspired

inspiration & expiration anesthetic during inspiration

eg., Boyle’s machine eg., Meckesson (labor

analgesia)

types of Boyle’s machine :

high pressure intermediate pressure low pressure

▪︎ cylinders ▪︎ master switch ▪︎ flow meter

▪︎ hanger yoke ▪︎ pipeline inlet connection ▪︎ hypoxia prevention
▪︎ cylinder pressure gauge ▪︎ pressure indicators safety devices
▪︎ pressure regulators ▪︎ gas power outlets ▪︎ check valves
▪︎ 2nd stage pressure ▪︎ pressure relief device
regulator ▪︎ low pressure piping
▪︎ O2 flush ▪︎ fresh gas
▪︎ flow adjustment control ▪︎ outlet

sources of O2 : cylinders, liquid tanks, O2 concentrator

Safety features of cylinder :
1. color
cylinders are made of an alloy of Molybdenum steel

O2 black body c̅ white shoulder

N2O blue

CO2 gray

N2 black

He brown
 Air white body c̅ black shoulder

Entonox blue body c̅ white shoulder

Cyclopropane orange

2. cylinder markings
• service pressure - max. pressure @ which a cylinder can be refilled @ 70 °F; only non
liquefiable gases
3. valve
• brass/ bronze valve
• packed type/ diaphragm type c̅ a pressure relief device (a spring & an opening)
• rotate handle wheel in anticlockwise direction to open
4. pin index safety system
• to connect cylinder to machine
• specific to cylinder
• full proof method to eliminate crisscrossing of cylinders
• each valve has holes arranged in an arc of circle → each hole as a number & machine has
corresponding pins

Air 1, 5

O2 2,5

N2O 3,5

Entonox 7

CO2 >7.5% : 1,6

< 7.5% : 2,6

5. bodock pressure seal

• to prevent leakage of gases when connected to boyle’s machine
6. size
• AA (smallest) to H (largest)
• E : 640 lts. → generally used for Boyle’s machine
measurement of contents of cylinder :
uses Bourdon’s pressure gauge
only for non liquefiable gases
pressures inside cylinder :
▪︎ O2 - 2000 Psi
▪︎ N2O - 760 Psi
▪︎ cyclopropane - 60 Psi
liquid O2 tank : 1 ml of O2 = 840 ml gas
Yoke assembly : a point where the cylinder is attached to Boyle’s machine & has a
unidirectional valve to prevent gas to enter another empty cylinder
O2 & N2O coming from high pressure system moves into intermediate pressure system &
finally into low pressure system
Manifold : multiple cylinders are linked to provide constant supply of gas

O2 concentrators :
▪︎ principal of Pressure swing adsorbent (PSA) technology
▪︎ delivers 96% pure O2

Intermediate pressure system :

1. Piping
2. Pipeline pressure indicators
3. Inlet connection system/ Diameter Index Safety System (DISS) : non-interchangeable
4. O2 fail-safe devices : when O2 conc. ↓ses → devices automatically ↓se N2O flow → to
allow recovery from anesthesia
5. O2 supply failure alarm
6. 2nd stage pressure regulator : in some machines, these ↓se pressure to 20-25 Psi
7. O2 flush valve : delivers high unmetered flow of O2 (35-75 L/min)
- used in cases of ↓sed O2 in cylinder

Low pressure system :

from Flow control valves to Common gas outlet
pressure : 10-15 Psi
components :
1. Bobin (small indicator)
@ the top of flowmeter there is a stop to prevent movement of bobbin into patient’s
mouth
reading of bobin (acc. to shape)
● circular → @ middle
 ● hob → @ bottom
● conical → @ top
2. Constant pressure variable orifice devices : a small control knob when turned
anti-clockwise will open the gas flow
internally, flow meters are slightly conical → as gases flow in, bobin doesn’t obstruct &
cause pressure build-up in the meter
flow meters for calibrated, touch sensitive and gas specific (color coded for O2 & N2O)
Assembly :
newer stations → O2 on right & N2O on left
to avoid confusion, O2 flowmeter should always be located in downstream
Adjustment controls :
usage of dual chambered flowmeter to have a precise control of gas flow in low flow
anesthesia
in 1st chamber they have 0-1 L & in 2nd chamber 1-10 L
low gas flow - laminar & high gas flow - turbulent
safety features :
min. mandatory O2 flow: 250 ml/min
link system: O2 & N2O flow meters are interconnected by a chain like system
- accidental closure of O2 flow meter causes automatic ↓se in N2O flow
O2 flow meter has 28 spokes & N2O flow meter has 14 spokes
back bar : framework of machine where vaporizer is mounted
O2 & N2O respective flow meter goes into back bar where it picks up anesthetic vapor
from vaporizer & goes into fresh gas outlet
Vaporizer - a specialized machine that holds inhalational anesthetic (volatile liquids stored
as liquids)

Disadvantages :
▪︎ m/c site for gas leakage
▪︎ prone to damage, especially control knob
▪︎ at low atmospheric pressures, flowa will be high
▪︎ erroneous readings
*Heidbrink flowmeter
 Breathing systems
circuit - a connection b/w boyle’s machine & ET tube
Classification :-
1. Open
SchimmelBusch mask
advantages : simple, easier
disadvantages : theater pollution
2. Semi open
aka Mapleson circuit
5 components
➢ machine end
➢ patient’s end
➢ adjustable pressure limiting valve
➢ reservoir bag (represents lung compliance)
➢ corrugated tubing
APL valve has lid & spring
unidirectional gas flow - lids closed
2 gases flow in 2 different directions - lids open
1. type A :
- circuit of choice for spontaneous respiration
- aka Magill circuit
- MV = 500 × 12 = 6000 ml (6 L/min)
- APL adjacent to patient end
- circuit c̅ least FGF requirement
2. modified type A :
- aka Lack circuit
- co axial (circuit c̅in a circuit)
- inner tubing is for expiration of gases
3. type B : obsolete
- APL & FGF close to patients end
4. type C : obsolete;
- no corrugated tubing;
- aka to & fro circuit
- eg., AMBU bag
5. type D :
- controlled ventilation
- FGF required is very least
- circuit D = 1.6 × 6 ~ 10 L/min
6. modified type D :
- Bain’s circuit
 - also a coaxial circuit
- APL distant for
- inner tubing is for inspiratory gases
- length = 1.6 mts
7. type E :
- aka Ayres T piece
- pediatrics
8. type F :
- Jackson Rees modification of Ayres T piece
- for children of age <6 yrs & wt. <20 kgs
performance depends on :
● FGF
● MV (TV × RR)
● mode of ventilation: spontaneous/ controlled
● I:E ratio, expiratory pause duration, peak inspiratory flow
● volume of reservoir bag/ tubing
● ventilation through mask/ ETT
● sampling site

type spontaneous controlled

A MV 3MV

B 2MV 2.25MV

C 2MV 2.25MV

D 2.5MV 1.6MV

E 2.5MV 3MV

F 2.5MV 1.5-2MV
3. Closed
if a pt. inhales 21% O2, he exhales 16% of O2 & 5% of CO2
pt. receives O2 from unidirectional valves → CO2 produced flows through expiratory limb
via another unidirectional valve → expired air containing both O2 & CO2 flows through an
unit containing soda lime → all of CO2 is reabsorbed & O2 is recycled
Slow reaction : CO2 + Ca(OH)2 → CaCO3
Fast reaction :
CO2 +H20 → H2C03
H2C03 + NaOH/ KOH → Na2CO3/ K2CO3 + H20
Na2CO3/ K2CO3 + Ca(OH)2 → CaCO3 + NaOH/ KOH +H2O
Parts :
▪︎ FGF
▪︎ corrugated tube
▪︎ patient’s end
▪︎ soda lime = 80% Ca(OH)2 + 3% NaOH + 2% KOH + 16% H2O
advantages : recycle of gases, less no.of flows
disadvantages :
▪︎ adds resistance
▪︎ soda lime + trilene → phosgene (respiratory irritant) + dichloroacetylene (neurotoxic)
▪︎ soda lime + sevoflurane (prolonged period) → compound A (nephrotoxic in lower group of
animals)
▪︎ bary lime [Ba(OH)2] → more exothermic reaction, more CO production, more compound A
▪︎ Li(OH)2 → no compound A
▪︎ inhalational anesthetic + soda lime → CO → HbCO

factors responsible for CO production :

- bary lime > soda lime > desflurane
- repeated usage
- high Temp.
- conc. of agent
- low FGF
- dessicated soda lime

Identification of dessication :
• indicators :

indicator color when fresh color when exhausted

phenolphthalein white pink

 ethyl violet white purple

clayton yellow red yellow

ethyl orange orange yellow

mimosa z red white

• in Capnography, when re breathing/ soda lime is dessicated → elevation of baseline

• heat production : bary lime > Li(OH)2
• absorbing capacity : Li(OH)2 > Ca(OH)2
• factors of absorption : size of granules → 4-8 mesh size
too large → reduced absorption
too small → channeling effect
 Regional anesthesia
Spinal anesthesia
aka Subarachnoid block
indications : any surgery @/ below the level of umbilicus
contraindications :

Absolute Relative

• ↑sed ICP • moderate hypovolemia/ hypotension

• bleeding disorders
[Plt <80 K, INR > 1.8]
• Infection @ the site of injection
• patient refusal
• severe hypovolemia/ hypotension
• severe hypertension
• mitral/ aortic stenosis
• drug allergy
• spinal deformities
• past h/o spine surgery
• chronic backache
• progressive neurological disorders
• septicemia
• heart block

site :
▪︎ adult : L3-L4
▪︎ children : L4-L5
* Tuffier's line : imaginary line passing through L4 spinous process/ L4-L5 interspace
Procedure (3Ps) :
1. Preparation
• prevention of infection
• keep an IV line active
• keep all resuscitation equipment ready
2. Position
• position - sitting/ Lt lateral/ prone
• approach - midline (b/w spinous process)/ paramedian (1 cm lateral to spinous
process)
3. Projection
structures pierced :
• skin
• S.C tissue
• supraspinous ligament
• interspinous ligament
• ligamentum flavum (max. resistance)
 • duramater
• arachnoid
Spinal needles :

Dura cutting needles Dura splitting needles

• makes a hole in Dura • makes a small vent

• more CSF loss → more headache • less CSF loss → less headache
• eg., Quincke Babcock needle • eg., Whitacare/ Sporte needle
• technically easier → layers can be • technically difficult
appreciated better

more gauge → finer needle → less CSF loss → less headache

Level of block required for common surgeries :

• LSCS upto T4
• prostate upto T10
• hip T4
• Foot & ankle upto T10
L2

Block monitoring :-

Sensory level pricking Motor level Bromage scale

By pin prick test, we can get 0 - can freely move leg &
the level of anesthesia acc. feet
to dermatome 1 - able to flex knees
manubrium - T2 2 - able to move only feet
nipple - T4 3 - no movement
xiphisternum - T6
umbilicus - T10

Factors of height of anesthesia :-

• Drug factors :
1. Baricity of drug
density of drug relative to density of CSF
hypobaric drug → floats in CSF → high level of anesthesia
hyperbaric drug → settles @ bottom → low level of anesthesia
2. Dose
dose = volume × concentration
level of anesthesia ∝ volume of drug ∝ dose of drug
• Patient factors
1. CSF volume
level of anesthesia ∝ 1/ CSF volume
children - more volume of CSF per segment - low level of anesthesia
adults - less volume of CSF
2. Age
old age → ↑ S.G → drug becomes hypobaric → high level of anesthesia
3. Pregnancy
gravid uterus compresses epidural & subarachnoid space → drug spreads faster
Progesterone ↑sensitivity to LAs → drug dose ↓ses
4. Height
level of anesthesia ∝ 1/ height
5. Gender
in males in left lateral position, spinal cord is curved → hyperbaric drug goes down
in females, pelvis size is broader → hyperbaric drug goes upto neck
• Procedure factors
1. Position
sitting position → hyperbaric drug will settle down
trendelenburg position → hyperbaric drug moves towards neck
2. Injection of epidural drug post spinal anesthesia → compresses subarachnoid space →
high level of anesthesia
Side effects :

CVS Bradycardia when HR >20% of baseline -

atropine/ glycopyrrolate
Hypotension preloading : 15-20 ml/kg RL/
NS
Inj. Phenyl epinephrine/
Mephentermine/ Ephedrine
Systemic vascular resistance decreases

Respi high level of anesthesia - intercostal muscle Supplement O2, reassurance

palsy - chest heaviness/ SOB

GIT Defecation (sphincter relaxation)

 Genitouri Urinary retention (detrusor muscle paralysis) Foley's catheterisation
nary

Other approaches :
1. Continuous spinal anesthesia
small catheter inserted to continuously increase drug dose
increased r/o cauda equina syndrome
in a very sick pt.
catheter doesn’t cause irritation
2. U/L spinal anesthesia
lateral position
hyperbaric drugs
only one side of body blocked
3. Saddle anesthesia
pt. made to sit after anesthesia
only saddle area blocked
no systemic A/Es
hemorrhoidectomy, sphincterotomy
4. Taylor’s approach
severe fusion of spine
reach subarachnoid space from L5-S1 using long spinal needle
High spinal : c/o SOB
Total spinal : enters arachnoid space → Unresponsive patient
LA toxicity :
Lignocaine - Seizures
Bupivacaine - Arrhythmia

Post dural puncture headache :-

cause : spinal anesthesia c̅ Dura cutting & thicker needles
females (after LSCS)
CSF leakage → ↓sed cushioning effect
24-48 hrs after spinal anesthesia
mild - moderate, dull boring type headache in occipital & frontal region
• a/w Nausea, vomiting, photophobia
• aggravating factors : walking, talking, coughing, straining
• relieving factors : rest
Rx :
↑se CSF production : ultrafiltration of plasma, adequate rest, good hydration
analgesics : caffeine + PCM
epidural blood patches : 10-15 ml of pt.s blood injected into epidural space → clot forms →
helps in healing
Epidural anesthesia

level : thoracic/ lumbar/ cervical levels

epidural catheter set
Tuohy needle :
to locate epidural space
slightly curved in ant. end & has a lumen
18G/ 16G is used
loss of resistance technique
on reaching epidural space, drug is sucked in
Factors :

Drug factors volume of drug

more drug, more block

Patient factors elderly & pregnancy -

narrow epidural space -
less volume

Procedure factors site of needle insertion

cervical >> thoracic

Advantages :
Prolong duration of anesthesia
No chance of PDPH
altered LOA
Stable hemodynamics
Disadvantages :
Technically difficult
Delayed onset (not used in emergencies)
Catheter migration
Severe PDPH : If catheter pierces dura

Caudal Anesthesia
only in children
left lateral position
Location : S4-S5
Advantage : no chance of neurological injury
Disadvantage : only supplement for GA
strict aseptic precautions needed
injury to bony structures leads to permanent damage

Peripheral Nerve Block

Goal : deposit drug near nerve, not injecting into it

Cervical plexus block :-
• Superficial cervical plexus block : @ lateral border of SCM
• Deep plexus block : along an imaginary line connecting cricoid cartilage and mastoid
process
• Indications :
LN biopsy
Small thyroid Sx
Carotid endarterectomy
• Complications :
Neurovascular injury
Epidural/intrathecal spread {most important}
Brachial plexus block :-
1. Interscalene approach :
• Shoulder and upper arm surgeries
• Complications :
phrenic nerve palsy
epidural/intrathecal spread
horners
ulnar sparing
2. Supra-clavicular approach :
• lateral to subclavian pulsation
• Sx below lower 1/3rd of arm
• Complications :
pneumothorax
phrenic nerve palsy
horners
3. Axillary approach :
• blocks Radial, ulnar & median nerves
• Use : Forearm surgeries
• Disadvantage : doesn’t block musculocutaneous nerves
• Complication : Axillary artery injury
4. Infra-clavicular approach :
• used for Radial, ulnar & Musculocutaneous nerve block
• only under USG guidance
• 2 cm medial & downward below coracoid process
• Complications : lung injury

@ elbow @ wrist

median nerve medial to brachial b/w palmaris

artery longus & FCR

ulnar nerve S.C @ medial medial to FCU

epicondyle tendon

radial nerve katerak to biceps anatomical

tendon snuff box

Intercostal nerve block :

• into subcostal groove @ mid axillary line in sitting position
• max. systemic absorption
Transverse abdominis plane (TAP) block :
• @ iliac crest
• b/w internal oblique and transversus abdominis muscles
• all abdominal Sx
Lumbar plexus block :
• aka Psoas compartment block
• only under USg guidance
• 5 cm lateral & 3 cm below an imaginary line from iliac crest to spinous process
• most risky : injury to renal vessels & kidney
Femoral block : 1 cm lateral to femoral artery; all LL Sx
Lateral cutaneous nerve block : 2 cm medial & caudal to ASIS
Obturator block :
• 2 cm lateral & caudal to pubic tubercle
• Indication : painful neurological spasms
Sciatic block :
• @ the point where midpoint of an imaginary line b/w greater trochanter and PSIS meets
c̅ the midpoint of imaginary line b/w greater trochanter & sacral hiatus
Popliteal block : medial to popliteal artery
Ankle block :
• Posterior tibial block : lateral to posterior tibial artery
• Sural nerve block : b/w lateral malleolus & achilles tendon
• Peroneal block : near anterior tibial artery pulsations
• Saphenous block : b/w medial malleolus & anterior tibial artery
 Local anesthesia
1st LA : Cocaine by Carl Koller for ophthalmic surgery

Classification

Based on structure :
• any LA = aromatic component (lipophilic) + tertiary amine (hydrophilic), connected by
intermediate chain

Amino amides Esters

Physical property Stable solutions Unstable solutions

Metabolism Liver Esterases

Exception Articaine metabolized Cocaine metabolized in

by esterases liver

Examples Lignocaine, Bupivacaine Cocaine (vasoconstrictor),

Procaine, Chloroprocaine

Short duration Intermediate Long duration

(Low potency) duration (high potency)

Procaine Lidocaine Bupivacaine

Chloroprocaine Mepivacaine Tetracaine
(shortest) Prilocaine Ropivacaine
Dibucaine
(longest)

Mechanism of action :-
• Na+ channel blockers
• Henderson Hasselbach equation : pH = pKa + log (non ionized)/ (ionized)
difference in extracellular & intracellular pH → non ionized form moves in & converts into
ionized form (active component) → blocks nerve conduction
• LAs have high affinity to block open & inactive channels
small, myelinated nerve fibers are easily blocked
• B > C = Aδ > Aγ > Aβ > Aα
• sequence of blockade : autonomic > sensory > motor
• sensory blockade : temp. (cold > hot) > pain > touch > pressure > proprioception
• regression in reverse order

Pharmacology :-
• potency ∝ hydrophobic nature
• onset ∝ concentration
• pKa low/ close to body pH → quicker onset
• dirty/ necrotic wound → pH drops down → when LA injected, whole drug converts into
ionized form → cannot enter cell & bind to Na+ channel → action not exerted
addition of NaHCO3 → ↑pH → ↑non ionized form → more amount goes in → quicker onset
onset ∝ absorption
• absorption depends on site of injection
• IV anesthesia > intercostal > caudal > paracervical > epidural > brachial > sciatic
• vasoconstrictors ↓se systemic absorption
pregnancy - Progesterone increases sensitivity to LAs

Local Anesthesia Systemic Toxicity

1. CNS
Cause : Lignocaine (IV/ high dose LA)
Symptoms :
• lightheadedness
• circumoral numbness
• tinnitus
• visual disturbances
• muscle twitching
• GTCS
Rx :
• on appearance of symptoms - stop injecting drug
• for GTCS :
● short acting Benzodiazepines (Midazolam)
● intubate using Thiopental/ Proposal & muscle relaxant
● continue mechanical ventilation (hyperventilation → ↓PaCO2 → ↓cerebral blood flow
→ ↓LA to brain)
2. CVS
• all LAs show -ve inotropy
• ↑ PR & QTc interval → ventricular arrhythmias → resistant to Rx
• m/c cause : Bupivacaine
Rx :
• stop injecting the drug
• start CPR
• 20% intralipid 1.5 ml/kg IV bolus f/b 0.5 ml/kg/hr infusion
• binds to Bupivacaine and prevents action
Prilocaine toxicity :
• methemoglobinemia
• toxicity → produces orthotolidine → binds to Hb → converts Fe+2 to Fe+3 (↓ affinity to
O2) → false ↓SpO2
• Rx : Methylene blue IV

Applications :
1. Labor analgesia
2. Painless IV cannulation
• EMLA cream (Eutectic mixture of LA) : 2.5% lignocaine + 2.5% prilocaine
• applied c̅ occlusive dressing for 30-45 mins
3. Bier's block/ IV regional anesthesia
• inject LA IV into forearm after applying tourniquet (post inflation)
• tourniquet pressure : 100-250 mmHg > SBP
• keep 2 tourniquet inflated
• secure IV line on opp. hand & keep resuscitation equipment ready
• drugs used : Lignocaine, Prilocaine
• drugs avoided : Bupivacaine, Ropivacaine
• indications : daycare Procedure
• not used for long procedures : r/o nerve compression & injury
• C/i : sickle cell anemia (tourniquet causes sickling)

Pharmacology of aminoesters :-
1. Cocaine
• CNS stimulation
• mydriasis
• potent vasoconstrictor
• metabolized in liver
2. Procaine
• LA of choice in pt. c̅ malignant hyperthermia
• interacts c̅ sulfonamides
3. Chloroprocaine
• short onset of action
• daycare anesthesia
4. Lignocaine
• pKa : 7.7
• earlier 5% lignocaine used for spinal - transient neurological symptoms
• max. dose :
w/o adrenaline : 5 mg/kg
c̅ adrenaline : 7 mg/kg
5. Prilocaine
• EMLA cream
• toxicity - methemoglobinemia
6. Bupivacaine
• long acting
• spinal anesthesia
• cardiotoxic
• max. dose : 2 mg/kg
7. Levobupivacaine : less cardiotoxic
8. Ropivacaine
• labor analgesia (less motor effect)
• slight vasoconstrictors
9. Dibucaine
• longest acting, most potent, most toxic
• to identify abnormal pseudocholinesterase
10. Meperidine
• used if allergy to both amides & esters
11. Etidocaine
• good surgical relaxation, long acting, not preferred
12. Tetracaine
• crystals
• can be made hyperbaric (mix c̅ CSF)/ hypobaric (mix c̅ NS)

Newer trends :-
1. Tumescent anesthesia
▪︎ liposuction
▪︎ very dilute large conc. of LA injected S.C
▪︎ 0.1% Lignocaine + Adrenaline
▪︎ max. dose : 35-55 mg/kg
2. Liposomal encapsulation (biodegradable)
3. Synera (S-caine)
▪︎ Lignocaine + Tetracaine + heating element
▪︎ creates exothermic reaction & produces surface anesthesia
4. TAC
▪︎ 0.5% Tetracaine + 1:2 lakh Adrenaline + 10% Cocaine
▪︎ not effective on skin
 Muscle relaxants
Purpose :- to secure airway & relax muscles
NMJ physiology :-

Presynaptic region
↓
Impulse
↓
activates Ca2+
↓
2+
Ca binds to vesicles
↓
Ach released into cleft
↓
Ach binds to receptors bringing
conformational change
↓
impulse propagates
↓
muscle contracts

Classification :-
Depolarizing : Succinylcholine
Non depolarizing :
Pancuronium
Vecuronium
Atracurium
Rocuronium

Succinylcholine
Dose : 1-2 mg/kg
Duration : 10 mins
Onset : 30 secs
• used in rapid sequence intubation (shortest acting)
MoA :
• non competitive block of Ach receptor
• reversed by pseudocholinesterase
Systemic effects :
• bradyarrhythmia
• sustained EOM ontraction
• post op myalgia
hyperkalemia
• ↑ intragastric pressure & aspiration
C/i :
• family h/o malignant hyperthermia
• neuromuscular disorder
• preexisting hyperkalemia
• h/o burns <6 months
• closed head injury, open globe injury
• sepsis
•hemiplegia
Reasons for prolonged duration of action :
• ↓ concentration
Liver failure
Pregnancy
• ↓ activity of pseudocholinesterase
Liver disease
Pregnancy, old age, burns
Drugs, OC pills
Atypical pseudocholinesterase
Phase ii block : Large doses (> 5mg/kg)
Atypical pseudocholinesterase :
• Homozygous - Prolongs duration by 6-8 hrs
• Heterozygous - Prolongs duration by 45 mins- 1 hr
Dibucaine number : Qualitative analysis of activity of pseudocholinesterase

Non depolarising muscle relaxants

MoA : Competitive blockade of ACh receptors
• End of Sx → Reversal agent (neostigmine)
• Sequence of blockade : Diaphragm → Small muscles → Intermediate muscles → Large
muscles
• Sequence of recovery : Diaphragm → Large muscles → Intermediate muscles → Small
muscles
• Upper airway muscles are sensitive (post op head up position)
Signs of adequate reversal :
• Regular respiration & adequate tidal volume
• Spontaneous eye opening
• Spontaneous limb movement
• Able to protrude tongue
• Able to cough, no cyanosis
• Able to lift head for > 5 sec
• Able to hold tongue depressor b/w central incisors
• Train of four ratio > 0.9 : Guaranteed recovery
Pancuronium : Sympathetic stimulation (used in shock patients), long acting
Vecuronium : most cardiostable; Cardiac surgeries, neurosurgeries.
Atracurium :
• Hoffman degradation (non enzymatic clearance)
• Liver & kidney transplant
• A/Es :
Laudanosine - seizures
Histamine release → Anaphylactic shock
Cisatracurium : Isomer of atracurium w/o histamine release
Rocuronium :
• fastest onset (30 sec)
• rapid sequence intubation when SCh is contraindicated
• Reversal : Sugammadex
• day care surgeries
Mivacurium :
• Shortest acting (10 mins)
• Metabolism : Plasma esterases
• Day care surgeries (Rocuronium > Mivacurium)

Sch, atracurium & Cisatracurium can be used in renal failure c̅ elevated S. Creatinine
 Intravenous anesthetics
Barbiturates
Thiopentane sodium :-
• yellow amorphous powder c̅ garlic smell
• onset : 15 sec
• alkaline pH
• termination of action : redistribution
• use : neurosurgeries (↓ICP, good anti-epileptic); hyperthyroidism (good anti-thyroid),
narcoanalysis
• A/Es : intraarterial inj. - severe pain, pallor, cyanosis, edema, gangrene - Rx : Papaverine
• Rx : do not remove cannula, inject NS or heparin & stellate ganglion block
• C/i : porphyria, hypotension, heart blocks
• porphyria → stimulate gamma amino levulinic acid → LMN paralysis, death

Methohexitone :-
• more potent
• seizure provoking
• dose : 1-1.5 mg/kg
• quick recovery profile (4 hrs)
• use : electroconvulsive therapy
• C/i : neurosurgery

Nonbarbiturates
Propofol :-
• white oil preparation containing egg lecithin & soyabean oil (painful)
Dose : 1-2.5 mg/kg before 6 hrs
Properties : quick recovery, antipruritic, antiemetic
Use :
• daycare surgeries
• endoscopy, colonoscopy
• sedation in ICU
• laryngospasm
A/Es :
• prolonged infusion → propofol infusion syndrome →
severe metabolic acidosis
refractory bradycardia
arrest
green color urine
Etomidate :-
• oily preparation - painful
• cardiostable
Uses :
• cardiac surgeries (DOC)
• brain aneurysm surgeries
• cardioversion
A/Es :
• suppression of adrenal hormone synthesis
• myoclonus
• highly emetogenic

Ketamine :-
• phencyclidine derivative
• stimulant (acts on NMDA receptor), ↑ catecholamines
• dissociative anesthesia
Dose :
• IV : 1-2 mg/kg
• IM : 4-6 mg/kg
Metabolism :
• ketamine → norketamine
• excreted through kidney
Systemic effects :
• ↑ HR, BP
• respiratory stimulant; bronchodilator
• ↑ ICP/ IOP
• analgesia
• nystagmus
• unpleasant hallucinations
• ↑ secretions
A/Es :
• unpleasant hallucinations (Rx : midazolam)
• ↑ oral secretions (Rx : anticholinergic)
use :
• shock, TOF, R→L shunting
• short duration procedures (I&D, burns dressing)
• post-op chronic pain
• low resource settings
• depression
• asthmatics
C/i : neurosurgeries; ocular surgeries; HTN; past h/o MI
 Inhalational anesthetics
For induction & maintenance of anesthesia
Mayer overton rule : Lipid solubility ∝ potency
Potency :-
Minimum alveolar concentration (MAC) : Min. amount of drug required to produce
immobility to painful stimuli
Factors affecting uptake of agent :-
1. From machine → alveoli
• Concentration effect : Inspired concentration ∝ quicker induction
• Second gas effect (@ start of surgery) : d/t rapid diffusion capacity of N2O → Rapid
onset of action of 2nd gas
• Alveolar ventilation ∝ more uptake (quick induction)
• FRC : Smaller FRC is easier to induce
2. From alveoli → pulmonary circulation
• Blood gas partition coefficient (B/G)
Blood gas partition coefficient = conc. in blood/conc. in alveoli
• high B/G : More concentration in blood → more soluble → delayed induction
• low B/G : Less concentration & solubility in blood → Quicker induction.
• B/G : Desflurane < N2O < Sevoflurane < Isoflurane < Halothane < Methoxyflurane
• MAC : N2O > Desflurane > Sevoflurane > Isoflurane > Halothane > Methoxyflurane
• Diffusion hypoxia/ Fink effect : Seen @ end of surgery & opposite to second gas effect
• less C.O ∝ more uptake (quick induction)

Factors of MAC :-

↑ ↓

> 42°C age

high barometric pressure hypothermia
chronic alcoholism pregnancy
hypernatremia hypoxia
IV agents/Local agents
hyponatremia
acute alcohol intoxication

Systemc effects :-

Respiratory • bronchodilation (halothane >> sevoflurane)

• irritants : isoflurane, desflurane
 • ↓se mucociliary clearance except ether
• ↓se pulmonary resistance except nitrous oxide
• sevoflurane preferred in lung injury & asthmatics

CVS • depressants
• desflurane : irritable, initial tachycardia
• halothane : max. ↓se in HR, nodal arrhythmia, prolonged QT interval
• isoflurane : preserves preconditioning

CNS • ↑ses cerebral blood flow & ICP

• electrical silence : flat EEG lines @ higher conc.
• enflurane : epilepsy

GI • all preserve liver function except halothane [halothane hepatitis]

• isoflurane, desflurane : less metabolized, preferred in CLD

Renal • methoxyflurane : max. fluoride ions, max. nephrotoxicity

• sevoflurane : preferred in low conc., for short duration
• desflurane : preferred

Uterus use : manual removal of placenta

complication : atonic PPH

Muscular ↑ses muscle relaxation

Ocular ↓ses IOP

Newer agents Older agents

(non flammable) (flammable)

Halothane Ether
Isoflurane Chloroform
Desflurane Trilene
Sevoflurane Cyclopropane
Methoxyflurane

Halothane :-
• Colorless volatile liquid
• stored in amber colored bottles (avoid sunlight)
• sweet smelling
• 2nd preferred for induction in children
• max. metabolism
• Halothane hepatitis :
● end product : trifluoroacetic acid
● risk factors :
females
40 yrs
obese
multiple exposure
autoimmune disorders

Isoflurane :-
• isomer of enflurane
• preferred in cardiace & neurosurgeries
• irritant
• avoid in children
• MAC : 1.15
• B/G : 1.38

Desflurane :-
• lowest B/G : 0.47
• least soluble : faster induction & recovery
• 2nd preferred for daycare surgeries
• irritant : post-op laryngospasm
• highest vapor pressure & least boiling point : requires specialized vaporizer (Tec6)
• expensive
• least metabolized
• max. interaction c̅ ozone layer

Sevoflurane :-
• sweet smelling liquid
• preferred for children & daycare surgeries
• nephrotoxic

Xenon :-
• ideal gas
• expensive
• least B/G
• no second gas effect/teratogenic/diffusion hypoxia

Nitrous oxide :-
• blue cylinder
• stored as liquid
• critical temp. : 36.5°C
• 1st demonstration by Horace wells
• MAC : 104 (least potent)
• B/G : 0.42
• used as carrier gas
• A/E : megaloblastic anemia, SACD
• max. diffusion capacity

Older agents :-
Ether :
• 1st demonstrated by Morton
• irritant
• B/G : 12 (max. solubility)
• preserves mucociliary function
Chloroform :
• sweet smelling
• ventricular arrhythmia
Cyclopropane :
• in orange cylinder @ 60 psi
• sudden discontinuation causes cyclopropane shock
Trilene :
• analgesic
• Trilene + soda lime = phosgene (respiratory irritant) + dichloroacetylene (neurotoxic)
Methoxyflurane :
• least MAC : very potent
• highest B/G
• potent nephrotoxic
 Oxygen therapy
Indications

1. Acute hypoxemia (PaO2 <60 mmHg)

2. SpO2 <98% for normal individuals
3. cardiac/ respiratory arrest
4. low C.O states
5. metabolic acidosis
6. respiratory distress

Low flow oxygen devices

aka variable performance devices

O2 supplementation < MV [5 L/min] → O2 diluted c̅ atmospheric air
1. Nasal prongs
• flow rate : 1-6 L/min
• FiO2 = 20 % + (4 × O2 flow rate)
• 2 small prongs placed into nose
• nasopharynx acts as reservoir
• advantages: comfortable, cheap, home therapy
• disadvantages : can't provide high flow O2, not effective in airway obstruction, can't be
titrated
2. Nasal catheter
• single lumen catheter inserted into nose
• disadvantages: dislodgement, mucosal trauma
3. Simple face mask (aka Hudson's mask)
• side holes : entrapment of atmosphere air
• flow rate : 5-10 L/min
• advantages : increases conc. upto 40-60 %
• disadvantage : claustrophobia, can't eat, need a tight seal to get accurate values, variable
FiO2
4. Non rebreathing mask
• Simple face mask c̅ reservoir bag → gases in reservoir bag provide for inspiration in next
breath
• reservoir bag needs to be inflated > 1/2
• 10-15 L/min delivered
• max. FiO2 : 90-100 %
• advantages: highest possible FiO2 delivered avoiding intubation/ NIV
• disadvantages : high flow might not be suited for long-term
• use : severe hypoxia

High flow devices

1. Venturi mask
labeled c̅ numbers indicating gas flow & FiO2
Venturi principle: when a gas flows through a narrow section, speed increases and pressure
decreases
entrapment of atmospheric O2 occurs
precise delivery of O2
uses : COPD
advantages :
▪︎ fine control
▪︎ fixed, precise, reliable O2
▪︎ high flow comes from atmosphere - saves O2 cost
▪︎ can be used for low FiO2 also
▪︎ decision making
disadvantages :
▪︎ expensive
▪︎ uncomfortable
▪︎ can't deliver high FiO2
2. High flow nasal cannula
Flow rate : 40-60 L/min
flow rate & temp. can be set
Heated humidifier air delivered through nasal prongs
nasopharynx acts as reservoir (+ve pressure created)
closing of mouth creates PEEP effect
3. Ambu bag (Artificial manual breathing unit)
aka manual resuscitator/ self inflating bag mask valve
max. O2 delivered (upto 100%)
during inspiration, unidirectional valve opens & allows air to go in
during expiration, inspiratory valve remains closed & gases exit through outlet
 Mechanical Ventilation
Normal physiology

inspiration is -ve pressure process (-5 to -8 cm H2O)

expiration is a passive process
ventilation perfusion :

zones alveoli ventilation perfusion V/Q inference

1 very big less less 2/1 wasted ventilation

2 small optimum optimum 4/5 ideal

3 very small maximum maximum 6/10 wasted perfusion

Changes expected after PPV :-

▪︎ ↓preload → ↓C.O, ↓BP (hypotension)
▪︎ resistance to cerebral blood flow → ↑ICP

Iron lungs :-
1st introduced during polio pandemic for children
creates –ve pressure → thoracic wall & alveolar expansion → pt. is able to breathe

Ventilatory cycling mechanism

inspiratory - expiratory changeover
types :-
1. volume cycled
2. pressure cycled
3. flow cycled
4. time cycled
parameters :-
▪︎ mode of ventilation
▪︎ RR
▪︎ TV or pressure
▪︎ inspiratory flow
▪︎ I:E ratio
▪︎ PEEP
▪︎ FiO2
▪︎ inspiratory trigger
Volume mode :
• monitor peak inspiratory pressure (PIP) & plateau pressure
• obstructive diseases → ↑sed airway resistance → ↑sed PiP
• @ the end of PiP, if inspiration is momentarily held, there is a pressure drop - the plateau
pressure (compliance of lungs)
• restrictive diseases → impaired lung compliance → ↑sed plateau pressure
Pressure mode :
• exhaled TV is monitored, relays the information about amount of gas pt. is receiving
Fraction of inspired oxygen [FiO2] :
• normally we inspire 21% O2
• initially FiO2 is 100% , thereafter titrated to 90% → 80% → 70%
• to maintain PaO2 >60 mmHg & SpO2 >90%
Inspiratory trigger :
amount of -ve pressure created to activate ventilator
flow/ pressure trigger
seen only in ACM/ SIMV mode
in SIMV, trigger - which @ a previously fixed point, will support pt.’s breath

Modes of ventilation
1. Spontaneous : pt. breathes on his own
2. Controlled mechanical ventilation (CMV) : every breath is initiated & controlled by
ventilator
• uses - GA, poisoning, muscle paralysis
• not used for prolonged period because of r/o muscle atrophy
3. Assist control mode (ACM) : mechanical breath will be initiated for every spontaneous
breath
• advantages → Tidal volume & alarm can be set
• disadvantages → requires deep sedation to ensure synchronization
• Intermittent mandatory ventilation (IMV) :
- no.of breaths & tidal volume are preset
- in b/w pt. can breathe on his own
- ventilator generates mechanical breath only if spontaneous breath is -nt
- high chances of asynchrony → breath stacking
• Synchronized Intermittent Mandatory Ventilation (SIMV) :
- weaning mode
- synchronizes c̅ respiratory effort
Non invasive modes of ventilation
Positive End Expiratory Pressure :-
prevents collapse
increased recruitment
reduce work of breathing
r/o barotrauma
↑ICP, ↓C.O
used for weaning
(N) PEEP : 3-5 cm
ARDS : 8-12 cm
Continuous Positive Airway Pressure (CPAP) :-
similar to PEEP
used in cases c̅ good muscle tone like covid patients
started c̅ pressure of 5-10 cm H2O
Bilevel Positive Airway Pressure (BiPAP) :-
inspiratory & expiratory pressure levels can be set separately
Volume Ventilation + ()
Airway Pressure Release Ventilation (APRV) :- relieve excessive pressure c̅in body to
prevent barotrauma
Automatic Tube Compensation (ATC) :- compliance & obstruction of tubes is verified and
compensation is made as required. used in children
Neurally Adjusted Ventilatory Assist (NAVA) :- senses phrenic nerve movements & assists
ventilation

Care of Ventilated patient

General care:
• care of ET tube - 2nd hourly suctioning
• good chest physiotherapy
• adequate sedation & analgesics
• humidified gases
• nutrition
• bed sores
• care of central/ IV line
• psychological support
• up-to-date documentation

Hemodynamic care:
• IV fluids (for r/o hypotension)
• vasopressors & inotropes (if BP not improving)

Ventilatory care:
• variable c̅ patients
• for covid pt.:
- NIV (HFNC > NIPPV) preferred
- low TV
- target P plateau pressure → <30 cms
- higher PEEP (>10 cms watch for barotrauma)
- avoid NM blockers (for r/o atrophy)
- moderate to severe cases → prone ventilation for 12-16 hrs
- lung recruitment maneuvers
- ECMO
therapy: target primary illness

HCW protection: use PPE, N95 masks, etc.

Weaning
very gentle
modes must be changed and pt. condition must be assessed regularly
clinical criteria :-
• main problem should be resolved
• pt. must be conscious, alert, obeying commands, hemodynamically stable c̅ good cough
reflex & minimal secretions
ventilator criteria:
• clinically stable patients are put on spontaneous breath trial
• pt. is on ventilator & alarm kept for 20-30 mins, during which pt. should maintain PaCO2
<50 mmHg, TV of 5-10 ml/kg, RR <35/min, MV <10 L
• if pt. is breathing fast → high chances of failure
• Rapid shallow breathing index (RSBI) = RR : TV → should be <100 to plan extubation
oxygenation criteria :
• target PaO2 : >60 mmHg (w/o PEEP) & >100 mmHg (c̅ PEEP)
• SpO2 >90 %
• PaO2 : FiO2 > 150
pulmonary reserves :
• VC > 10 L
• if VC is less → pt. can’t cough → pooling of secretions, aspiration
• PiP <30 cm c̅ good lung compliance (>30 ml/cm)
 Daycare anesthesia
Pt. operated & discharged on same day (<24 hrs)
Procedures :-
• any surgery <3 hrs
• Sx not a/w post-op complications (hernia, hydrocele, fibroadenoma)
Patent selection :
• ASA grade 1 or 2 pt..
• age : 50 weeks - 50 yrs
• accompanied by responsible attender
Anesthetic factors :
• PAC
• 6-8 hrs NBM
• premedication : Midazolam (short acting BZD)
• monitoring
General anesthesia :
• induction agent : propofol
• opioids : fentanyl/remifentanil (short acting)
• inhalational agents : sevoflurane
• muscle relaxants : rocuronium + sugammadex >> mivacurium
• airway Mx : no C/i for ET intubation; LMA preferred
Regional anesthesia : preferred drug : Chloroprocaine
• spinal/epidural/peripheral blocks can be given
Modified Aldrete scoring (Discharge criteria) :

0 1 2

Activity none move 2 extremities move 4 extremities

Respiration apnea dyspneic/limited deep & free

Circulation >50% 20-50% BP +/- 20% of

preanesthetic

Conscious not arousable fully awake

responding

Oxygenation <90% needs O2 supplement >92%

to maintain 90%

Keep in early recovery post-op ward → scoring for 1-2 hrs → if >9, stepdown → discharge
m/c A/Es : drowsiness, sore throat
m/c cause of delay in discharge : post-op nausea/vomiting
 CPR
BLS
ACLS
Pre-op DOC to reduce anxiety : Midazolam
Pre-op drug to reduce secretions : Glycopyrrolate
Pre-op Antibiotic timing : 30 min - 1 hr before incision
m/c nerve injured intra-op : Ulnar nerve
m/c intra-ophthalmic complication : corneal abrasion
DOC for post-op nausea/vomiting : ondansetron
m/c cause for post-op loss of vision : ischemic optic neuropathy
m/c cause of intraop anaphylaxis : antibiotics

Induction Maintenance Muscle relaxant

Pediatrics Propofol Desflurane Cisatracurium

Liver disease Propofol Sevoflurane

Renal disease Propofol Desflurane

CVS Etomidate Isoflurane Vecuronium

COPD Ketamine Sevoflurane

NeuroSx Thiopentone Sevoflurane

Obese Propofol Desflurane

Day care Sx Propofol Sevoflurane Mivacurium/

Rocuronium +
Sugammadex