access www.jppgrneeupdate.com -Free updates- www.jppgmee1.1pdate.com Free NEn sample ques1ions www.jppgmeeupdate.

Cata(yst fora[[ <Pq :Merfica{ <E~aminations

(.Al~$l 'loptr$ ...__

Volume 3
cct.wd J ri>t:1
.-IJ,/, lttdiu 2011 Surgical Sciences
A I f.~J.4'ZOI J
-- PG/ 101 J .-

gery, Obstetrics & Gynecology,

Orthopedics , Ophthalmology,
ENT, Anesthesiology

Ashfaq UI Hassan

JAYPEE

access www.Jppgm~update.com -Free updates www.Jppgme-eupdate.com -Free NEET sa m pie q ue511 ens www.jppgmeeu pdate.<
.

ANESTHESIOLOGY
v Term ANESTHESIA coined by Olive_r Holmes. TN 1995

./ Anesthesia was first used by Morton.rr

-
v Nitrous oxide was discovered by Priestleyr

_./ Anesthetic properties of nitrous oxide were discovered by Humphry Davy MAH 2012
.; - Spina.I analgesia was first described by Bierr ....

./ IV anesthesia was discovered by Lundyr TN 1989

. - -. - . - ~ .. ~
./ IV Regional Anesthesia was discovered by Bier.r

./ Xenon: William Ramsay

7 -Balanced anesthesia: Evolved by Lundyrr

:> Anatomy Important in Anesthesia: High Yield for 2011-2012

.
0 .-- Extent of larynx: C3 -C6r
'.
: . - ~--- --
0 Extent of trachea: C6-T5r
_..,. . ...., ...
0 Diameter of trachea: 1.2 1. 6 ems DNB 1983

0 Angle of right main bronchus to vertical: Only 25rr. AllMS 1985

~5--Ang1E! ot 1eitln_a_1ni>ronc_t1usto vertical: 45~

0 Carina is at level of: T4 ROHTAK 1989

Jf-iP in adult.is done in L3-L4inte-rspace.r..-
0 LP in children is done in L4L5 interspace.r..-

Q Infant Larynx
,.. One third of size of adult larynx.
--' . - -~ ~ -- ---- .
,.. Suglottic area is the narrowest area in infants.
-;;. -,n-iant.. tissue ~ftei- is an~ more pliable.
..... :_,_ .
,.. Epiglottis tilts more posteriorly.
f:otioWingfeatures distinguishinfant larynx from adult larynx:
. ./ Epiglottis is long and leafy Delhi 2008,
'
. Subglottic region is narrowest laryngeal portion Delhi 2008:
Large tongue Delhi 2008 i

PGl1998
- Boyles law: Volume a 1/Pressure
.~ --

Charles law: Volume a temperature

Avagadros law: Equal volume of gases at same temperature and pressure contain same number of
molecules.

r : . 491
 Anatomical Dead Space AllMS 09
''0 A normal individual at rest inspires approximately. 12 to 16 times per minute, each breath having a tidal
volume of approximately 500 ml..-.- .
- --- -
0 A portion (approximately 30%) of the fresh air inspired with each breath does not reach the alveoli but
remains in the. conducting airways of the lung. This component of each breath, which is not generally
1
J available for gas exchange, is called the anatomic dead space.

I
t.

Increased by.-.-.- Decreased by.-.-.-

ll ./ Old age ./ Intubation
1 ./ Neck extension ./ Tracheostomy
.i '
j ./ Jaw protrusion ./ Hyperventilation
'.j
j ./ Bronchodilator ./ Neck flexion
i
! V".. jlung volume ./ bronchoconstriction
:l ./ Atropine Al 1999
L!
1
./ Halothane Al 1999
1j

I :>i,~::g
./ Inspiration Al 1999
J
Volumes and Capacities: High Yield for 2011-2012
MEN . WOMEN
..
3300 ml 1900 ml

f~ - 2.iv 500 ml 500 ml

1000 ml 700 ml

I : ~: ERV+RV=FRC
+ 1200 ml

6000ml
+ 1100 ml

4200 ml
. ..

I
f~-i
:;,.:-~ ;;
M,~


IRV+ TV+ERV=VC
IRV+ TV=INSPIRATORY CAPACITY

Airway is Assessed by

~ : :::::~::It~:~::: crassifieatton f(iew of Larynx at Laryngoscopy)*

t . _,_.

-
-
Thyromental distance
-

Sternomental distance
~<''":""r"'.r-""-"~~ ..- - '

Wilsons score.

.
~ .. ~-'492,.,
}
q Airway Protection is by
,... Head tilt, chin lift and jaw thrust maneuver

,.. Oropharyngeal and nasopharyngeal airways

,... LMA (Laryngeal Mask Airways)

,.. ET (Endotracheal tube)

- . - ---~ ~ .. -

,.. Combitube

Premedication (AAAAAA),..,..
Anxiolysis JKBOPEE 2012

Amnesia

Anti emetic PGl2002

Antiacid

Analgesic .: JKBOPEE 2012

Anti autonomic

);;>- Allodynia: D Perception of non painful stimulus as painful .... AllMS 2006
}';>- Analgesia: D Absence of perception of pain ..
}';>- Anesthesia: D Absence of all sensattonw f
}';>- Dysthesia: D Unpleasant pain sensation .. t
i;
[
}';>- . Hypalgesia: D [response to noxious stimulusrr
);;>- Hyperalgesia: D jresponse to noxious stimulus
rf
D [response to mild stimulation
r:
}';>- Hyperasthesia: r
r~
);;>- Hyperpathia: D Presence of hyperasthesia, allodynia, hyperalgesia fi
}';>- Neuralgia: D Pain distribution along a nerve f
F
);;>- Parasthesias: D Abnorma_l sensation perceieved without apparent stimulus r
t
I
Radiculopathy: D Functional abnormality of motor roots
}';>-
i
Minimum alveolar concentration: MAC: High Yield for 2011-2012 t
~

D MAC is the best index of potency of anesthetics. rrr ~

D It is unaffected by sex or duration of anesthesia. r
~

D Nitrous oxide has highest MAC and Methoxyflurane the highest .......
~
It is.alveolar vapor phase concentration
fn response to a standard noxious stimulus.
of an inhaled anesthetic that prevents movement in 50% of patten.ts
r
1~
;~ Factorst MAC: ---~.J ~
: 0 Hyperthermia......... ~;.
O MAO inhibitors 1:
-0 Hypernatremia...... 1~:
r
'-'---o~_c_h_ro_n_i_c_A_lc_o_h_o_l_ab_u_s_e~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-'-'\ (.

r~~-~--~~&
.
I
.._f 493.......
......_....:..-..,. .
r
 :r. Factors decreasing MAC:
~-,.__ ... _ '. - . - - ~ ...... ---- -- -~ .. - ;.,,_-. -- .
:a -Hypoxia;;:;: , - - ;

.
'a Hypothermia ..
:a Metabolic acidosise-
1
1 a Pregnancy
:a
I
Acute alcohol abuse.
:a '
Drugs: opoids, propofol, ketamine, benzodtazepenes, lidocaine, barblturatesw

.... >Mc measures potency of inlialational anesthetic . .-_.;.

.... Oil gas partition coefficient measures anesthetic potency
. -- .. - - . . '- - .,. -

..,_ Blood gas partition coefficient measures solubility of general anesthetics.

. _.,.. ....

t. ..,_ Gases with high blood solubility have slower rate of induction and recovery.**
.
. ...,. - ----.
1 --.;.:- c;~~~s ~ith-~~ blood ~~lubility have higher rate of i~duction and recover-Y~ ..

j. c:> Remember Colors of

. l
1 Gas Color of Cylinder
-,; Nitrous-oxide blue
./ Cyclopropane orange
; ../ Oxygen black body with white shoulder JK BOPEE 2011 :
./ Thiopentoneyellowee
'. ./ Carbon dioxide grey
1 ./ Halothane purple (red)*
: ./i
Helium brown
./ N2 black
; ./ Air grey body with black and white shoulder

~ Pin lndicies
_Gases Pin Code Index
... _...',_,_._ ---- --l------- .... ..,,,._ .... --- ,_ - -
./ Air .- 1,5
. . 1,6
./ co2 (>7.5%) ..

./ Co2 (<7.5%).- 2,6

2,5
3,5 KCET 2012

o Ga_s cylinders are. made of steel alloy (molybdenum) . ; ,, '.

C)-c;;;~-pip;;;~~-;~d; ~i;;~-1;~;~~p;;;~t~bi~g. - ~- '
-------------- .
Gases stored in Liquid Form are: ***
,.... Nitrous oxide
. ~--- ......... ---~
'
..,_ Carbon dioxide
.- -:"' _.,.... __ .... --~----- - - - ...... ------- -- -~-~-- --- ..... ,._, " __ ... , ...... .... _ . ..... ~
_

..,_ Cyclopropane.

~ Muscle Relaxants
. Depolarizing MR

> Usually short actingrr PGl2000

> Cause Fasciculation'sr

> No reliable antagonists.r
> No fade JIPMER1999

> No post tetanic facilitation PGl2000

- .. - ..
Examples: Succinyl choline, Deca_methonium
NON D~POLARIZING
MR
};;- - long actingrr

};;- Don't causemuscle fasicutations=

> Neostigimine as effective antagoniste
> Post tetanic facilitation seen. AllMS 1993

> Train of four used. Al 2008

};;- Diaphragm is resistant to non depolarizing agents. JIPMER2003
. -- --- .. - .,.. - -
Examples: Mivacurium, Pipecuronium,Doxacurium, NGallamine
Also Remember:
Directly acting MR : Dantrolene and Quinine

Centrally acting MR is: Mephensin,Baclofen, benzodiazepine

./.. Ultra.short acting: succinyl cholinerr

./ Short acting: rapacuronium, mivacuriumrr

...,-7--"filtermedfateacti~g: atracurium, cisatracurium, vecuronium, rocuronium...::r

./ Long acting: gallamine, pancuronium, d tubocurarine, doxacuriumrrr

Depolarizing MR NON Depolarizing MR

~~.:;::-:TM~~-~[ef~sicui~ti~~ i: ._ Musclef asiculation absent r PGl2000
NQ_T revehed by cholinesterases Reversed by cholinesterases=
(potentiate btock) ...... Present train of four fader. Al 2008
Absent train of four fader. Present tetanic fader PGl2000

r . ~--~:.,
1_ .
t,_,_ -~-----.-~_,
495. _
 -----

-;- Absent ietanic iacie;:- - . .. - - - , Present tetanic f acilitationr

Absent tetanic facilitationr Effect of non depolarizing drugs causes more blockade

Effect of non depolarizing drugs causes i Diaphragm, adductors of larynx, corrugator supercilli are
less btockade= . resistant ....

:> Succinyl Choline:**** High Yield for 2011:-2012

- .$uccinyl choline is a depolarizing muscle. reiaxant .... PGI 1997
--- - - -'~ . ,_. - _---I - -- .._ -- --. -. ~-~--~~- -- - _... C ->~- : ,,,..._:_,_ -- '-. ,__,., . _,., . .,_,_.-.... ' ,,. ..... --- -- -. --. - .

Action not antagonized by anticholinesterase agents; r

~;;.- - Pila5i(t;1<>ci<.is. persisient.ciepo1ari:Z.ation.of inusC:1e- en-Ciplat:eanli5 i-ailicY1n aC:i1a:n~ -
. .. .. . - ... --

Phase II is slow onset, desensitization of receptor to acetyl choline.

... - - - --' - -- - .. ,. ---- .. - ,.. ... -- ..... --- .... ,,. ... -...... -.. ..

- Dual block JKHND 2006

..... - -- - -

l Order of depolarization is neck, timbs-sface, jaws, eyes-trunk-respiratory

l --- - ._. -- . - - .

l- May cause histamine release ~

Biotransforniation rapidly hydrolyzed by pseudocholinesterase. rr JK BOPEE 2001

.;--Onset of action: Intravenous: Initial effect within 0.5~1 minute Intramuscular: Initial effect within 3 mfnut~s--:, ,_.,
Elimination: Renal; about 10% as unchanged succinylcholine.
-- ... ,--.-.;_ ......._.--;-.-- -
ii. Precautions:
'Pediatric patients are especially susceptible to succinylcholtne-induced myoglobinemia, rnyoglobinurta, and
\
-cardlac effects. Hyperkalemic rhabdomyolysis resulting in cardiac arrest and death has occurred in apparently:
healthy pediatric patients after administration of succinylcholine.

Succinylcholine is contraindicated in patients with skeletal muscle myopathies. Additionally, succinylcholine

should not be used in patients with major burn injury, severe trauma, extensive denervation of skeletal muscle,
or upper neuron injury. Use of succinylcholine in these patients may result in "dangerous hyperkalemia" . .-.-.-

Cardiac arrest has occurred when succinylcholine was used in patients with these conditions.

; ..,. Caution required inpatients with cardiovascular function impairment.

~. .
..,. Effects may be prolonged in patients with renal function impairment, but to a lesser extent than for
gallamine .

..,. Caution also required in Conditions that may lead to low plasma pseudocholinesterase activity;
(severe anemia, dehydration, exposure to neurotoxic insecticides or other cholinesterase inhibitors, severe'
hepatic disease or cirrhosis, malnutrition, pregnancy, recessive hereditary trait)

Conditions that may be adversely affected by increase in intraocular pressure (open eye injury, glaucoma,,
ocular surgery)

Fractures or muscle spasm

! ..,. Malignant hyperthermia,

 Adverse Effects:
Moderate risk of side effects
. associated. with histamine
. release.,..,..

More likely than other neuromuscular blockingagents to cause bradycardia or cardiac arrhythmias.e'
'~.increased . intraocular-pressure, malignant hyperthermia; rhabdomyolysis" "leading to myoglobinemia. an"d-
myoglobinuria, postoperative muscle pains and stiffness, and excessive salivation have been reportrr

Important about Succinyl Choline

Succlnytcholine causes Hyperkalemia** AllMS'2003

Succinylcholine causes muscle pain** Al 1991

,,.._...-.~~,.._ -:- ----- .. ... - , " ,... . .. ..,.

lit Succinylcholine increases Intra ocular pressure

Succinylcholine increases intra gastric pressure*

-~-:;:--~. - .. - . - ; --.--- .- ...... - ,... .. -. .... -
. Succinylcholine increases jntra cranial pressure** AllMS 2002

Succinylcholine triggers Malignant Hyperthermia. AllMS 1993

..... -- ............... ------- -- -.- ,.

.. Succinytcholine causes vagal stimulation. AllMS 2005

.,,; ...: ...'.~---~ _: .... __ __,__ : - -- - -< . - -

Succinylcholine is the shortest acting MR.*

.~ succinylcholine causes dual/biphasic block.

Succinylcholine has shortest duration of action due to rapid hydrolysis by pseudocholineesterase.

Succinylcholine is Important Factor in Triggering Hyperkalemia

. .
. Facfors increasing this susceptibility are:
; ./,. Massivetrauma (Rhabdomyolysis)** AllMS 2000
;./ Burns AllMS 2000
~ ./ Acidosis*
i
: ,/ Spinal injury*
-~
I
, ./
I
Closed head injury*
)

i ./ Tetanus~
] ./ Myopathies
j ./ Prolonged immobilization*
l ./ Encephalitis/stroke* PGl2005
ii ,/
~
I
Renal dysfunction .
i ,/
\
Necrotizing pancreatitisss
{ ../ This is a dangerouscomplicationas it can lead to cardiac arrest and sudden death.
)

j ./ Maximum chances of Hyperkalemiaare usually in 7-14 days time following trauma and between 3 days
\ 6 months followingparaplegia. AllMS 1999
t .
 ~ Rocuronium: High Yield for 2011-2012
1' Rocuronium ** ,.
.~ Is indicated as an adjunct to genera! anesthesia to facilitate rapid-sequence or routine tracheal intubation
and to induce skeletal muscle relaxation during surgery or mechanical ventilation
--i
j i
~ Is a nondepolarizing neuromuscular blocking agent with a rapid to intermediate onset of action, depending
i
I l
on dose, and with an intermediate duration of action

~ Rocuronium produces neuromuscular blockade by competing with acetylcholine for cholinergic receptors at

!
!
the motor end plate

~ Mutagenicity: No rnutagenic effect was observed with the Ames test . The micronuCleus test did not suggest.
1
1 mutagenic potential
1l '
J ;~ Rocuronium is recommended for intravenous administration only.
'!
~ '~ Produces pain on im injection. AIPGME 2012
-:I
l
,J 9 Atracurium and Cisatracurium
'l

! D Reversal not required.

,l '
D
----,,~--.-
Undergo spontaneous non enzymatic degradation.(Hoffmans elimination)**
.. -----.-.----,--- - ..,. - - --
PGI 1997, JK BOPEE 2011

I
0 Pharmacokinetics are independent of renal and hepatic functions and

0 Can be safely used in renal/ liver diseases. PGI 1997

:fa . Laudanosi~eis produced as a metabolite responsible for seizure actiVfty:

D Atracurium causes bradycardia.
~,v- -
*
0 Can be safely used in myasthenia gravis. *

0 Can be used in patients with high serum creatinine Al2010

~ Atracurium: High Yield for 2011-2012 .

ls muscle relaxant with its metabolism independent of hepatic or renal metabolism .
. :/ Available. as Atracurium Besylate
./ Dose - 0.5 mg/kg

',/ Effect: Releases histamine but in significant amount at clinical doses

'./ Allergic reactions ranging from prurttic rash to angioneurotic edema can occur
~ Frequently Asked Questions
D Shortest acting non depolarizing MR:.Mivacurii.Jm..- ...-

D Shortest acting depolarizing MR: Succinylcholine= Al 1992

- - - - -
D Overall shortest acting MR: Succinylcholiner
. . ':.......... '' - - ..

D Shortest acting local anesthetic: Chtorprocainee'

..... - _,,.,

D Contraindicated in renal failure: Gallamine, metocurine .... Al 1991

- .
D MR Causing ganglion block: Curare, Gallamine, Trimethapan, Pancurontumw
- -- ...-..-.. -------- --- ----- .. ' . - ... - . - - _,_

D MR used in asthma: Atracurium, Vecuronium.-.-.

~ D Tubocurarine
D Causes Maximum histamine release.,..,..

D Causes maximum ganglion block .-

0 Causes bronchoconstriction.,..
. --~~--- : ... ~- ---~<-.- : __ - -
D Does not cross placenta and used in obstretics.

c> Reversal of Muscle Relaxants

-PEN:
-. . --
Pyridostigmine
D Edrophonium

. D Neostigmine. PGI 1997

./ Neostigimine is commonly used.

./ Acts by anticholineesterase activity and prevents hydrolysis of Ach allowing it to accumulate .

. ./ Antagonizes only non depolarizing MR.

: ./ Usually given along with atropine/glycopyrollate.

Balanced Anesthesia
D . Evolved by Lundy. ..-.-
D Thiopental for induction . .-
--- . . .. .. - .. --:- -.
O N20 for amnesia,..
' .. -- - .
D Mepridine for analgesia,..

-a - curare for muscie i-eiaxation ......

c> Local Anesthetics (LA)

. ~ . LA(Local Anaesthetics) inhtbtt propagation of nerve impulses.

~ LA in general block Na channels .- PGI 1997

--- ..... --- -- -- --- . . :----- ---..-- .- -- ---- - .--,.-. . .

. ~- Potency of these agents depends on lipid solubility. PGl2004

_ ---- .. - -------~"-- . .. . - . ... __ - - -... - .... - -- .. ---

~ Low PK means increased activity. PGl2004

r--r7"?-~- .......... -~'74"'

!
! :,-_ . 49.9 .
t.._ ~-~..:.-..:....~---'""""..:Ii
'
 ..,.. Type C Fibres followed by Type B Followed by Type A are most susceptible . .- Al 1995 .

..,_ Smaller diameter fibres are blocked earlier than larger diameter fibres . ..-

..,_ Non myelinatedfib.res are also blocked earlier tha~ myelinated fibres . .-r
. --- - - . - ~--- - -- . - ~ . ,, . - . - -" .

..,_ Absorption rates: intrapleural> intercostal> pudendal>caudal>epidural>brachial plexus>caudal AllMS 09

Cocaine is a local vasoconstrictor anaesthetic.

- ~- -Ad-di,ti~n -~f l~~l-~~~~~~~~t~i~t~r ~~~h- ~s ~ci~~nali.~e ~red~c~s ab~~~pti~~ ~~d reduc~~. toxictty ~~d-- p~ol~ngs
anesthetic action.

Vasoccnstrtctors
"Decrease the systemic absorption of local anaesthetics in blood, so increases the concentration. thereby
increasing the duration of action."

Vasoconstrictors used are: Adrenaline: Duration of both sensory and motor blockade is increased by addition of
epinephrine to lignocaine but only sensory block is prolonged if epinephrine is added to bupivacaine with no
effect on motor blockade. .

Lignocaine with adrenaline should not be used for:

0 Ring block of fingers, toes, penis, pinna (absolute contraindication)

;0 When an inhalational agent (halothane) which sensitizes myocardium to adrenaline is used.
0 Myocardial ischemic patients
;0 Hyperthyroid patient
~0 Severe hypertensives
.0 Intravenous regional anesthesia (Biers block)

Adrenaline is added for its vasoconstrictor effect along With anaesthettc in local anesthesia for the purpose 0
; ./ . Reduce systemic toxicity
AP 2005.
) ./ Delay absorption of anesthetic
AP 2005
./ Prolong the anesthetic action
AP 2005

Amide Linked LA are:

Al 2007
Lidocaine Bupvicaine . Dibucaine . Prolocaine Mepivicaine : Ropivicaine

EsterLinked LA are:
-Al 2003
i
! Cocaine. ;: Procaine ; . Benzocaine : Tetracaine .; Chlorprocaine~
I
i
<':> Amide LA

1.'. -: __ Pr~~~~-e mar~- i~t~n~ ~ _l~~~~r lasting anesthesia.

- - ~ ~-- - ..... - ... __
Bind to a1 acid glycoprotein.
l
I -~-;,-:-_
. -Nat hyd~alysed
v . .
by esterases.
..

I
:

!
~ .......... .,..1.-- ----- . " --- .- ... -~

./ Rarely cause hypersensitivity reactions

.... . - -

I .-:--,.:r.-.:----:~~1
COMED 2006

. . soo: '/ , 1
J~.-,......oi-~~ l-.._.,,__ . . . .:_. -.- ......- ....
 Ll Shortest acting LA is: Chlorprocaine . Al 1997

Ll Longest acting: Dibucaine

~..,.~.,_,., .. ,, .... .., ~ --~Y ~ -- .. - , .,-. -- .,. v ,-;. _.__ -;"-- -~-, ._..,. ., ... ,. - ,.. ,_.. , .... ~-:- ----
L] LA causfng Methhemoglobinemia: Prtlocaine'

~ Lignocaine
Ll Most commonly used LA.
Ll Amide linked. Al 1998

Ll Also used for: VT, VES (Ventricular tachycardia, ventricutar extra systoles)
...
Ll 5% Concentration is used in subarachnoidspace. AllMS 1992
-- ....... - ~ - ..
Ll Maximum dose as Local anesthetic is AllMS 1992

Ll Maximum dose with adrenaline is 7 mg/kg Al 1992

Causes:
Depression,

Tremor,
Convulsions, PGl2004
Bradycardia,
' Hypotension,
Cardiac failure. PGI 2004.
Bronchospasm,
Urticaria, angioedema. *
~ Bupivicafne: High Yield for 2011-2012
. Bupivicaine is LA of choice for isobaric spinal anesthesia,..,...
. ' - - -~ .

Amide with duration greater than 2 hours PG12005

- 13'upiVicain'e is contraindicated for intravenous regional anesthesia (Biers Block)......... AllMS 2004
. Bupivicaine is highly cardiotoxic and causes:rr AllMS 2004
./ AV Heart block
./ Prolong QT interval
./ OysarythmiasNF
, ./ Circulatory collapse/ cardiac failure.
)-- .. . .. . .. . . . . . .
Cardiotoxicity is more pronouncedin pregnancy, Hypoxia and associatedacidosis. There are more chancesof
fatal arrhythmias after iv dose. Bupivicaine binds more strongly to sodium channels and depolarizes
.
membranesto a greater extent.
- '. . . -- -
Cardiotoxicity is not easily reversed becauseof inhibition of epinephrine stimulated Camp. PGl2006
-.; Amidarone is the DOC for Oysarrythmias due to Bupivicaine.,...
-- --
LEVO Bupivicaine is used b)f epidural/ intrathecal route. PGl2004

r--- . o;~-~--r--
- 501':
 . - ------------------~------------
:> EMLA Cream
Is a mixture of 2. 5% Lidocaine and 2. 5% Prilocaine (NOT Procaine) PGl2006

It allows Anesthesia of intact skin:

It is used for:
D Making comfortable venipuncture in children.-.-
'
'
'D Skin grafting.-
'. D Circumcision.-
:D Needle phobias.-

D Naturally occuring LA: Cocaine ......

D Vasoconstrictor: Cocaine.- Al 1999

0 Maximum Methhemoglobinemia is due to: Prilocaine AllMS 09

0 Most used for Biers Block: Prilocaine ...

0 Bestfor isobaric spinal anesthesia: Bupivicalnew

. 0 Contraindicated in IV regional anesthesia: Bupivicainer

----'---- ...... ---------_.._. .. -
--' - -- --
' ..
0 Not surface Anesthetics: Bupivicaine, mepivicaine, procaine ...

:> Methemoglobinemia: High Yield for 2011-2012

Methemoglobinemia results from exposure to chemicals that oxidize the ferrous (Fe2+) iron in hemoglobin to the
ferric (Fe3~).state.
,.-J,

: ..,.. Dapsone,

; ..,.. Local anesthetics (particularly, Prilocaine benzocaine),

i
:..,.. Nitrites, nitrates, naphthalene, nitrobenzene and related chemicals,
\
: ..,.. Oxides of nitrogen,

-.: ..,.. Phenazopyridine,

'...,.. Primaquine and related antimalarials, and sulfonamides.

"Methemoglobinuria" is seen With:

_,
i
'
j
-- Prilocaine
Lignocaine
:l
i

! -- Benzocaine
Sulfonamides

--
.;
1 Phenacetin
!
~ ~'
Nitrites
'!
{
l
1- - N20
 Ketamine
.CJ Ketamine. causes almost complete anesthesia ..
. _,.,. -. ---~- ..... ~ .... -- .. ' _,_ ~.,i ~- - .,_, ....... ~ ,_ .......... -
-1 ~-- : --~-~- .,._. - - - -- .. -- - . ------- ---- ~--~-----
CJ Ketamine causes dissociative anesthesia. AllMS 2006

Is a phencyclidine. MH 2008
--- - . . . ... -- .
causes sympathetic stimulation**

. Increases salivation

Increases muscle tone

Increases cardiac output. (Useful in hypovolumic shock)*

. Causes bronchodilatation. (Useful in asthma)*

Causes (Hallucinations, delusions, illusions)* Al 1993

Causes profound analgesia . MAH 2012, PGI 2006

. , -
... Increases all pressures: (BP, ICT, IOT)*** PGI 1997

Contraindicated in Any condition in which a significant elevation of blood pressure would be hazardous, such as:
. 1. Hypertension, severe or poorly controlled
2. Myocardial infarction, recent
3. ' Stroke,
. 4. history of Cerebral trauma
5. lntracerebral mass or hemorrhage AllMS 2006

Excellent Analgesics:***
O Ketaminerr.

0 Buprenorphine=
O Trilener
...
0 Sulfantenylr

Anesthetics with good analgesic properties:

"~,..
\
N20
,.;,.. Ether
'
i,.. Ketamine
- --
' Anesthetics with weak analgesic properties:
~~ Halothane i
t r
\. ~ Thiopentone [

1..:~=:~--;;,_E_to_m_i_d_at_e-"--'--'---'-.:;,, ,:, __c-:-----=---'---.:__:__'-----''---'----'------'-------------:. .:. -.;.._J- r

f
-~----- --- ._,,__ . _Js
.. 5~3.-;
 ,__...__ .;.__,_ .._...~"--~------...___..,_,_,,,____._...,. _
Thiopentone
Ultra short acting barbiturate. Because of rapid redistribution. Al 1996.

Cerebroprotective AIPGME2012

Decreases intracranial pressure and cerebral blood flow.,....

./ Cerebral perfusion pressure is increased

\

~ ./ Pain threshold decreased.

Respir.atory depressant. Causeslaryngeat.spasrn .

. CVS effects:
.; ',/. Venous poolingr
s

., ; ./ Decreased contractility

i ./ Decreased cardiac output

./ Negative ionotropic effect

; ./ Increases myocardial oxygen consumption.

.
Musculo Excitatory:

; Lacks analgesic effect. PGI 2005.

1
-On intra arterial im injection first sign is white hands and cyanosis. ,....,.... Al 1997 I

t 1st symptom is pain.

. Papaverine, prostacycline, stellate ganglion/brachia I plexus block is used

- ; Can precipitate porphyria and is contraindicated in porphyria. rcr PG12004

: IV injection presents as pain, rash, hypotension, spasm. PGl 2003

Potenttal cerebral. protective mechanisms

- Decrease cerebral metabolism

Increase cerebral blood flow

: Mild hypothermia
i
: Prevent hyperthermia

' Thiopentone anesthesia AIPGME 2012

Maintain normoglycemia

' Inhibit release of excitatory neurotransmitters (eg, glutamate, aspartate)

Enhance release of inhibitory neurotransmitters (eg, GABA)

Block neuronal calcium influx

Propofol
Propofol is the "agent of choice" for day care anesthesia.,....,.... Al 2008, JK BOPEE 2011
-- -- -. -- .. . ..-- - .: .. - .-'-- .- .. -- ....
Propofol is used for only "IV administration" as 1% solution . ..-

Causes pain on IV administration. AllMS 2006

The induction dose in an adult is 1.5-2.5mg/kg.r

--,504
 . It is used "both" for induction as well as maintenance of anesthesia :

. Induction and recovery from propofol is smocthw

.- . ~ - . - ....

Incidence from nausea and vomiting is low . .-

Propofol has minimal effects on hepatic and renal systems .

. . Propofot supportsgrowth of bacteria. As a result "disodium.ectetate and sodium meta bisufrate" are used m
preparations to retard the growth of bacteria;.-.-

Contains egg extract. Al 2008

-.-- -. . ' - -
Propofol resembles barbiturates and also has "anticonvulsant" properties . .-

Propofol is safe in Porphyriar SGPGI 2002

-:-...,. ,_ - -
Propofol does not trigger malignant hyperthermia ....
. .

CNS Effects are:

Decreases Cerebral blood flow
. Decreases tntracrantat pressure
Decreases intraocular pressure
Cerebroprotective PGI 2005
.;_~~~-..:--~- .: :~.. ,. . . . . - -. -
CVS Effects are:
- -~ -
Dose dependent decrease in BP due to vasodilatation as well as myocardial depressant effect' . .-
SGPGI 2002'
;.,".. .;' : --
Respiratory Effe<:ts are:
Propofol is a respiratory depressant
; Remember Propofol has CNS, CVS and Respiratory depressant effects . .-

Other features of Propofol

./ Antiemetic SGPG12002

./ Ahtipruritic

./ Antioxidant

./ Propofol should not be used in extremely ill patients as it causes "propofol infusion syndrome".

Propcfcl.infusion syndrome:
; ./ Associated with long 'term propofol use.
./ is rare but fatal.
1
./ Characterized by:
.~
./ Lactic acidosis
./ Lipaemic plasma
./ Cardiac failure.*

. -. -sos ..
'.
i..-ft.. ..~------ _...~:- ..
 Fos propofol:

Is water soluble and hence is associated with

D [pain, **

D t hyperlipdemia*

D trisk of sepsis
D It is used along with fentanyl especially for procedures like endoscopy, colonoscopy, bronchoscopy.ss

Etomidate
./ lmidazole derivative .

./ Acts at GABA a receptor. rr

./ Minimal respiratory depression .

./ Decreases intracranial pressure and cerebral blood flowrr

./ Does not have analgesic properties.

./ Etomidate has "Minimal effects on cardiovascular system". AllMS 09

.,/ Mild reduction in peripheral resistance

./ Myocardial contractility usually unchanged

-
:c
./ Cardiac output usually unchanged

./ Causes adrenocortical suppression by inhibiting 11 B hydroxylase and 17 a hydroxylase.

PGI 2006, KCET 2012

ls a selective positive allosteric modulator at GABA A receptor

~
j Sedative hypnotic without any analgesic properties
',\
t

'~ Side Effects:

A
~
:,j, Excitatory phenomenon causing myoclonus, hiccups and other
-:~
).
Involuntary movements
I
l~ High incidence of nausea and vomiting
l Pain on injection and thrombophlebitis
j
I Causes adrenocortical suppression by inhibiting enzymes hydroxylases involved in cortisol and aldosterone

.-~
l (rnineralocorticoid) production. AIPGME 2012

:l Contraindicated in porphyria and adrenal insufficiency

;~
. ~
i
l
i O Pain on intraarterial injection: thiopental'e
!
! O Pain on intravenous injection: etomidate (thrombophelebitis as well)r
-~

j .O Pain on intravenous injection: propofol, methohexitol, thiopental (thrombophelebitis not seen)r

;:l
~:l " ,_,., ~----

506.
:> Important Points
v" Intravenous anesthetic used in shock: Ketamine,....,....

v" IVA safe in e_orphyria: e_ropofol,ketamine,....,....

./ IVA which precipitates porphyria: Thiopentone, Methohexitone.,.... JK BOPEE 2011

./ IVA with high incidence of venous thrombosis: Propofol..-

v" IVA which can cause postoperative vomiting: Ketamine,....

- :> Stages of Anesthesia:***

Guedels Stage of Anesthesia
Based on Ether PGI 1987
1st Stage: stage of analgesia: onset of loss of consciousness**

. 2nd Stage: stage of excitation: stage of deleriumss

3rd Stage: stage of surgical

anesthesia Eyes centrally fixed
Plane I Beginning of intercostal muscle paralysis, corneal laryngeal reflexes lost
Plane II Complete paralysis of intercostal muscles. Light reflex lost
Plane Ill Beginning of diaphragmatic paralysis, fully dilated pupils, intercostal paralysis
Plane IV Surgical anesthesia 3 KERALA 1998
Lacrimation occurs in stage 3 CUPGEE 1995
--- .
4th Stage Medullary paralysis, cardiorespiratory arrest

Ether: Morton First used Ether

. Disadvantages Advantages

..,_ Irritant ..... Good muscle relaxant

, ..,_ Excessive salivation ..... . Wide safety margin
..,_ Inflammable ..... Cheap
..,_ Slow induction and slow recovery ..... Easyto adminiter

..,_ Volatile liquid. ..... Minimal cardiac depression

, ..,_ Can be used by Endotracheal route/mask ..... Hyperglycemia PGI 1988

JIPMER1990 ..... Inflammable PGI 1986

..... Contraindicated in
..... Diabetes mellitus
..... Diathermy
..... Beta blocker use

50-7.
-~--- ----
 ----------- ..-----------~---------------- - , ... -- -- ---------- -------------------------
~ Chloroform
..,. CardiOtoxic,...,...

..,. Emetic,...,...

..,. Hepatotoxtce-

..,. Diabetogenic ,...

..,. . Causes malignant hyperthermia= -

~ Halothane
-./ Non inflammable, colorless liquid with pleasant vapor .... ,...

v" Decomposed by light and stabilised by thymol.,...

.~ . .. . .. . . . ' - .
v" Corrodes metals,,..._

v" Soluble in rubber, plastics . ..-

Arrythmogenic,...

Myocardial depressant . ..-..- KCET 2012

Vagal stimulant,..,...

Sensitizes heart to adrenaline.,... Al 2001

jlCT. (Less than halothanejw

Dissolves rubber. AllMS 1993

' ~ - - -
May cause PPH (Relaxes uterine muscle) and bronchodilator (used in asthma) - KCET 2012
Hepatotoxic

_ Drager narko test is used for halothane

Halothane and other halogenated inhalational anesthetic agents, such as enflurane, isoflurane,
sevofli.Jrane, and desfturane, are known to cause severe liver dysfunction. PGI 2001
When the World Health OrganizatiOn (WHO) drug monitoring database was reviewed for the medications
that most commonly cause fatal hepatotoxicity; halothane was one of the 10 most common causes.
_ ,...(Post operative jaundice) PGI 1999
- -
Two major types of hepatotoxicity are associated with halothane administration. The two forms appear to be
unrelated and are termed.
- -
Halothane and other halogenated inhalational anesthetic agents, such as enflurane, isoflurane,
sevoflurane, and desflurane, are known to cause severe liver dysfunction . ..-

When the World Health Organization (WHO) drug monitoring database was reviewed for the medications that
most commonly cause fatal hepatotoxicity; halothane was one of the 10 most common causes.
~ - .- .. .. ,

Two major types of hepatotoxicity are associated with halothane administration.

 Type I (Mild) and Type II (Fulminant)
Type 1 hepatotoxicity is benisn, self-limiting, and relatively common (up to 25-30% of those that receive
halothane).
D This type is marked by mild transient increases in serum transaminase and glutathione 5-transferase
concentrations and by altered postoperative drug metabolism.
'D Type I hepatotoxicity is not characterized by jaundice or clinically evident hepatocellular disease.'.
Type I probably results from reductive (anaerobic) biotransformation of halothane rather than the normal
oxidative pathway.
D It does not occur following administration of other volatile anesthetics because they are metabolized to a
lesser degree and by different pathways than halothane.

Type II hepatotoxicity (also called halothane hepatitis) is associated with massive centrilobular liver necrosis
that leads to fulminant liver failure; the fatality rate is 50%.
D Clinically, it Is characterized clinically by fever, jaundice, and grosslyelevated serum transaminase levels.
D Type II hepatotoxicity appears to be immune mediated. Halothane is oxidatively metabolized, producing,
trifluroacetyl metabolites to an intermediate compound. These metabolites bind liver proteins and,
in genetically predisposed individuals, antibodies are formed to this metabolite-protein complex.
The antibodies in turn mediate subsequent type II toxicity.
D Volatile anesthetics other than halothane also have the potential to cause type II hepatotoxicity. This risk is.
directly related to the relative degree of their oxidative metabolism to acetylated protein adducts.

lsoflurane
...,. Leads to coronary steal phenomenon (dilitazem) also causes.
- - - -~4 -~-- - - -- - -""' - -~ _.__ _. _ _,_ --- ----- ~ ~----

.... Particularly useful in neurosurgery, myasthenia gravis and renal failure.

Enflurane
I Contraindicated in epilepsy.. I
Methoxyf~urane
LI Nephrotoxic..-..-
... _ .... ...,_, __ ... -
_._

D Highest fiuoride content=

D Causes oxalate stones . ..-

Desflurane
~ Fluorinated congener of isoflurane . ..- AllMS 2004
~ ..... - - --'-- .... -- - ~-:-. -----~-
-;~-~L.~; t;(~~d ~~<l ti~s~e~ga~ p~rtit1~ri ~~~ii1c1e-~t:;;- -- WB 2006

..7-~usecflii-oF>o proceeiu'res._.
./ Minimal cardiac depression ..-
--~~--[esisoluble- ~- - .- -
 ----- ,__,._,.. ,..-...~.- .......... ~.. ---.~~- --......- . ._.... ...__ ~------'- ......... - ....... ------------------- ---- ...

Sevoflurane
Agent of choice in induction for paediatric age group and elderly. BHR 2005
- -
Not used in closed circuits because of toxic product (olefin) production.

Non pungent MAH 2012

- -
lnhalational agent of choice in pediatric population. PGI 2005, MAH 2012

Fast acting JK BOPEE 2006

O ~mootli induction**
0 ~afe in children
0 ~weet odor
0 ~peedy onset of action
o ~afe CVS profie: ' -

~Adverse Effects with Sevoflurane

Raised intracranial tension
Respiratory depression Delhi 2008
-
Nephrotoxicity

The Physical Properties of Inhalation Anesthetics

0 Halothane: Sweet smell
0 lsoflurane: Pungent ethereal odor with airway irritation
O Sevoflurane: Non-pungent, sweet odour MAH 2012
O Desflurane: Pungent and airway irritant

The Triad of General Anesthesia Includes Karnataka 2009

Analgesia
; Amnesia
Muscle relaxation
'
.J The advantagesof lsoflurane for general Anesthesiain a cardiovascularpatient are: AP 2005
l
j Decreasedincidence of arrhythmias
l
l Vasodilatory effect

l Early recovery
I
'j Nitrous Oxide
~j' 0 Color of cylinder of Nitrous oxide is: bluerr PGl2004
.,!
I!
0 Code: 3,Srr (PIN index) PGl2003
~1 0 MAC: 104r
.l 0 Discoveredby Priestley. Also called as laughing gasr TN
;1 ~---- ~~ - - - --- .
. 510 !
~..... ~.. . ~- - - .. --- - .. - ~
LI Usually used in 50-65 % mixture with oxygen.

LI Lighter than air and has high solubility in blood ...........

0 Entonox is 50% N20 and 50%02 ..-..- KCET 2012

D It is not used in Pneumo conditions such as pneumothorax, volvolus of gut..-

-
LI It is a non irritant, colorless, inorganic gas.,...

Advantages:

.,.. Inert gas

.,.. Minimal CVS effects

.,.. Rapid induction and Recovery

.,.. Has analgesic properties

.,.. Non inflammable anesthetic

. .,.. Safe anesthetic

'
Disadvantages:

Has low Blood solubility but that is not an advanta~ It diffuses rapidly to alveoli from blood and dilutes
alveolar air. This causes excess of N20 in alveoli so partial pressure of 02 in alveoli is reduced resulting in
'Hypoxta. (Diffusion Hypoxia)***

Not used in pneumo conditions.

Side effects:

Diffusion Hypoxia/Second gas effect ...... COMED 2005

Methemoglobinemiarr ;

i
Bone marrow suppressionr..- _ DNB 2001 r
I'
Megaloblastic anemia..-.- UPSC 01 Ir
1'
i
"Nitrous Oxide" l
l
!
Can produce signs of vitamin 812 deficiency (megaloblastic anemia, peripheral neuropathy) following long
administration. For this reason it is not used as a chronic analgesic or a sedative in critical care settings'.
Side effects of nitrous oxide:

EXPANSION OF AIR POCKETS: Exchange with nitrogen in any air containing cavity in the body.
HEMATOLOGICAL EFFECTS: Nitrous oxide inactivates the cobalt in vitamin 812 and irreversibly fn activates
the enzyme methionine synthetase Megaloblastic anemia has occurred with N20 periods of 6-12hrs
s NERVOUS SYSTEM: increases cerebral blood flow and intracranial pressure when used alone. When
co-administered with other anesthetics, increase in cerebral blood flow is abolished. It causes peripheral
neuropathy because of vitamin 812 defiency.
 r- ~

l :> Not Used In:**** AllMS 09

0 Pnemothorax
-- - - ~
..... '

0 Air embolism

0 Obstructed middle ear .

0 Obstructed bowel

0 Pulmonary bleb

0 Cochlear surgeries
j -- .... - --
0 Microaryngeal surgery
1I . - - ...
l 0 Vitreoretinal surgery
I
'
.i )
.,.. Second gas effect:
l
v" Seen during induction of anesthesia.,...,...
l ' v" As the gas is used in high concentration, N20 enters at high rate and any other anesthetic agent added.
will also be delivered at high rate. JK BOPEE 2012

l .,.. Diffusion hypoxia:

~j During recovery phase N20 having low blood solubility diffuses rapidly into alveoli and dilutes alveolar
air and reduces partial pressure of oxygen causinf diffusion hypoxia,...,...,.. PGI 1998

:> ExplosiveAgents:***
v" Ether
~'~ ....... - ..
v" Cyclopropane
. ~ ~ - . - ... - ~ .. - . -
v" Ethylene

v" Ethyl chloride

~;~ XENON Anesthesia

w~l
I :-
f.fa~
:.I"
::i~al
Non explosive
CVS effects.
. (

fa
~~
Environmental friendly
I ,_
I ;
~t -
- . Rapid induction_/recovery
Low blood solubility
No malignant hyperthermia
Ii
~ . -.
Eg: Patient with mitral stenosis had preanaesthetic checkup. Increased liver enzymes were noted.
~ . _Xena~ as an inhalational (!gent is preferred.

~I
"'.!- ,--~-~--~-1
. 512
~---'-~----.. ! ,.__ ----.
J
 :> Spinal Anesthesia: High Yield for 2011-2012
Ill- In children spinal anesthesia is administered in L3L4 space.r.- Al 1997
Ill- In adults spinal anesthesia is administered in L4L5 space.rr
Ill- Epidural, spinal, caudal is the same procedure.
Ill- Nerve roots in cauda equina are the sites of action. r
Ill- Autonomic pre ganglionic fibres are earliest to be blocked (sympathetic) AllMS 1992
Ill- Percentage of xylocaine used in spinal anesthesia is: 2%-5%.
Ill- Sixth cranial nerve. is the commonest cranial nerve to be effected in spinal anesthesia. r
Ill- Cauda equina syndrome is possible complication.
Ill- Touhy needle is used during the procedure. r
Ill- High spinal anesthesia is characterized by hypotension and bradycardia. r
. -~ .. --- - .- -- ~--
. 111-. Ephedrine is the agent of choice as a vasopressor. PGI 2004

Contraindications of spinal (centrineuraxial) anesthesia:***

./ Patients refusal Al 2003
./ Inability of patient to maintain stiffness during needle puncture .
./ Raised ICP
./ Severe Hypovolumeia Al 2003
. ./ Severe stenotic heart disease
./ Marked skin sepsis and marked spinal deformity
./ Marked coagulopathy, blood dyscrasia. Al 2003

c:::> Adverse Effects of Central Neuraxial Block Include Karnataka 2009

Hypotension
Nausea and vomiting
Orinary retention

In Epidural Anesthesia, anesthesia used is: Bihar 2004

i
Buprenorphine
Bupivacaine
. Morphine,
.. - .
I!
t
"'-

Fentanyl

:> High/Total Spinal Anesthesia f

r
./ If there is inadvertent intrathecal injection.
~--- .~ ...... ----- --- - - -- ------- -- - - ---- - . -- - - .
- -
./ Can occur due to intrathecal injection of largr amount of drug.
'
-~~-Markecfhypotensfon, apnea~dilated pupils, bradycardia are seen.
-- ----- ,,___ - -- .. .. -- - --- - --- -. - - ......... -- -- - .. . ..
.._ - - -
AllMS 2001 [
./ Subarachnold Lavage, iv fluids and vessopressors, head down position are used as treatment optionr.-. __!
'' 513
I . - ... - -
.------~----,.;. ...._._.-__,. __ , ..... ___,_ .__..,, <----- .. ---'- ,. . . _, . . . . . ,.~~,---------------------------

:> Post dural Puncture Headache (PDPH)**** High Yield for 2011-2012
it Post dural Puncture Headache (PDPH) or post L~ headache is the second most common complication after
hypotension in spinal anasthesia.,....,....

It occurs due to low CSF pressure. /(SF leak..-..- Al 1995

....,._...., - -
- Onset is usually in 12-72 hours.

Lasts 7 -10 days. Al 1994

ir;; lncreasecl'incidence with early mobilization of patient. is seen. ..-

Use of small gauge needles prevents it.,....

Post dural Puncture headache is different as it is a postural headache worsened by standing or sitting and -
improved in supine position.w

Post dural Puncture is not treated effectively by NSAIDS.

.. -- - ..
Post dural Puncture headacheis effectively treated by caffeine and Epidural Blood patch ..... ,...

PDPH occurs hours to days after puncture.

Post dural headacheis caused by decreased intracranial pressure due to leak of CSF from puncture site.,...

Post dural Puncture headache depends on needle size and can - be prevented by using thinner needles.
However it is not only the needle size but also the needle design and orientation which influence the
incidence of Post dural Puncture headache.
- .- -- - ~
. "Sprottee needle or whitacare needle" reduces risk of PDPH. orr PGl2004

~ Higher Incidence of Post Dural Headache is seen in

0 Pregnant patients

0 Female sex
--
0 Younger patients

0 Larger needles
. - ~.

0 Multiple punctures.

Ephedrine is used as a vassopressoracting on a as well as 8 receptors. (DOC)

"'---~..t_.,,;. ~---~;~- --" ~--.--- . .,, -

Mephentramine is used if ephedrine is not available. Al 2006

Doxapram
_Doxapram is a "respiratory stimulant" and "CNS stimulant "(analeptic) and not a specific reversal agent.
- 1.: .,/ Doxapramis administered intravenously ,...
'
Doxaprarn causesincrease in tidal volume and respiratory rate. (Peripheral actiom=
Doxapram stimulates chemoreceptors in the carotids which in turn stimulate respiratory centre in brain
i
~ stem. (Central action)
~; ./ Doxapram_ is a white, odourless powder stable in light and air with acidic pH. ..-
I
;~--<--<--~.--! '
~- ~1-4; -
.....,..,,..;....,:...._;_, __ ~,--,...- --. ~-1
 Doxapram is used:

;./ In respiratory failure and respiratory depression.je

./ In treatment of COPD/COAD.*

./ Side effects: Pain and redness at injection site, flushing, sweating, headache, nausea diarrhea, enlarged pupils*

Other Respiratory Stimulants are

Almitriner... .

Amiphenazolerr

Demifline .. ..-

Bemegriderr

Nikethemider

Pentetrazol r

BLS has three components

A Airway (FIRST)

B Breathing

C Circulation

ATLS is advanced trauma Life Support

GCS is Glasgow Coma Scale

ABCDE is Airway, Breathing, Circulation, Disability assessment, Exposure

Adult BLS Sequence

Ensure that the scene is safe

Assess the victim's level of consciousness by asking loudly "Are you okay?" and by checking for the victim';
responsiveness to pain.

If the victim has no suspected cervical spine trauma, open the airway using the head-tilt/chin-lift maneuver;
if the victim has suspected neck trauma, the airway should be opened with the jaw-thrust technique. If the jaw-
thrust is ineffective at opening/maintaining the airway, a very carefut head-tilt/chin-lift should be performed.
~- .... ------- ~ - . . ' - ~-~
. Assess the airway for foreign object obstructions, and if any are visible, remove them using the finger-.
sweep technique. Blind finger-sweeps should never be performed, as they may push foreign objects deeper
into the airway.

Look, listen, and feel for breathing for at least 5 seconds and no more than 10 seconds.
-~,-.---~- - -~- .
If the patient is breathing normally, then .the patient should be placed in the recovery position and
monitored and transported; do not continue the BLS sequence .

If patient is not breathing normally, and the arrest was witnessed immediately before assessment, then
immediate defibrillation is the treatment of choice.
 Attempt to administer two artificial ventilation's using the mouth-to-mouth technique, or a bag-valve-mask
(BVM). The mouth-to-mouth technique is no longer recommended, unless a face shield is present. Verify that
the chest rises and falls; if it does not, reposition (i.e. re-open) the airway using the appropriate technique
and try again. If ventilation is still unsuccessful, and the victim is unconscious, it is possible that they have a
foreign body in their airway. Begin chest compressions, stopping every 30 compressions, re-checking the
airway for obstructions, removing any found, and re-attempting ventilation .
...

If the ventilation's are successful, assess for the presence of a pulse at the carotid artery. If a pulse is
detected, then the patient should continue to receive artificial ventilation's at an appropriate rate and
transported immediately. Otherwise, begin CPR at a ratio of 30:2 compressions to ventilation's at 100
compressions/minute for 5 cycles.
~ - - ,.,... -- -
After 5 cycles of CPR, the BLS protocol should be repeated from the beginning, assessing the patient's
.
. airway, checking for spontaneous breathing, and checking for a spontaneous pulse.

Causes of Delayed Recovery from Anesthesia JK BOPEE

:a Overdose of anaesthetic.
lo Duration and type of Anesthesia.
. ~ - - .
0 Hypothermia
' 0 Hypo calcemia
0 Hypo kalemia
0 Hypo/Hypernatremia
'O Hypoxia/Hypercapnia
'D Hypo/Hyperglycemia
.
0 Hypo thyroidism

0 Renal failure
LI Hepatic failure
LI Cardiac failure

Drugs Used in Postoperative Shivering are

LI Clonidine
LI Mepridine
LI. Trarnadol
....
O Pethidine (NOT with MAO inhibitors) Al2010

:> Nitric Oxide (Old Drug but Important for PG Exams)

./. Nitric oxide is NO .
'~7 . . it- is also-
called as EDRF.-(.EriCiothelial derived re taxing factor).
-:;- 1t is produced from arginine by enzyme NO synthetase. PGl2007
./ -""has a short t~ (4 seconds):
~7 --.ft: acts v1a c- GMP pathway. - - . AIPGME 05, AllMS.93.

516'
 There are 3 forms of NOS

a NOS 1 : in nervous system

a NOS 2: in macrophages
LI NOS 3: in endothelium
D It relaxes smooth muscles specifically

0 Dacreasespulmonary artery pressure

a Vasodilates corpora cavernosa. Leads to penile erection PGI 2007 :

D . Inhaled NO exerts effects on pulmonary system only

I a It prevents platelet aggregation AllMS 04

0 It functions as a neurotransmitter

0 It mediates bactericidal actions of macrophages

'Drugs Forming NO
LI 'Sodium nitroprusside. PGI02

0 Nitroglycerine

D Hydralazine

Oxygen Toxicity
./ Carbon dioxide narcosis

v' Bronchopulmonary dysplasia

v' Alveolar edema

v' Retrolental fibroplasias .

v' Epilepsy

0 Nasal cannula delivers 44% maximum oxygen concentration . COMED 01

O Venture mask/oxygen mask delivers 60% maximum oxygen concentration

O Ventilator delivers 100% maximum oxygen concentration

Oxygen is delivered by
v' . Oxygen tent
- . - -- - . . ..'- ....
v' Oxygen apparatus
~ Poly mask
v' Venturimask
-~ . Nasal catheter
v' BLB mask

:> Hyperbaric Oxygen Therapy is given in

..,,, Histotoxfc anoxf a
v' Carbon monoxide poisoning
v --Gas-gangrene - -- -- oNBOf

. 51.7 ..
:) Malignant hyperthermia (Repeated Often and High Yield for 2011-2012)
.,... Occurs in individuals with an inherited abnormality of .skeletal-muscle sarcoplasmic reticulum that causes a
rapid increase in intracellular calcium levels in response to halothane and other inhalational anesthetics or to
succinylcholine. ,....,...

..... Defect in ryanodine receptors in Sarcoplasmic rettculum.e'

.,... Mitochondrial and sarcolemma damage is a feature. r

.,... Marked rise in intracellular Ca++ occurs . ..-

..... Elevated temperature, increased muscle metabolism, rigidity, rhabdomyolysis, acidosis, and
cardiovascular instability develop . ..-

..... Hyperkalemia AllMS 2007

...,:- Metabolic acidosis AllMS 2007

..... Hypertension.

..... This condition is often fatal.

..... Rise in end tidal C02 *

..... Tachycardia

Trigerring Agents
./ Succinyl choline,...,...
./ Ether,..-
./ Cyclopropane
./ Halothane ..-..-
./ Fluranes, ..-..-
./ Lidocaine and amides ..-..-
-
./ TCA,..-..-
./ MAO inhibitors, ........
- ..,..
./ Phenothiazines ,...

tntrevenous dantrolene is indicated to reverse the symptoms of the malignant hyperthermic crisis syndrome
occurring during or followingsurgery or anesthesia**
Malignant hyperthermia should be treated immediately with cessation of anesthesia and intravenous
administration of dantrolene sodium. Procainarnide should also be administered to patients with malignant
\

; hypertherrnia because of the likelihoodof ventricular fibrillation in this syndrome.

 -
Causes of Postoperative Hypertension:***
Pr~ operative withdrawal of anti hypertensive's.
Pre operative Phaeochromocytoma
Pain
Reaction to tracheal tube
Excessivefluid administration.
Hypothermia
Hypoxemia
--
- Hypercarbia
Fuli hladd~r

Neurolept Malignant Syndrome

Is a potentially life Threatening idiosyncratic reaction to neuroleptic drugs.
D Fever
D Muscular rigidity
D Altered mental status
D Autonomic dysfunction
Pathological abnorrnality is central 02 receptor blockade or dopamine depletion in the hypothalamus and
nigrostriatal I spinal pathways. This leads to an elevated temperature set point, impairment of normal
thermal homeostasisand extrapyramidally induced in muscle regidity.
.. Is usually associated with. potent neuroleptics such as haloperidol and fluphenazine, which block central
02 receptors but it has now been reported to occur with all drugs that affect the central dopaminergic
system (including dopamine agonists and levodopa). In these cases neurolept malignant syndrome is
precipitated by rapid withdraw( of the dopaminergic agonists.
Amantadine is a dopamine agonist and its withdraw! precipitates neurolept malignant syndrome.
- 9 ,. N.M.S. is also associatedWith other drugsthat have central 02 receptor antagonist activity Metoclopromfde.
It is secondonly to haloperidol in triggering neurolept malignant syndrome.
Domperidone like metocloprornideis a D2 blocker and is similar to metoclopromide in all respects except that
Domeperidone does not cross C.N.S. and so it does not cause neurolept malignant syndrome.

:> Granisetron: High Yield for 2011-2012

Is a potent, selective antagonist of 5-~ydroxytryptamine (serotonin) subtype 3 (5-HT3) receptors.

The most common side effect of chemotherapyadministration is nausea,with or without vomiting.

Nitrogen mustard, nitrosoureas, streptozotocrn, DTIC, cisplatin, and actinomycin are highly emetogenic and
produce vomiting in virtually all patients.
Doxorubicin, daunorubicin, and conventional-dosecyclophosphamideare moderately emetogenic.
Emesis is a reflex causedby stimulation of the vomiting center In the medulla. Input to the vomiting center
comes from the chemoreceptor trigger zone (CTZ) and afferents from the peripheral gastrointestinal tract,
cerebral cortex, and heart.

519
I.. -
---- --" ------ -- -- "- -- --- -- . ----c.. . -~-- - - .. -~-- . . ~"""~ailW..,_ 1.-P l r

In addition, a conditioned reflex may contribute to anticipatory nausea arising after repeated cycles of
chemotherapy
The serotonin receptor antagonists ondansetron and granisetron are the most effective drugs against highly
emetogenic agent
Granisetron is indtcated for the prevention of nausea and vomiting associated with radiation, including total
body irradiation and fractionated abdominal radiation
Granisetron is indicated for the prevention of nausea and vomitingassociated with initial and .repeat courses
of moderately or severely emetogenic cancer chemotherapy.

Latest SHT3 Antagonists

D Ondansterone

D Dolasteron

0 Palonosteron
D Granisetron

Stellate Ganglion Block

'
Stellate ganglion is so called because it is star shaped. It is inferior sympathetic Cervical ganglion or
cervicothoracic ganglion when it is blocked it causes

Ptosis-droopingof upper eyelid

Miosis-constrictionof pupil
Anhydrosis-lossof sweating on that of face
Enophthalrnos- retraction of eyeball
- . . ---
- Loss of ciliospinal reflex-pinching_ skin on nape of does not produce dilatation of pupil; which normally
takes place

Aspiration Pneumonia
.v", Volume of aspirate>25 ml.
.. -. .
./ Aspirate pH<2.5
./ Partiaily digested food .
./ [Ccnscious level (anesthesia, stroke, seizures)
---:./ At high risk for aspiration
./ Children and elderly
-;/ Diabetecs
./ Pregnant
./ Obese
./ Leads to chemical pneumonitis, infection and bacterial pneumonitis
I._. _:.~-~n~e~ns syndrome is aspiratloriof gastric contents. (Prevented.by Selllcks maneuver) JIPMER 1993

. .
_. . -..a.--- . . -'"'--- -- - .J
!) Basic Life Support: High Yield for 2011-2012
a Known as CPR, is intended to maintain organ perfusion unt~l definitive interventions can be instituted.
--- ~-- -.-- -- --~ -- ..,. -. -

a The elements of CPR are the maintenance of ventilation of the lungs and compression of the chest.
'cf 0 Mouth-to-riiouth-respiration may be used if nospeciflc rescue equipment is immediately .avattabte (e.g.,
plastic oropharyngeal airways, esophageal obturators, masked Ambu bag). ,...,...
. .. .. . - .. . . - ... .
O Conventional ventilation techniques during CPR require the lungs to be inflated 10 to 12 times per minute,
i.e., once every fifth chest compression when two persons are performing the resuscitation and twice in
succession every 15 chest compressions when one person is carrying out both ventilation and chest wall
compression..... JK BOPEE 2011
a Chest compression is -based on the assumption that cardiac -compression allows the heart to maintain a pump
function by sequential filling and emptying of its chambers, with competent valves maintaining forward
direction of flow .
.............. . . -.
0 The palm of one hand is placed over the lower sternum, with the heel of the other resting on the dorsum of
the lower hand.
--o--rile sternum is depressed, with the arms remaining straight; at a rate of approximately so to 100 per
minute ...
' - ...
0 Sufficient force is applied to depress the sternum 3 to 5 cm, and relaxation is abrupt . ..-

During CPR
./ #Ribs, sternum, vertebrae occur
./ Injury to lungs
./ Rupture liver and spleen

Advanced Life Support

Is intended to achieve adequate ventilation, control cardiac arrhythmias, stabilize blood pressure and cardiac
output, and restore organ perfusion.
The activities earned out to achieve these goals include .
-: ./ fntubation with an endotracheal tube, ......
; ./ Defibrillation/cardioversion and/or pacing, and ......
: ./ Insertion of an intravenous line .....

0 Ventilation with O~ (room air if 02 is not immediately available) -may -promptly reverse hypoxemia and

acidosis~.
-
0 When possible, immediate defibrillation should precede intubation and insertion of an intravenous line
'
~a-- -~CPR-should-be carried out while the defibrillator is being charged ..

0 As soon as a diagnosis of VT or VF is- obtained, a zoo-, shock should be deli~ered. Additional shocks at higher
energies, up to a maximum of 360 J, are tried if the initial shock does not successfully abolish VT or VF. *
o~ -Epinephrine; --1~ mg -intrave-no-usiy, is give~n--after f aifeci defibrillation, and attempts to defibrillate - are
repeated. *
.
i .-~ -- -~ . ~ , - -----
.
521.
 If the patient is less than ful(y conscious upon reversion, or if two or three attempts fail, prompt intubation;
ventilation, and arterial blood gas analysis should be carried out
After initial unsuccessful defibrHlation attempts, or with persistent electrical instability, a bolus of 1 mg/kg
lidocaine is given intravenously and the dose is repeated in 2 min in those patients who have persistent
ventricular arrhythmias or remain in VF. This is followed by a continuous infusion at a rate of 1 to 4 mg/min.
If lidocaine fails to pr~vide control, other antiarrhythmic therapies should be tried.
For persistent, hemodynamically unstable ventricular arrhythmias.
~0 Intravenous amiodarone has emerged as the treatment of choice *
l
'. 0 Intravenous procainamide may be tried for persisting, hemodynamically stable arrhythmias; or *
.B~etyliumtosylate(may be tried. as an alternative for u~stable arrhythmias . -

:) Retrobu lbar Block

D . Is reglona! anesthesia for eye surgery.rr
; - -- .. ' ,_. -- - - -- ..
' - .":.-~:

O LA is injected behind eye into cone formed by extraoccular muscles . ..,.,...

' ~- ------.--
. - . ' ~ -- ' . . .
D - Lldocaine, bupivicaine and hyaluronidase are combtned.w
. -
-<-~'-. --
-
' .
.

D After block, onset of ptosis indicates successful needle placement

....... --

D . Optic, oculomotor, abducens, nasociltary nerve and ciliary ganglion are affected in conal block . .-
0 Lacrimal, frontal, infraorbital and trochlear nerves outside the cone are least affected.w
.D Anesthesia, akinesia and abolishment of occulocephalic reflex are determinants of successful block.
D . Superior oblique is the last muscle to get paralyzed in this block. AllMS 2006
,- - - --- -- ..
Complicationst
. . - .

\ ../ Retrobutber hemorrhagerr PGI 2004

'~
; ./ Globe perforationrr PGI 2004.
,_,J
f~ Optic nerve atrophyr PGI 2004
;~
,:;.;

' .'.~
.J ./ Convulsionsrr
t~
:-.i

0i
> ./ Occulocardiac reflex
'~
. ./
Pulmonary edema
'j

-~ ; ./ Trigeminal block
~ ; ./ Respiratory arrest
')

'.l
:?\jJ B-rachial plexus block: needle is passed lateral to subclavian artery. (Risk of pneumothorax)
;:.'.~
t1 Phre.nic nerve block: Neddle is passed into scalenus anterior muscle.
~~11
:,J '. ~ DOC in status epilepticus: IV lorazepam
~i
i';~
.;
_~ DOC in anaphylactic shock: IV adrenaline
-~~
"--':-~
~-0h-W~--.--,-1
.522 . ' l
'r - ' -,. .", r- -.~
c> Mallampati Grading
Is used for assessing oral cavity before intubation. Al2000
A.ssesses size of tongue, pharyngeal pillars, uvula
Grading:
./ Grade I faucial pillars, soft palate, uvula seen
: ./ GradelI faucial pillars, soft palate
l

./ Grade Ill soft palate seen

i ./ Grade IV hard palate seen

c> Rapid Sequence Induction

Used to reduce risk of aspiration pneumonia.

Patient is preoxygenated prior to induction.

. Induction by thiopentorie is done.

Pressure over cricoid (sellicks maneuver) to prevent regurgitation.

- ~ .

Prior curarization with non depolarizing MR plus use of suxarnethonium is done.

c> Circoid Pressure

Is one of the methods of prevention of acid aspiration syndrome
~__,_"----- ..... ----. --
.: .. ----- -- - . -
It is used to prevent regurgitation by occluding the esophagus between the cricoid carttlage and the
vertebrae, as recommended by Sellick
-----:--_. ..... _. . . .. - - - . - .... - ..... - . . - . . -
It should be applied as the patient loose consciousness, using the tips of first two
Fingers and thumb of an assistant to apply pressure on the cricoid cartilage.
~;;----This method must not be used during act.Ive vomiting as it may lead to esophag-eal rupture .

c> Features of Nasal Airway

O The nasal airway 1S more traumatic than oral air-Way. There is more mucosa! damage and bleeding.,..,..
O The incidence of infections is also more with nasal airway as compared to oral airway. (Sinusitis, otitis
media),..
. :0 The nasal airway is not usually used in anticoagulated patients due to high risk of bleeding and is better
l

avoided.
1 0 There is displacement of endotracheal tube in nasal airway.
- .
However the benefits of nasal airway are:
,...... . . -..-.------ ....
./ It is better tolerated than oral airway.
./ Less chances of displacement.
./ Maintains good oral hygiene. AllMS 2007

rr. . -- .._..-.-~ ...

 Contratndications of nasal/oral intubation:
' :/ . Laryngeal edema_.;~

./ Laryngo tracheobronchitisr AllMS ~995'.

'
./ Epiglottitisr
~ - - ---~ . ' . -. : : "'":;="""-"

Nasal intubation is Contraindicated in:

. Basal skull#
CSF Rhinorrhea AllMS 1995

; Nasal obstruction

Adenoids
' Bleeding disorders
Previous nasal surgery

9 Endotracheal Intubation
_EndotrachealJubes:.
D Made of PVC. r r
D Resistance to air flow depends on diameter of tube . ..-
;D Len cuffed tubes are usually used in children. Tube size is given in millimeters . ..-..-
;D Tubes with high pressure low volume are associated with more ischemic damage. rir
; D Tubes with low pressure high volume are associated with more chances of sore throat, aspiration..
difficult insertion. rir

Also remember: Endotracheal intubation is associated with:***

'.-- Hypertension*
:. - Tacchycardia*
~ , Raised lntraoccular tension
[i ; Raised lntracranial tension
:~

~ . Arryhthmias
1 It decreases anatomical dead space.
il~ 1t increases resistance to respiration. Indicated:
'~~
'.j , ./ To deliver PPV . .,;.;,._
~
-~~ Protection of Respiratory tract from gastric aspiration.rirrir
ri
'A
r.i . ./ Head and neck operations that preclude manual airway support. rir
'

:a
:.i ./ To maintain airwayr
1.i
~ : ./ Tracheobronchial toiletrir

~ ./ Unconscious patients. rir

01'
~ . involves: Extension ofatlanto occipital join( Flexton of lower. cervical spine
~
m
~
e- .....,..,..,...,,~.~~- l
'
., 524 . . .
. 1
\
 Complications of Intubation
Hypertension ....

tlCT ....

jlOT.-

tHeart rate ..
--- . - . ' -.
Arrhythmias.-

Airway trauma ....

Esophageal intubation .. - -

Edema, stenosis ..
- .. . ~- ..

Hoarsness ..
Laryngospasm ..

Laryngeal Mask Airway

~ Laryngeal Mask Airway: High Yield for 2011-2012

LMAJs a supraglottic ~irway

used in place of face mask or tracheal tube during administration of an anaesthetic to facilitate ventilation
and passage of tracheal tube in a patient with difficult airway, and to aid in ventilation during fibreoptic
bronchoscopy as well as placement of bronchoscope.

LMA that has an orifice through which- nasogastric tube. can be inserted and that facilitates positive- pressure
ventilation

L.MA partially protects larynx from pharyngeal secretions (but not gastric regurgitation) and it should remain
in place until patient has regained airway reflexes.

- The reusable LMA.whkh is autoctavabte, is made, of silicone rubber.

It is available in many sizes- 1, 1.5, 2, 2.5, 3, 4, 5; PGI 2009

Contraindications to use of LMA:

./ . Risk of pulmonary aspiration of gastric contents

./ Hiatal hernia with significant gastroesophageal reflux

./ Morbid obesity
---~- ... -
Intestinal obstruction
- - -
Delayed gastric emptying

Poor pulmonary 'compttance

./ Increased airway resistance

./ Glottic or subglottic airway obstruction

./ . Limited mouth opening (<1 :5mm)

525
~ LMA Quick Revision Points

. Also called as Bain mask .,..,.

Used for airway maintainence. AllMS 2003

-. ~ - - _.

Protects larynx from pharyngeal but not gastric secretions .,.

Indicated ,in: difficult airway management during CPR .,. PGI 2001
:~"-when difficult intubation is anticipated ...

Contraindicated in oropharyngeal mass/ abscess., pregnancy, hiatal hernia, full stomach

Ad~antages:
. ./ Easy to insert.
1 ./ Does not require MR/ Laryngoscopes
; ./ Specific Cervical spine positions not required.

~ Anesthesia Gas Delivery Systems

Mapelson A.,. Mapelson s.- Mapelson Cr Mapelson Dr ! Mapelson E.,..
':''."' -~::::.:.. -=.-::- ." ; .. - ..
., ~~ ......

Magillsystem Not commonly Waters system Bain coaxial system . Ayres T tube.
used
For spontaneous For postoperative Assisted controlled MAH 2012
brea~hing recovery ventilation
Flow rate=minute . For infants/young
volume Al 2000 children
Flow rate 2-3x minute
: volume

llll- Boyles apparatus: Continuous flow machine Low resistance circuit PGI 2006.
llll- PIN index system prevents delivery of gases and prevents wrong attachment of cylinders .

.- Gas cylinders are composed of molybdenum steel

llll- End tidal C02 is used as an early and reliable indicator of air embolism in anesthesia. COMED 2008
.- Best.technique to monitor babys breathing and detecti_ngapnea is irnpedence pulmonometry. . Al 2007 .

~ Soda Lime
: 0 94% Ca(OH)i+ 5%NaoH + 1% KoHrr JIPMER2000
D Granules size is 4-8 mesh. r
"'-n- soda lime is contraindi~ated with trilene due to formation of phosgene gas.
~so'da-1ime should. not be used with:
:-.; sevonurane
'
1./ Chloroform*
'
.1./ Trilene
. .. . . . . , :~-. ~- .. . . - .
 Bara Lime

80 % Ca(OHh, 20% Ba(OHh

'~-~--- .. - --- - - - .. --- -- ----
Granules size is 4-8 mesh

C02 absorption is increased by:

1
\ ...
../ Resistance in circuit.
i ../ Small granule size
''II'; Low flow rate.
C02 absorptfon is decreased by:
; ../ High flow rate and tidal volume
../ Dead space
, ../ Channeling
../ Large granule size

Capnography: *** AllMS 09

Is monitoring of partial pressure of C02 in expired gases .
.
C02 absorbs infra red radiation.
Flat capnograph is seen in:
D Equipment failure
:D Disconnection
.: D Total occlusion
;D Accidential extubation
D Bronchospasrn

!) Indications for Mechanical Ventilation

Ventilation failiure
Oxygenation failure
Failure to Ventilate

Neurological Problems
. ,.. Central: Loss ofventilatory drive due to sedation, narcosis, stroke or brain injury .
. ,.. Spinal: Spinal cord injury, cervical-loss of diaphragmatic function, thoracic-loss of intercostals.
,.. Peripheral: Nerve injury (e.g. phrenic nerve in surgery), Guillain-Barre syndrome (demyelinatlon);:
poliomyelitis, and motor neuron disease.
M.uscu1ar Problems
.: ~ Myopathic disorders: Myasthenia gravis, steroid induced myopathy, protein malnutrition .
. ,.A.natomical Problems
! ,.. Chest wall: Rib fractures or 'flail chest, obesity, abdominal hypertension, restrictive dressings .
-: ,.. Pleura: Pleural effusions, pneurnothorax, hemothorax.

~, ,._~ .... ---~--. ..

i - 527..
L. .. '- --~.--- l
 .. --- . ----- --- -- - ------------------------~--------
,.. Airways: Airway obstruction (in lumen, in wall, outside wall), laryngeal edema, inhalation of a foreign:
object, bronchospasm.
-Gas Exchange Problems
. . .

',.. Ventilation perfusion mismatch, particularly increased alveolar deadspace

,.. Acute lung injury (ALI), lung contusion.
'

~ Continuous Positive Airway Pressure (CPAP): High Yield for 2011-2012

-Also called continuous distending pressure (CDP)
Refers to the application
.
of continuous
.
pressure
-
during both inspiration
'
and
'
expiration in a spontaneously
.

breathing baby
By CPAP:
Alveoli are kept open
Increases FRC of the lungs
Better gas exchange
Improve oxygenation C02 wash out and better blood Ph
Splints the upper airways
Stimulate 'J' receptors by stretching the lung/pleura and providing positive feed back to respiratory Center
by Hering-Breuer reflex
1 Improve type II pneumocyte function and recycling of surfactant
:=i:

l Promote growth of premature lung Improve lung compliance

.~
j
-~ Contraindications for CPAP:
D Progressiverespiratory failure with PaC02 > 60 mm Hg/Pa02 < 50 mm Hg
D Congenital malformations of the airway
D Cardiovascularinstability
D Poor respiratory drive PGI 2009:

~ Capnography: High Yield for 2011-2012

Determination of end tidal C02 (EtC02) concentration to confirm adequate ventilation is useful during all
anaesthetic procedures, but particularly for GA.
_It is a valuable monitor of pulmonary, cardiovascular and anaesthetic breathing systems.

../ Increasedmuscle tone (as from muscle relaxant reversal)

../ Convulsions
 Causes of Decreased EtC02
- ./ .Hypothermia _ ..

./ Increased depth of anesthesia

- -~---:use-of m~s~L~ - ~ei~~ants

./ Decreased transport of C02 to lungs (impaired peripheral circulation)

./ - Decreased t~~~~d~t of~CO~ through,the-i~ngs.(pul~cmary embolus, surgical manipulattcns)

./ Increased patient dead space

_ ./ .Hyperventilation _ -
. . . '
.. _.,._ : ..... -~.--. - .. - .:
./ Leakage in sampling line
~--;- ::- atbcka-g~ ~f-s~~p-li~g--line
Causes of Absent EtC02
.t- Dtscorinection _
--~~.:~.- ~~~ ...... __:._:-. ~ -------~
.;. .,.,~---.:.~ ... ' .. : .: ..
./ Apneic patient, stopped ventilator
-:7-;-E59ilha-geat-in-tubatior1 .. -

Membrane Oxygenators
Are devices used incardiopulmonary by pass surgeries
Theiimprove efflciency of gas exchange and decrease_trat.ima to blood elements.
; Lessen RBc damage AllMS
Lessen Platelet trauma
.-,

~ Lessen WBC trauma

; Lessen Protein denaturation.
i.

Gases Used to Create Pneumoperitoneum

Carbon dioxide

Oxygen
"';;~-~oom air
Nitrous oxide

:> Brain Death

a This is a state with cessation of cerebral blood flow;

heart continues to function.

~a--cnt:enafo.r~the~diagnosisofbrain aeath - .. - -- - '"

.---- - --- - _.. ---,--~

529 _
i.
1 .......... - ...
LI They contain three essential elements:

./ w;despread cortical destruction shown by deep coma, unresponsiveness to ail forms' of stimulation;
JIPMER 2003 .

./ Global brainstem damage demonstrated by absent pupillary light reaction and the loss of oculovestibular
and corneal reflexes; and

./ Lower brainstem destruction indicated by complete apnea. The pulse rate is also invariant and
unresponsive to atropine.
. .
Cl The. proof that apnea ts due to irreversible medullary damage requires that the PCOz be high enough to

stimulate respiration during a test of spontaneousbreathing (apnea test) ...

LI The possibility of profound drug-induced or hypothermic depression of the nervous system should be
excluded, and some period of observation, usually 6 to 24 h, is desirable during which this state is shown to
be sustained

LI An isoelectric EEG may be used as a confirmatory test for total cerebral damage but is. not absolutely
necessary.

LI In Nutshell:

.... Absent brain stem reflex JIPMER 2005

..... Absent motor activity JIPMER 2005

..... Coma
. .

' .... Puppilary dilatation. PGI 2007

.... Spinal cord reflexes + or -

. Pain Scales
CJ Visual analogue scale (VAS) measures pain intensityrr

LI Verbal and numerical rating scaler

CJ Faces scaler
CJ . Cheops scaler
-. ~ . --~- .
CJ Mc Gill pain questionnairerr '

Dexmedetomine
Is a new drug which causes sedation without respiratory depression.

It Has:
CJ Sedative properties
LI Analgesic properties
CJ Sympatholytic properties
; CJ Anxiolytic properties
 lntrapleural Analgesia
lntrapleural analgesia provides effective pain relief for many procedures, including upper abdominal and
thoracic procedures.
~------ ...--

- lntrapleural analgesia involves placement of analgesic agents (usually a local anesthetic) in the intrapleural
space, usually through a single shot or catheter.

- ,,.. . . - -. . ... - --- - - -- _,,

The action of intrapleural local" anesthetic agents is believed to occur principally by diffusion through the
parietal pleura to anesthetize the intercostal nerves.

The close proximity of the thoracic- sympathetic chain indicates that the sympathetic nervous system could
be involved after an intrapleural blockade.
-~, .) ...... .. ---

However,
. -
little ~- alteration of.hemodynarriic
. .
parameters has been noted,
.
probably due to the unilateral nature
of these blocks. '

Transdermal Opioids
. 0 Transdermal fentanyl has been approved for use in patients with cancer-induced pain.
---- ----.~-., ..... - ,.: __ - - --- -----.
_,. ,.,,.... '- ._,_.:.

0 Fentanyl meets the criteria for use in a transdermal delivery system in that it is both highly lipid soluble and
potent enough for transdermal use.
--,., ..... ,. --- -- ' ., '

0 . The TIS is self-adhesive with a selectively permeable membrane; which comes in various sizes to vary the
rate of delivery.
0 These patches provide the predicted amount of medication in the range of 25 to 100 mg per hour.
----:-.-.--.
0 Because the skin is not uniform, the rate of transfer varies with the site on.which the patch is placed as well as
the patient's gender, age, skin, blood flow, sweat gland activity, temperature, and pH of the skin.
0 Fever or local heating, such as the use of a heating pad, increases the release of fentanyl, which may
precipitate respiratory depression.
-~--- --- -~ --.-- .. ~------- ----. - -------- - . - . - .. . - -
O Respiratory depression, nausea, and vomiting all are reported side.effects.

:> Intravenous Patient-Controlled Analgesia: High Yield for 2011-2012

,o PCA provides individualized opioid dosing withoutextensive nursing intervention.
--.. -~ . .'-~--- ... __ .. : ~- - - -. ~ .. ' - .. .. . .- -
O PCA allows patients to give themselves pain medication in a highly controlled manner.
"--5---Aiter analg~sia has been established with a loading dose of opioid, patients give themselves small doses of
opioids to maintain their level of analgesia.
. . . . '
'
- - - . ,, .. . -. . '

O Reduced contact with the nursing staff and the patient's fear of inadvertently administering an overdose or
of addiction to the opioid are potential disadvantages of PCA.
0 Advantages of PCA are

""' lrnmedtate delivery of medication, _._.

: .,.. Rapid onset of analgesia, and _.

; ""' Patient control over pain medication. _.

531
0 Lockout Interval. This is the period during which the PCA unit is refractory to further demands bX the
. patient. The lockout interval is a needed safeguard to prevent patients from. taking a further dose before
they appreciate the full effect of the preceding dose.

D Opioid Selection. The _ideal PCA agent would have a rapid onset of action with a medium duration of action.
There should not be a ceiling to the analgesic effect, and the agent should not cause nausea, vomiting, or
respiratory depression or impair bowel motility .

...D Morphine is one of the most commonly use~ analgesics for PCA
- - - - ,

D Meperidine is the other than morphine that has been approved by the Food and Drug Administration for PCA use.

D . Fentanyl has been used extensively to provide postoperative analgesia. It. has a more rapid. onset than less.
lipid-~oluble drugs but has extremely variable interpatient requirements._ It does not release histamine, has
no active metabolites, and has a paucity of other side effects.

D Other opioids that have been used successfully for PCA .incl~de alfentanil, sufentanil, and hydrornorphone.

D Complications. The most-feared complication ..of optoiduse is respiratory depression ...

~ Indications of Hypothermia:***
D Neurosurgery.-.- .

D Cardiac surgery.-.- PGI 1998

0 ~arotid surgery.-.-

D ARDS.-
..
D Traumatic brain injury.,..

D Malignant hyperthermta= PGI 1998

--- . -
D Prolonged surgeries=

D Procedures in which ischemia can occur=

-. - -
D Decreases EEG activity. AllMS 2006

Drugs are associated with Hypothermia are: AP 2007

Alcohol
Amphetamine

Chlorpromazine

~ Neural Destruction: High Yield for 2011-2012

~eurectomy.
: i.
<\
Transection of nerves to relieve pain.
i' Neurectomy is used to treat painful neuromas
A number of procedures have therefore been described to prevent this recurrence,
./ Separating the two nerve ends,
Burying the nerve in muscle,
./ Burying the nerve in bone, or covering the nerve with Silastic

.1
-~

.
""-----~ .. '- -- ---l
 Rhizotomy

',.. Refers to ablation of the sensory root

. ,.. This can be done either as an open procedure, intradurally or extradurally, or as a percutaneous procedure
using radiofrequency coagulation or injection with phenol.
.,.. Patients selected for rhizotomy undergo a preoperative series of selective root blocks. Subsequent pain
relief does not guarantee equally successfulsurgical outcome.
,.. The most common indication is for rhizotomy pain following unsuccessfuldisk procedures.
I
. ,.. Example: Retrogasserian Rhizotorny for Trigeminal Neuralgia

Dorsal Root Entry Zone Lesioning

,.. Lesioning of the dorsal root entry zone (DREZ)

.,.. Lissauer's tract and the dorsal horn gray matter are coagulated down to the Rexed V lamina, including the
second-order neurons in the sensory and pain pathway. Lesions are made in line, close enough together so as
to coalesce and produce a continuous zone of obliteration
,.. The greatest success is achieved for pain secondary to plexus avulsion and spinal cord injury.

Caudalis DREZ Coagulation

,.. Nucleus caudalis DREZ coagulation was introduced as an extension of DREZ lesioning
: ,.. The trigeminal nucleus caudalis contains second-order neurons subserving pain, temperature, and crude
touch from the fifth, seventh, ninth, and tenth cranial nerves.

Cordotomy

,.. The goal is to coagulate the spinothalamic tract in the anterior cord and ventral to the dentate ligament,
which can be visualized myelographically.
. ,.. Cordotomy is most useful in patients with cancer who have unilateral pain in the trunk or lower extremity;
however, it is possible to treat upper extremity pain. Bilateral procedures should be separated by at least
2 weeks.. Immediate pain relief is excellent in 95% of cases.

Myelotomy

,.. It consists of splitting the spinal cord in a midline sagittal plane, usually at and above the level of pain.
Myelotomy is of particular value for bilateral and midline pain, especially pain involving the perineum.
The resulting pain relief is widespreadand often extends beyond the area of analgesia.

Midbrain Tractotomy

,.. Midbrain tractotorny consists of stereotactic ablation of the spinothalamic tract at the level of the
midbrain, just below the superior colliculus. At this level, the tracts from the face and body are close
to each other, with the face represented more medially. Tractotomy has been performed throughout the
brain-stem, including the pons and the medulla.

Thalamotomy

,.. Destructive lesions of the thalamus are probably useful in relieving diffuse pain secondary to cancer or the
intermittent neuralgic pain or allodynia and hyperpathia present in some patients with neural injury pain.
-. .

533
 I Sympathectomy
i ,.. Sympathectomy is a uni~ue form of neuroeblation that is indicated for the treatment of causaigfa,.reflex:
sympathetic dystrophy, or Raynaud's phenomenon;
,_. It is also used to relieve visceral pain, since afferent fibers from the viscera travel in the sympathetic
1! nervous system.
l .

. lI :> Bispectral Index (BIS): High Yield for 2011-2012

i . .,... Is one of several recently developed technologies which purport to monitor depth of anesthesia.
l
1
AIPGME 2012

I l
.,...

.,...
BIS monitors can replace or supplement Guedel's classification system for determining depth of anesthesia.
- ... -- ~. ,

Titrating anesthetic agents to a specific bispectral index during general anesthesia in adults (and children
. - .. ,-- .. --~

over 1 year old) allows the anesthetist to adjust the amount of anesthetic agent to the needs of the
patient, possibly resulting in a more rapid emergence from anesthesia. Use of the BIS monitor may reduce .
the incidence of intraoperative awareness in high risk procedures or patients and may also have a role in
predicting recovery from severe brain injury.
J

l
l

::. i;}j
..

I
~
- ~-~
">~

I
''.':!

-~;:,i

'7.1
" ..:_, .
. .;:;
.;\~

~F1~~--.~-)"';, ...... ....,..::-,,....y-,. ., ,.,..,_ ....... ,

. . 534:; . . ., 1

. ~.~i--:. .~--i ..:_...;. :.::..~- .-J

, .
"
'i