15 ANAESTHASIA

CHAPTER

Airway adjuncts Airway devices

Keeps the airway open by
preventing tongue fall

OP
airway

aka Guedel's airway

NP
airway
Laryngeal mask airway
(aka Supraglottic airway Endo-tracheal tube
devices)
Easier to insert (used in difficult More secure airway (lower
intubations) risk of aspirations)
Blind procedure (no laryngoscopy) Laryngoscope is needed
Increased risk of aspirations

Laryngoscope

OP airway can cause gag reflex in

conscious patients
Hence NP airway used in conscious McIntosh
patients Curved blade
Used in adults
Measurement of size
From mouth to angle of mandible Straight blade for the larger epiglottis
in pediatric patients
Miller's
Straight blade
Used in pediatrics

McCoy
Has a lever

Left hand
Right side of mouth
Sweep tongue from right to left
Pressure forward and upward
Video Laryngoscopy Upper incisors m/c injured
Best for difficult intubations
 Anaesthesia BTR by Dr. Zainab Vora

Endo-tracheal tube

Double lumen ET tube

2 cuffs, 2 ports, 2 tubes
Used for single lung ventilation

Uncuffed Modifications of ET tube

Used in pediatric age group
To avoid sub-glottic stenosis
Position to insert ET tube
To confirm intubation
ETCO² on capnography
Oral surgeries PNS surgeries
pnS - South

Intubation stylet Flexion at C spine

Bougie Flexible and metallic Extension at A-O joint
Used as guidewire to insert ET tube Used to alter the shape of ET tube
Vowels stick

Laryngeal mask airway

First generation LMA Second generation LMA Intubating LMA I-Gel LMA
Only one tube for Two tubes Can be used to intubate Takes up heat from body
ventilation One for ventilation and and expands to seal
one for gastric aspiration

LMA Proseal is the most

commonly used LMA
Oxygen delivery systems

Nasal prongs Hudson's mask Venturi mask

40% 60% 60%

5 L/min 10 L/min 15 L/min

Fixed O²
Bernoulli's principle

Non
High flow nasal C- PAP
rebreathing
cannula (NIV)
mask

85% 100% 100%

15 L/min 60 L/min No limit

Gas cylinders Diameter index safety system

B/w is oxygen
Nitrous oxide - blue For pipelines
Blue and white - N²O with oxygen Intermediate pressure systems
Mixed - Air
All grey - CO² White - Oxygen
Blue - N²O
Pressure - 2000 Psi for all (750 for N²O) Black - Air
Yellow - Vaccum

Pin index safety system

Yellow vaccum
cleaner
Air - (1,5)
O² - Two atoms (2,5)
N²O - Three atoms (3,5)

CO² - (1,6)
Entonox -1
 BTR by Dr. Zainab Vora Anaesthesia

Needle Gauge

14 Orangutan - Largest
16
17 Wait for 1 year
18 Green signal at 18
20
22
24 Yellow - sevoflurane - kids
26

Measured in gauge
Gauge is inversely related to diameter
Minimum 18 gauge needle to be used
in ATLS - 96ml/min

Foley's and NG tube

NG tube insertion
Measure size - NEX in adults and NEMU in kids

GORY
from PB

Fowler's position (aka beach chair position)

Measured in French (Fr)

French is directly proportional to
diameter
External diameter is considered here
Females - 14 Fr
Males - 16 Fr Fowler's position is also used in various
French are extrovert neurosurgeries
Female- 14 Risk of air embolism
37
 Anaesthesia BTR by Dr. Zainab Vora

Central Line

3 ports

Central venous catheter Chemo port

For chemotherapy

>3 ports

Swan Ganz catheter

PCWP measurement Internal Jugular vein - Safest
Core temperature can be measured Subclavian vein - Risk of pneumothorax
Temp at lower end of Femoral vein - Line related sepsis, thrombosis
esophagus is m/c used for
core body temperature

Monitoring of Anesthesia

Electromyography

Bispectral Index Ulnar Nerve (adductor policis tested)

Intra-op depth of anaesthesia measurement Facial nerve (orbicularis oculi)
BIS of 40-60 is ideal Train of Four (0.5 sec apart)
> 0.9
Central Neuraxial Anesthesia

Skin and subcutaneous tissue

Stripes
Wings
Supraspinous ligament
Interspinous ligament
Tuhoy Needle

Ligamentum flavum
Epidural space is a negative pressure space
Epidural Anesthesia (loss of resistance is felt)
Dura mater Continuous anesthesia can be given
Arachnoid membrane
Post neuraxial shivering
Spinal Anesthasia
More with epidural than spinal anesthasia
The most efficient way to prevent is by
avoiding cold epidural and intravenous fluids.
IV Meperidine is the DOC for it.
Tramadol is also useful in post anesthasia
No wings shivering.
Special tip

Spinal cord extent

Post-dural-puncture Headache At birth : L3 (upper border) like collagen in
Onset 12-72hrs and last for 1-2 weeks. Adults : L1 (Lower border) would healing
Aggravated by sitting and relieved by lying down.
Risk factors : Young, pregnant, female, large needle
Level at which LP done
Prevention by smaller needle
Mx : Caffeine and analgesics Lumbar Puncture done at L3-L4 in adults
Refractory : Epidural blood patch Posterior superior Iliac crest is the landmark
Early ambulation doesn't increase risk of PDPH In children at level L4-L5

Regional Anesthesia

Anterior ethmoidal Naso - ciliary nerve

Infra-Orbital nerve block
nerve block block
 Anaesthesia BTR by Dr. Zainab Vora

Inhalational Anaesthetics

"Hollow"thane
Sevo PIL hepatitis Desi - Pungent, Potent

Sevoflurane Isoflurane Halothane Desflurane

Sweet smelling Liver transplant AI Hepatitis Specialised surgeries
Induction in children Coronary steal Only used in Special TEC-6 vaporiser
Cardiac surgery phenomenon asthmatics Pungent smell (can't be
Toxic compound-A (bronchodilator) used to induce)
(nephrotoxic)

MAC - Minimum alveolar concentration

It's ED⁵⁰ for anaesthetics
Min dose at which there is immobilisation
Inversely related to potency of the inhalational agent HIDden potential
Desflurane > Isoflurane > Halothane Halothane > Isoflurane > Desflurane

Blood/gas coefficient
Indicates time needed for induction
More BG - More time needed (more in blood)
Less BG - Less time needed (more in alveoli)
Xenon has the lowest BG coefficient (quickest induction and recovery)
Halothane > Isoflurane > Desflurane

Nitrous Oxide
Minimum potency But used due to its second gas and concentration effect
Second gas effect : Better uptake of secondary gases because of N²O
Concentration effect : Gets absorbed in blood quicker and hence more partial pressure O² in alveoli
Fills empty cavities : Because it vaporises so easily, it can get accumulated in body cavities, hence
avoided in closed space surgeries (ear surgeries, pneumothorax)
Diffusion hypoxia : During recovery, rapid elimination causes a reduction in the partial pressure of
oxygen leading to hypoxia (Pre-oxygenation with 100% O² needed)
Maximium incidence of PONV with Nitrous oxide
 BTR by Dr. Zainab Vora Anaesthesia

IV Anaesthetics

Propofol
DOC for TIVA (Total IV Anesthesia) Cardiac surgery
DOC for - daycare/specialised sx Inhalational : Sevoflurane
DOC in porphyria patients IV agent : Etomidate
Contains egg (C/I in egg allergy) NDMR : Vecuronium
Painful injection
Anti-emetic properties
Asthma
Inhalational : Halothane
Ketamine IV agent : Ketamine

NMDA antagonist at Phencyclidine site

Dissociative anesthesia Neurosurgery
No pain after recovery Inhalational : Desflurane
DOC in shock - ↑ ICP, ↑IOP IV agent : Thiopentone
DOC in asthma
Has addictive potential (Schedule X)
Increased salivation Day care anaesthasia
C/I in hypertensive/ glaucoma/ epileptics
IV agent : Propofol
Inhalational : Sevoflurane
Etomidate NDMR : Rocuronium

DOC in cardiac surgeries

S/e : Adrenal supression
Heart for my "date"

Thiopentone
DOC in seizures (neuroprotective)
DOC in hyperthyroidism

Local Anesthetics

Na channel blockers (inactivated state)

Lignocaine aka lidocaine is an intermediate acting LA (DOC in Bier's block)
Cardiotoxic - Bupivacaine (not used for Bier's block)
LA toxicity : CNS + CVS effects (DOC : 20% Intra-lipid)
41
 BTR by Dr. Zainab Vora Anaesthesia

Muscle Relaxants

Non Depolarising muscle relaxants Depolarising muscle relaxant

Curare drugs Succinylcholine (aka Suxamethonium)
Competitive antagonist of It has a rapid-onset (30–60secs) and short
acetylcholine duration of action
Reversal is via Neostigmine Rapid hydrolysis by plasma cholinesterase
(aka pseudocholinesterase)
Vecuronium - Most cardio stable
Rocuronium - Day care anesthasia
Atracurium and Cis-atracurium
} Reversal by
Sugammadex
Because of fast onset and recovery, it's the
muscle relaxant of choice in Rapid sequence
intubation (RSI)
safe in renal and liver failure
Increases gastric pressure and can cause
Pancuronium - Longest acting
hyperkalemia (hence Rocuronium is used in
Can cause post op paralytic ileus and urine retention RSI now)
Causes post op Muscle pain
Post op rigidity due to - Fentanyl (opioid)
Neostigmine
Used for reversal of NDMR
Acetylcholine esterase inhibitor (indirectly acting
cholinergic)
Decreased breakdown of acetylcholine at the motor
endplate - more Ach

Hoffman elimination
Atracurium and Cis-atracurium
Spontaneous non-enzymatic degradation
Safe in Liver and Renal failure
By product - Laudanosine (Seizures)

Malignant Hyperthermia

Genetic predisposition Presentation

Mutation of ryanodine receptor (Ryr 1 gene), Rigidity and muscle spasm (masseter spasm)
located on chr 19. High fever and sweating
Ryr 1 is responsible for calcium release from the Increased metabolism : EtCO² increases (step
sarcoplasmic reticulum. ladder pattern on capnography)
Mutated Ryr-1 releases too much calcium on Muscle damage : ↑ K+ (hyperkalemia)
certain triggers causing spastic contractions
Management
Trigger
Dantrolene Sodium + 100 % O²
Inhalational anesthetics 41
Discontinue causative agent
Succinylcholine (DMR) Electrolyte correction
 Anaesthesia BTR by Dr. Zainab Vora

Capnography

Surest sign of endotracheal intubation

Step-ladder pattern - Malignant hyperthermia
Shark fin pattern (bronchospasm)
COPD, asthma
Sudden loss of waveform
ETT disconnected, dislodged, kinked or
obstructed.

Hypoventilation

CPR assessment
Attempt to maintain minimum of 10 mmHg Hyperventilation

Mapleson Circuits

Adults - Mapleson A, D Pediatrics - Mapleson E, F

A - APL adjacent (spontaneous) E - Ayre's T tube
D - APL distant (controlled) F - Jackson Reece
Spontaneous ventilation in children

Soda Lime
Active ingredient that absorbs CO² is CaOH² (80%)
If NaOH - Soda lime, If BaOH² - BARALYME
Small amount of KOH present.
End product - CaCO³ + NaOH (soidum hydroxide is
regenerated)

Bane's circuit (co-axial) Sevoflurane reacts with soda Lime to

Tube within tube
Modification of type D produce Toxic compound -A
 Anaesthesia BTR by Dr. Zainab Vora

One liners
Pre-op drug DOC to reduce anxiety : Midazolam
Pre-op drug DOC to reduce secretions : Glycopyrrolate
Pre-op Antibiotic time : 3omins - 1hr before incision (Cefazolin)
MC nerve injured intra-op : Ulnar nerve
MC intra-ophthalmic complication : Corneal abrasion
Post op Vision loss mcc : Ischemic optic neuropathy
Max PONV with : Nitrous Oxide
PONV DOC : Ondansetron (5HT³ inhibitor)
MCC of intra-op anaphylaxis: Antibiotics

Mallampatti Grading
Difficult intubation

PUSH
2 3 4
1 Pillars of tonsils
Uvula
Soft palate
Hard palate

Entire uvula - 1 floor -4

ASA Grading
1 - Healthy
2 - Mild disease (under control)
3 - Disease not under control Well controlled diabetes - ASA 2
4 - Constant risk of death Diabetes with HbA1c of 9 - ASA 3
5 - Won't survive without the procedure
6 - Brain dead (organ donation)

Pre-op drugs discontinuation

Clopidogrel : 7 days
Warfarin : 5 days Aspirin can be continued in
Aspirin : 3 days
1. Percutaneous coronary intervention (PCI)
LMWH : 1 day 7 -5-3-1
2. Coronary artery disease (CAD)
UFH : 4 hrs
3. Stroke in the past 9 months

Lithium : 2 days (12-24 hrs half life)

Anti-depressants : 3 weeks TCA - 3 weeks

ACE I / ARB / OHA / Insulin : Skip morning dose

 BTR by Dr. Zainab Vora Anaesthesia

Basic life support

1st step
Verify scene safety Recovery position
Check for responsiveness When normal pulse
Call the emergency services and breathing
present

2nd step
Check for breathing
Check the pulse (Carotid pulse for 10 secs) Rescue breathing
When pulse present but no breathing
3rd step (If no breathing + no pulse) 10 breath/min
Keep checking pulse every 2 mins
Start CPR
30 :2 (Compression : Breath)
100-120 compressions/min
5-6 cm depth (1/3 of AP diameter)
Allow complete recoil

If AED arrives
Put AED and follow automated
instructions
Continue CPR till ROSC or untill ALS
providers arrive

ACLS

1st step Shockable rhythm Non Shockable

Shock Epinephrine ASAP
Start CPR
Continue CPR for 2 mins Continue CPR for 2 mins
Oxygen
Epinephrine every 3-5 mins Epinephrine every 3-5 mins
Attach defibrillator
Shock Continue CPR for 2 mins
Continue CPR for 2 mins Repeat
2nd step Repeat
Amiodarone/Lidocaine can Pulseless
Check if rhythm is
be used electrical
shockable or not
activity

V fib
Asystole

V tach No role of Amiodarone

or Lidocaine here
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