OBSTETRICS

Physiological changes
1) CVS: aortocaval Lt uterine displacement
2) Resp: FRC
3) GIT: aspiration
4) Blood: hypercoagulable state, physiological anemia
5) Regional: doses (d.t epidural pr: engorged epidural vs)

GA for C-S
1) LT uterine displacement
2) Preoxygenate 100% O2
3) Rapid sequence crash induction + cricoid pr
4) Fully awake extubation

Anesthesia for Preclampsia

1) Mg
2) Regional anesthesia
3) GA: modified rapid sequence induction + fent + lidocaine
4) Avoid: ketamine, pancuronium, ergotamine
5) Fetus: IUGR, Naloxone 10/kg for resp (-)

Obstetric for non-obs surgery

1) Physiological changes
2) Teratogenicity
3) Tocolytics
4) Fetal assessment
5) Monitoring (mother + fetus)
6) Avoid: ketamine ( ut hypertonicity) neostigmine (ut contractions)
7) Aortocaval
8) Aspiration prophylaxis

Anesthesia for assisted reproductive techniques (ARTs)

1) Lithotomy
2) Ovarian hyperstimulation $
3) Avoid: metoclopramide, domperidone, (D2 blockers prolactin)
4) Avoid: NSAIDS
5) Regional
 6) GA for laparoscopic ovum pick up (TIVA or volatile)
7) Day case

RESPIRATION
Anesthesia for pt ARDS
1) Fluid restriction &diuretics
2) NO rebound pulm HTN
3) Prone rebound hypoxemia when turned supine
4) Steroid cover
5) Xigris: stopped 2 hr preop & restart 12 hr after surgery
6) Ventilatior special mode, high flow, high pr
7) TIVA

CVS
Mgt for pt Ht Block
1) Avoid drugs w AVN conduction: BB, CCB, Digoxin
2) Use drugs w AVN conduction: atropine, isoprenaline, pancuronium
3) Preop: temporary/permanent pacemaker
4) Standby pacemaker
5) Pt is volume/preload dependent so AVOID: hypoTN, hypovolemia, bl
loss, vasodilators.

Mgt of pt pacemaker (PM)

1) Preop:
1. Pacemaker (type, battery site, functn, pacemaker failure $)
2. S.K+
3. digoxin
4. anticoagulant (&regional anesthesia)
5. PM: switch to asynchronous mode
6. AICD: switch off (monitor only mode)
2) Anesthesia: AVOID:
1. Etomidate
2. Sux
3. N2O
4. Hyperventilation
3) Precautions e cautery (EMI= electromagnetic interference)
4) Postop: AVOID: shivering, switch PM to synchronous, switch AICD
back on.
 NEUROSURGERY
SAH (subarchnoid hge)
1) CP: hdache, LOC, focal neurological deficit.
2) ECG: ischemic changes, arrhythmias, pulm edema.
3) hypoTN anesthesia
4) total hypothermic circulatory arrest
5) ruptured aneurysm
6) complications:
a. delayed recovery
b. cerebral vasospasm ttt
c. cerebral salt wasting $
d. hydrocephalus

Cerebral Vasospasm
1) HHH (HTN, Hypervolemia, hemodilution)
2) Nimodipine / nicardipine
ORTHOPEDICS
1) Cement implantation $
2) Pulmonary fat embolism (pelvic surgery &long bones)
3) DVT pulm embolism
4) Tourniquet
5) Malignant hyperthermia

VASCULAR
Carotid Endarterectomy
1) Pt = IHD + stroke
2) Monitoring: all CVS + all CNS monitors (esp awake, distal stump pr)
3) Br protection:
1. ABP
2. Hypothermia
3. PaO2
4. PaCO2
5. Hct = 30
6. Bl sugar (normoglycemia)
7. Drugs: anticonvulsant, CCB (nimodipine)
8. Thiopentone
9. Volatiles: iso
4) shunt
 5) b4 anastomosis: ABP
6) after anstomosis: ABP
7) postop compications:
1. hyper-reperfusion $
2. delayed recovery
3. stroke
4. damage of carotid body: resting PaCO2
5. HTN: dt. Damage of carotid baroreceptors
6. Surgical:
Pneumothorax
Recc laryngeal N palsy
Phrenic N injury
Airway edema

Aortic Surgery
A. Ascending aorta: Cardio pulm bypass (CPB)
B. Aortic arch: deep/ total hypothermic circulatory arrest
C. Thoracic/abdominal: aortic cross clamp, endovascular aortic surgery

Thoracic/abdominal aortic surgery:

1) Monitoring: SSEP, renal (UOP)
2) One lung ventilation
3) Aortic cross clamp
4) Bypasses &shunt
5) Spinal cord protection
6) Renal protection
7) Declamping
8) Postop complications:
A. Paraplegia
B. Renal failure
9) Bloody surgery
Lengthy surgery
Myocardial protection (dt. Severe HTN above clamp)
Br protection

CARDIAC SURGERY
CPB
A. PREBYPASS:
1) Hemodynamics
 2) Bleeding prophylaxis
3) Anti-coagulation
B. BYPASS:
1) Myocardial protection: cardioplegia, hypothermia
2) Renal protection
3) Cerebral protection
4) Flow & MAP
5) Monitoring
6) Anesthesia during CPB
C. WEANING:
1) Rewarming
2) De-airing
3) Declamping
4) Weaning & difficult weaning
D. POSTBYPASS:
1) Reversal of anti-coagulation (heparin reversal)
2) Control of bleeding

Pediatric CPB
1) Circuit priming: blood
2) Pump flow: 150-200 ml/min ()
3) 1ry pump failure: incidence (uncommon)
4) Hemostatic defects: incidence (common)

Causes of 1ry pump failure/ difficult weaning off bypass

(A) Surgical/ Technical
1) Graft kink/spasm/occlusion
2) Prolonged bypass cross clamp time
3) Excessive cardioplegia
4) Air embolism
5) Vavlular dysfunction
6) Cardiac tamponade (post op)
(B) Myocardial
1) Stunning
2) Ischemia
3) Reperfusion injury
(C) Metabolic
1) Acidosis
2) Ca
3) K, K
 4) Residual anesthetic effect (volatile, thiopental)
(D) Medical
1) SVR
2) PVR
3) Arrhythmias (eg. Ht block)

THORACIC SURGERY
Thoracotomy (pneumonectomy)
1) Predicted post op FEV1
2) Lateral/ prone
3) One lung ventilation
4) Thoracic epidural
5) Post op complications:
Resp: pulm edema, ARDS, brochopleural fistula, pl effusion,
bronchial stump disruption, bronchial torsion
CVS: arrythmias, herniation of the heart, shock
CNS: paraplegia, recurrent laryngeal N, phrenic N
6) Bloody & lengthy surgery

Esophageal surgery
1) One lung ventilation
2) Thoracic epidural (advantages)
Pulm: respiratory complications
CVS: coronary VD, preload, afterload
post op ileus
Early ambulation
hypercoagulable state: DVT pulm embolism
ICU stay
3) Bloody
4) Lengthy
5) Complications

N-M DISEASE
Myasthenia
1) Preop Leventhal score (predictor of post op mechanical ventilatn)
2) Preop steroid cover, plasmapharesis
3) Preop pyridostigmine ( dose or miss last dose)
4) Regional preferred: AVOID high blocks
 5) AVOID: ms relaxant (resistant to sux, sensitive to NDMR) if
needed use minimal dose, guided by N(+)
6) Criteria of extubation
7) Post op MV

Ms dystrophies (eg. Duchene, Becker)

1) Malignant hyperthermia (associated)
2) Cardiomyopathy
3) Kyphoscoliosis (restrictive lung disease, pulm HTN)
4) Regional preferred
5) AVOID: sux (hyperKalemia VF, malignant hyperthermia) & NDMR

Myotonia
1) Malignant hyperthermia (associated)
2) Difficult intubation (trismus)
3) Difficult mechanical ventilation
4) CVS: Cardiomyopathy, cor pulmonale, arrythmias
5) AVOID: sux, NDMR, neostigmine (ms spasm), postop shivering

OBESITY (BARIATRICS)
Pathophysiological changes (metabolic $)
1) Respiration:
a. Restrictive lung disease
b. V/Q mismatching
c. OSA
d. Difficult intubation/ mask ventilation
2) CVS: HTN, IHD, pulm HTN corplumonale (RVF)
3) GIT: delayed gastric emptying, regurgitation, aspiration
4) Blood: incidence DVT
5) Metabolic: hyperglicemia (DM), hyperlipidemia

Anesthesia for obese pts

1) Regional +/- light GA
2) Difficult intubation
3) Drug dosing:
Lipid soluble: total BW (d.t large volume of sistibution)
Hydrophilic: lean/ ideal BW (d.t small volume of sistibution)
4) mechanical ventilation: 7-10 ml/kg of Ideal BW
5) post op:
 analgesia: regional
complics: pulmonary, DVT pulm embolism
OSA: CPAP

OSA
As obesity +
1) CPAP preop & postop
2) Difficult extubation precautions.

BLOOD
Sickle cell anemia
1) AVOID:
1. HypoTN
2. Hypothermia
3. Hypoxia
4. acidosis
5. dehydration
6. stasis
2) Crises (4) & ttt
3) Preop exchange transfusion HbS<30% HbA>60%
4) Difficult intubation
5) Repeated bl transfusion (HBV, HCV, HIV)

Hemophilia
1) Preop: F8=100%, F9>30%
by FFP, Cryo, F8 concentrate, desmopressin DDAVP
Bethesda unit of inhibition: if highly +ve ttt:
Massive F8
Porcine F8
F9
F7 (novoseven)
Plasmapharesis
2) AVOID regional anethsia CI#
3) HBV, HCV, HIV (repeated bl & plasma transfusion)
4) Measures to bl loss intraop
5) CI# nasal intubation, gentle oral suction under vision
6) Postop: maintain F8>50% 2 wks postop

PEDIATRICS
Physiology
1) CVS: HR-dependent (bradyshock)
2) CNS: MAC
3) Resp: airway: large prominent occiput, epiglottis, narrowest
subglottic
4) Liver: immature HYPOGLYCEMIA, immature drug metabolism,
incidence of halothane hepatitis
5) Kidney: immature must give Na (obligate Na losers) but Na load
6) Blood: physiological anemia (HbF HbA), bl.vol=85 ml/kg
7) Metabolic: HYPOGLYCEMIA (<40mg/dl), rapid fluid turnover
(TBW= 70% of body weight) rapid dehydration
8) HYPOTHERMIA ( body fat, surface area)

GA Mgt
1) Fasting hours
2) Preop: sedation outside OR
3) Monitoring: most imp: precordial stethoscope
4) Induction: inhalation, IV, steal, awake intubation
5) Airway mgt: Intubation (ETT size, length, cuff), LMA
6) Maintenance
7) Fluids & Bl (transfusion point: loss>10% of blood volume)
8) Post op:
Croup
Laryngeal spasm
ANALGESIA (postop pain mgt)

Prematurity
1) CVS: persistent fetal circulation (PDA, PFO e Rt to Lt shunt)
2) CNS: kernicerus, ICHge
3) Resp: RDS, apneic spells
4) Metabolic: hypoglycaemia, hypothermia#
5) ROP: retinopathy of premature

Congenital diaphragmatic hernia

1) C/P:
A. Resp: hypoxia, hypercapnia, resp&metabolic acidosis
B. CVS: pulm HTN, persistent fetal circulation (PDA, PFO, RVF)
2) awake intubation (AVOID +ve pr ventilation gastric inflation,
more hypoxia)
 3) ventilation: RR, TV (permissive hypercapnia) Avoid pneumothx
on healthy side
4) post op:
ECMO
Tolazoline
Pulm VD: NO, PGI2
CHPS
1) C/P:
Dehydration & shock
Metabolic: early alkalosis, late acidosis (severe dehydration)
paradoxical aciduria
Electrolytes: Na, K, Cl
2) Evacuate stomach by NG tube
3) Rapid sequence crash induction sux & cricoid pr /awake intubation

TOF
1) C/P:
Aspiration pneumonia
Dehydration, acid-base, electrolyte disturbance
2) advance ETT beyond fistula (guided by auscultation, gastostomy)
3) spont ventilation b4 closure of fistula (avoid +ve pr ventilation b4
closure)

Cleft lip & palate

1) URTI
2) Difficult intubation &mask ventilation
3) Gauze in cleft
4) ETT: armoured/ RAE oral
5) Dinghman
6) Epinephrine injection
7) ORAL PACK
8) Eye protection

Cerebral Palsy
1) Chest infection
2) Ms relaxant: dantolene, baclofen pump
3) Difficult intubation (rigidity)
4) Anti-epileptics

Fetal surgery (open)

 1) GA: volatile 2 MAC
2) Fetal anesthesia: 2 MAC & fent:10-20 g/kg umbilical vessels
3) Fetal monitoring: pulse oximeter, bl gases from umb A
4) AVOID: fetal hypothermia, hypovolemia (O-ve blood)
5) Postop:
Epidural analgesia
Tocolytics: Mg, indomethcin, B2 agonist, CCB

Fetoscopic surgery
A. Anterior placanta: epidural (except polyhyramnios=GA) fetal
anesthesia: fent/ pancuronium (in umbilical vessels)
B. Posterior placenta: GA (as above) d.t difficult access of umbilical
vessels

GERIATRIC
Physiological changes
1) CVS: slow circulation time
2) CNS: dementia, br atrophy, MAC
3) Resp: FRC, compliance, difficult mask ventilation (loss of
buccal pad of fat), difficult mask ventilation (edentulous)
4) Liver & kidney: metabolism & drug clearance

LAPAROSCOPY
A. Trendlenberg: CVS, Resp, CNS (neuro), others
B. Pneumoperitoneum
C. CO2 insufflation: CVS, Resp, CNS effects

AMBULATORY
A. Surgery: duration, not lengthy, not bloody, not major
B. Pt: contraindications #
C. Anesthesia:
1) Regional
2) Drugs
3) Airway mgt
Post op complications: pain (mgt), PONV (mgt), bleeding
Discharge criteria: for GA & regional. Scores: 1-modified Aldrete, 2-
post-anesthesia discharge score.
 TRAUMA
Golden hour
Permissive hypotension: CI# 1- head trauma 2- pregnancy
PRIMARY SURVEY: A B C D (disability) E (exposure from hd
to toe)
SECONDARY SURVEY: (workup)
hd trauma & cx spine
chest trauma
abdominal trauma
othropedics
airway trauma
+ history of medical illness &last meal

Airway Trauma
Types of airway trauma: maxilla, mandible, fr base, larynx,
trachea, bronchi
C/P: of airway obstruction (= resp distress)
Assessment of airway
Intubation
Extubation. Precautions for difficult extubation

MUSCULO-SKELETAL DISEASE
Scleroderma
1) Difficult cannulation
2) Difficult intubation
3) Steroid cover
4) CVS: HTN, pulm HTN, pericarditis, CHF, arrhythmias
5) Pulm: IPF, pulm HTN
6) Renal: RF

Kyphoscoliosis
1) Malignant hyperthermia
2) Difficult intubation
3) Restrictive pulm disease (PFTs)
4) pulm HTN
5) one lung ventilation
6) SSEP, MEP, intraop wake up test
7) Bloody & lengthy surgery
 NEURO-PSYCHIATRIC DISEASE
Stroke
1) Anti-plt
2) Sux hyperkalaemia

Epilepsy
1) Anti-epileptic side effects
2) Carbamazepine, phenytoin = Enz(+), valproate = enz(-) serum
level
3) AVOID: ketamine, pethidine, atracurium, enflurane
4) It fit occurs: ttt

Parkinsonism ( Dopamine, A.Ch)

1) AVOID: metoclopramide (D2 blocker crosses BBB)
2) Can give: Anticholinergic, neostigmine (cannot cross BBB)
3) Adverse effects of L-dopa: CNS, CVS: tachy, arrhythmias, GIT:
N&V
4) Difficult intubation (rigidity)
5) Difficult ventilation
6) Difficult regional anesthesia
7) Autonomic dysfunction: HTN
8) Sux may hyperkalaemia

MISCELLANEOUS
Porphyrias
1) AVOID: drugs precipitate attack (see table)
2) AVOID: dehydration attack (preop fasting for too long: give IV
fluids)
3) Bl loss liberal transfusion stragtegy (Hct > 30%) since anemia
attack
4) REGIONAL : recommended
5) C/P of acute attack, diagnosis & ttt

Anesthesia for pt HIV

1) Complete aseptic conditions
2) Guard against HIV transmission to OR personelle
3) C/P: CVS, CNS, Renal, Blood
4) Mediastinal L-adenopathy (mediastinal $, SVC $)
 5) Adverse effects of: antivirals, antifungals, antibiotics

Anesthesia for pt C
1) Gen condition: anemia, cachexia, debilitation, malnutrition,
immunocompromised, infection
2) Secondaries:
a. Brain: ICT
b. Bone:
pathological fractures, positioning problems, transport
vertebral metastasis: CI # regional
cx spine: difficult intubation
hypercalcemia
c. lung
d. liver
3) Radiotherapy: fibrosis, airway burn, vomiting
4) Chemotherapy: immunosupression, vomiting (acid-base & electrolyte
disturbance), BM (-), anemia, thrombocytopenia, tumor lysis $,
special complications: cardiotoxic (daunorubicin, doxorubicin), IPF
(belomycin, buslphan), nephrotoxic (methotrexate, cisplatin),
hepatotoxic, neurotoxic.
5) Ectopic hormone production

Precautions for Bloody surgery

A. To Blood loss:
1) Hypotensive anetshesia
2) Tourniquet
3) Local infiltration of adrenaline
4) Elevation 10-15o
B. To give blood rapidly
1) Preop autologous blood donation
2) Normovolemic hemodilution
3) Cell saver devices
4) Wide bore cannulae
5) Type-specific cross matched blood
6) Rapid infusion devices
7) Blood warmers
8) Antifibrinolytic agents: aprotinin, Epsilon Amino Caproic Acid,
tranexamic acid
9) Blood substitutes
10) Normothermia
Precautions for Lengthy surgery
1) To hypothermia:
I. Warm IV fluids
II. ambient room temp
III. Warm blanket/ mattress
IV. Warm humidified inspired gases
V. Low flow anesthesia
VI. Cotton wrapping of the limbs
VII. Blood warmers
VIII. Warm irrigating fluids
IX. Monitoring by temp probe
2) DVT prophylaxis
3) Pressure sore prophylaxis
4) Avoid N2O: peripheral neuropathy, agranulocytosis
5) Use Isoflurane (more rapid recovery)
6) High volume low pr ETT cuff ( frequent monitoring of intracuff pr)
7) IV fluids: physiological salt solution

TRANSPLANTATION
Anesthesia for pt transplanted organ
1) Complete aseptic conditions
2) Steroid cover
3) Adverse effects of immunosuppressive
4) Organ protection
5) Dennervated: Ht, Lung

Anesthesia for pt transplanted lung

1) Preop bronchiolitis obliterans (most common complication)
2) Loss of lymphatics extravascular lung water fluid
restriction
3) Monitor: biphasic capnography
4) REGIONAL: recommended
5) Cuff of ETT: avoid suture line
6) Ht + Lung transplant: fluid mgt = challenging
7) + others: (steroid cover, immuno suppressives, complete aseptic
conditions)

Anesthesia for pt transplanted heart

1) Denervated Ht= preload (volume)-dependant, brady/tachy, +/-
pacemaker, responds to direct agents: isoprenaline, epinephrine,
 glucagon. Not responsive to: vagolytics & anticholinergics:
(atropine, pancuronium) or opioids &neostigmine. AVOID: VD &
hypovolemia.
2) Monitor = ECG shows 2 P waves (native & donor SAN)
3) + others: (steroid cover, immuno suppressives, complete aseptic
conditions)

ANY ORGAN TRANSPLANTATION

Indications: end stage organ failure & (its causes)
CIs #: age >65, other end organ failure, malignancy (metastasis), psychiatric
probs (pt non-compliance), HIV +, active infection, + sth special for each
organ:
Liver: alcoholic
Renal: Glomerulonephritis, oxaluria, reversible RF
Ht: pulm HTN (combined Ht & lung)
Pancreas: morbid obesity
Donor Criteria: ABO compatible, HLA (not for liver), healthy organ
Recipient C/P
Organ: preservative solution (UW solution), cold &warm ischemic time
Anesthetic Mgt:
A. Preop:
C/P: organ failure
Preparation (pt optimisation)
IMMUNOSUPRESSIVES: methyle prednisolone + .
ABs: 1-cephazolin/ imepenem 2-antifungal: fluconazole 3-
antiviral:acyclovir, gancyclovir 4-pneumocystis carnii: sulfamethoxazole
trimethoprim (SMZ-TMP)
Complete aseptic conditions
B. Intraop:
Graft: source: cadaver/ living related, preservative solution, warm&cold
ischemia time, orthotopic/paratopic
Monitoring
Surgical technique: (organ & vessel anastomosis)
IMMUNOSUPRESSIVES: b4 declamping: methyl prednisolone +
Graft reperfusion: DECLAMPING problems
Monitoring of new graft func, hyperacute rejection, early graft
dysfunction & ttt
C. Postop: ICU
Pain Mgt
Monitoring
IMMUNOSUPPRESIVES
Complications:
a) ORGAN: failure (1ry organ failure), acute rejection
 b) Lumen: leakage, stricture
c) BVs: hge, hematoma, thrombosis (arterial, venous) prophylaxis & ttt
d) Infections & complications of immunosupressives: opportunistic
infections
e) Surgical complications
f) Others:
Qs related to transplants:
1) Anesthetic mgt of organ transplantation
2) Anesth mgt of pt transplanted organ
3) Postop mgt of pt transplanted organ

IMMUNOSUPPRESSIVES
A. STEROIDS
B. CALCINEURIN INHIBITORS:
1. Cyclosporine (Neural): adv effects:
HTN
Nephrotoxic
Neurotoxic: fits, coma
hepatotoxic
2. Tacrolimus (FK 506): (the same) + hyperglycemia. Used in cyclosporine-
resistant acute rejection
C. PURINE SYNTHESIS INHIBITORS
1. Azathioprine: adv effects:
Anemia
Thrombocytopenia
Leukopenia
hepatotoxicity
2. MMF (mecophenolate mophetil): the same
D. ANTI T-CELL ANTIBODIES:
1. Monoclonal (OKT 3): used in steroid resistant acute rejection. Adv
effects:
Bronchospasm
Pulm HTN
Resp failure
$ of cytokine release: fever, chills, flushing, chest pain
Prophylaxis & ttt: anti-H diphenhydramine, hydrocortisone, methyl
prednisolone
2. Polyclonal (Thymoglobulin)
+ All cause opportunistic infections
Thank you