Anesthesiology PDF

ANESTHESIOLOGY
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ANESTHESIOLOGY INSTRUMENTS 1
ANESTHESIOLOGY
CONTENTS
ANESTHESIOLOGY INSTRUMENTS................................................................................................................................. 4
GENERAL FEATURES OF ANESTHETIC INSTRUMENTS ............................................................................................... 4
ANESTHETIC CYLINDERS ............................................................................................................................................ 4
PIN INDEX .................................................................................................................................................................. 4
ANESTHETIC GASES ................................................................................................................................................... 4
ANESTHETIC MACHINES AND CIRCUITS .................................................................................................................... 5
MAPLESON SYSTEM .................................................................................................................................................. 5
OXYGEN CONTROL DEVICES ...................................................................................................................................... 5
DEVICES FOR CO2 ABSORPTION ............................................................................................................................... 6
DEAD SPACE .............................................................................................................................................................. 6
ENDOTRACHEAL TUBE .............................................................................................................................................. 7
LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION ............................................................................................... 7
NASOTRACHEAL INTUBATION ................................................................................................................................... 9
LARYNGEAL MASK AIRWAY ....................................................................................................................................... 9
TRENDELENBERG POSITION ...................................................................................................................................... 9
GENERAL FEATURES OF MONITORING DURING ANESTHESIA .................................................................................. 9
CENTRAL VENOUS PRESSURE MONITORING .......................................................................................................... 10
PULMONARY ARTERY CATHETER ............................................................................................................................ 10
CAPNOGRAM .......................................................................................................................................................... 11
ANESTHETIC COMPLICATIONS .................................................................................................................................... 11
AIR EMBOLISM ........................................................................................................................................................ 11
RESPIRATORY COMPLICATIONS .............................................................................................................................. 11
MALIGNANT HYPERTHERMIA ................................................................................................................................. 12
INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS .................................................................................... 12
RESUSCITATION....................................................................................................................................................... 13
MENDELSON SYNDROME........................................................................................................................................ 13
HYPOTHERMIA IN ANESTHESIA............................................................................................................................... 14
CLINICAL ANESTHESIA ................................................................................................................................................. 14
HISTORY OF ANESTHESIA ........................................................................................................................................ 14
STAGES OF ANESTHESIA .......................................................................................................................................... 14
PREANESTHETIC ASSESSMENT ................................................................................................................................ 14
PEDIATRIC ANESTHESIA .......................................................................................................................................... 15
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ANESTHESIOLOGY
ANESTHESIA IN HEAD INJURY ................................................................................................................................. 15

CARDIOVASCULAR ANESTHESIA.............................................................................................................................. 15
ANESTHESIA IN ENT ................................................................................................................................................ 16
OBSTETRIC ANESTHESIA .......................................................................................................................................... 16
ANESTHESIA IN ORTHOPEDICS ................................................................................................................................ 16
RESPIRATORY ANESTHESIA ..................................................................................................................................... 16
DAY CARE ANESTHESIA ........................................................................................................................................... 17
DRUGS OF ANESTHESIA .............................................................................................................................................. 17
PREANESTHETIC DRUGS .......................................................................................................................................... 17
GENERAL FEATURES OF ANESTHETIC DRUGS ......................................................................................................... 17
INHALATIONAL ANESTHETICS ..................................................................................................................................... 18
MINIMUM ALVEOLAR CONCENTRATION ................................................................................................................ 18
PARTITION COEFFICIENT ......................................................................................................................................... 18
GENERAL FEATURES OF INHALATIONAL ANESTHETICS........................................................................................... 18
XENON..................................................................................................................................................................... 19
NITROUS OXIDE ....................................................................................................................................................... 19
TRILENE ................................................................................................................................................................... 20
ETHER ...................................................................................................................................................................... 20
HELIUM ................................................................................................................................................................... 20
CHLOROFORM ......................................................................................................................................................... 20
HALOTHANE ............................................................................................................................................................ 20
ENFLURANE ............................................................................................................................................................. 21
ISOFLURANE ............................................................................................................................................................ 22
DESFLURANE ........................................................................................................................................................... 22
SEVOFLURANE ......................................................................................................................................................... 22
METHOXYFLURANE ................................................................................................................................................. 23
INTRAVENOUS ANESTHETICS ...................................................................................................................................... 23
GENERAL FEATURES OF INTRAVENOUS ANESTHETICS ........................................................................................... 23
PROPOFOL ............................................................................................................................................................... 24
KETAMINE ............................................................................................................................................................... 24
THIOPENTONE ......................................................................................................................................................... 25
ETOMIDATE ............................................................................................................................................................. 26
LOCAL ANESTHETICS ................................................................................................................................................... 26
GENERAL FEATURES OF LOCAL ANESTHETICS......................................................................................................... 26
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ANESTHESIOLOGY
BUPIVACAINE .......................................................................................................................................................... 28
LIGNOCAINE ............................................................................................................................................................ 28
PRILOCAINE ............................................................................................................................................................. 29
COCAINE .................................................................................................................................................................. 29
PROCAINE................................................................................................................................................................ 29
BIER’S BLOCK/IVRA ................................................................................................................................................. 29
PERIBULBAR AND RETROBULBAR BLOCK ................................................................................................................ 30
STELLATE GANGLION BLOCK ................................................................................................................................... 30
BRACHIAL PLEXUS BLOCK ........................................................................................................................................ 30
CELIAC PLEXUS BLOCK ............................................................................................................................................. 30
NEUROMUSCULAR BLOCKERS .................................................................................................................................... 31
GENERAL FEATURES OF NEUROMUSCULAR BLOCKERS .......................................................................................... 31
DEPOLARISING MUSCLE RELAXANTS – SUCCINLY CHOLINE ................................................................................... 31
FEATURES OF NON DEPOLARIZING MUSCLE BLOCKERS ......................................................................................... 33
D-TUBOCURARINE ................................................................................................................................................... 33
PANCURONIUM ...................................................................................................................................................... 33
VECURONIUM ......................................................................................................................................................... 34
MIVACURIUM.......................................................................................................................................................... 34
ATRACURIUM .......................................................................................................................................................... 34
GALLAMINE ............................................................................................................................................................. 34
ALCURONIUM ......................................................................................................................................................... 35
SPINAL, EPIDURAL AND CAUDAL ANESTHESIA and pain management ...................................................................... 35
SPLANCHNIC BLOCK ................................................................................................................................................ 35
NEURAXIAL BLOCKADE............................................................................................................................................ 35
SPINAL ANESTHESIA ................................................................................................................................................ 35
EPIDURAL ANESTHESIA ........................................................................................................................................... 37
CAUDAL ANESTHESIA .............................................................................................................................................. 37
OTHER BLOCKS ........................................................................................................................................................ 38
PAIN ............................................................................................................................................................................ 38
GENERAL FEATURES OF PAIN .................................................................................................................................. 38
ASSESSMENT OF PAIN ............................................................................................................................................. 38
ANALGESIC DRUGS .................................................................................................................................................. 39
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ANESTHESIOLOGY
ANESTHESIOLOGY INSTRUMENTS
GENERAL FEATURES OF ANESTHETIC INSTRUMENTS
Rotameter Constant pressure, variable orifice, flow meter for gases

and liquids
Rotameter Height of bobbin rise indicates flow rate
st nd
MC cause of inaccurate reading in Rotameter 1 Static Electricity, 2 Dirt
Wright spirometer Used for calculation of expired volumes
Types of Pneumatographs measuring airway resistance Fleisch’s type, Venturi type, Turbine type
Used to protect airway LMA, endotracheal tube, combitube
Least damage to blood elements Membrane oxygenator
ANESTHETIC CYLINDERS
Filling ratio of anesthetic cylinder Filling ratio is the weight of the fluid in
the cylinder divided by weight of water
required to fill the cylinder
Color of oxygen cylinder Black cylinder with white shoulders
Color of ethylene cylinder Purple
Color of nitrous oxide cylinder Blue
Color of cyclopropane cylinder Orange
PIN INDEX
Pin index of nitrous oxide 3,5

Pin index Pin is present on machine, not effective if wrong gas is
filled in cylinder, hole position on cylinder valves
System preventing Incorrect gas Cylinder attachment Pin Index Safety system
ANESTHETIC GASES
Gas filled as liquid in cylinders CO2, N20, cyclopropane

Gas stored in liquid form N2O
Nitrous oxide Cylinder blue in color, MAC 105
Tare weight is used for Gas Cylinders
For high pressure storage of gases, cylinders are made Molybdenum steel
of
Pressure of N2O at 20*C 745 psi
High pressure in gas cylinder indicate Impurities in N2O
Critical temperature of air -140.6*C
Critical temperature of oxygen -119*C
Critical temperature of N2O 36.5*C
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ANESTHESIOLOGY
ANESTHETIC MACHINES AND CIRCUITS
Anesthesia breathing circuit Cylinder is a part of high pressure system, O2 flush

delivers < 35 liters
Boyle’s machine Continuous flow, low resistance
Boyle’s law At constant temperature, volume of a given mass varies
inversely with its absolute pressure
High pressure system in anesthesia machine is delivered Hanger yoke
by
Principle of Boyle’s apparatus Continuous Flow
Heidbrink meter in Boyle’s apparatus Indicates flow of gases
Bernoulli principle In laminar flow, velocity of flow through a tube is
inversely related to its pressure against the size of tube
Modified bernoulli Pressure change = 4 * (velocity)^2
Clayton is used in closed breathing circuit as Indicator
MAPLESON SYSTEM
Most efficient anesthetic circuit for GA with Mapleson A

spontaneous respiration
Air flow in Magill’s circuit (Mapleson A) Equal to minute volume
Magill’s circuit Ideal for adults, semiclosed, spontaneous breathing is
must
NOT suited for both controlled and assisted ventilation Mapleson A
No corrugated tube in Mapleson C
Bain circuit Mapleson type D, can be used for both controlled and
spontaneous ventilation
Bain circuit Inner tube for inspiration, circuit of
choice for controlled ventilation, light
weight, fresh gas flow should be 1.5 times of
minute volume
Mapleson system used in children Ayer T tube
Ayre’s T piece Mapleson E
Features of Ayre’s T piece No reservoir bag, no expiratory valve
Most appropriate circuit for ventilating spontaneously Jackson Ree’s modification of Ayre’s T piece
breathing infant during anesthesia
Rebreathing prevention valve Light, well designed, used at expiratory end of tube
Rebreathing circuit To and fro circuit, circle system, water system
OXYGEN CONTROL DEVICES
Assessment of oxygen in a cylinder attached to Bourdon pressure gauge

anesthesia machine
Used for proper oxygen flow to patient Proportionator between N2O and O2 control valve,
different pin index, calibrated oxygen corrected analysis
System Maintaining O2 concentration by limiting N2O Pneumatic Interlock Oxygen Ratio Monitor Controller
flow (ORMC)
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ANESTHESIOLOGY
System Maintaining 25% O2 concentration and Link 25 Proportion Limiting system(Datex Ohmeta
Maximum N2O:O2 flow ratio of 3:1 System)
Safety measures to prevent delivery of hypoxic mixture Location of oxygen valve after N2O valve, location of fail
to patient safe valve downstream from nitrous oxide supply
source
Oxygen concentrator Zeolite activation, delivers O2,requires power supply
Oxygen content in anesthetic mixture 33%
Fixed performance oxygen provided by Venturi mask
Delivery of oxygen in basic life support Through mask
Humidification of air is needed in Face mask
Oxygen delivery regulated by Oxygen tent, oxygen apparatus, poly mask, venti mask
Maximum O2 concentration achieved in venturi mask 60%
Side effects of oxygen therapy Absorption atelectasis, decreased pulmonary
compliance, decreased vital capacity, endothelial
damage
Oxygen given during anesthesia to prevent Hypoxia
90% oxygen by Non rebreathing mask
Safe oxygen concentration in therapy is to achieve PaO2 > 50 mm Hg
Humidity of dry 100% oxygen 0 mg H2O litre
Artificial nose Heat and moisture exchanger
DEVICES FOR CO2 ABSORPTION
CuSO4 present in Amsorb

Ba (OH)2 present in Baralime
Decrease CO2 absorption High flow, medium granule, No resistance in circuit
Decreases CO2 absorption Increased tidal volume, increased dead
space
Increases CO2 absorption Resistance in circuit
Soda lime is used to absorb CO2 in Closed circuit system
Reacts with soda lime Trilene
Main component of soda lime in closed circuit Calcium hydroxide
Composition of soda lime 90% Ca(OH)2 + 5% NaOH + 1% KOH
NOT a component of sodalime Ba OH2
Soda lime does NOT contain CaCl
NOT true about soda lime Used in treatment of alkalosis
Water is used for hardening in Soda lime
Color change in Mimoza 2 Red to white
Signs of soda lime exhaustion Change of color of granules, rise in ETCO2
in capnography, rise in BP followed by
fall, rise in pulse rate, deepening of
spontaneous respiration, increased oozing
from wound, increased sweating
DEAD SPACE
Normal dead space 30% of tidal ventilation
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ANESTHESIOLOGY
Anatomical dead space is increased by Atropine, Halothane, Inspiration

Dead space is increased by Anti cholinergic drugs, standing, hyperextension of neck
Physiological dead space is decreased by Neck flexion
Anatomical dead space in Supine position Decreases
Anatomical dead space decreased by Massive pleural effusion
Dead space NOT increased by Endotracheal intubation
Least amount of CO2 present in Anatomical dead space - end inspiration phase
ENDOTRACHEAL TUBE
Size of endotracheal tube in 1 – 6 months 2 – 4 mm

aged
Size of endotracheal tube in 6 months to 1 3.5 – 4.5 mm
year aged
Size of endotracheal tube in 1 – 6 years [Age/3] + 3.5
Size of endotracheal tube more than 6 [Age/4] + 4.5
years
Length of endotracheal tube in neonate 10 – 11 cm
Length of endotracheal tube in elder [age/2] + 12
children
Reasonable size of endotracheal tube in 3 year old 4.5 mm
Curved blade in adult laryngoscope is Macintosh
Endotracheal cuff High volume low pressure, low volume high pressure
Size of endotracheal tube in children less than 6 years (Age/3.5)+3.5
Diameter and length of endotracheal tube in full term 3.5 mm and 12 mm
infant
McIntosh tube for Adults
Magill’s tube Children
Armoured endotracheal tube is used in Neurosurgery
RAE endotracheal tube Red
RAE tube is used in LASER surgery
Diameter of ET tube in child less than 1000 g 2.5,3
Direct laryngoscope in right handed person Left hand
Type of endotracheal tube and blade in children Uncuffed tube with straight blade
Cuff pressure in ET tube should not exceed 23 mm Hg
LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION
High airway resistance seen in Main bronchus

Airway assessment Mallampatti grading, Cormack and
Lehare (based on laryngoscopy), Wilson’s
scoring, LEMON law
LEMON law Look externally, evaluate 3-3-2 rule,
Mallampatti, Obstruction, Neck mobility
Normal thyromental distance >6.5 cm
Mallampatti grading for Inspection of oral cavity before intubation
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ANESTHESIOLOGY
Mallampatti classification is based on Opening of mouth

Clinical predictor of a difficult intubation Large tongue
is postulated to be responsible for a grade
III Mallampatti view of oral cavity
NOT an indication for endotracheal intubation Pneumothorax
Both orotracheal and nasotracheal intubation is Acute laryngotracheobronchitis
contraindicated in
Difficulty in intubation Burns in head and neck, Still’s disease, Down’s
syndrome
Features of difficult airway Miller’s sign, TMJ ankylosis, micrognanthia and
macroglossia
Used in difficult intubation Helium O2 mixture, entoxon, sevoflurane
Maneuver performed during laryngoscopy and Flexion of neck, extension of head at atlantooccipital
intubation joint, in straight blade laryngoscope epiglottis is lifted
by tip, upper incisors are most vulnerable to damage by
laryngoscopy so laryngoscope should not be levered
against them
Endotracheal intubation in children Small morbidity on prolonged intubation
NOT seen during laryngoscopy Hypotension
Sellick’s original description of cricoid Extending head
pressure
Sellick maneuver is used to prevent Gastric aspiration
Sellick maneuver is effective in prevention Passive regurgitation and subsequent
of aspiration
NOT a maneuver performed during laryngoscopy Laryngoscope is lifted upwards levering over the upper
incisors
Effective adjuvant in attenuating Succinylcholine
hypertension and tachycardia associated
with laryngoscopy and intubation
High potassium level with scoline for Chronic paraplegia
intubation occurs with
Most accurate measurement of correct placement of ET End Tidal CO2
tube
Correct placement of endotracheal tube judged by Arterial CO2, Breath sounds, Chest X ray
Speedy intubation, breath sounds were observed to be Endobronchial intubation
decreased on left side and high end tidal CO2
Laryngoscopy and intubation is associated with Hypertension and tachycardia, raised IOT, raised ICT,
decreased lower esophageal sphincter tone, arrhythmia
Endotracheal intubation Reduces normal anatomical dead space
A child has been intubated and connected to anesthesia Increase the flow
machine. A problem has occurred in anesthesia
machine and the child collapsed after 2 minutes. What
to do next
Laryngeal complication of Prolonged ET intubation Stenosis, Ulceration, Abductor paralysis
Prevention of intubation induced Local anesthesia, fentanyl, diltiazem
laryngeal spasm
Drug that can precipitate reflux Promethazine
Treatment of severe tracheal stenosis due to Tracheal resection and end to end anastomosis
endotracheal intubation for more than 2 weeks
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ANESTHESIOLOGY
Surgery for extensive tracheal stenosis Grillo or Barclay procedure
NASOTRACHEAL INTUBATION
Merits of nasotracheal intubation Good oral hygiene

Nasal intubation is contraindicated in CSF rhinorrhoea
LARYNGEAL MASK AIRWAY
Supraglottic type of airway management Laryngeal mask airway

NOT a definite airway Laryngeal mask apparatus
NOT an advantage of laryngeal mask airway Aspiration is prevented
Laryngeal mask airway NOT used for Large tumor in oral cavity
Laryngeal mask airway is used for Maintenance of airway
Laryngeal mask airway More reliable than face mask, alternative to
endotracheal tube, does NOT require laryngoscope and
visualization
LMA Intubation can be done, size 1 for neonates, size 3 for
adults
Plan C of anesthetic airway management Insertion of laryngeal mask airway and fibroptic
bronchoscopy
TRENDELENBERG POSITION
Maximum vital capacity decreased in Trendelenberg position

Trendelenberg position decrease Vital capacity, FRC, compliance
Trendelenberg position does NOT cause decrease in Respiratory rate
Position with least vital capacity in GA Trendelenberg
GENERAL FEATURES OF MONITORING DURING ANESTHESIA
Individual operative awareness by Bispectral imaging

Organ at greatest risk of ischemia under Heart
conditions of normovolemic hemodilution
Best to monitor intraoperative myocardial ischemia Transesophageal echocardiography
Most sensitive and practical technique to detect Regional wall motion abnormality detected with help of
myocardial ischemia in perioperative period 2D transesophageal echocardiography
5th vital sign Pulse oximetry
Pulse oximetry At 660 nm, oxyhemoglobin reflect more light than
deoxyhemoglobin, reverse is true at 940 nm
Pulse oximetry detects inaccurately in presence of Nail polish, methemoglobinemia, skin pigmentation
Inadequate ventilation during intraoperative period is Pulse oximetry
best assessed by
Beer Lambert Law Pulse oximetry
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ANESTHESIOLOGY
Oxygen saturation is measured by Pulse oximeter

Used to monitor respiration in non intubated neonate Impedance pulmonometry
Non ventilated baby is in incubator, best way to Impedance pulmonometry
monitor baby’s breathing and detect apnea
A postoperative patient with pH 7.25 MAP 60 mm Hg Fluid therapy with CVP monitoring
treated with
Least affected during anesthesia Brainstem auditory evoked potential
Somatosensory evoked potential is Thoracic and abdominal aorta surgery
important during
MC nerve used for monitoring during anesthesia Ulnar nerve
Modality best utilized for neuromuscular Train of four
monitoring during maintenance of
anesthesia
NOT a cause of bacterial sepsis in ICU patient on Humidified air
invasive monitoring
CENTRAL VENOUS PRESSURE MONITORING
MC vein for CVP monitoring Right Internal Jugular Vein

While inserting CVP, patient developed respiratory Pneumothorax
distress
MC complication of central venous catheter Catheter related infection
Complications of CVP line Airway injury, hemothorax, septicemia, air embolism,
pulmonary edema
CVP monitoring is most useful in Guiding hemodynamic therapy
In a patient with multisystem trauma, presence of Cardiopulmonary problem
hypotension with elevated CVP is suggestive of
CVP does NOT indicate Tissue perfusion
PULMONARY ARTERY CATHETER
Swan Ganz catheter measure PCWP, mixed venous oxygen saturation, Right atrial
pressure
While introducing Swan Ganz catheter, its placement in PA pressure tracing has dicrotic notch from closure of
pulmonary artery can be identified by pulmonary valve > diastolic pressure is higher in PA
than in RV
Swan Ganz catheter is used to measure Pulmonary artery pressure, pressure of
cardiac chambers, pulmonary capillary
wedge pressure, cardiac output and
cardiac index, blood sample for mixed
venous oxygen saturation, to measure
temperature of pulmonary artery
Pulmonary wedge pressure is indirectly Left atrial pressure
Measurement of intravascular pressure by pulmonary At the end of expiration
artery catheter
Left atrial filling pressure closely Pulmonary capillary wedge pressure
resembles
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ANESTHETIC COMPLICATIONS 11
ANESTHESIOLOGY
CAPNOGRAM
Capnography is based on Luft principle

NOT a cardiovascular monitoring technique Capnogram
Flat capnogram Disconnection of anesthetic tubing, accidental
extubation, mechanical ventilation failure
Phases of capnogram Phase 0 – inspiratory phase, phase 1 – dead
space and little or no CO2, phase 2 –
mixture of alveolar and dead space gas,
phase 3 – alveolar plateau with peak
representing end expiratory and end tidal
CO2
ANESTHETIC COMPLICATIONS
AIR EMBOLISM
End tidal CO2 decreased during surgery Air embolism

Significant air embolism occurs with volume 100 cc
Diagnosing air embolism with tracheoesophageal Very sensitive investigation, continuous monitoring to
echocardiography detect venous embolism, interferes with Doppler when
used together
Factors favoring embolism is a patient with major Mobility of fracture, diabetes
trauma
Air embolism in neurosurgery is maximum in Sitting position
Most sensitive investigation for air embolism Transesophageal echo > Doppler ultrasound
Known case of thyrotoxicosis posted for Air embolism
abdominoperineal resection. sudden drop in BP and
end tidal CO2, Mill Wheel murmur
Most serious complication of sitting position Air embolism
Transesophageal echocardiography Can quantify the volume of air embolised, Very
sensitive investigation, Continuous monitoring is
needed to detect venous embolism
RESPIRATORY COMPLICATIONS
Anesthetic complication with respiratory infection Bacteremia, Increased mucosal bleeding, laryngospasm
Aspiration pneumonitis Affected by volume of aspiration and pH of aspiration
fluid, increased incidence during induction,
inflammation, infection
Obstruction of respiration in comatose patients is Falling back of tongue
mainly due to
NOT a cause of respiratory insufficiency in immediate Mild hypovolemia
post operative period
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ANESTHESIOLOGY
NOT a common cause of respiratory distress in post Mild hypovolemia

operative period
On doing laparoscopic cholecystectomy, patient To deepen plane of anesthesia
developed wheezing, what is used in treatment
MALIGNANT HYPERTHERMIA
Does NOT trigger malignant hyperthermia N2O

Drug causing malignant hyperthermia Succinyl choline
Hyperthermia is caused by MAO inhibitors
Earliest sign in development of Malignant hyperthermia Increased CO2
Increased heat production in malignant hyperthermia Increased muscle metabolism by excess of calcium ions
NOT seen in malignant hyperthermia Bradycardia
Rise in end tidal CO2 during surgery Malignant hyperthermia, thyroid storm, neuroleptic
malignant syndrome
Causes of sudden increase in end tidal CO2 Hyperthyroidism, shivering
End tidal CO2 increased to maximum level in Malignant hyperthermia
Difference between malignant hyperthermia and Elevated CPK level
thyrotoxicosis
Enzyme marker of malignant hyperthermia Serum CPK
Malignant hyperthermia Succinlycholine and halothane predispose, dantrolene
used in all cases, propofol is safe, muscle biopsy is
diagnostic, hyperkalemia
Treatment of malignant hyperthermia Dantrolene, cooling, discontinue inhalational
anesthetic, give O2 therapy with 100% O2
Drug of choice for Halothane induced Malignant Dantrolene
hyperthermia
INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS
Normal urine output 1 ml/kg/hr

Treatment of postoperative shivering Pethidine
Shivering is abolished by Meperidine
Post anesthetic shivering may increase metabolic rate 5
by factor of
Causes of postoperative hypertension Preoperative hypertension, inadequate analgesia,
pheochromocytoma, hypoxemia, hypercarbia
Most common rhythm disturbance during early Tachycardia
postoperative period
Most common intraoperative complication Dysrhythmia
reported during anesthesia in ASA I and
ASA II patients
Advantage of Intraoperative anesthesia record Test for quality assurance, medicolegal purposes,
Reference for future
Post anesthetic discharge scoring system includes Pain, Ambulation, Nausea and vomiting
Drug of choice for maintaining Esmolol
intraoperative heart rate
Bradycardia during anesthesia Atracurium, Propofol, succinylcholine
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ANESTHESIOLOGY
Intraocular pressure is lowered by Morphine, Thiopentone, Halothane

Allergic reaction in anesthetic practice Atracurium, Thiopentone, Procaine
Analgesic effect is absent in Thiopentone, methhexitone
Management of postoperative nausea and Promethazine
vomiting
RESUSCITATION
Fifth vital sign Pain

Adrenaline in CPR Can be given intrathecally, IV route is better than
intracardiac
Does NOT occur during cardiac resuscitation DIC
Compression to breath ratio in adult advanced life 30 : 2
support
Recent CPR guideline Chest compressions 100 per minute, no breathing, as soon
as VT/VF disappears 300 J (monophasic) or 150 J (biphasic)
defibrillation 5 cycles. If defibrillation fails, adrenaline and
then amiodarone
Exact order of CPR CAB
Best chances of successful recovery after CPR in Ventricular tachycardia
Drug NOT used in Cardiopulmonary resuscitation Sodium bicarbonate
During cardiopulmonary resuscitation, intravenous Hypocalcemia, calcium channel blocker toxicity,
calcium gluconate is indicated in electromechanical dissociation
Cardiopulmonary resuscitation Adrenaline is given if cardioconversion fails
NOT an indicator for adequacy of preoperative C reactive protein
resuscitation
Patient become pulse less after an antibiotic Immediate chest compression
administration
Outcome of cardiac resuscitation worsen with 5% glucose
Outcome following resuscitation of a cardiac arrest is 5% dextrose
worsened if during resuscitation patient is given
Immediate defibrillation is advised when ECG shows Ventricular tachycardia
NOT used for cardiac arrest following ventricular Atropine, External cardiac pacing
fibrillation
Asynchronous cardioversion given in Ventricular fibrillation
NOT true about Bag mask ventilation Child minimum size 450 ml
MENDELSON SYNDROME
Mendelson syndrome Aspiration of gastric contents

Critical pH of Mendelson syndrome 2.5
Complete bilateral white out in chest X ray in Mendelson 8 – 24 hours
syndrome in
Accidental aspiration of gastric contents Tracheal intubation and suctioning
into tracheobronchial tree should be
initially treated by
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CLINICAL ANESTHESIA 14
ANESTHESIOLOGY
HYPOTHERMIA IN ANESTHESIA
Hypothermia is used in Hyperpyrexia, prolonged surgeries

Hypothermia is used in Hyperthermia, neonatal asphyxia, cardiac surgery
Hypothermia can be Beneficial to patient
CLINICAL ANESTHESIA
HISTORY OF ANESTHESIA
Anesthesia W.G.Morton (1846)

th
World ether day 16 October 1846
Anesthetic effects of ether Morton
STAGES OF ANESTHESIA
Stage II of surgical ether anesthesia Loss of consciousness to beginning of spontaneous

respiration
Pupil in second stage of anesthesia Partially dilated
Stage III of surgical anesthesia Beginning of respiration to respiratory
paralysis
Definitive sign of stage III phase 1 of anesthesia Fixation of eye ball
Feature of stage III plane 3 of anesthesia Absent thoracic respiration
PREANESTHETIC ASSESSMENT
POSSIUM scoring system for Anesthesia

ASA classification done for Status of patient
An hypertensive man on medication not affecting ASA II
physical activity
ASA 2 Mild systemic disease
ASA 3 Severe systemic disease
ASA 4 Severe disease, constant threat to life
ASA 5 Moribund patient
ASA 6 Brain death
Scoring system for severity of illness APACHE II, SAPS
Karnofsky performance index 0 to 100 (moribund 10, dead 0)
ECOG performance scale 0 – fully active, 5 - dead
Smoker scheduled for elective surgery Effect of nicotine on aorta and carotid bodies can
increase sympathetic tone, muscle relaxant dose
requirements are increased, smoking decreases
surfactant levels
Smoking should be stopped 6 weeks before surgery
Aspirin should be stopped 7 days before surgery
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ANESTHESIOLOGY
Clopidogrel should be stopped 1 day before surgery

Ticlopidine should be stopped 10 – 14 days before surgery
MAO inhibitors should be stopped 3 weeks before surgery
Lithium should be stopped 48 – 72 hours before surgery
Drugs that can be continued irrespective Anti thyroid drugs and anti tubercular
of anesthesia drugs
Drug that can be given in normal dose Calcium channel blockers
during anesthesia, as they can prevent MI
Levodopa should be stopped 4 – 6 hours before surgery (recent
recommendation is that it can be
continued)
Important drug to be stopped before OCP
abdominal surgeries
PEDIATRIC ANESTHESIA
Method of choice for induction in children Inhalational > intravenous

NOT used for induction of anesthesia in children Morphine
Narrowest part of larynx in infant is at cricoid level, in Laryngeal edema, trauma to sub epiglottic region, post
administering anesthesia this may lead to operative stridor
Neonatal circumcision done under General anesthesia
Postoperative pain relief in children by Intravenous narcotic infusion in lower dosage
5 year child, squint correction, induction uneventful, He wanted to see if there is oculocardiac reflex
after conjunctival incision, surgeon grasps medial
rectus, anesthetist looks at cardiac monitor
Most appropriate anesthetic in a 5 year old boy Induction with intravenous suxamethonium and N2O
undergoing tendon lengthening procedure for oxygen for maintenance
Duchenne muscular dystrophy
Anesthesia for ducchene muscular Halothane and propofol
dystrophy
ANESTHESIA IN HEAD INJURY
RTA , head injury used for induction Thiopentone

Agents used for Non head injury trauma patient Ketamine, etomidate
CARDIOVASCULAR ANESTHESIA
Anesthesia for pregnant woman with coarctation of General anesthesia

aorta
Most common cause of mortality and morbidity in Cardiac complication
patients undergoing major vascular surgery
Maintenance of anesthesia during triple vessel coronary Opioids > isoflurane
artery disease bye pass
52 year male, triple vessel coronary artery disease with Opioid
poor left ventricular function. CABG surgery decided.
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ANESTHESIOLOGY
Preferred for maintenance of anesthesia

NOT used in controlling heart rate intraoperatively Verapamil
NOT used in controlling heart rate intraoperatively Propanolol/Metoprolol
Anesthesia of choice for hypotension during surgery for Phenylephrine
aortic stenosis
ANESTHESIA IN ENT
Anesthesia of choice in infected tooth posted for Enflurane

extraction
NOT done if fire breaks out during vocal cord surgery 100% oxygen after discontinuing anesthetic gases
Anesthesia used in microlaryngoscopy Pollard tube with infiltration block
Hypotensive anesthesia in nasopharyngeal carcinoma Phentolamine, halothane, sodium nitroprusside
given by
OBSTETRIC ANESTHESIA
NOT a cause of decreased anesthetic requirement Increased lumbar lordosis

during pregnancy
Primigravida with mitral stenosis and mitral Neuraxial blockade
regurgitation in labour, best way to provide anesthesia
for normal delivery
Anesthesia of choice for manual removal of placenta General anesthesia
Most preferred technique for painless Lumbar epidural
labor
Most adequate anesthesia in breech General anesthesia
A primigravida with rheumatic heart General anesthesia with thiopentone and
disease with severe mitral stenosis and is succinylcholine
planned for elective LSCS. Anesthesia of
choice
Anesthesia in LSCS desirable up to T4
ANESTHESIA IN ORTHOPEDICS
Anesthesia in total hip replacement Combined spinal and epidural
RESPIRATORY ANESTHESIA
Safest to use in asthmatic Chloral hydrate

During rapid sequence induction of anesthesia Preoxygenation is mandatory
Inducing agent contraindicated in asthma Althesin
Intravenous agent containing two steroids Althesin
in structure
After hyperventilation for some time, holding the Due to lack of stimulation by CO2, anoxia can go into
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DRUGS OF ANESTHESIA 17
ANESTHESIOLOGY
breath is dangerous since dangerous level

Patients NOT breathing after anesthesia is due to Prolonged anesthesia, Neuromuscular blockage,
Recurrent intubation leading cord’s failure
Drug that may precipitate bronchospasm Methohexitol
in patients with reactive airway
DAY CARE ANESTHESIA
Most preferred for day care surgeries Propofol, fentanyl, isoflurane
DRUGS OF ANESTHESIA
PREANESTHETIC DRUGS
Main aim of pre anesthetic medication To make anesthesia pleasant and safe
Drug commonly used in pre anesthetic medication Diazepam, scopolamine, morphine
Pre anesthetic medication Fentanyl, Diazepam, Atropine
Most potent antiemetic agent used in preoperative Metoclopromide
period
Pre anesthetic medication causing longest Lorazepam
amnesia
During GA shivering is abolished by suppression of Hypothalamus
Preanesthetic effects of atropine Decrease secretion, prevent bradycardia, prevent
hypotension, bronchodilatation
NOT a preanesthetic agent Aspirin
Preanesthetic medication is NOT for Decreasing dose of inducing agent, decreasing BP
GENERAL FEATURES OF ANESTHETIC DRUGS
Drugs interfering in anesthesia Calcium channel blockers, beta blockers,

aminoglycosides
Calcium channel blockers in anesthesia Given in normal doses as they prevent MI and angina
preoperatively
Anesthetic agents that does NOT suppress cerebral Ketamine, Nitrous oxide
metabolic rate
Airway resistance is reduced by Slow flow rate
Anesthesia for bariatric surgery Anticipated difficult intubation,
Desflurane is an ideal inhalational agent,
High tidal volume, more IV fluid
replacement
Most important monitoring during Vigilant anesthesiologist
laparoscopic surgery
Minimum O2 requirement during Triservice anesthetic apparatus
anesthesia
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INHALATIONAL ANESTHETICS 18
ANESTHESIOLOGY
Dexmedetomidine Alpha 2 agonist, anxiolytic, hypnotic, used

for sedation in ICU, maintains
hemodynamics
INHALATIONAL ANESTHETICS
MINIMUM ALVEOLAR CONCENTRATION
MAC is an indicator of Potency

MAC refers to Minimum Alveolar concentration
Lowest concentration of anesthetic agent in alveoli to Minimum alveolar concentration
produce immobility in response to painful stimulus in
50% of individual
MAC 95 is how much times that of MAC 1.5 times more
50
Relationship between hypothermia and MAC decreases 5% per degree centigrade
minimum alveolar concentration decrease
Alveolar concentration of anesthetic gas is affected by Alveolar ventilation, Partition coefficient, Alveolar blood
flow
Factors decreasing MAC Hypothermia, hyponatremia, anemia
NOT decreasing MAC Hypocalcemia
PARTITION COEFFICIENT
Partition coefficient of gas Measures solubility

Blood gas partition coefficient Solubility
Least Blood gas partition coefficient Desflurane
Oil gas partition coefficient Potency
GENERAL FEATURES OF INHALATIONAL ANESTHETICS
Route of fastest reversible anesthesia Inhalational

Ideal gas Obeys Charles, Boyle’s, Avagadro laws
Exception to Meyer Overton rule Non anesthetics, non immobilizer, cut off effect
Marie’s law Hypovolemia causes tachycardia
Pungent volatile anesthetic agent Desflurane, isoflurane
During general anesthesia, FRC decreases by 15 – 20%
Respiratory irritation is seen with Desflurane
Cyclopropane Explosive
First reflex to appear in recovery of GA Swallowing reflex
Increases speed of induction with inhalational agent Increased alveolar ventilation
Action of inhalation agents can be increased by Given along with nitrous oxide
Carbogen 30% CO2 and 70% oxygen
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ANESTHESIOLOGY
Most metabolized anesthetic Halothane
XENON
Xenon Non explosive, minimum cardiovascular side effects,

low blood gas solubility, rapid induction and recovery,
Heavier than air
Anesthesia for mitral stenosis with liver failure Xenon
Enhances CT Brain Xenon
Important step to prevent Hypoxia while using Xenon Denitrogenation
NITROUS OXIDE
Inhalational agent with fastest onset of Nitrous oxide

action
Critical temperature of nitrous oxide 36.5 *C
Nitrous Oxide J.B.Priestly
Distortion of Capnography, Highest MAC Nitrous oxide
Effects of Nitrous oxide on environment Green House Effect (Global Warming),No Ozone
Depletion
Type of Oxygen and Nitrous Oxide Cylinders ‘E’
Diffusion hypoxia occurs due to Nitrous oxide
Anesthetic agent NOT metabolized in body Nitrous oxide
Least diffusion coefficient Nitrous oxide
At the end of anesthesia after discontinuation of nitrous Diffusion hypoxia
oxide and removal of endotracheal tube, 100% oxygen
administered to patient to prevent
How long after termination of an 5 – 10 minutes
anesthetic that included nitrous oxide,
should you be concerned about diffusion
hypoxia
Second gas effect is characteristically seen Nitrous oxide and halothane
in
Anesthesia for Malignant Hyperthermia Nitrous oxide
Expands air filled cavities Nitrous oxide
Hematological manifestation common with Nitrous oxide
Pneumocephalus created during surgery, Nitrous oxide 7 days
avoided for
Use of Nitrous oxide in contraindicated in Cochlear implant, microlaryngeal surgeries,
vitreoretinal surgery
Vitamin Deficiency caused by Nitrous oxide Vitamin B12
Sub acute combined degeneration is Nitrous oxide
associated with
Least diffusion coefficient Nitrous oxide
Contraindicated in Pneumo conditions Nitrous oxide
Use of nitrous oxide NOT contraindicated in Exenteration operation
Nitrous oxide is indicated in Exenteration operation
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ANESTHESIOLOGY
Side effects of Nitrous oxide Bone marrow suppression, Megaloblastic anaemia,

Agranulocytosis
Bone marrow depression after prolonged Nitrous oxide
administration of
Does NOT cause hepatitis Nitrous oxide
TRILENE
Trilene + Sodalime Phosgene – Neurotoxic

Good Analgesia Trilene
NOT compatible with sodalime Trilene
ETHER
Used without Skeletal Muscle Relaxant Ether

Anesthetic agent contraindicated in cauterization Ether
Most effective muscle relaxant Ether
Hyperglycemia is caused by Ether
Maximum emesis Diethyl ether
Stages of anesthesia established with Ether
No effect on heart Ether
Disadvantages of ether Slow induction, cauterization cannot be used, irritant
nature increases salivary and bronchial secretions
NOT true about ether Affects blood pressure and is liable to produce
arrhythmia
HELIUM
In patient with fixed respiratory obstruction helium is Decreases turbulence

used along with oxygen instead of plain oxygen
Helium Atomic number 2, viscosity zero, used in COPD
Heliox Inert, low viscosity, decreases airway resistance
Heliox Helium is inert gas, mixture of He and O2, reduces work
of breathing
CHLOROFORM
Anesthetic causing maximum emesis Chloroform

Superseded because of cardiotoxicity Chloroform
HALOTHANE
Anesthetic agent maximally absorbed by Halothane

PVC endotracheal tube
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ANESTHESIOLOGY
Tissue blood gas solubility coefficient of Human fat

halothane is maximum in
Side effect of halothane Hepatotoxicity
Trifluoric acid in urine caused by Halothane
Maximum cardiac depression Halothane
Halothane metabolism does NOT cause formation of Iodide
Volatility of an anesthetic agent is directly proportional Halothane
to lowering the flow in portal vein. Portal flow is
maximally reduced by
Most hepatotoxic anesthetic agent Halothane
General anesthesia of choice in children Oxygen + N2O + Halothane
Anesthetic drug sensitizing heart to adrenaline Halothane
Ether Linkage is NOT seen in Halothane
NOT a fluorinated agent Halothane
Halothane on hydrolysis liberate Trifluoroacetate, F2, Br2
Preservative used in halothane Thymol
Halothane sensitizes heart to Exogenous and endogenous adrenaline, dopamine
Halothane Sensitizes heart to action of catecholamines, relaxes
bronchi, may cause liver cell necrosis
Halothane Non irritant, bronchodilator, vasodilator
No analgesic action Halothane
Postoperative rigors Halothane
Better to use in thyrotoxic patient Halothane
Anesthesia with least analgesic property Halothane
Repeated use of Halothane Hepatitis
Agent that corrodes metal in vaporizers and breathing Halothane
system
Post operative jaundice because of Halothane
Agent dissolving rubber Halothane
Maximum uterine relaxation Halothane
Avoided in surgery for biliary atresia in 2 year child Halothane
Halothane 20% metabolized, not given in same patient within 3
months
Smooth induction Halothane
Does NOT have analgesic property Halothane
Shivering in early part of postoperative period may be Halothane
due to
Anesthetic drug when given second time causes Halothane
Fulminant hepatitis
Halothane hepatitis is associated with Centrilobular necrosis
Contraindications of halothane Pheochromocytoma, head injury, MS, AS
ENFLURANE
Anesthetic with high epileptogenic potential Enflurane
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ANESTHESIOLOGY
ISOFLURANE
Anesthesia of choice for liver disease, renal disease and Isoflurane

neurosurgery
Inhalational anesthesia of choice for day care surgery Isoflurane
General anesthesia of choice in Myocardial Ischemia Isoflurane
Least cardiotoxic anesthetic agent Isoflurane
Fluoride content is least in Isoflurane
Agent used in increased ICT Isoflurane
Coronary steal phenomenon is associated with Isoflurane
Liver disease, Renal disease, Neurosurgery, Day care Isoflurane
anesthesia
DESFLURANE
Desflurane is a structural analogue of Isoflurane

Fluorinated methyl ethyl ether Desflurane
Desflurane Pungent and irritable to airway
Minimally metabolized Desflurane
Anesthesia of choice in epileptics Desflurane
Anesthesia of choice in geriatric patients Desflurane
CO (carbon monoxide) Production Desflurane
Treatment of status epilepticus Desflurane
Inhalational agent with rapid induction Desflurane
70 year old male, surgery for 4-6 hours. Best Desflurane
inhalational agent
Least soluble Desflurane
Minimum blood gas solubility coefficient Desflurane
Minimum Blood gas partition coefficient (0.4)– Fastest Desflurane
acting
Least soluble Desflurane
MAC of desflurane 6
Desflurane vaporizer is heated to 39*C
SEVOFLURANE
Sevoflurane + Sodalime Compound A

Inhalational anesthesia of choice in Pediatric Patients Sevoflurane
A patient with elevated liver enzymes Sevoflurane
and reduced hepatic venous flow is posted
for a surgery. Inhalational agent
preferred in anesthesia
Prolongation of QT Interval Sevoflurane
Nephrotoxic byproduct of Sevoflurane Compound A (Vinyl Ether)
Volatile agent used for Induction in Children Sevoflurane
Should NOT be used with Soda Lime Sevoflurane
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INTRAVENOUS ANESTHETICS 23
ANESTHESIOLOGY
Soda lime circuit NOT used with Trichloroethylene

Fastest acting inhalational agent Sevoflurane
Raise in ICT Sevoflurane
6 month child posted for correction of PDA, inhalational Sevoflurane
agent
Contraindicated in closed system anesthesiology Sevoflurane
Sevoflurane Isopropyl ether, MAC is 2%, good to use in old age,
formation of compound A with baralime
Sevoflurane MAC is higher than isoflurane, Blood gas coefficient is
higher than desflurane, More cardiodepressant than
isoflurane
Sevoflurane Nephrotoxic at higher doses
METHOXYFLURANE
Slowest induction and recovery Methoxyflurane

Methoxyflurane Most potent inhalational anesthetic,
highly soluble in rubber tubing of closed
circuit, highest level of fluoride
Methoxyflurane Nephrotoxicity
Least MAC Methoxyflurane
Maximum Blood gas partition coefficient (15)– slowest Methoxyflurane
acting
Anesthetic agent with boiling temperature more than Methoxyflurane
75*
INTRAVENOUS ANESTHETICS
GENERAL FEATURES OF INTRAVENOUS ANESTHETICS
NOT an intravenous anesthetic Cyclopropane

IV anesthesia with shortest elimination time Midazolam
NOT contraindicated in renal failure Midazolam
Intravenous anesthesia of choice in head injury Thiopentone/Propofol
TIVA Reduces cerebral metabolism and CBF
Droperidol + Fentanyl Neuroleptic analgesia
Ratio of droperidol and fentanyl in 50:1
neuroleptic analogue
Neuroleptic analgesia Can be used along with O2 and N2O, Causes focal
dystonia, Cause hypotension
Droperidol + Nitrous oxide Neuroleptic anesthesia
IV anesthesia causing muscle rigidity Fentanyl
Commonest artery for cannulation Radial
Safely used in porphyria Midazolam, Pethidine
Rapid induction in emergency LSCS Prevent gastric aspiration
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ANESTHESIOLOGY
Least elimination half life Midazolam

Total Intravenous Anesthesia Propofol + Remifentanil
Severely ill patient maintained on infusional anesthetic Etomidate, Propofol
nd
agent and started deteriorating on 2 day. The
probable culprit may be
PROPOFOL
Nausea and vomiting NOT seen Postoperatively in Propofol

IV anesthesia in Porphyria Propofol
IV anesthesia in Malignant Hyperthermia Propofol
Day care Anesthesia Propofol
Laryngeal mask airway used Propofol
Related to Egg Propofol
Drug of choice for inducing for a case of tooth Propofol
extraction under GA for day care
IV anesthetic having maximum antiemetic action Propofol
Induction of choice for street fit patient Propofol
Propofol is preferred in Day care anesthesia Recovery is rapid even if used for long time
Induction agent of choice in day care anesthesia Propofol
Propofol Does NOT trigger malignant hyperthermia, contains
egg, suitable for day care surgery
Early MTP in day care facility Propofol
Causes pain of IV injection Propofol
Propofol Undergoes hepatic metabolism, Chemically it is
derivative of di-isopropylphenol
Propofol Cerebral protector, Pleasant sedation and recovery,
Antiemetic effect, Suppression of airway reflex, Does
not cause airway irritation
Administration of drug by intravenous route is painful Di-isopropylphenol
Propofol infusion syndrome Lethal disease which constitutes triad of
metabolic acidosis, skeletal myopathy,
acute cardiomyopathy
Side effect of propofol Profound apnea and hypotension
KETAMINE
Dissociative anesthesia produced by ketamine is Amnesia, Analgesia with loss of consciousness,

characterized by Catatonia
Ketamine is a NMDA blocker
Ketamine belongs to Phencyclidine
IV anesthesia of choice in Asthmatics Ketamine
IV anesthesia of choice in Shock Ketamine
IV anesthesia of choice in Cyanotic Heart Disease Ketamine
Induction agent acts by blocking glutamate requiring Ketamine hydrochloride
NMDA receptor
Anesthetic agent contraindicated in raised ICT Ketamine
Emergence phenomenon is seen with Ketamine
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ANESTHESIOLOGY
Anesthetic agent with additional smooth muscle Ketamine

relaxing property
Post procedure delirium is seen with Ketamine
Emergence delirium Ketamine
IV anesthesia causes maximum bronchodilatation Ketamine
Intravenous anesthesia with loss of consciousness Ketamine
Hallucinations are associated with Ketamine
Hypotension is NOT caused by Ketamine
Does NOT cause uterine relaxation Ketamine
Dissociative anesthesia Ketamine
Maximum analgesia Ketamine
Increased ICT Ketamine
Increased cerebral oxygen consumption is Ketamine
caused by
NOT used for postoperative nausea and vomiting Ketamine
Ketamine Direct myocardial depression, emergence phenomenon
is more likely if anticholinergic premedication is used,
may induce cardiac dysarrythmia in patients receiving
TCA
Increases cerebral oxygen consumption Ketamine
Dose of ketamine 2 mg/kg iv
Contraindicated in uncontrolled hypertension Ketamine
Intraocular pressure increased by Ketamine
Increased cardiac oxygen demand Ketamine
Ketamine contraindicated in Ischemic heart disease, aortic aneurysm
Ketamine is contraindicated in Hypertension
Ketamine produces Inotropic effect
Profound analgesia Ketamine
Ketamine acts by Blocking NMDA receptor
Anesthetic agent causing hypertonia Ketamine
Rigidity is associated with Ketamine, fentanyl
Anesthetic agent contraindicated in epilepsy Ketamine
THIOPENTONE
IV anesthesia of choice in Pediatric Patients Thiopentone

Cerebral protection Thiopental sodium
Thiopentone is often used because of the Smooth induction
advantage of
Rapid sequence Induction Thiopentone
Adequate sign of Induction in Thiopentone Loss of eyelash Reflex
Smooth induction Thiopentone
Thiopentone’s short t ½ is due to Redistribution
First symptom in accidental intraarterial injection of Pain
Thiopentone
Do NOT trigger malignant hyperthermia Thiopentone
IV thiopentone for induction in antecubital vein, severe IV lignocaine through same needle
pain on whole hand. Next line
Drug NOT suitable for acute porphyria Thiopentone sodium
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LOCAL ANESTHETICS 26
ANESTHESIOLOGY
Added to thiopentone to improve its solubility Sodium carbonate

Thiopentone Metabolism Redistribution
NOT a bronchodilator Thiopentone
Commonly used in narcoanlaysis Thiopentone
Percentage of thiopentone used in induction 2.5%
Dose of thiopentone for induction 5 mg/kg
Thiopentone Seizure, truth spell, reduction of ICP, cerebral
protection, maintenance of anesthesia
Intravenous thiopentone cause Rash, pain, spasm, hypotension, muscular excitation
Intraarterial thiopentone cause Vasospasm
Primary mechanism of cerebral protection effect of Decreased cerebral metabolism
thiopentone
Barbiturates Anticonvulsant, Brain protection, Induction of
anesthesia
Pentothal sodium is preferably injected in to Veins over outer aspect of forearm
Commonly used to induce anesthesia Thiopentone
Barbiturate contraindicated in Acute intermittent porphyria
Thiopentone is NOT indicated in Shock
Cerebral metabolism not affected with use of Thiopentone
ETOMIDATE
Highest Incidence of Vomiting Etomidate

Intravenous anesthetic induction with minimum effect Etomidate
on cardiac functions and myocardial oxygen demand
Induction agent that may cause adrenal cortex Etomidate
suppression
Etomidate Intravenous, inhibits cortisol synthesis, pain at site of
injection
Enzyme blocked by etomidate 11β- Hydroxylase
Least change in blood pressure produced by Etomidate
Inducing agent producing cardiac stability Etomidate
Vitamin deficiency caused by Etomidate Vitamin C
Does NOT cause myocardial depression Etomidate
Least effect on heart Etomidate
A Patient has severe Mitral Stenosis. Anesthetic agent Etomidate
of choice is
LOCAL ANESTHETICS
GENERAL FEATURES OF LOCAL ANESTHETICS
Mechanism of action of local anesthetics Blockade of voltage dependent sodium

channels, binds to both open and
inactivated sodium channels, slowing of
axonal impulse conduction, increase in
membrane refractory period
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ANESTHESIOLOGY
Features of local anesthesia Low kA, fastest action

Speed of onset of local anesthesia is related pkA
to
Duration of onset of local anesthetic is Protein binding
related to
Potency of local anesthetic is related to Lipid solubility
Mechanism of action of local anesthetics Stabilization of membrane
Local anesthetic Inhibits generation of action potential, toxicity reduced
by addition of vasoconstrictor
Local anesthetic Duration depends on protein binding, potency depends
on lipid solubility, low pKa is more active, higher dose
produce more block, signal transduction blockade
Amide local anesthetic NOT metabolized by Cholinesterase
EMLA Mixture of local anesthetics used in children
EMLA Xylocaine with prilocaine (5% + 5%)
EMLA is NOT appropriate for Laceration repair
Anesthetic with vasoconstrictor is contraindicated in Finger block
Long acting local anesthetics Bupivacaine, etidocaine, dibucaine, tetracaine
Local anesthetics acting more than 2 hours Bupivacaine, etidocaine
NOT a cause of postoperative numbness and Systemic toxicity of local anesthesia
paresthesia after fracture forearm reduction
Local anesthesia contraindicated in Porphyria Ropivicaine
Paraplegia is associated with Intradural administration Chlorprocaine
of
Local anesthetic most likely to provide allergic reaction Benzocaine
Anesthetic agent with longer duration of action Benzocaine
Benzocaine 20%
Used for topical administration only Benzocaine
Longest acting local anesthetic Tetracaine
Contraindicated in Neonates Mepivacaine
Local anesthetic ineffective topically Mepivacaine
Fibers first blocked in Local Anesthesia Autonomic Nervous System (Preganglionic sympathetic)
Local anesthetics act by Inhibiting Sodium Pump
Sequence of recovery from Local anesthesia Preganglionic sympathetic, Proprioception, Motor
Dibucaine test detects Percentage inhibition of Pseudocholinesterase activity
Earliest sensation lost in local anesthesia Cold sensation
Nerve fibers affected by local anesthesia first Type C
Susceptibility to Local Anesthetic C>B>A
Order of sensitivity of nerve fibres to local anesthesia in Preganglionic sympathetic B, Pain C and A-delta,
decreasing order sensory, motor
Amide like local anesthetics Lignocaine, bupivacaine, mepivacaine
Sodium bicarbonate with local anesthetic Increases speed and quality of anesthesia
Route in which absorption of local anesthetic is Interpleural >Intercostals
maximum
Local anesthesia cannot be used at site of infection Spread of infection, Lowered efficacy
Blockade of nerve conduction by local anesthetic is Need to cross the cell membrane to produce the block
characterized by
Most potent and longest acting anesthetic agent Dibucaine
Mechanism of action of local anesthetics is that they act Activated state
on Na+ channels in their
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ANESTHESIOLOGY
Local anesthetics Block release of sodium into cell

Allergic reaction causing local anesthetics Ester linked drugs
Local anesthesia having highest protein Tetracaine
binding capacity
BUPIVACAINE
Topical use of local anesthetic NOT required Bupivacaine

Most cardiotoxic local anesthetic Bupivacaine
NOT used topically Bupivacaine
Concentration of Bupivacaine used in Spinal anesthesia 0.5 %
Cardiac Resuscitation Toughest Bupivacaine
Contraindicated in Regional IV Anesthesia Bupivacaine
Anesthetic drug hazardous if used in Bier’s block Bupivacaine
Anesthetic agent for spinal / epidural anesthesia Bupivacaine
Maximum dose of Bupivacaine 3 mg/Kg
Levobupivacaine is administered Intrathecally, epidurally
NOT true about bupivacaine Cause methemoglobinemia
Treatment of bupivacaine toxicity Epinephrine, benzodiazepine, isoproternol, bretylium
Treatment of Bupivacaine induced Arrhythmia Bretylium
Treatment of hypothermia induced Bretylium
arrhythmia
Treatment of Bupivacaine Induced Cardiac Toxicity Rapid Bolus of 20% Intralipid 1.5 ml/Kg
(Weinberg Recommendation)
Bupivacaine poisoning treated with Esmolol, Sotalol, Diazepam
Bupivacaine Must never be injected into a vein, More cardiotoxic
than lignocaine, 0.25 percent is effective for sensory
block
LIGNOCAINE
Local anesthesia more safe in surface and Lignocaine

infiltrating anesthesia
Concentrations of lignocaine 1%,2%,4%,5%
Maximum dose of lignocaine as local anesthesia 500 mg
Lignocaine in high dose cause Convulsion, respiratory depression, hypotension,
cardiac arrest
Cardiac Resuscitation Easiest Lignocaine
Concentration of lignocaine 5%
Hyperbaric local anesthesia used for Spinal anesthesia 5% Xylocaine with dextrose
Percentage of Lignocaine used in Spinal anesthesia 5%
Maximum dose of Lignocaine 4.5 mg/Kg (Plain),7 mg/Kg (With Adrenaline)
Recommended infusion rate of Lignocaine in treatment 1 – 1.5 mg/Kg/min

of Persistent Ventricular fibrillation
DOC Ventricular tachycardia Lignocaine
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ANESTHESIOLOGY
Cardiac or CNS toxicity when standard doses of Lignocaine concentration are initially high in relatively
lignocaine administered to patient with circulatory well perfused tissues such as brain and heart
failure because
Adrenaline is added to lignocaine to prolong its effect 1 in 2,00,000
and decrease its absorption into blood stream in a ratio
of
Lignocaine is NOT used in Convulsions
PRILOCAINE
Safest local anesthetic Prilocaine

First local anesthetic Prilocaine
Associated with methemoglobinemia Prilocaine
Prilocaine concentration 4%
COCAINE
Only local anesthetic associated with hypertension Cocaine

Ester Linked Metabolised by Liver Cocaine
Local anesthetic contraindicated with Adrenaline Cocaine
Local anesthetic first used clinically Cocaine
Main disadvantage of using cocaine as LA Epithelial erosions
PROCAINE
Local Anesthesia of choice for Malignant hyperthermia Procaine

Anesthetic agent with no surface action Procaine
Drug cannot be used for surface anesthesia Procaine
First Synthetic Local anesthetic Procaine
Shortest acting local anesthetic Procaine
BIER’S BLOCK/IVRA
Bier’s block Intravenous regional block

NOT used in IVRA for trigger finger Lignocaine + ketorolac
Local Anesthesia used for Bier’s block Prilocaine
Anesthetic modality contraindicated in sickle cell Intravenous regional anesthesia
anemia
In Bier’s block, tourniquet cannot be 30 minutes
released before
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ANESTHESIOLOGY
PERIBULBAR AND RETROBULBAR BLOCK
Local Anesthesia for retrobulbar block Prilocaine + Hyaluronidase

Last muscle to be rendered akinetic in retrobulbar block Superior oblique
Peribulbar block is given in Periorbital space
Advantage of peribulbar block Reduces the risk of CNS side effects from
intradural injection, usually obviate the
need for 7th cranial nerve anesthesia,
reduce the risk of retrobulbar hemorrhage
Complication of peribulbar block Retrobulbar hemorrhage, globe rupture, optic neuritis,
local anesthesia solution can migrate to brain,
vasovagal syncope
STELLATE GANGLION BLOCK
Successful signs of stellate ganglion block Nasal stuffiness, Guttman sign, Horner syndrome
NOT a sign of stellate ganglion block Exophthalmos, Bradycardia
ICU, invasive monitoring, intraarterial cannula in radial Stellate ganglion block
artery, swelling and discoloration of right hand. Next
step
BRACHIAL PLEXUS BLOCK
In interscalene brachial plexus block, block Anterior and middle scalene

is given between
Interscalane approach of brachial plexus block does Ulnar nerve
NOT provide anesthesia to distribution of
Nerve spared in axillary approach Musculocutaneous nerve
Pneumothorax is a complication of Brachial plexus block
CELIAC PLEXUS BLOCK
Most common complication of celiac plexus block Postural hypotension

MC complication of celiac plexus block Hypotension
Position best describes celiac trunk Anterolateral to aorta
Celiac plexus is located Anteromedial to lumbar sympathetic chain
MC side effect of Celiac Plexus block Diarrhea and Hypotension
Location of celiac plexus Anterior or anterolateral to aorta
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NEUROMUSCULAR BLOCKERS 31
ANESTHESIOLOGY
NEUROMUSCULAR BLOCKERS
GENERAL FEATURES OF NEUROMUSCULAR BLOCKERS
MC cause of Anaphylactic Reaction Neuromuscular Blocker

Prejunctional receptors are blocked by d-tubocurarine
Extrajunctional receptors are blocked by Succinyl choline
Drugs increasing neuromuscular blockade Clindamycin, Streptomycin
Hypothermia is useful in potentiation of Neuromuscular block
Intraperitoneal irrigation cause potentiation of curare Kanamycin
effect and results in respiratory distress
Neuromuscular action of curare brought about by Competitive inhibition
Longest acting Neuromuscular blocker Pancuronium
Muscle relaxant with longest onset of action Alcuronium
Shortest acting neuromuscular blocker Mivacurium
Central muscle relaxants act by Inhibiting spinal polysynaptic reflexes
Muscle relaxant having maximum duration of action Doxacurium
Muscle relaxant causing pain on iv injection site Rocuronium
Neostigmine is used for reversing adverse effect of D-tubocurarine + pancuronium
Train of four is characteristically seen in Non depolarising muscle blocker
Cardiovascular side effects are minimal with Rocuronium, doxacurium, vecuronium
Muscle relaxants Benzodiazepine, Pancuronium, Gallamine
Muscle relaxant with ganglion blocking action Curare, pancuronium, trimethophan
Muscle relaxant acting directly on Muscle Dantrolene
Metabolite of carisoprodol Meprobromate
Features of carisopodol Centrally acting, prodrug of
meprobromate, sedation is common
Metaxolone Centrally acting muscle relaxant
Cyclobenzaprine Centrally acting muscle relaxant,
structurally related to TCA, blocks alpha
motor neurons, can be used in whiplash
injuries and fibromyalgia, can cause
aggressive behavior in elderly
Baclofen Centrally acting muscle relaxant
Least sensitive to muscle relaxant Diaphragm
Post paralytic syndrome Prolonged weakness caused by neuromuscular blockers
Sugammadex Reversal of neuromuscular blocking agent
During anesthesia with muscle relaxants, Mid position
vocal cords are in
Rocuronium is inactivated by Sugammadex
Gantacurium is inactivated by Cysteine adduction
DEPOLARISING MUSCLE RELAXANTS – SUCCINLY CHOLINE
MC anaphylactic Neuromuscular Blocker Succinylcholine

Depolarizing muscle relaxant Succinylcholine
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ANESTHESIOLOGY
Succinylcholine NOT contraindicated in Cerebral stroke

Succinylcholine induced hyperkalemia is associated Tetanus, Closed head injury, Hepatic failure
with
Depolarizing blockers Potentiated by isoflurane, cannot be reversed by
neostigmine
Post anesthetic fasciculations Succinylcholine
Shortest acting muscle relaxant Succinylcholine
Succinylcholine is short acting because of Rapid hydrolysis
Completely metabolized Succinylcholine
Postoperative muscular pain after use of Succinylcholine
Malignant hyperthermia is caused by Succinylcholine
Succinyl choline No fade on train of four stimulation, no post tetanic
stimulation, train of four ratio >0.4
Train of fasciculation Scoline
Muscle relaxant increasing intracranial pressure Succinylcholine
A patient with myasthenia gravis who is Succinyl choline
managed on oral neostigmine can be
expected to have prolonged response to
Administration of succinylcholine to paraplegic, Hyperkalemia
appearance of dysrhythmia, conduction abnormalities,
finally cardiac arrest
Extensive soft tissue injury, muscle relaxant that may Succinylcholine
lead to cardiac arrest
Treatment of prolonged succinylcholine apnea due to Continue anesthesia and mechanical ventilation till
plasma cholinesterase deficiency recovery
Bradycardia is common after injection of Succinyl choline
Succinylcholine apnoea is due to Decreased pseudocholinesterase
Condition relatively resistant to muscle relaxation by Myasthenia gravis
suxamethonium
Train of four ratio >0.4
Time gap between supramaximal given in 0.5 sec
train of four stimuli
Phase II blocker Scoline
Muscle relaxant increasing intracranial tension Suxamethonium
Contraindication for succinyl choline Recent burns, recent cerebral stroke,
recent crush injury
Succinylcholine NOT contraindicated in Hepatic failure
Administration of succinylcholine in paraplegic cause Dangerous hyperkalemia
Hyperkalemia due to succinylcholine is NOT seen in Abdominal sepsis
Bradycardia is common after injection of Succinyl choline
Feature of depolarizing blockade Progression to dual blockade
In pseudocholinesterase deficiency, drug to be used Scoline
cautiously is
Pseudocholinesterase Succinylcholine is metabolized by it
Phase II blockade produced by Succinyl choline
Fasciculations with succinyl choline are Eyelids
first seen over
Scoline asphyxia is due to deficiency of Pseudocholinesterase
Shelf Life of Succinyl choline 2 years
First treatment for abnormal atypical Continue IPPV
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ANESTHESIOLOGY
pseudocholinesterase
FEATURES OF NON DEPOLARIZING MUSCLE BLOCKERS
Non depolarizing blockade is potentiated by Quinidine

Action of Non depolarizing muscle relaxants increased Hypothermia, Aminoglycosides, Halogenated
by inhalational agents
Drug depending on total body weight Succinyl choline
Long acting non depolarising muscle blocker Piperacuronium
Shortest acting Non depolarising muscle blocker Rapacuronium
Muscle most resistant to non depolarising block Diaphragm
Non depolarising blockers Competitive blocker of acetylcholine, Mg++ potentiates
the block, Ca++ antagonises the block, hypothermia
prolongs the block
Non depolarizing muscle relaxant Ganglion blockade, Histamine release, Interact with
antibodies
AV430A Gantacarium, steroidal muscle relaxation,
onset and duration is same as
suxamethonium, can be safely given in
trauma unlike suxamethonium
NOT an amino steroid derivative Alcuronium
D-TUBOCURARINE
Muscle relaxant causing jaundice as an adverse effect d-tubocurarine

d-tubocurarine acts at Myoneural junction
Tubocurarine action is easily reversed by Neostigmine
Antibacterial NOT to be used with d-tubocurarine Streptomycin
Drug used for d tubocurarine reversal Neostigmine
D- tubocurarine Excreted unchanged in kidney, causes hypotension by
ganglion blocking action, vagolytic action
d-tubocurarine acts by Inhibiting nicotinic receptors at myoneural junction
Tubocurare affects which muscle first Respiratory muscles
Skeletal muscle most sensitive to Muscles of jaw and larynx
tubocurare
Muscle least affected by d-tubocurare Diaphragm
First to recover after muscle relaxants Diaphragm
PANCURONIUM
Intubation dose of pancuronium 0.08 mg/kg

Conscious, alert, voluntary respiratory effort was Incomplete reversal of pancuronium
limited, BP and Heart rate normal
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ANESTHESIOLOGY
VECURONIUM
Vecuronium Short duration of neuromuscular block, in usual doses

the dose adjustment is not required to kidney disease,
has high lipophilic property
Vecuronium Low incidence of CVS side effect
Site of action of vecuronium Myoneural junction
MIVACURIUM
Mivacurium Slow onset of action, short duration of

action
Mivacurium Histamine Release
Degraded by Pseudocholinesterase Mivacurium
Shortest acting Non depolarising skeletal muscle Mivacurium
relaxant
Mivacurium Flushing, bronchospasm, increasing the dose produces
rapid onset of action
ATRACURIUM
Muscle Relaxant in Hepatic Failure Cis atracurium

Muscle Relaxant in Renal Failure Cis atracurium
Laudonosine is a breakdown product of Cisatracurium
Drug excreted by Hoffman elimination Atracurium
Patient recovered spontaneously from the effect of Atracurium
muscle relaxant without any reversal
Ideal muscle relaxant for a neonate undergoing Atracurium
portoenterostomy for biliary atresia
Hypersensitive to neostigmine, elective LSCS under Atracurium
general anesthesia
NOT eliminated by kidney Atracurium besylate
Muscle relaxation of choice for operating exstrophy Atracurium
Cisatracurium preferred over atracurium due to No histamine release
Seizures after atracurium infusion Due to accumulation of laudonosine
Hypersensitive to neostigmine, best muscle relaxant Atracurium
Drug inactivated in plasma by spontaneous non Atracurium
enzymatic degradation
GALLAMINE
Muscle relaxant contraindicated in renal failure Gallamine

Mainly excreted by kidney Gallamine
Muscle relaxant most sensitive to myasthenia gravis Gallamine
patient
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SPINAL, EPIDURAL AND CAUDAL ANESTHESIA and pain management 35
ANESTHESIOLOGY
ALCURONIUM
Drug causing anaphylactoid reaction Alcuronium

NOT a synthetic muscle relaxant Alcuronium
SPINAL, EPIDURAL AND CAUDAL ANESTHESIA AND PAIN

MANAGEMENT
SPLANCHNIC BLOCK
Naturally employed technique for Splanchnic block Braun’s method
NEURAXIAL BLOCKADE
Contraindications for neuraxial blockade Patient refusal, coagulopathy, severe hypovolemia,

patient on anticoagulants
Neuraxial blockade in NOT contraindicated in Pre existing neurological deficits
Centrineuraxial (spinal and epidural) anesthesia is NOT Patient on aspirin
contraindicated in
NOT a contraindication for neuraxial blockade Patient on antihypertensive medication
SPINAL ANESTHESIA
First spinal anesthesia Augustin Bier

Spinal puncture used to determine Spinal fluid pressure, types and number of cells present,
protein and sugar levels
Lumbar puncture is dangerous in Cerebral tumor
Subarachnoid space ends at S2
Yellow ligament Ligamentum flavus
Traumatic needle Quincke
Atraumatic needle Sprotte
Deposition of drug in spinal anesthesia Subarachnoid space
Level of Blockade in Spinal/Epidural anesthesia T12 – L2
Pierced during lumbar puncture Ligamentum flavum, Interspinous ligament,
Supraspinous ligament
Does NOT pierce lumbar puncture Posterior longitudinal ligament
High spinal anesthesia Hypotension and bradycardia
Anesthetic block injected for paravertebral block is least Subarachnoid space
likely to diffuse into
Spinal anesthesia injected into space between L3-L4
Structures pierced in lumbar spinal puncture Ligamentum flavum, duramater, supraspinous ligament
Structure NOT pierced in lumbar Posterior longitudinal ligament
puncture
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ANESTHESIOLOGY
Fibre lost first in spinal anesthesia Sympathetic

First blocked in spinal anesthesia Autonomic preganglionic
Last affected fibres in spinal anesthesia Pressure
Last to recover in spinal anesthesia Preganglionic autonomic
Brewer Luckhardt reflex in spinal Reflex hypotension due to pooling in
anesthesia spinal anesthesia
Spinal anesthesia Decline in cardiac output may occur following pooling
of blood in post arteriolar vessels
Feature of spinal anesthesia Autonomic level is 2 segments higher than
sensory which is 2 segments higher than
motor
Spinal anesthesia in children Can be given at any age, should be given
in lower space, preloading is not required
in children, chances of systemic toxicity is
high
Paramedian Spinal anesthesia prevents penetration of Supraspinous and Interspinous ligament
Duration of Spinal anesthesia depends on Site of Injection, Quantity of drug injected, Type of drug
used
Post spinal headache due to CSF leak
Spinal headache is due to Decreased CSF pressure
Post spinal headache can last for 7 days
Low incidence of post spinal headache with Thin needle
Post dural puncture headache Small bore needle prevents it, occurs immediately after
spinal anesthesia, occurs due to low CSF pressure
Post spinal headache CANNOT be decreased by Supplement of fluids
Post dural puncture headache is due to Seepage of CSF
Management of post dural spinal Extradural autologous blood
headache
Sudden aphonia and loss of consciousness during spinal Vasovagal attack
anesthesia
Best way to prevent hypotension during spinal Preloading with crystalloids
anesthesia
MC complication of spinal anesthesia Hypotension
NOT a management of hypotension during spinal Lowering head end
anesthesia
Management of hypotension due to subarachnoid block Administration of 1 L ringer lactate before block,
vasopressor drug like methoxamine, use of inotropics
like dopamine
Vasopressor of choice in hypotension produced during Ephedrine
subarachnoid block
NOT a contraindication for Spinal and epidural Hypertension
anesthesia
Maximum safe dose of lignocaine for spinal anesthesia 25 – 100 mg
Percentage of xylocaine in spinal 5%
anesthesia
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ANESTHESIOLOGY
EPIDURAL ANESTHESIA
Analgesia of choice in a pregnant woman with a cardiac Epidural Anesthesia

disease for LSCS
Epidural space lies between Dura and vertebral column
Site of action of epidural anesthesia Substantia gelatinosa
Touchy needle is for Epidural anesthesia
Methods of epidural anesthesia Loss of resistance technique, hanging drop
technique – Gutierrzer’s sign (sudden
sucking of drop in epidural space),
Durant’s sign – rapid injection of drug in
epidural space causes increase in rate and
depth of respiration, Westpal sign –
absence of knee jerk after epidural
anesthesia
In epidural anesthesia, features suggesting Loss of resistance sign, negative pressure
that the needle is in epidural space sign, mackintosh extradural space
indicator
Walking epidural Ultra low dose epidural used especially for
labor
Epidural anesthesia is preferred over Spinal anesthesia Dura is NOT penetrated
NOT a contraindication for epidural Previous MI
anesthesia
Epidural anesthesia is NOT indicated in Patients with hypovolemia
Complication of Epidural anesthesia Total Spinous analgesia
NOT a complication of epidural anesthesia DIC
NOT a complication of epidural anesthesia Headache
Does NOT increase ADH output Epidural and spinal anesthesia
During epidural anesthesia, sudden hypotension is due Drug has entered subarachnoid space
to
Epidural narcotic preferred over epidural LA because No motor paralysis
Drug used for epidural analgesia Morphine, Fentanyl
Epidural anesthesia in pregnancy Decrease venous return, venous pooling
Anesthetic of choice in epidural anesthesia during Bupivacaine
labour
NOT a complication of epidural anesthesia Hypertension
Epidural opioids Acts on dorsal horn substantia gelatinosa, may cause
pruritis, may cause respiratory depression
Epidural anesthesia Contraindicated in coagulopathies, venous return
decreases
Treatment of broken epidural catheter Can be left in situ
CAUDAL ANESTHESIA
Caudal block is a kind of Epidural block

Caudal block is commonly used in Children
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PAIN 38
ANESTHESIOLOGY
LSCS should NOT be carried out under Caudal anesthesia

Drug NOT given in central neuraxial Remifentanyl
block or caudal block
OTHER BLOCKS
A 20 year old boxer sustains a lip Mental nerve block

laceration during a practice match, the
wound is complex and crosses the
vermilion border. Best way to achieve
anesthesia
Site of phrenic nerve block 3 cm above clavicle at the posterior border
of sternomastoid
Site of block in thyroid surgery Upper cervical ganglion
Approach for inferior alveolar nerve block Approached lateral to pterygomandibular
raphe between buccinator and superior
constrictor
Nerves blocked in ankle block Superficial peroneal nerve, deep peroneal
nerve, saphenous nerve
Block for injury at medial aspect of foot Posterior tibial nerve
Advantages of ilioinginal block for Postoperative analgesia, allows
inguinal hernia maneuvers, avoid hypotension, no risk of
GA
PAIN
GENERAL FEATURES OF PAIN
Visceral pain Poor localization, Diffuse in nature, High threshold

NOT a feature of visceral pain Very rapid adaptation
Perception of ordinary non noxious stimuli as pain Allodynia
WHO 3 step ladder is used in management of Pain
Transcutaneous nerve stimulation to control pain by Gateway theory of pain
Neurochemical mechanism of analgesia VR-1, Nicotinic cholinergic, Nociception pattern,
Anandamide
ASSESSMENT OF PAIN
Pain rating index provided by McGill questionnaire

Best scale to measure pain in children of 5 years of age CHEOPS
Visual analogue scale most widely used to measure Pain intensity
CHEOPS for post operative pain in children. NOT include Oxygen saturation
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PAIN 39
ANESTHESIOLOGY
ANALGESIC DRUGS
Shortest acting intravenous analgesic Remifentanil

Remifentanyl is more potent than Alfentanyl
Narcotic of choice for outpatient anesthesia Alfentanyl
Analgesic property Ketamine, nitrous oxide
Least analgesic Halothane
Post thoracotomy pain managed by IV fentanyl
Management of chronic pain Intrathecal hyperbaric phenol, anterolateral cordotomy,
epidural fentanyl, patient controlled analgesia,
anticonvulsant drugs
Drug of choice for controlling severe pain in cancer Morphine
patients
More analgesic effect than morphine Heroin
Analgesic suited for hemodynamically unstable patients Fentanyl
Fentanyl Rapid onset and shortest duration of
action
Least likely to cause hypotension at Fentanyl
standard dose
Most potent analgesic Sulfentanyl
Most potent synthetic opioid Sulfentanyl
Pain during thoracotomy IV fentanyl
Drug for OPD analgesia Alfentanyl
Ketorolac Its analgesic efficacy is equal to morphine in
postoperative pain
Ketorolac tromethamine is useful as Non narcotic non steroidal
Tolerant to morphine, Pain management by Fentanyl
Longest acting analgesic in postoperative pain Opioids
Percentage of Sucrose for Analgesia 12 – 50%
Effective and safe drug for intractable pain in terminal Oral morphine
cancer stage
Analgesic effect is not mediated by opioid Nefopam
receptors in
Flupirtine Non opioid analgesic
Treatment for severe pain after thoracotomy Intercostal cryoanalgesia
Patient controlled anesthesia Can be given epidurally, intravenously,
suitable for children
Effect of chilling in refridgeration Interference with conduction of nerve
anesthesia impulse, reduction of metabolic rate and
oxygen requirement, inhibition of
bacterial growth and infection
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ANESTHESIOLOGY

ANESTHESIA IN HEAD INJURY ................................................................................................................................. 15

GENERAL FEATURES OF ANESTHETIC INSTRUMENTS

Rotameter Constant pressure, variable orifice, flow meter for gases

Pin index of nitrous oxide 3,5

Gas filled as liquid in cylinders CO2, N20, cyclopropane

ANESTHETIC MACHINES AND CIRCUITS

Anesthesia breathing circuit Cylinder is a part of high pressure system, O2 flush

Most efficient anesthetic circuit for GA with Mapleson A

OXYGEN CONTROL DEVICES

Assessment of oxygen in a cylinder attached to Bourdon pressure gauge

DEVICES FOR CO2 ABSORPTION

CuSO4 present in Amsorb

Normal dead space 30% of tidal ventilation

Anatomical dead space is increased by Atropine, Halothane, Inspiration

Size of endotracheal tube in 1 – 6 months 2 – 4 mm

LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION

High airway resistance seen in Main bronchus

Mallampatti classification is based on Opening of mouth

Surgery for extensive tracheal stenosis Grillo or Barclay procedure

Merits of nasotracheal intubation Good oral hygiene

LARYNGEAL MASK AIRWAY

Supraglottic type of airway management Laryngeal mask airway

Maximum vital capacity decreased in Trendelenberg position

GENERAL FEATURES OF MONITORING DURING ANESTHESIA

Individual operative awareness by Bispectral imaging

Oxygen saturation is measured by Pulse oximeter

CENTRAL VENOUS PRESSURE MONITORING

MC vein for CVP monitoring Right Internal Jugular Vein

PULMONARY ARTERY CATHETER

Capnography is based on Luft principle

End tidal CO2 decreased during surgery Air embolism

NOT a common cause of respiratory distress in post Mild hypovolemia

Does NOT trigger malignant hyperthermia N2O

INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS

Normal urine output 1 ml/kg/hr

Intraocular pressure is lowered by Morphine, Thiopentone, Halothane

Fifth vital sign Pain

Mendelson syndrome Aspiration of gastric contents

Hypothermia is used in Hyperpyrexia, prolonged surgeries

Anesthesia W.G.Morton (1846)

Stage II of surgical ether anesthesia Loss of consciousness to beginning of spontaneous

POSSIUM scoring system for Anesthesia

Clopidogrel should be stopped 1 day before surgery

Method of choice for induction in children Inhalational > intravenous

ANESTHESIA IN HEAD INJURY

RTA , head injury used for induction Thiopentone

Anesthesia for pregnant woman with coarctation of General anesthesia

Preferred for maintenance of anesthesia

Anesthesia of choice in infected tooth posted for Enflurane

NOT a cause of decreased anesthetic requirement Increased lumbar lordosis

Anesthesia in total hip replacement Combined spinal and epidural

Safest to use in asthmatic Chloral hydrate

breath is dangerous since dangerous level

DAY CARE ANESTHESIA

Most preferred for day care surgeries Propofol, fentanyl, isoflurane

GENERAL FEATURES OF ANESTHETIC DRUGS

Drugs interfering in anesthesia Calcium channel blockers, beta blockers,

Dexmedetomidine Alpha 2 agonist, anxiolytic, hypnotic, used

MINIMUM ALVEOLAR CONCENTRATION

MAC is an indicator of Potency

Partition coefficient of gas Measures solubility

GENERAL FEATURES OF INHALATIONAL ANESTHETICS