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Agents Used for maintaining anesthesia (or induction in pediatrics). All bronchodilate (except desflurane which can cause bronchospasm) and are not metabolized by the body (except halothane). All (except nitrous oxide) can trigger malignant hyperthermia (MH). Minimal alveolar conc: 1 MAC = conc of volatile needed to achieve no response to surgical stimulus in 50% of pts Halothane (MAC=0.8): slowest onset but highest potency, nonirritating (used for inhalational induction) Isoflurane (MAC=1.5): slow onset, irritating, preserves renal, hepatic, coronary, and cerebral blood flow Sevoflurane (MAC=2.2): nonirritating (used for inhalational induction), rapid onset but expensive Desflurane (MAC=6): rapid onset/offset, irritating, requires special vaporizer due to high vapor pressure Nitrous oxide (MAC=104): fastest onset, lowest potency, cheap, decreases requirement of other volatiles Induction Agents Most potentiate GABAA inhibitory receptors in the CNS Propofol: dec N/V, myocardial depression, vasodilation Etomidate: painful injection, minimal depression of cardiopulm fxn (ideal for CVD pt), adrenal suppression Thiopental: dec cerebral O2 consumption, neuroperfusion maintained (ideal for neurosurg), cardiopulm depression Ketamine: antag NMDA receptor, inc cardiac demand and secretions, works IV/PO/PR/IM, emergence delirium in pedi Midazolam: premedication for sedation/anxiolysis, cardiopulm depression (like other BDZs) Neuromuscular Blocking Agents (NBMAs) NMBAs facilitate intubation and provide optimal relaxation. Depolarizing: succinylcholine (hyperK+, MH, inc ICP) Non-depolarizing: rocuronium, pancuronium, cis-atracurium (varying pharmacokinetics, reversible by anticholinesterases) Local Anesthetics Bind to Na+ channel in inactivated state, no threshold potential reached, affects rapid firing nerves first (myelin >>> unmyelin) Amides: Two is in name (ie, lidocaine, prilocaine, bupivacaine), hepatic metabolism Esters: One i in name (ie, novacaine, procaine, tetracaine), metabolized by plasma esterases, PABA metabolite allergy Opioids (potency relative to morphine) Agonize opioid receptors (namely , , ) Sufentanil (1000x) > remifentanil (300x) > fentanyl (100x) > alfentanil (15x) > morphine (1x) > meperidone (0.1x) Can cause resp depress, urinary retention, N/V, constipation Reversal Agents Acetylcholinesterase inhibitors: neostigmine, physostigmine Anticholinergic: glycopyrrolate (prevents bradycardia during reversal, decreases secretions)

Other Topics Laryngeal mask airway (LMA): tube attached to inflatable cuff which surrounds glottic structures and provides a patent, supraglottic airway for ventilation Rapid Sequence Intubation (RSI): For anyone at risk for aspiration - difference is no mask ventilation after induction (could introduce air into GI tract leading to vomiting). Paralyze and immediately intubate. - Preoxygenate for 3 minutes at 100% O2. - Pretreat with opioids to reduce sympathetic response to intubation. Also give reglan/bicitra to reduce risk of gastric aspiration syndrome. - IV induction followed by NMBA (ie, rocuronium) - Intubate, verify placement, and secure ETT Nasogastric/Orogastric Tube (NGT/OGT) Placement: Used for gastric lavage and/or decompression - Measure tube from nose to earlobe and then to point midway between xyphoid and umbilicus. Mark length with tape. - Nasal insertion (NGT): lubricate tip, direct tube along nasal floor to posterior pharynx, then direct tube downwards. Oral insertion (OGT): Direct tube to back of tongue and then downwards - Advance tube till tape mark is at nostril (NGT) or lip (OGT). If tube meets resistance or fogs with coughing (possible tracheal intubation), retract tube and readvance. - Confirm placement by aspiration of gastric fluid or injecting 10-20cc air with subsequent whoosh auscultated over stomach. Tape tube in place once placement confirmed. Credits - Clinical Anesthesia, Barash (5th Ed) - Anesthesia Secrets , Duke (4th Ed) - Basics of Anesthesia, Miller (6th Ed) - Pocket Clinician Manual of Anesthesia Practice, Pardo (1st Ed) - The Medical Students Anesthesia Pocketbook University of Texas Health Science Center Houston

Anesthesiology Basics for Medical Students

Pre-Operative History Focus on the organ systems at risk for complications from anesthesia as well as upper/lower airways. CAD (quantify exertion, ie flights of stairs), HTN (controlled?), hepatic or renal dz, endocrine (DM control, steroid use, thyroid) GERD, smoking/EtOH/drugs, FHx (malignant hyperthermia or pseudocholinesterase deficiency), surgical/anesthesia hx (complications? difficult intubation?), last meal, medications, allergies Pre-op labs: ECG, CXR, PFTs, H&H, coags, electrolytes, UPT Pre-Operative Physical Exam Special emphasis on neck/airway: facial trauma, neck range of motion, micrognathia, macroglossia, deviated septum/polyps, TMJ mobility, dentition, thyromental distance (thyroid cartilage to mandibular mentum with neck in full extension) ASA Physical Status Classification System: ASA 1 normal, healthy pt ASA 2 mild systemic dz ASA 3 severe systemic dz ASA 4 severe dz threat to life ASA 5 not expected to survive without operation Mallampati Scoring (1 to 4 from L to R) and Airway Grades

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Class 1: Full tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only hard palate visible

Invasive Monitoring Transesophageal echo (TEE): assess wall motion abnl, EF, intracardiac air; used in CABG, thoracic aorta or valvular surgeries, lung transplant, tamponade, major thoracic trauma Arterial line (A-line): allows beat-to-beat BP monitoring and easy arterial access (ie, for frequent ABGs) Central venous line: monitor intravascular volume and RV fxn Pulmonary artery (PA) catheter: measures RAP, PA, wedge pressure (LVEDP), CO, and PvO2

Preoxygenation Using the thumb and index finger of each hand, create two semicircles around the mask ensuring it fits over the pts mouth and nose. Place remaining fingers along mandible and lift chin to form tight seal. MAINTAIN THE SEAL! Proper preoxygenation (SaO2 100%, end tidal O2 > 80%) allows up to six minutes of apnea more time for you to secure the airway.

A neuromuscular blocking agent (NMBA) like succinylcholine (depolarizing) or rocuronium (non-depolarizing) is given next. Muscle relaxation takes place (flaccid jaw, decreased TOF twitches). Proceed to intubation if instruments are ready. Endotracheal Tube (ETT) Intubation Start by holding either the curved Mac or straight Miller laryngoscope in your left hand (regardless of handedness). Using your right thumb and index finger in a scissor-like fashion to open the pts mouth. Tilting the head back can help.

Intraoperative Assessment ASA Monitoring Standards: Oxygenation (inspired O2, pulse ox), ventilation (end-tidal CO2, chest excursion), circulation (continuous EKG, HR, BP, palpable pulses), and temperature (probe) are continuously monitored in every anesthetic. Train of Four (TOF): Four sequential stimuli at 2Hz over peripheral nerve. Compare amplitude of 4th vs 1st twitch. Highly subjective (over underestimates NMJ blockade). As blockade deepens, lose earlier twitches (ie, twitch 4 is lost first, twitch 1 is last)

Carefully insert the laryngoscope into the right side of the pts mouth, advance it to the epiglottis, and sweep the tongue to the left. If using the curved Mac blade, advance further into the vallecula. Lift the laryngoscope using your upper-arm (no rotational motion of the wrist should occur) towards the juncture of the opposite wall and ceiling. Look for the vocal cords (typically white) with attached vestibular folds and arytenoid cartilage. This is different from the esophagus which is, more or less, a large hole with no defining characteristics.

IV Induction Induction choices include propofol, etomidate, ketamine, thiopental; assess anesthesia by brushing eyelashes and looking for eyelid motion (lash reflex).

Once the cords are visualized, do not lose your view! Have an assistant pass the ETT tube to you and carefully insert it between the cords until the balloon is no longer visible. Remove the laryngoscope, remote the stylet from the ETT, inflate the balloon cuff, attach the ETT to the circuit, confirm placement (bilateral breath sounds, fogging of the tube, end- tidal CO2), and tape in place.

Capnography : A-B - exhalation of CO2 from dead space; B-C combination of dead space and alveolar gas; C-D exhalation of mostly alveolar gas; D end tidal point; D-E: inhalation of CO2 free gas Anesthesia Reversal As case nears completion, TOF used to assess spontaneous recovery from non-depolarizing NMBA. Lack of twitches indicates blockade is still too intense to reverse Even with return of spontaneous breathing and all four twitches on TOF, pt may still have 75% of NMJ receptors blocked. Ultimately reverse with anticholingeric (neostigmine) and glycopyrrolate (an anticholingeric which prevents bradycardia from excess muscarinic activity) Extubation Criteria VSS, purposeful movement, spontaneous respirations > 8/min, negative inspiratory force (NIF) < -20 Rapid shallow breathing index (RSBI)=(RR)/(tidal V in liters) Goal is RSBI < 100 breaths/min/L