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The Medical Students Anesthesia

Pocketbook
University of Texas Health Science Center Houston
Table of Contents
ACKNOWLEDGEMENTS...........................................................................................................................2
ANESTHESIA OVERVIEW.........................................................................................................................3
INTRODUCTION...........................................................................................................................................3
PREOPERATIVE HISTORY AND PHYSICAL.................................................................................................3
IVS AND PREMEDICATION.........................................................................................................................
ROOM SETUP AND MONITORS...................................................................................................................
INDUCTION AND INTUBATION.....................................................................................................................!
MAINTENANCE.........................................................................................................................................."#
EMERGENCE..............................................................................................................................................""
PACU CONCERNS......................................................................................................................................"$
COMMONLY USED MEDICATIONS......................................................................................................13
VOLATILE ANESTHETICS.........................................................................................................................."3
IV ANESTHETICS......................................................................................................................................."%
LOCAL ANESTHETICS..............................................................................................................................."&
OPIOIDS....................................................................................................................................................."&
MUSCLE RELAXANTS................................................................................................................................"
REVERSAL AGENTS/ ANTICHOLINERGICS..............................................................................................."
PHARM CHARTS.......................................................................................................................................18
INHALATIONAL ANESTHETICS.................................................................................................................."'
MAC.........................................................................................................................................................."'
INTRAVENOUS ANESTHETICS...................................................................................................................."!
IV FLUIDS....................................................................................................................................................2
ASA CLASSIFICATION.............................................................................................................................21
MALLAMPATI CLASSIFICATION.........................................................................................................22
!UICK REFERENCE/REVIEW...............................................................................................................23
PROCEDURE CHECKLIST......................................................................................................................2"
INTUBATION...............................................................................................................................................$(
IV LINE PLACEMENT.................................................................................................................................$(
BAG MASK VENTILATION........................................................................................................................$(
VENTILATOR SETTINGS............................................................................................................................$'
ARTERIAL LINE PLACEMENT...................................................................................................................$'
CENTRAL LINE PLACEMENT....................................................................................................................$'
SPINAL.......................................................................................................................................................$!
EPIDURAL..................................................................................................................................................$!
RESOURCES................................................................................................................................................3
NOTES...........................................................................................................................................................31
C#$%&'()%#&*: Trent Bryson MS4, Tanner Baker MS4, Claudia Moreno MS4,
Darrell Wilcox MS3, and Allison DeGreeff MS3
Ackno)led*e+ents
,e the contributors )ould first and fore+ost like to thank the faculty at the University of
Texas at Houston for their su--ort. *uidance. and teachin*s in hel-in* us create this
-ocket book. ,e )ould also like to thank the residents for their contributions to our
learnin* and skill develo-+ent as )ell as in hel-in* us revise the content to be as
detailed. succinct. and accurate as -ossible.
$
Anesthesia /vervie)
Ada-ted fro+ 0A Medical Students Anesthesia Pri+er1 by 2oy 3. Soto. M4 5roysoto6ucla.edu7
I$%&#+),%'#$
8n +any -ro*ra+s across the country. +edical students are only ex-osed to t)o )eeks of
anesthesiolo*y durin* their third or fourth year. The student often attends daily lectures
and +i*ht be told to 9read Miller:s ;asics of Anesthesia9. but often by the ti+e the
student has finally fi*ured out )hy )e are doin* )hat )e:re doin*. the rotation is over.
and he or she leaves )ith only a +ini+u+ of anesthesia kno)led*e.
This -ri+er is intended to *ive a brief overvie) of )hat )e do. )hen )e do it. and )hy
)e do it for standard. unco+-licated cases ... the ty-es that you are bound to see durin*
your rotation. ;y no +eans is the infor+ation contained co+-rehensive. or intended to
allo) you to -ractice anesthesia solo. but it is intended to *ive an overvie) of the 9bi*
-icture9 in a for+at that can be <uickly read in one sittin*. and then referred to as needed.
=ee- in +ind that there are +any )ays to acco+-lish the sa+e thin* in anesthesia. and
you )ill undoubtedly see techni<ues that differ fro+ )hat )e:ve )ritten here. but our
*oal a*ain is to -resent you )ith a si+-le overvie).
Anesthesia is a challen*in* and excitin* s-ecialty. but can also be extre+ely frustratin* if
not tau*ht clearly durin* the short ex-osure that +any +edical students *et to the field.
P&-#.-&/%'0- H'*%#&1 /$+ P21*',/3
Unlike the standard internal +edicine H>P. ours is +uch +ore focused. )ith s-ecific
attention bein* -aid to the air)ay and to or*an syste+s at -otential risk for anesthetic
co+-lications. The ty-e of o-eration and the ty-e of anesthetic )ill also hel- to focus the
evaluation.
/f -articular interest in the history -ortion of the evaluation are?
Coronary Artery Disease @ ,hat is the -atient:s exercise toleranceA Ho) )ell )ill his or
her heart sustain the stress of the o-eration and anestheticA Askin* a -atient ho) he feels
5i.e. S/;. CP7 after cli+bin* t)o or three fli*hts of stairs can be very useful as a 9-oor
+an:s stress test9.
Hypertension @ Ho) )ell controlled is itA 8ntrao-erative blood -ressure +ana*e+ent is
affected by -reo-erative blood -ressure control.
Ast!a @ Ho) )ell controlled is itA ,hat tri**ers itA Many of the stressors of sur*ery as
)ell as intubation and ventilation can sti+ulate bronchos-as+. 8s there any history of
bein* hos-italiBed. intubated. or -rescribed steroids for asth+aA This can hel- assess the
severity of disease.
"idney or #i$er disease @ 4ifferent anesthetic dru*s have different +odes of clearance
and or*an function can affect our choice of dru*s.
3
%eflux Disease @ Present or notA AnesthetiBed and relaxed -atients are -rone to
re*ur*itation and as-iration. -articularly if a history of reflux is -resent. This is usually
an indication for ra-id se<uence intubation 5succinylcholine C cricoid -ressure7.
S!okin& @ Currently s+okin*A Air)ay and secretion +ana*e+ent can beco+e +ore
difficult in s+okers.
Alcool Consu!ption or Dru& A'useA @ 4rinkers have an increased tolerance to +any
sedative dru*s 5conversely they have a decreased re<uire+ent if drunk7. and are at an
increased risk of he-atic disease. )hich can i+-act the choice of anesthetic a*ents.
Dndocrine?
Steroids E -atients )ith recent steroid use +ay re<uire -reo-erative steroids to cover
secondary adrenal su--ression.
Dia'etes @ ,ell controlledA The stress res-onse to sur*ery and anesthesia can +arkedly
increase blood *lucose concentrations. es-ecially in diabetics.
Tyroid E Hy-oFHy-er +etabolic states affect the cardiovascular syste+. renal clearance.
and ther+ore*ulation.
Medications @ Many +edications interact )ith anesthetic a*ents. and so+e should be
taken on the +ornin* of sur*ery 5blood -ressure +edications7 )hile others should
-robably not 5diuretics. diabetes +edications7.
Aller&ies @ ,e routinely *ive narcotics and antibiotics -erio-eratively. and it is i+-ortant
to kno) the ty-es of reactions that a -atient has had to +edications in the -ast. The G"
anesthesia aller*en is the non@de-olariBin* -aralytics. The G$ class is antibiotics.
(a!ily History @ There is a rare. but serious disorder kno)n as 4/3'5$/$% 21.-&%2-&4'/
that affects susce-tible -atients under anesthesia. and is heritable. Another heritable
disorder is .*-)+#,2#3'$-*%-&/*- +-6','-$,1 )hich affects succinylcholine duration and
+ay re<uire extended -osto-erative ventilation.
Anestesia istory @ Has the -atient ever had anesthesia and sur*ery beforeA 4id anythin*
*o )ron*A
#ast Meal @ ,hether the -atient has an e+-ty sto+ach or not i+-acts the choice of
induction techni<ue 5another indication for ra-id se<uence intubation7.
,hile a history of a difficult intubation +ay be the +ost reliable -redictor of future
difficult intubations. the -hysical exa+ is also i+-ortant to hel- -redict -otential
-roble+s. Hor the -hysical exa+. the s-ecific areas )hich are of -articular i+-ortance to
the anesthesiolo*ist include the cardiovascular syste+. lun*s. headFneckFu--er air)ay.
si*ns of -reexistin* neurolo*ical dysfunction. and si*ns of coa*ulation dysfunction.
Many tests have been -ro-osed to hel- -redict difficulty )ith intubation. but no sin*le
factor. taken inde-endently. has been able to acco+-lish this *oal. Ho)ever. )hen
%
+ulti-le factors are taken to*ether. the -redictive value is increased. The follo)in* so+e
s-ecific as-ects of the headFneckFu--er air)ay exa+ )hich can be used to hel- -redict
difficulties that +ay be encountered.
HeadFIeckFU--er Air)ay exa+
(acial trau!a or defor!ities@ +ay +ake it difficult to -erfor+ laryn*osco-y.
De$iated septu! or nasal polyps@ can -ose difficulty )ith nasal intubation or )ith
insertin* a naso*astric tube. -ossibly resultin* in bleedin*.
)eck ran&e of !otion@ the -atient needs to be able to assu+e the sniffin* -osition
5cervical flexion and atlanto@occi-ital extension7 so that the oral. -haryn*eal. and
laryn*eal axes are ali*ned )hich )ill facilitate vie)in* the *lottic o-enin*. Ior+al
-atients should achieve 3& de*rees or +ore of atlanto@occi-ital extension. )hich can
assessed by observin* the an*le traversed by the occlusal surface of the +axillary teeth
)hen the head is fully extended fro+ the neutral -osition. 4ifficulty )ith intubation +ay
be -redicted by a si*nificant reduction in the ability to achieve this de*ree of extension or
if the -atient ex-eriences any -ain. tin*lin*. or nu+bness durin* this +ove+ent.
TM* !o'ility and de&ree of !out openin&@ this is i+-ortant for deter+inin* the
ade<uacy of s-ace for +ani-ulatin* the laryn*osco-e and endotracheal tube. Measure
the inter@incisor distance. An o-enin* of J 3 c+ or $ fin*er breadths )ill likely not
-rovide ade<uate s-ace and +ay result in a difficult intubation. 8n addition. ask the
-atient to +ove the lo)er incisors as hi*h on the u--er li- as -ossible 5u--er li- bite test7.
8f the lo)er incisors do not reach the ver+ilion border of the u--er li-. this +ay be a si*n
of inade<uate translational +ove+ent of the TMK. )hich is also necessary for successful
laryn*osco-y.
Dentition@ 8t is i+-ortant to note the -resence of dentures. -oor dentition. loose teeth. or
ca-s. )hich +ay not tolerate di*ital +ani-ulation or +ay be at risk of da+a*e )hen the
laryn*osco-ic blade is inserted into the +outh. 4entures should be re+oved before
sur*ery. 8n addition. the -resence of -ro+inent +axillary incisors +ay result in
obstruction of the vie) of the *lottis. Conversely. edentulous -atients are *enerally easy
to intubate. but +ay -ose difficulty )ith +ask ventilation.
Ton&ue+,roparynx@ 4irect laryn*osco-y allo)s visualiBation of the larynx by dis-lacin*
the ton*ue anteriorly into the +andibular s-ace. )hich +oves the ton*ue out of the line
of si*ht. A nor+al siBed ton*ue )ill *enerally fit easily into the s-ace bet)een the t)o
+andibular ra+i. Ho)ever. if the ton*ue is too lar*e 5+acro*lossia7 or the +andible is
too s+all 5+icro*nathia7. there )ill likely be difficulty )ith -ro-er visualiBation of the
*lottis. The Malla+-ati classification is a +ethod to assess the ton*ue siBe in relation to
the siBe of the oro-harynx. The test is -erfor+ed by havin* the -atient sit )ith their head
in the neutral -osition. and then o-en their +outh as )ide as -ossible and -rotrude the
ton*ue as far as -ossible. They should not -honate. as this can elevate the soft -alate and
alter the vie). A Class 3 or % vie) +ay be associated )ith difficult laryn*osco-y.
&
The siBe of the +andible can be assessed by +easurin* the thyro+ental distance. This is
the distance fro+ the +entu+ of the +andible to the thyroid cartila*e. A thyro+ental
distance of c+ 5a--roxi+ately 3 fin*er breadths7 or less. as often seen in -atients )ith a
recedin* +andible or a short neck. +ay indicate a -ossible difficult intubation.
Alternatively. the sterno+ental distance 5fro+ +entu+ to sternal notch7 can also be used.
)hich assesses the siBe of the +andible and neck. A sterno+ental distance of J "3 c+
+ay also -oint to difficulty )ith intubation.
Hinally. a -hysical status classification is assi*ned. based on the criteria of the A+erican
Society of Anesthesiolo*ists 5ASA"@&7. )ith ASA@" bein* assi*ned to a healthy -erson
)ithout +edical -roble+s other than the current sur*ical concern. and ASA@& bein* a
+oribund -atient. not ex-ected to survive for +ore than t)enty four hours )ithout
sur*ical intervention. An 9D9 is added if the case is e+er*ent. The full details of the
classification scale are also detailed later.
IV* /$+ P&-4-+',/%'#$
The t)o skills you should take the o--ortunity to -ractice )hile on your rotation are 8L
insertion and air)ay +ana*e+entFintubation. Dvery -atient 5)ith the exce-tion of so+e
children that can have their 8L:s inserted follo)in* inhalation induction7 )ill re<uire 8L
access -rior to bein* brou*ht to the o-eratin* roo+. The key to success )ith 8L
-lace+ent is -re-aration and -atience. All of us have successfully found and cannulated a
vein. only to find that )e left the ba* of 8L fluid or the ta-e across the roo+. Ior+al
saline. Mactated 2in*er:s solution. or other balanced electrolyte solutions 5Plas+alyte.
8solyte7 are all co++only used solutions intrao-eratively.
Many -atients are understandably nervous -reo-eratively. and )e often -re+edicate
the+. usually )ith a ra-id actin* benBodiaBe-ine such as intravenous +idaBola+ 5)hich
is also fabulously effective in children orally or rectally7. Metoclo-ra+ide. ;icitra. andFor
an H$ blocker are also often used if there is a concern that the -atient has a full sto+ach.
and anticholiner*ics such as *lyco-yrrolate can be used to decrease secretions.
R##4 S-%). /$+ M#$'%#&*
;efore brin*in* the -atient to the roo+. the anesthesia +achine. ventilator. +onitors. and
cart +ust be checked and set u-. The anesthesia +achine +ust be tested to ensure that the
*au*es and +onitors are functionin* -ro-erly. that there are no leaks in the *as delivery
syste+. and that the backu- syste+s and fail@safes are functionin* -ro-erly.

The +onitors that )e use on +ost -atients include the -ulse oxi+eter. blood -ressure
+onitor. and electrocardio*ra+. all of )hich are ASA re<uire+ents for -atient safety.
Dach are checked and -re-ared to allo) for easy -lace+ent )hen the -atient enters the
roo+. Nou +ay see so+e +ore co+-licated cases that re<uire +ore invasive +onitorin*
such as arterial or central lines.
8n the o-eratin* roo+. the anesthesia +achine can su--ort non@invasive and invasive
+onitors. ,hile in the +aOority of cases. non@invasive +onitorin* is sufficient. exa+-les
and indications of invasive +onitors include?
Arterial lines for continuous blood -ressure +onitorin* E usually radial. but can
be brachial. fe+oral. etc.
o Used in any case )here )ide s)in*s in blood -ressure are ex-ected.
)here ti*ht control of blood -ressure is needed. in cardio-ul+onary
by-ass cases. or )hen there )ill be the need for +ulti-le blood *as
analyses.
Central venous lines for +easurin* CLP@ ty-ically 8K or subclavian
o Used in any case )hen there is the need to closely +onitor the
intravascular volu+e status or there is a need to evaluate ri*ht ventricular
function.
Pul+onary artery catheter for +easurin* ,ed*e -ressure 5MLD4P7
o Used to deter+ine 2AP. PA. MLD4P. C/. and Pv/$. These +easure+ents
are hel-ful )hen faced )ith -oor left ventricular function. valvular
disease. recent M8. A24S. +assive trau+a. +aOor vascular sur*eries. or
)hen there is a critical need to accurately assess the intravascular fluid
volu+e or the res-onse to blood -ressure interventions.
Transeso-ha*eal echo 5TDD7 E used in +any CL cases
o Used to evaluate re*ional )all +otion abnor+alities indicative of
+yocardial ische+ia. to evaluate stroke volu+eFeOection fraction. to
evaluate cardiac valvular function. to look for intracardiac air. to +onitor
chan*es in cardiac function. or to evaluate ade<uacy of intravascular fluid
volu+e.
The anesthesia cart is set u- to allo) easy access to intubation e<ui-+ent includin*
endotracheal tubes. laryn*osco-es. stylets. oralFnasal air)ays and the +yriad of dru*s
that )e use daily. A -ro-erly functionin* suction syste+ is also vital durin* any ty-e of
anesthetic.
(
,hen it co+es to dra)in* u- the initial dru*s. there are % cate*ories of dru*s that should
be ready for each case? induction a*ents. sedationFanal*esia dru*s. reversal a*ents. and
e+er*ency dru*s. At ti+es. the s-ecific dru*s +ay vary de-endin* on the case. but the
follo)in* are +ost co++only used. The first 3 cate*ories should be dra)n u- in
-re-aration for the case. but the e+er*ency dru*s are often already -re-ared.
-nduction A&ents
Midocaine 5"P7 5"#+*F+M7 E 4ra) u- in a &cc syrin*e
Pro-ofol 5"#+*F+M7 E 4ra) u- in a $#cc syrin*e
2ocuroniu+ 5"#+*F+M7 E 4ra) u- in a &cc syrin*e
Sedation+Anal&esia Dru&s
Lersed 5"+*F+M7 E 4ra) u- in 3cc syrin*e
Hentanyl 5&#+c*F+M7 E 4ra) u- in &cc syrin*e
%e$ersal A&ents
Ieosti*+ine 5"+*F+M7 E 4ra) u- in &cc syrin*e
3lyco-yrrolate 5#.$+*F+M7 E 4ra) u- in &cc syrin*e
.!er&ency Dru&s 5QAt Her+ann. these dru*s are already -re-ared and should be found
in -lastic ba*7
QPhenyle-hrine 5"##+c*F+M7 E 8n "#cc syrin*e
QD-hedrine 5&+*F+M7 E 8n "#cc syrin*e
QSuccinylcholine 5$#+*F+M7 E 8n "#cc syrin*e
Atro-ine "+*F+M E 8n 3cc syrin*e

/ther -re-arations that can be done before the case focus on -atient -ositionin* and
co+fort. since anesthesiolo*ists ulti+ately are res-onsible for intrao-erative -ositionin*
and resultant neurolo*ic or skin inOuries. Heel and ulnar -rotectors should be available. as
should axillary rolls and other -ads de-endin* on the -osition of the -atient.
'
I$+),%'#$ /$+ I$%)(/%'#$
Nou no) have your sedated -atient in the roo+ )ith his 8L 5*ender selected at rando+ ...
you *enerally anesthetiBe +en and )o+en the sa+e7. and he:s co+fortably lyin* on the
o-eratin* table )ith all of the afore+entioned +onitors in -lace and functionin*. 8t is
no) ti+e to sto) your tray tables and brin* your seats to the full u-ri*ht -osition.
because it:s ti+e for take@off. 8ndeed. +any -eo-le co+-are anesthesia )ith flyin* an
aircraft since the take@off and landin* can be <uite rocky at ti+es )hereas the actual
flyin* can see+ like s+ooth sailin*.
The first -art of induction of anesthesia should be -re@oxy*enation )ith "##P oxy*en
delivered via a face +ask. The *oal should be an end@tidal oxy*en concentration of +ore
than '#P. a Sa#$ of "##P. or lackin* end tidal *as +onitorin*. at least four full tidal
volu+e breaths )ith a ti*ht fittin* +ask. Perfor+in* a 0Oa) thrust1 or 0chin lift1 )ill
o-ti+iBe the -atients air)ay for ba* +ask ventilation.
The reason )e -re@oxy*enate -rior to induction and intubation is to +axi+iBe the a+ount
of ti+e a -erson can tolerate a-nea )ithout desaturatin*. This translates to +ore ti+e
available to secure the air)ay. )hich is very i+-ortant if the -atient turns out to have an
unantici-ated difficult air)ay. ,hen breathin* sto-s. the bodys oxy*en stores are
li+ited to the oxy*en in the blood and the oxy*en in the lun*s. A nor+al -erson uses
a--roxi+ately $&#@3## +M of oxy*en each +inute and can desaturate in as little as 3# E
# seconds of a-nea. ,ithin the lun*s. the functional residual ca-acity 5H2C7 is
a--roxi+ately 3 liters in a nor+al -erson. ,hen breathin* roo+ air 5$"P /$7. the H2C
contains +ostly nitro*en and a relatively s+all a+ount of oxy*en. Ho)ever. )hen
breathin* "##P /$. this effectively re-laces the nitro*en )ith oxy*en )ithin the H2C and
creates a tre+endous additional reserve of oxy*en that can be used by the body. This -re@
oxy*enation can -rovide 3 E additional +inutes of a-nea before si*nificant /$
desaturation occurs.
A*ain. usin* the exa+-le of a nor+al s+ooth induction in a healthy -atient )ith an
e+-ty sto+ach. the next ste- is to ad+inister an 8L. anesthetic until the -atient is
unconscious. A useful *uide to anesthetic induction is the loss of the lash reflex. )hich
can be elicited by *ently brushin* the eyelashes and lookin* for eyelid +otion. Patients
fre<uently beco+e a-neic after induction and you +ay have to assist ventilation. The
+ost co++on choices used for 8L induction. -robably in order of fre<uency. are
Pro-ofol. Thio-ental. Dto+idate. and =eta+ine.
Assu+in* that you are no) able to +ask ventilate the -atient. the next ste- is usually to
ad+inister a neuro+uscular blockin* a*ent such as succinylcholine 5a de-olariBin*
!
relaxer7 or vecuroniu+ 5or any of the other @oniu+s or @uriu+s. )hich are all non
de-olariBin* relaxers7. A t)itch +onitor is usually used to ascertain de-th of relaxation.
and )hen the t)itch has sufficiently di+inished. intubation can be atte+-ted. Iote that
the above induction a*ents usually last for less than ten +inutes. so +any of us )ill turn
on a volatile anesthetic a*ent )hile )e are +ask ventilatin* and )aitin* for the +uscle
relaxant to take effect. Try to kee- a *ood +ask seal so you don:t anesthetiBe yourself ...
/nce the -atient is ade<uately anesthetiBed and relaxed. it:s ti+e to intubate. assu+in*
you have all necessary su--lies at the ready. Hold the laryn*osco-e in your left hand
5)hether you:re ri*ht or left handed7 then o-en the -atient:s +outh )ith your ri*ht hand.
either )ith a head tilt. usin* your fin*ers in a scissors +otion. or both. 8nsert the
laryn*osco-e carefully and advance it until you can see the e-i*lottis. s)ee-in* the
ton*ue to the left. Advance the laryn*osco-e further into the vallecula 5assu+in* you:re
usin* a curved Macintosh blade7. then usin* your u--er ar+ and I/T your )rist. lift the
laryn*osco-e to)ard the Ouncture of the o--osite )all and ceilin*. There should be no
rotational +ove+ent )ith your )rist. as this can cause dental da+a*e. ,hen -ro-erly
done. the blade should never contact the u--er teeth. /nce you see the vocal cords. insert
the endotracheal tube until the balloon is no lon*er visible. then re+ove the
laryn*osco-e. hold the tube ti*htly. re+ove the stylet. inflate the cuff balloon. attach the
tube to your circuit and listen for bilateral breath. 8f you have chest rise )ith ventilation.
+istin* of the endotracheal tube. bilateral breath sounds and end tidal C#$. you:re in the
ri*ht -lace and all is )ellR Ta-e the tube securely in -lace. -lace the -atient on the
ventilator. and set your *as flo)s a--ro-riately.
M/'$%-$/$,-
As )ith flyin* an air-lane. the +aintenance -ortion of anesthesia can be very s+ooth. but
)hen thin*s *o )ron*. they can *o very )ron* very <uickly. Therefore it is vital to
continually +onitor blood -ressure. -ulse. D=3. #$ saturation. te+-erature. end@tidal #$.
C#$. I$#. and volatile a*ent levels. -resence or absence of t)itch. and -atient -osition.
as -ositionin* chan*es can occur )ith table +ove+entFtilt 5or sur*eon in-ut7.
8t is also vital to -ay attention to the case itself. since blood loss can occur very ra-idly.
and certain -arts of the -rocedure can threaten the -atient:s air)ay. es-ecially durin* oral
sur*ery or DIT cases. 8t is also i+-ortant to kee- track of the -ro*ress of the case. 8t is a
co++on be*inner:s +istake to *ive -atients a +uscle relaxant that lasts for an hour )hen
the case only has "# +inutes to *o. A *ood anesthesiolo*ist has a 9sixth sense.9 He or she
"#
is al)ays -ayin* attention to the tone of the -ulse oxi+eter or the slur-in* of blood into
the suction canister. Li*ilance is key to a *ood anesthetic.
/ne can also -re-are for -otential -ost@o-erative -roble+s durin* the case. by treatin*
the -atient intrao-eratively )ith lon*@actin* anti@e+etics and -ain +edications.
E4-&5-$,-
Usin* our analo*y of flyin* an air-lane. a -oor landin*Fe+er*ence can be disastrous.
=no)in* )hen to turn do)nF off your anesthetic a*ents co+es )ith ex-erience and
attention to the -ro*ress of the sur*ical case. D+er*ence isn:t as easy as it +i*ht at first
see+. since very i+-ortant ste-s have to take -lace before a -atient can be safely
extubated.
,hen usin* nonde-olariBin* neuro+uscular blockin* a*ents such as 2ocuroniu+ or
Cisatracuriu+. a -eri-heral nerve sti+ulator is used to +onitor the -har+acolo*ical
effects of these dru*s. and the dosa*e can be titrated to effect. Iear the end of the case.
the nerve sti+ulator is used to assess the de*ree of s-ontaneous recovery fro+ these
dru*s. Ieosti*+ine. an anticholinesterase dru*. is ty-ically used as a reversal a*ent
)hen the s-ontaneous recovery is occurrin*. as deter+ined by the -resence of t)itches
induced by the nerve sti+ulator. ,hen utiliBin* a train@of@four sti+ulation. the *reater
the nu+ber of visible +uscle t)itches. the *reater the de*ree of s-ontaneous recovery
that has occurred. A lack of +uscle t)itches indicates the blockade at the neuro+uscular
Ounction is still too intense and the ad+inistration of neosti*+ine is not likely to facilitate
reversal. 8t is also i+-ortant to note that even )ith % t)itches and the return of
s-ontaneous breathin*. the -atient +ay still have u- to (&P of the IMK rece-tors
occu-ied by the blockin* a*ent. The ade<uacy of recovery fro+ the neuro+uscular
blockin* dru*s can be tested clinically by the ability of the -atient to +aintain a head lift.
le* lift or hand*ri- stren*th for S & seconds.
/nce a -atient has ade<uately recovered fro+ the effects of the neuro+uscular blockin*
a*ents. is able to breathe on his o)n. is able to follo) co++ands. de+onstrates
-ur-oseful +ove+ents. and can -rotect his air)ay. he is +ost likely ready to be
extubated. 8n addition. the follo)in* -hysiolo*ical -ara+eters are also used to assess
readiness for extubation.
RR > 8 & < 30/min
TV > 5 cc/kg
TV/RR > 10
PaO2 > 65-70 mmHg on FiO2 < 40%
PaO2 < 50 mmHg
H!mo"#namic $%a&i'i%#
T!m(!)a%*)! a% '!a$% 35
+,F > -20
Suction +ust al)ays be close at hand. since +any -atients can beco+e nauseous after
extubation. or si+-ly have co-ious oro-haryn*eal secretions. /nce the -atient is
""
reversed. a)ake. suctioned. and extubated. care +ust be taken in transferrin* hi+ to the
*urney and oxy*en +ust be readily available for trans-ortation to the recovery
roo+FPost@Anesthesia Care Unit 5PACU7. Hinally. re+e+ber that )henever extubatin* a
-atient. you +ust be fully -re-ared to reintubate if necessary. )hich +eans havin* dru*s
and e<ui-+ent handy
PACU ,#$,-&$*
The anesthesiolo*ist:s Oob isn:t over once the -atient leaves the o-eratin* roo+. Concerns
that are directly the res-onsibility of the anesthesiolo*ist in the i++ediate -osto-erative
-eriod include nauseaFvo+itin*. he+odyna+ic stability. and -ain.
/ther concerns include continuin* a)areness of the -atient:s air)ay and level of
consciousness. as )ell as follo)@u- of intrao-erative -rocedures such as central line
-lace+ent and -osto-erative T@rays to rule out -neu+othorax.
8n su++ary. anesthesia is a s-ecialty in )hich an extensive kno)led*e of -hysiolo*y and
-har+acolo*y can be a--lied to the care of -atients in a uni<ue one@on@one intensive care
settin*. Challen*e us to teach you )hat you don:t understand. and *et as +uch -ractice
)ith air)ay +ana*e+ent as -ossible. Also. re+e+ber that at the heart of anesthesiolo*y
are the A;C:s @ air)ay. breathin* and circulation. Io +atter )hat field you +ay enter.
basic kno)led*e of the A;C:s is -art. of any co+-lete -hysician:s re-ertoire. DnOoyR
"$
Co++only Used Medications
V#3/%'3- A$-*%2-%',*
All are 'roncodilators, except for desflurane /ic is irritatin& and !ay
cause 'roncospas!0 Ad!inistered alone 1i0e0, /itout narcotics2, inaled
anestetics increase respiratory rate 'ut decrease tidal $olu!e0
.xcept for alotane, inaled anestetics are not !eta'oli3ed 'y te 'ody and
are eli!inated 'y $entilation0
All $olatile anestetics 1'ut not nitrous oxide2 are capa'le of tri&&erin&
!ali&nant yperter!ia 1MH20
Wile in !any cases $olatile anestetics are used for !aintenance of
anestesia, in so!e circu!stances tese dru&s !ay 'e cosen to induce
anestesia suc as in pediatrics cases in /ic te cild !ay not tolerate -4
place!ent a/ake0
Halotane
Pro? Chea-. nonirritatin* so can be used for inhalation induction
Con? Mon* ti+e to onsetFoffset. Si*nificant Myocardial 4e-ression.
SensitiBes +yocardiu+ to catechola+ines. Association )ith He-atitis
-soflurane
Pro? Chea-. excellent renal. he-atic. coronary. and cerebral blood flo)
-reservation
Con? Mon* ti+e to onsetFoffset. irritatin* so cannot be used for inhalation
induction
Desflurane
Pro? Dxtre+ely ra-id onsetFoffset
Con? Dx-ensive. Sti+ulates catechola+ine release. Possibly increases
-osto-erative nausea and vo+itin*. 2e<uires s-ecial active@te+-erature
controlled va-oriBer due to hi*h va-or -ressure. 8rritatin* so cannot be
used for inhalation induction
Se$oflurane
Pro? nonirritatin* so can be used for inhalation induction. Dxtre+ely ra-id
onsetFoffset.
Con? Dx-ensive. 4ue to risk of 0co+-ound A1 ex-osure +ust be used at
flo)s S $ MF+in. Theoretical -otential for renal toxicity fro+ inor*anic
fluoride +etabolites.

)itrous ,xide
Pro? 4ecreases volatile anesthetic re<uire+ent. 4irt chea-. Mess +yocardial
de-ression than volatile a*ents
Con? 4iffuses freely into *as filled s-aces 5bo)el. -neu+othorax. +iddle ear. eye.
4ecreases Hi#$. 8ncreases -ul+onary vascular resistance
"3
IV A$-*%2-%',*
Most sedati$e ypnotics /ork trou& te ini'itory &a!!a5a!ino'utyric
acid 1GABA2 neurotrans!itter syste! in /ic increased cloride
conductance leads to neuronal ini'ition0 Most -4 induction a&ents 'ind to a
specific site called GABAA for tis ini'itory effect, and tey a$e a rapid
onset due to lipopilic properties /ic allo/ te! to 6uickly partition into
te i&ly perfused lipopilic 'rain and spinal cord0 Tey also a$e sort
duration of action, /it teir ter!ination of effect due to redistri'ution into
less perfused tissues suc as !uscle and fat0
Bar'iturates 1e0&0, tiopental2
4ecrease 8CP by decrease in cerebral oxy*en consu+-tion. Since cerebral
-erfusion is -reserved. desirable dru* for neurosur*ery cases. Causes
res-iratory and cardiac de-ression.
Pro? Dxcellent brain -rotection. Sto-s seiBures. Chea-
Con? Myocardial de-ression. Lasodilation. Hista+ine release. Can
-reci-itate -or-hyria in susce-tible -atients
7ropofol
8n adults. induction dose ".& to $.& +*Fk* )hile continuous infusion of
"## to $## +icro*ra+sFk*F+in +aintains unconsciousness. These values
differ for children and for the elderly.
Pro? Prevents nauseaFvo+itin*. Uuick recovery if used as solo anesthetic
a*ent
Con? Pain on inOection. Dx-ensive. Su--orts bacterial *ro)th. Myocardial
de-ression 5the +ost of the four7. Lasodilation. cross reactivity in -atients
)ith e** aller*y.
.to!idate
Mini+al de-ression of cardiovascular and -ul+onary function. 8deal for
-atients )ith CL4 or he+odyna+ic instability. 8nduction dose of #.$ to
#.% +*Fk* that causes -ain on inOection and +yoclonus. Su**ested that it
+ay su--ress cortisol synthesis.
Pro? Meast +yocardial effect of 8L anesthetics
Con? Pain on inOection. Adrenal su--ression 5A si*nificance if used only
for induction7. Myoclonus. IauseaFLo+itin*
"eta!ine
,orks via anta*onis+ of the I@+ethyl@4@as-artate rece-tor channel
co+-lex. Mini+ally de-resses the cardiores-iratory syste+. 8nduction
dose of " to $ +*Fk* in adults. 4irectly sti+ulates SIS and increases ;P
and heart rate. 8ncreasin* de+and on the heart and is not a *ood choice for
CA4 -atients.
Pro? ,orks 8L. P/. P2. 8M @ *ood choice in uncoo-erative -atient )ithout
8L. Sti+ulation of SIS *ood for hy-ovole+ic trau+a -atients. often
-reserves air)ay reflexes
Con? 4issociative anesthesia )ith -osto- dys-horia and hallucinations.
8ncreases 8CPF8/P and CM2#$. Sti+ulation of SIS bad for -atients
)ith co+-ro+ised cardiac function. increases air)ay secretions
"%
Dex!edeto!idine
Selective al-ha@$ adrener*ic a*onist. )hich is used in the o-eratin* roo+
as an adOunct to *eneral anesthesia. or to -rovide sedation for a)ake
fibero-tic intubation or for re*ional anesthesia. 8t is *enerally *iven as a
loadin* dose of #.&@" +c*Fk* over "# +inutes. follo)ed by an infusion of
#.$ to #.( +c*Fk*Fhr. 8t -roduces sedative@hy-notic and anal*esic effects
)ithout causin* res-iratory de-ression.
Ben3odia3epines 1BD82
Usually -rovided as -re+edication for sedation and anxiolysis before
*eneral anesthesia. Pro-erties include anxiolytic effects to sedation and
unconsciousness at hi*her doses. MidaBola+ 5Lersed7 induction dose of
#." to #.$ +*Fk* and infusion rates of #.$& to " +icro*ra+Fk* -er +inute.
;4Vs -roduce res-iratory. cardiovascular. and u--er air)ay reflex
de-ression and in the -resence of hy-ovole+ia. +ay cause si*nificant
hy-otension. 2eversal of the sedative action of these co+-ounds )ith the
co+-etitive anta*onist. flu+aBenil.
L#,/3 A$-*%2-%',*
.sters @ MetaboliBed by -las+a esterases @ one +etabolite is PA;A. )hich can
cause aller*ic reactions. Patients )ith 9aller*y to novacaine9 usually do )ell )ith
a+ides for this reason. All have only one 9i9 in their na+e. e*. Procaine.
Tetracaine. Chlor-rocaine.
A!ides @ MetaboliBed by he-atic enBy+es. All have at least t)o 9i9s in their
na+e. e*. Midocaine. 2o-ivicaine. ;u-ivicaine
O.'#'+*
Morpine E de-resses breathin* -rinci-ally by i+-airin* the +edullary res-onse
to C/$. Also tri**er the che+orece-tor tri**er Bone 5CTV7 )hich +ay lead to
nausea. and +ay in turn sti+ulate the vo+itin* center and -roduce e+esis. Also.
+or-hine decreases 38 +otility and -ro-ulsion. -roduces urinary retention. and
releases hista+ine by sti+ulatin* baso-hils in the lun*s and +ast cells in the skin.
8n the CLS. +or-hine +ay -roduce vascular dilation. decrease SL2. and overall
hy-otension. 8t is lon* actin* > renally excreted active +etabolite has o-iate
-ro-erties. therefore be)are in renal failure
De!erol @ eu-horia. sti+ulates catechola+ine release. so be)are in -atients usin*
MA/8:s. renally active +etabolite associated )ith seiBure activity. therefore
be)are in renal failure
"&
(entanyl+Alfentanil+Sufentanil+%e!ifentanil @ More -otent than +or-hine. )ith
Sufentanil bein* the +ost -otent 5u- to ".###x as -otent7. 8n addition. all are
shorter actin* than +or-hine. )ith 2e+ifentanil bein* the shortest. /ften used to
attenuate the stress res-onse to sur*ical sti+ulation. Mo) doses -roduce brief
effect. but lar*er doses are lon* actin*. increased incidence of chest )all ri*idity
vs. other o-iates. no active +etabolites. usually safe in -atients )ith +or-hine
aller*ies.
M)*,3- R-3/7/$%*
D-.#3/&'8'$5
Succinylcoline @ inhibits the -ost@Ounctional rece-tor and -assively
diffuses off )ith increased 8CPF8/P. +uscle fasciculations and -osto-
+uscle aches. tri**ers MH. increases seru+ -otassiu+ es-ecially in
-atients )ith burns. crush inOury. s-inal cord inOury. +uscular dystro-hy or
disuse syndro+es. 2a-id and short actin*.
N#$+-.#3/&'8'$5
Many different kinds. all endin* in 0oniu+1 or 0uriu+1. Dach has a
different +etabolis+. onset. and duration +akin* choice de-end on
s-ecific -atient and case. So+e exa+-les? 7ancuroniu! @ Slo) onset.
lon* duration. tachycardia due to va*olytic effect0 Cisatracuriu!@ Slo)
onset. inter+ediate duration. Hoff+an 5nonenBy+atic7 eli+ination so
attractive choice in liverFrenal disease. %ocuroniu! @ Hastest onset of
nonde-olariBers +akin* it useful for ra-id se<uence induction.
inter+ediate duration.
R-0-&*/3 A5-$%*/ A$%',2#3'$-&5',*
R-0-&*/3 A5-$%*
All are acetylcholinesterase inhibitors. thereby allo)in* +ore acetylcholine to be
available to overco+e the neuro+uscular blocker effect at the nicotinic rece-tor.
but also causin* +uscarinic sti+ulation.
5Choliner*ic Crisis SLUD CB2? Salivation. Lacri+ation. Urination. Diarrhea.
Ciliary constriction5+iosis7. Bronchos-as+. Bradycardia.7
)eosti&!ine @ shares duration of action )ith *lyco-yrrolate 5see belo)7
.droponiu! @ shares duration of action )ith atro-ine 5see belo)7
7ysosti&!ine @ crosses the ;;;. therefore useful for atro-ine overdose
A$%',2#3'$-&5',*
3iven )ith reversal a*ents to block the +uscarinic effects of choliner*ic
sti+ulation. also excellent for treatin* bradycardia and excess secretions
"
Atropine @ used in conOunction )ith Ddro-honiu+. crosses the ;;;
causin* dro)siness. so +aybe bad at end of sur*ery for reversal. so+e use
as -re+ed for all children since they tend to beco+e bradycardic )ith
intubation and -roduce co-ious drool
Glycopyrrolate @ used in conOunction )ith neosti*+ine. does not cross
;;;
Central Anticholiner*ic Syndro+e?
;lind as a bat 5;lurred vision7
2ed as a beet 5Hlushin*7
4ry as a bone 5Anhydrosis7
Hast as a hare 5Tachycardia7
Mad as a hatter 54eleriu+7
"(
Phar+ Charts
I$2/3/%'#$/3 A$-*%2-%',*
I$2/3/%'#$
A$-*%2-%',*
M/9#& A+0/$%/5-* P&'4/&1 U*- T#7','%1/,#$,-&$*
N'%&#)* O7'+-
Io odor
Hast induction and recovery
Mini+al cardio-ul+onary
de-ression
3ood anal*esic
Minor sur*ery
Used in co+bination )ith
*eneral anesthetics for
*eneral anesthesia
Acute@IFL
Chronic@inhibition of ;"$
+etabolis+ and induction
of ;"$ 4DH8C8DICN
H/3#%2/$-
Pleasant odor
Slo)er induction and recovery
Most )idely used -edi
anesthetic )orld )ide.
Asth+a -atients 5no
bronchoconstriction7
Slo) inductionFrecovery
SensitiBes +yocardiu+ to
catechola+inesLent.
Arryth+ias
He-atotoxicity
E$63)&/$-
Pleasant odor
Mess S.D. than Halothane
Adults Hy-otension
SeiBures 6 hi*h W X
Ie-hrotoxicity
I*#63)&/$-
Stable cardiac rhyth+
2a-id onsetFrecovery
Mini+al +etabolis+lo) tox
-otential
Dxcellent Muscle relaxant
Most )idely used
anesthetic in adults.
Pun*ent odor 5not *reat for
kids7
;roncho@irritant
D-*63)&/$-
2a-id onsetFrecovery
Hi*h -otency 5least soluble7
Dven less +etabolis+
A+bulatory sur*ery 5for
ra-id recovery7
Lery -un*ent
8rritatin* to air)ays
MA2NI3/SPASM
Dx-ensiveYYY
S-0#63)&/$-
Hast inductionFrecovery
Hi*h -otency 5least soluble7
Ionirritatin* va-or
/ut-atient anesthesia
8nhalation 8nduction
5es-ecially children7
M-%2#7163)&/$-
2enal Toxicity
Iitrous /xide 4esflurane. Sevoflurane. Dnflurane 8soflurane Halothane Methylfurane
HASTDST S-eed of /nset SM/,DST
M/,DST Potency H83HDST
Hi*h MAC Mo) MAC
5"#%7 57 5$.$7 5".&7 5#.'7
MAC
Mini+u+ Alveolar Concentration E defines the a+ount of anesthetic necessary to
achieve no res-onse to sur*ical sti+ulus. The nu+bers listed above are the
concentrations necessary to achieve " MAC. or no res-onse in &#P of the -o-ulation. A
MAC of ".3 is $ standard deviations u-. or )here !&P dont res-ond. A MAC of ".& is
the MAC ;A2. )here sy+-athetic outflo) is co+-letely blocked. ,hen usin* +ulti-le
a*ents. MACs are additive. i.e. Z MAC of nitrous 5&$P7 C Z MAC of Sevo 5"."P7 is
e<ual to $.$P sevo alone.
"'
I$%&/0-$#)* A$-*%2-%',*
I$%&/0-$#)*
A$-*%2-%',*
O$*-% E3'4'$/%'#$ P2/&4/,#:'$-%',* A+0/$%/5-*/
U*-
D'*/+0/$%/5-*
B/&('%)/%-*
5H>A7
@Thio-ental
@Methohexital
@Thia+ylal
3#@%#
sec
@"#@"$ hrs
@ 3@ hrs
2edistribution 2a-id onset
Hast recovery
Anesthesia for
short
-rocedures.
Io anal*esia
AlkalineFTissue
8rritant.
2es- > CL
de-ression
Mo) T8 /4 risk
B-$8#+'/8-.'$
-*
5H>A7
@4iaBe-a+
@MidaBola+
@MoraBe-a+
3@& +in
@$#@%# hrs
@$@ hrs
4e+ethelated in the
Miver.
5-rolon*ed t"F$ )ith
cirrosis. etc7
2elative ra-id
onset
Mini+al res-
and CL
de-ression
Preanesthetic
Iot a *ood
anal*esic
Cant -roduce
sur*ical anal*esia
D'**#,'/%'0-
5H>A7
@=eta+ine
@$@3 hrs 8ntense
anal*esia and
a+nesia
2adiolo*ical
-rocedures in
children.
;ronchodilato
r
4issociative
anesthesia 5887
un-leasant
recovery )F
hallucinations
and ni*ht+ares
M'*,-33/$-#)*
5H>A7
@Dto+idate
@Pro-ofol
[" +in
%#@&#
sec
%@'hrs
3@hrs Mar*e volu+e of
distribution. hi*hly
li-o-hilic
Prevents IFL.
<uick recovery
Hy-otension. cv
de-ression.
re<uires
+echanical
ventilation.
discoloration of
urine 5*reen7
O.'#'+*
;A<
@Mor-hine
@Hentanyl
@Me-eridine
54e+erol7
@Sufentanyl
$@( hrs
3@% hrs
$@% hrs
Mini+al CL
effects at
nor+al
dosa*es
4ose related
cardiac
de-ression.
Me-eridine@
cardiac
de-ression
"!
8L Hluids
H#= M),2>
Ty-e \ H2 " $ 3 %
Maintenance -er hour
5%. $. " rule. or k* C%# in anyone over $# k*7
" " " "
4eficit
5Hrs IP/ x Maintenance7
"F$ "F% "F% @
8nsensible Moss
53@"& ccFhr ? case de-endent7
Dsti+ated blood loss
5"?" colloid. 3?" crystalloid7
A33#=/(3- B3##+ L#**
The allo)able loss is calculated by +ulti-lyin* the blood volu+e 5;L7 by the -ercent
fro+ startin* he+atocrit 5HCTs7 to threshold he+atocrit 5HCTt7 for transfusion.
A;M ] ;L x 55HCTs@HCTt7FHCTs7
;lood volu+e is deter+ined by +ulti-lyin* the )ei*ht by a constant.
Ieonates ] !# ccFk*
8nfants ] '# ccFk*
Adult +en ] # ccFk*
Adult )o+en ] &# ccFk*
E7/4.3-
A &# k* )o+an co+es in after fastin* for "$ hours for elective sur*ery. Her -re@o-
he+atocrit )as 3&. Nou decide that in order to transfuse she +ust have a he+atocrit less
than $&. /ver the course of the sur*ery she loses $&# ccs of blood each hour for 3 hours.
She has only +ini+al blood loss durin* the last hour of her % hour sur*ery.
Ty-e \ H2 " $ 3 %
Maintenance -er hour
5%. $. " rule. /2 k* C%# in anyone over $# k*7
!# !# !# !#
4eficit
5Hrs IP/ x Maintenance7
"$ x !# ] "#'#
&%# $(# $(# @
8nsensible Moss
53@"& ccFhr ? case de-endent7
' ' ' '
Dsti+ated blood loss
5"?" colloid. 3?" crystalloid7
Col E $&#
C&1*? @A
Col E $&#
C&1*? @A
Col E $&#
C&1*? @A
@
Total crystalloid "3'' """# """# !'
Additionally. she should be transfused as she -assed her threshold for transfusion durin*
the third hour. Since that -oint )as close to the end of sur*ery. transfusion -robably
could be held off until arrival at PACU since transfusion reaction is not easily noticed
)hile under *eneral anesthesia.
$#
ASA Classification
The -ur-ose of the *radin* syste+ is si+-ly to assess the de*ree of a -atients 9sickness9
or 9-hysical state9 -rior to selectin* the anesthetic or -rior to -erfor+in* sur*ery.
4escribin* -atients -reo-erative -hysical status is used for recordkee-in*. for
co++unicatin* bet)een collea*ues. and to create a unifor+ syste+ for statistical
analysis. The *radin* syste+ is not intended for use as a +easure to -redict o-erative
risk.
The +odern classification syste+ consists of six cate*ories. as described belo).
ASA P21*',/3 S%/%)* ;PS< C3/**'6',/%'#$ S1*%-4B
ASA PS C/%-5#&1 P&-#.-&/%'0- H-/3%2
S%/%)*
C#44-$%*C E7/4.3-*
ASA PS " Ior+al healthy -atient Io or*anic. -hysiolo*ic. or
-sychiatric disturbance^
excludes the very youn*
and very old^ healthy )ith
*ood exercise tolerance
ASA PS $ Patients )ith +ild syste+ic
disease
Io functional li+itations^
has a )ell@controlled
disease of one body syste+^
controlled hy-ertension or
diabetes )ithout syste+ic
effects. ci*arette s+okin*
)ithout chronic obstructive
-ul+onary disease 5C/P47^
+ild obesity. -re*nancy
ASA PS 3 Patients )ith severe
syste+ic disease
So+e functional li+itation^
has a controlled disease of
+ore than one body syste+
or one +aOor syste+^ no
i++ediate dan*er of death^
controlled con*estive heart
failure 5CHH7. stable
an*ina. old heart attack.
-oorly controlled
hy-ertension. +orbid
obesity. chronic renal
$"
failure^ bronchos-astic
disease )ith inter+ittent
sy+-to+s
ASA PS % Patients )ith severe
syste+ic disease that is a
constant threat to life
Has at least one severe
disease that is -oorly
controlled or at end sta*e^
-ossible risk of death^
unstable an*ina.
sy+-to+atic C/P4.
sy+-to+atic CHH.
he-atorenal failure
ASA PS & Moribund -atients )ho are
not ex-ected to survive
)ithout the o-eration
Iot ex-ected to survive S
$% hours )ithout sur*ery^
i++inent risk of death^
+ultior*an failure. se-sis
syndro+e )ith
he+odyna+ic instability.
hy-other+ia. -oorly
controlled coa*ulo-athy
ASA PS A declared brain@dead
-atient )ho or*ans are
bein* re+oved for donor
-ur-oses

BASA PS ,3/**'6',/%'#$* 6&#4 %2- A4-&',/$ S#,'-%1 #6 A$-*%2-*'#3#5'*%*
Malla+-ati Classification
The Malla+-ati Classification is based on the structures visualiBed )ith +axi+al +outh
o-enin* and ton*ue -rotrusion in the sittin* -osition 5ori*inally described )ithout
-honation. but others have su**ested +ini+u+ Malla+-ati Classification )ith or )ithout
-honation best correlates )ith intubation difficulty7.
Class 8? soft -alate. fauces. uvula. -illars
Class 88? soft -alate. fauces. -ortion of
uvula
Class 888? soft -alate. base of uvula
Class 8L? hard -alate only
$$
Uuick 2eferenceF2evie)
Pre@Anesthesia Dvaluation
o Cardiac Patient E decreased exercise tolerance i+-ortant si*n^ if able to
cli+b S$ fli*hts of stairs. cardiac reserve -robably intact
Post@M8 E infarction risk stabiliBes at &@P after +onths
Perio-erative M8 +ortality $#@&#P
8f no -rior M8. -erio-erative risk #."3P
/ccur in %'@($ hrs -ost@o-
Io elective sur*ery )ithin +onths of M8
Prior Cardiac Sur*ery or PTCA is not contraindication to sur*ery
Contraindication to sur*ery ] M8 J" +onth. unco+-ensated CHH.
severe AS or MS
Dvaluation
MaOor risk E unstable coronary syndro+e
8nter+ediate risk E +ild an*ina. -rior M8. CHH. 4M
Minor risk E a*e. abnor+al D=3. arrhyth+ia. decreased
functional ca-acity. stroke. uncontrolled HTI
Studies E D=3. Holter. stress test. technetiu+ !!+. thalliu+
i+a*in*. coronary an*io*ra-hy
o C/P4
Dx-lain obstruction
4eter+ine severity and res-onsiveness to albuterol. *et PHTs.
CT2 if hi*hly sy+-to+atic
8ncreased risk if -re@o- PTs J&#P -redicted
Also hel-ful to deter+ine ho+e /$ re<uire+ent. hos-italiBation
history. and )hich +edicines used ho) often
o 4M
,atch for si*ns and sy+-to+s of +yocardial dysfunction. cerebral
ische+ia. HTI. renal disease
Correct hy-o*lyce+ia. 4=A. and lytes before sur*ery
Maintain *lucose bet)een "$#@"'#
2e*lan C H$ blocker
Si*ns of autono+ic neuro-athy E i+-otence. HTI. neuro*enic
bladder. orthostasis
May also develo- arthro-athy leadin* to difficult cervical
extension. 8f cannot -ut -al+s and fin*ers flat to*ether. likely to
have +ore difficult air)ay due to lack of extension.
$3
Mali*nant Hy-erther+ia E skeletal +uscle hy-er+etabolic syndro+e
o Tri**erin* anesthetics E halothane. esflurane. isoflurane. desflurane.
sevflurane. succinylcholine
o 3ene E Ca channel of skeletal +uscle sarco-las+ic reticulu+ )ith
decreased reu-take of Ca
o Sy+-to+s E increased H2. increased breath rate. increased etC/$ 5+ost
sensitive7. unstable ;P. cyanosis. coca@cola colored urine
Mate si*ns 5@$% hrs7 E increased te+-erature. +uscle s)ellin*.
heart failure. 48C. liver failure
o Confir+ dia*nosis by lar*e difference bet)een venous C/$ and arterial
C/$
o Mabs E 2es-iratory and +etabolic acidosis. hy-oxia. hy-erkale+ia.
hy-ercalce+ia. hi*h +yo*lobin. hi*h CP=. +yo*lobinuria
o 8ncidence E "?$$#.###^ "?%#.### )ith succinylcholine
o Mortality E "#P overall. (#P )ithout dantrolene
o Huture anesthesia E no -retreat+ent )ith dantrolene. flush anesthesia
+achine
o TT
" @ Call for hel-
$ @ Sto- volatile anesthetic
3 E "##P /$
% E Manually hy-erventilate
& E S)itch to a clean breathin* circuit
E Sto- sur*ery. +aintain on sedative@hy-notic anesthesia
( E 4antrolene $.&+*Fk* 5+ixed )ith sterile )ater7 < "# +inutes to
+ax dose of "#+*Fk*. Maintenance dose at "+*Fk* < hrs for ($
hours.
' E Correct +etabolic acidosis )ith IaCH/3 "@$+*Fk*. Correct hi*h
=C
! E Cool -atient )ith iced 8L IS. and cold fluids in *astric lava*e. in
-eritoneal or thoracic cavity if o-en. and P2
"# E Maintain urine out-ut )ith +annitol or lasix. 4o not use CC;
o 8L Hluids 5M2. IS7
o Maintenance 5%C$C"7 C IP/ ti+e 5Maintenance Q G hrs7 C Dva-orative
loss 5"@'ccFk*Fhr7
Mocal Anesthetics
o Dsters E 1 0i1 in na+e 5i.e. novocaine7. +etaboliBed by -las+a
-seudocholinesterases. /ne of its +etabolites is PA;A. )hich causes
aller*ic reactions 5i.e. )ith Procaine and Tetracaine7. CSH has no
esterases. Sulfa aller*ic -atients.
o A+ides E 2D 0i1s in na+e 5ie. Midocaine. ;u-ivicaine7. +etaboliBed by
liver enBy+es. +ay cause +ethe+e*lobine+ia 5-rilocaine. bu-ivicaine7.
aller*ic reaction rare. so+e bad hy-eractivity reactions
$%
o Mechanis+ E decrease -er+eability to Ia ions. binds to Ia channel in
inactivated state. no threshold -otential reached. affects ra-id firin* nerves
first. +yelinated SSS un+yelinated
o Contraindications E hy-ersensitivity. severe heart block. ,P, syndro+e
o Toxicity E often follo)s -redictable -attern of tinnitus. -erioral nu+bness
and tin*lin*. sense of doo+. seiBure. co+a.
Cardio E decreased -hase 8L de-olariBation. increased P2. )ide
U2S
Pul+onary E -hrenicFintercostal nerve -aralysis
CIS E diBBiness. circu+oral nu+bness. tinnitus. blurred vision.
excitatory si*ns CIS de-ression
Muscle E toxic inOected 8M
Midocaine kno)n to decrease coa*ulation
Air)ay Mana*e+ent
o MMA E sub for DT tube as lon* as inflation^ +ay be used as *uide for
intubation
Pro-ofol used for induction E relaxes Oa)
=ee- in -lace until -atient o-ens +outh on arousal
Co+-lications E as-iration. +ucosa inOury. laryn*os-as+Fcou*hin*
Contraindication E risks for *astric as-iration such as 3D24.
-re*nancy. recent +eal
Mendelssohns Syndro+e
o As-iration -neu+onia secondary to as-iration of *astric contents
o TT E su--ortive ad+ission to 8CU. continued intubation. res-iratory
thera-y. suctionin*. /$. no antibiotics. <uestionable steroids
Antibiotics only used in -resence of -ositive culture. Should not
be *iven -rior to this.
o Pneu+onia E delay sur*ery '@"$ hours. P/ antacids. H$ blockers. 2e*lan.
ra-id se<uence. on suction after intubation. suction of -harynx
o 2isk E anesthesia. +uscle relaxants. trau+a. full sto+ach. delayed *astric
e+-tyin*. -re*nancy. obesity. i+-aired MCS tone
o Sx E dys-nea. tachy-nea. increased H2. )heeBin*. CT2 )ith lo)er lobe
infiltrates. hy-oxia
2a-id Se<uence 8ntubation E used in anyone at risk for as-iration. MaOor
difference is that there is no ba*@+ask ventilation follo)in* induction. as this
could introduce air into the 38 track causin* vo+itin*.
". Pre-aration E check Aller*ies. Medications. Past +ed hx. Last +eal.
Events surroundin* incident 5AMPLE7. Also check su--lies and
+onitors.
$. Preoxy*enate E "##P for 3 +inutes
3. Pre@treat E o-ioids to reduce sy+-athetic res-onse to intubation. ra*lan
and bicitra to reduce risk of *astric as-iration syndro+e
%. Paralysis and anesthesia E 8L induction follo)ed i++ediately by
succinylcholine. often use -ro-ofol due to its anti@e+etic action
$&
&. Pass tube E i++ediately follo)in* fasiculations fro+ succinylcholine
. Post@tube +ana*e+ent E ta-e tube. o-ioids. etc. etc.
Dxtubation Criteria
o Tidal volu+e S &ccFk*
o 2es-irations s-ontaneous and S'F+in
o I8H of @"# to @"&
o Patient sho)in* -ur-oseful +ove+ent
o Te+-erature of 3& C or *reater
o He+odyna+ic stability
o Pa/$ _ # on Hi/$ %#. Pco$ ` && ++H*
Maryn*os-as+
o Children at es-ecially hi*h risk
o Try to break first by *ivin* hi*h -ositive -ressure
o 8f cannot break. +ust use succinylcholine to -aralyBe -atient to ba*@+ask
or re@intubate.
Pre@o- 2oo+ Pre- Checklist
Machine E +achine checkout. /$ calibration. *as level
Suction
Monitors E A line. central line. Pulse /x. ;P. D=3. ;8S
Air)ay E laryn*osco-e. oral air)ay. +ask. tube. /3. Te+- -robe
IL E alcohol. needle. flush on he-lock. ta-e. 8LH
Dru*s E -ro-ofol. eto+idate. -aralytic. narcotic. versed. -henytoin. atro-ine. e-ine-hrine.
succinylcholine
S-ecial. Seat
Labs E ty-e and cross. H>H. coa*s
$
Procedure Checklist
The -ur-ose of this section is to -rovide you )ith a list of -rocedures you +ay be
re<uired to -erfor+ or assist durin* the rotation. 4ue to the fact that these are +ore
easily learned in a 0see one. do one. teach one1 fashion and that -rocedures +ay vary
de-endin* on available e<ui-+ent. details on ho) to -erfor+ are intentionally left blank
)ith a+-le roo+ for you to take notes. Procedures you are +ore likely to -erfor+ and
assist on are listed earlier. 8f you are lookin* to do the+ yourself. it +ay be hel-ful to
read u- on that -rocedure before hand and take notes here to hel- Oo* your +e+ory )hen
the o--ortunity arises.
I$%)(/%'#$
IV 3'$- .3/,-4-$%
B/5 M/*: V-$%'3/%'#$
$(
V-$%'3/%#& S-%%'$5*
A&%-&'/3 L'$- P3/,-4-$%
C-$%&/3 L'$- P3/,-4-$%
$'
S.'$/3
E.'+)&/3
$!
2esources
The follo)in* are a short list of additional resources that you +i*ht find hel-ful durin*
your anesthesia +onth in findin* +ore in de-th details about anesthesia.
T-7%
Mor*an 3D. Mikail MS. Murray MK. 0Clinical Anesthesiolo*y1 Mc3ra) Hill Medical.
$##& 5aY(&7
3lidden 2S. 0IMS Anesthesiolo*y1. Mi--incott ,illia+s > ,ilkins. $##3. 5aY$#7
W-(
Lirtual Anesthesia Text ;ook htt-?FF))).virtual@anesthesia@textbook.co+Findex.sht+l
,orld Anaesthesia /nline htt-?FF))).nda.ox.ac.ukF)fsaFindex.ht+
3#
Iotes
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