KEYWORDS

by Doaa Kamal

KEY WORDS
OBSTETRICS
Physiological changes
1) CVS: Hyperdynamic: blood volume, HR, SVR. Aortocaval $ (28 wks)
Lt uterine displacement, auto-transfusion 500-1000 ml after delivery.
2) CNS: progesterone sedation MAC.
3) Resp: FRC, upper airway edema, difficult intubation.
4) GIT: aspiration, delayed gastric emptying.
5) Blood: hypercoagulable state, physiological anemia.
6) Regional: doses (d.t epidural pr: engorged epidural vs & intra-abd pr).

GA for C-S
1)
2)
3)
4)
5)
6)

Physiological changes.
Lt uterine displacement.
Preoxygenate 100% O2.
Rapid sequence crash induction + cricoid pr.
Fully awake extubation.
Awareness under GA.

Anesthesia for Preclampsia

1) Mg (anticonvulsant) + anti HTN ttt. [Dose, toxicity, antidote: Ca2+].

2) Regional anesthesia (precautions: low plt count, coagulopathy, volume preload).
3) GA: modified rapid sequence induction + fentanyl (naloxone & neonatologist
available) + lidocaine + esmolol + nitroglycerin.
4) Avoid: ketamine, pancuronium, ergotamine.
5) Fetus: IUGR, Naloxone 10 g/kg for resp (-).

Obstetric for non-obs surgery

1)
2)
3)
4)

Physiological changes.
Teratogenicity.
Tocolytics.
Choice of anesthesia Regional (1st choice).
GA: use time tested anesthetics (morphine, halothane:tocolytic)

5) Aortocaval $ (28 wks).

6) Aspiration prophylaxis.
7) GOOD analgesia (pain stimulates uterine contractions).
8) Fetal assessment.
9) Monitoring (mother + fetus).
10) Avoid: ketamine (uterine hypertonicity) neostigmine (uterine contractions).

Anesthesia for assisted reproductive techniques (ARTs)

1)
2)
3)
4)
5)
6)
7)

Lithotomy.
Ovarian hyperstimulation $.
Avoid: metoclopramide, domperidone, (D2 blockers prolactin).
Avoid: NSAIDS.
Regional.
GA for laparoscopic ovum pick up (TIVA or volatile).
Day case.

KEYWORDS

by Doaa Kamal

RESPIRATION
Anesthesia for pt ARDS
1)
2)
3)
4)
5)

Fluid restriction &diuretics.

NO rebound pulm HTN.
Prone rebound hypoxemia when turned supine.
Steroid cover.
Xigris: stopped 2 hr preop & restart 12 hr after surgery.
6) Ventilatior special mode, high flow, high pr. Or special ICU ventilator with built in
vaporizer.

7) TIVA.

CVS
Mgt for pt Ht Block
1)
2)
3)
4)
5)

Avoid drugs w AVN conduction: BB, CCB, Digoxin.

Use drugs w AVN conduction: atropine, isoprenaline, pancuronium.
Preop: temporary/permanent pacemaker.
Standby pacemaker.
Pt is volume/preload dependent so AVOID: hypoTN, hypovolemia, bl loss,
vasodilators.

Mgt of pt pacemaker (PM)

1) Preop:
1. Pacemaker (type, battery site, functn, pacemaker failure $).
2. S.K+.
3. Digoxin.
4. Anticoagulant (&regional anesthesia).
5. PM: switch to asynchronous mode.
6. AICD: switch off (monitor only mode).
2) Anesthesia: AVOID:
1. Etomidate.
2. Sux.
3. N2O.
4. Hyperventilation.
3) Precautions e cautery (EMI= electromagnetic interference).
4) Postop: AVOID: shivering, switch PM to synchronous, switch AICD back on.
5) How to use DC shock in case of cardiac arrest.

NEUROSURGERY
Brain Protection
1)
2)
3)
4)
5)
6)

MAP CPP (CPP = MAP ICP/ or Cerebral Venous Pr).

Temp: mild hypothermia 34o. AVOID: hyperthermia.
PaO2: 60-90 mm Hg.
PaCO2: 35-40 mm Hg mild hyperventilation (mild hypocapnia).
Hct ~ 30%.
Normoglycemia [AVOID: hyperglycemia & glucose containing solutions &
G5%. AVOID: hypoglycemia glucose is the only nutrient utilised by neurons].
7) CVP: 5-10 cm H2O ( IV fluids to maintain CPP).

KEYWORDS

by Doaa Kamal

8) AVOID: coughing (good ms relaxation), straining, vomiting, convulsions,

PEEP ICP.
9) Slight head elevation.
10) Drugs:

Mannitol (brain dehydrating measures).

Lasix (brain dehydrating measures).

Steroids.

Anti-epileptics.

Others: nimopdipine (Ca Channel blocker for SAH).
11) Anesthetics:

BDZ: avoid preop sedation to prevent CO2 retention.

IV: thiopental (of choice), propofol. AVOID: ketamine.

Volatiles: iso & sevo (of choice) AVOID: halothane & N2O.

Ms relaxants: AVOID: sux (if possible) Except: full stomach, difficult airway.

Opioids: fentanyl.

Craniotomy
1) Preop assessment: document neurological deficit.
2) Premedications: AVOID: sedation CO2 retention ICP.
3) Choice of anesthetic agents:

IV: thiopental (of choice), propofol. AVOID: ketamine.

Volatiles: iso & sevo (of choice) AVOID: halothane & N2O.

Ms relaxants: AVOID: sux (if possible). Except: full stomach, difficult airway.

Opioids: fentanyl.
4) ETT: armoured. Airway complications: kinking, slippage.
5) Adrenaline injection: precautions & management of IV escape.
6) Positioning & Mayfield fixator.
7) Brain protection measures.
8) Fluid management: type, amount, blood & bl. products.
9) Hypotensive anesthesia.
10) Precautions for lengthy surgery.
11) Precautions for bloody surgery.

Posterior Fossa (sitting / prone)

1) Position: sitting/prone: complications. Sitting CI 1-ASD (paradoxic air embolism.
Screen by Echo) 2-cerebral ischemia (carotid duplex).
2) Venous air embolism.
3) Pneumocephalus.
4) Affection of vital centres: abrupt hemodynamic changes: HR, BP.
5) Post op complications: bulbar palsy (stridor, dysphagia, aspiration)

SAH (subarchnoid hge)

1)
2)
3)
4)
5)
6)

CP: hdache, LOC, focal neurological deficit.

ECG: ischemic changes, arrhythmias, pulm edema.
HypoTN anesthesia.
Total hypothermic circulatory arrest.
Ruptured aneurysm.
complications:
a. Delayed recovery.
b. Cerebral vasospasm ttt: HHH & Nimodipine
c. Cerebral salt wasting $ ( ANP hypoNa+, hypovolemia).
d. Hydrocephalus.

HHH = (HTN, Hypervolemia, hemodilution).

KEYWORDS

by Doaa Kamal

Transphenoidal Hypophysectomy

Preop: Neurological deficit ( ICP, optic N compression visual field defect)
Hormonal profile: GH Acromegally
ACTH Cushing
TSH hyperthysoidism
Prolactin amenorrhea, galactorrhea, infertility.

Armoured ETT, or oral RAE.

Oral pack.

Eye protection.

Adrenaline injection.

Hypotensive anesthesia

Hemorrhage from cavernous sinus.

Post op complications: DI (ttt: desmopressin), CSF rhinorrhea (ttt: lumbar drain).

Spine Surgery
For: Trauma, decompression (laminectomy, discectomy),
(fixation), spinal cord tumour, correction of kyphoscoliosis.
Preop assessment:

Airway (Cx): neck mobility.

stabilization

Cervical injury: quadriplegia, spinal shock

Neurological deficit (if denervation injury AVOID sux hyperkalemia).

Intubation:

Cx: 1-Difficult airway algorithm (awake fibre optic) 2-In line
stabilization (collar/traction/halo vest) 3-Armoured tube 4-Transoral
approach nasal intubation.

Dorsal: (DLT) Double lumen tube, OLV (one lung ventilation).
Monitoring: wake up test, SSEP, MEP. (Stop NDMR, remifentanyl. TIVA)
Positioning: supine/prone/lateral.
Hypotensive anesthesia.
Spinal cord protection measures.
Precautions for lengthy and bloody surgery.
If Kyphoscoliosis: preop CXR (Cobbs angle), ABG, PFT (restrictive lung
disease), Echo (pulmonary HTN, associated CHD), associated with
malignant hyperthermia.
Complications:

Phrenic N injury (C3,4,5) post op mechanical ventilation
(*Criteria for weaning from MV)

Pneumothorax.

Traction carotid body bradycardia, arrythmias.

Post op blindness (prone position).

Airway edema.

Venous air embolism.

Quadriplegia, spinal shock (if cervical spinal cord injury).

ENT & PLASTIC SURGERY

1) Difficult airway management.
2) Eye protection.

KEYWORDS

by Doaa Kamal

3) ORAL PACK.
4) Hypotensive anesthsia.
5) Special ETTs: armoured, RAE oral/nasal, laser tubes, larygectomy tubes,
microlaryngeal tubes. Airway complications: ETT kinking, slippage, missed oral pack
6) Adrenaline injection.
7) Intraoperative arrhythmias (hd&neck surgery).
8) Ear surgery: avoid N2O (discontinue 20 mins before graft), smooth / deep extubation.
9) Post op laryngeal edema.
10) Neck surgery pneumothorax.
11) Day case surgery.

Total Laryngectomy
1.
2.
3.
4.
5.
6.

Geriatric pt (comorbidities).
Heavy smoker COPD.
Alcoholic.
Malignancy (cachexia, metastasis, chemo, radio).
Difficult airway management.
ETT: laryngectomy tube / armoured tube.

7. After laryngectomy: give the surgeons sterile ETT and sterile breathing circuit.

8. Bloody surgery.
9. Lengthy surgery.
10. Complications:
1) Venous air embolism.
2) Pneumothorax.
3) Endobronchial intubation.
4) Traction on vagus nerve: bradycardia, arrhythmias.
5) Compression on: Carotid A cerebral ischemia, stroke. IJV cerebral
edema, delayed recovery.

OPHTHALMIC SURGERY
1) Measures to IOP: head elevation, mild hyperventilation (mild hypocapnia),
AVOID: coughing (good ms relaxation), straining, vomiting.
2) GA: drugs AVOIDED ( IOP):

Sux Rocuronium instead, or defasiculating dose of NDMR.

Ketamine.

Atropine (in glaucoma).
3) Occulo-cardiac reflex bradycardia, arrhythmias.
4) Smooth/ deep extubation.
5) Regional anesthesia: Indications, CIs #, complications.
6) Squint suspect Malignant hyperthermia.
7) Some are day case surgeries.

RENAL DISEASE
Pathophysiology of Chronic Renal Failure
1)
2)
3)
4)
5)
6)
7)

CNS: uremic encephalopathy, fits.

CVS: HTN, pericarditis, pericardial effusion.
Pulmonary: pulm edema, pleural effusion.
Liver: HBV, HCV (dialysis).
GIT: delayed gastric emptying full stomach.
Blood: anemia, thrombasthenia ( plt function coagulopathy).
Metabolic & electrolytes: metabolic (uremic) acidosis, K+, Na+, Ca, Ph.
5

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by Doaa Kamal

8) Complications of dialysis: dialysis disequilibrium $, volume depletion, residual

heparin effect, K+.

Anesthesia for pt with CRF

1) Dialysis on the night of operation.
2) Regional: coagulation, avoid volume preload, hypoTN ttt by vasopressors.
3) GA: choice of drugs: drugs AVOIDED:

BDZ: valium active metabolite.

Opioids: morphine active metabolite, pethidine norpethidine
(convulsions).

IV: ketamine active metabolites (longer duration).

Volatiles: methoxyflurane, sevo with low flow anesthesia compound A.

Ms relaxants: sux hyper K+, pancuronium & pipecuronium renally
excreted.
4) Fluids: Normal saline (avoid K+ containing solutions), packed RBCs, fluid restriction.

LIVER DISEASE
Pathophysiology of Liver disease
1)
2)
3)
4)
5)
6)

CVS: hyperdynamic circulation: blood volume, HR, SVR.

CNS: hepatic encephalopathy, ICT (in acute stage).
Pulmonary: hepatopulmonary $ (arterial hypoxemia).
Renal: hepatorenal $.
GIT: esophageal varices (hematemesis), portal HTN.
Blood:

Anemia, thrombocytopenia, hypersplenism.

Coagulopathy: PT & INR.
7) Metabolic: metabolic alkalosis, K+ (K-losing diuretics), K+ (K-sparing
diuretics), Na+ (2ry hyperaldosteronism), albumin, hypoglycaemia.

Anesthesia for pt with Liver Disease

1) Regional: caution for coagulopathy (PT &INR).
2) GA: choice of drugs:

Opioids: fentanyl. AVOID: morphine.

IV: propofol, thiopental.

Volatiles: isoflurane, sevoflurane (preserve hepatic blood flow). AVOID:
halothane.

Ms relaxants: atracurium, cisatracurium (of choice), sux prolonged.
AVOID: pancuronium, vecuronium.
3) Fluids:

Glucose-containing solutions.

Colloids preferred.

Whole blood, FFP, platelets.

INTESTINAL OBSTRUCTION
1)
2)
3)
4)
5)

Rehydration.
Correct acid-base balance.
Correct electrolyte disturbances.
Aspiration prophylaxis.
Removal of ryle and suction immediately b4 induction.

KEYWORDS

by Doaa Kamal

6) Rapid sequence crash induction with cricoid pressure & suction unit available.
7) AVOID: N2O.
8) Fully awake extubation.

UROGENITAL SURGERY
TURP
1.
2.
3.
4.
5.
6.

Geriatric pt (comorbidities).
Obstructive uropathy renal impairment.
Malignancy (cachexia, metastasis, chemo, radio).
Lithotomy position.
Choice of anesthesia: regional preferred (advantages).
Complications:
1) TURP $: dilutional hypoNa+ (C/P & ttt), HTN, pulmonary edema/congestion.
2) Hypothermia.
3) DIC (release of tissue thromboplastin & fibrinolytic agents).
4) Dilutional thrombocytopenia.
5) Septicemia: (AB prophylaxis).
6) Bladder perforation.
7) Solute toxicity:

Distilled water hemolysis.

Glycine toxicity & hyperammonemia.

Dextrose/sorbitol hyperglycemia.
8) Haemorrhage (blood loss). [How to calculate amount of blood loss in TURP?]
N.B. Amount of fluid absorbed in TURP: unknown = ECF2
preop s.Na x ECF1 = postop s.Na x ECF2
N.B.(ECF1= 20% of Body Wt)

Radical Cystectomy
1.
2.
3.
4.
5.
6.

Geriatric pt (comorbidities).
Obstructive uropathy renal impairment.
Malignancy (cachexia, metastasis, chemo, radio).
Lengthy surgery.
Bloody surgery.
Position: lumbar hyperextension CVS: congestion, CNS: cerebral edema,
delayed recovery.
7. Complications of urinary diversion (ileal pouch):
1) HypoK+.
2) Hyperchloremic metabolic acidosis.

[Radical] Nephrectomy
1.
2.
3.
4.
5.
6.

Geriatric pt (comorbidities).
Malignancy (cachexia, metastasis, radio, chemo, paramalignant $).
Position: modified lateral position.
Bloody surgery.
Complications: pneumothorax, diaphragmatic injury.
Tumor thrombus extension to IVC & Rt atrium:
1) Pulmonary embolism.
2) May require total hypothermic circulatory arrest.
3) N.B. CVP and pulm artery catheters: may dislodge thrombus.
7. Post op pain management: good analgesia HUGE incision.

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by Doaa Kamal

Renal Transplantation (see later p.14)

ENDOCRINE
DM
1. Preop:

On oral and controlled and minor surgery shift to short acting oral.

On insulin or uncontrolled or major surgery shift to crystalline insulin
& glucose-insulin infusion.

Comorbidities: HTN, IHD, renal impairment, loose teeth.

AVOID morning hypoglycemic.
2. Intraop:

Periodic check of s.glucose level: /1 hr for IDDM, /2 hr for NIDDM.

Glucose-insulin infusion: glucose 5% (1 ml/Kg/hr),
Insulin infusion (unit/hr) = s.glucose/ 150

Add K+ (15 mlEq) as insulin causes intracellular shift of K+.

Tight glycemic control: keeping RBS: 80-120 mg/dl.
3. Postop:

On oral and minor surgery shift back to oral.

On insulin or major surgery crystalline insulin (sliding scale) &
glucose-insulin infusion.

Perioperative complications:
1) DM Comas: (a) Hypoglycemic (b) DKA (c) Hyperglycemic non-ketotic.
2) Infections.
3) Delayed wound healing.

Thyrotoxicosis
1. Preop preparation:
1) For elective surgery (6-8 wks) carbimazole + propranolol.
2) For urgent surgery (eg. TURP) (2 wks) propranolol + carbimazole + K-iodide.
3) For emergency surgery (eg. intestinal obstruction) propranolol/esmolol, Kiodide, hydrocortisone.
2. Preop assessment: thyroid profile, airway (tracheomalacea), CXR (retrosternal extension,
tracheal shift), VC mobility.
3. Difficult airway management.
4. Armoured ETT. Airway complications: neck ext slippage ETT, kinking.
5. PROPER EYE protection (exophthalmos).
6. Intraop complications:
1) Pneumothorax.
2) Venous air embolism.
3) Thryotoxic crisis (C/P & ttt):
CP: sinus tachy140, Fever40oC, sweating, N&V, coma.
Ttt: cooling, rehydration, propranolol, hydrocortisone, propylthiouracil, Na/K
iodide.
7. Deep extubation to assess VC mobility.
8. Post op complications (& management):
1) Thyrotoxic crisis.
C/P: sinus tachycardia 140, fever 40oC, sweating, N&V.
Ttt: rehydration, cooling, hydrocortisone, propranolol, propylthiouracil, K or Na
iodide.
2) Neck hematoma immediate wound re-exploration.
3) Pneumothorax.
4) Recurrent laryngeal N injury:

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by Doaa Kamal

Unilateral
Bilateral
Partial (adduction)
Hoarseness
Stridor
Complete (abduction)
Hoarseness
Aphonia + aspiration
8. Tetany (hypoparathyroidism hypocalcemia).

Pheochromocytoma
1. Preop assessment: C/P [tachycardia, palpitations, sweating, HTN, postural hypoTN], Inv:
VMA, MIBG scan, echo (catecholamine cardiomyopathy).
2. Preop preparation: (2 wks) 1) -blockade 1st: (phenoxybenzamine) 2) Next: -blockade:
propranolol, atenolol, labetalol.
3. Surgical approaches (& positions): open (supine/lateral), laparoscopic (lateral).
4. Regional anesthesia does NOT block CA release from the tumour.
5. Anesthetic drugs avoided from each group.
6. Hemodynamic changes before tumor ligation:

ttt HTN: nitroglycerin, nitroprusside, phentolamine, hydralazine, MgSO4, labetalol.

ttt tachycardia: propranolol, esmolol.
7. Hemodynamic changes after tumor ligation: complications:

HypoTN IV volume replacement, vasopressors: phenylephrine/ norepinephrine.

Hypoglycemia measure RBS, G5%.

Somnolence delayed recovery.
8. If bilateral adrenalectomy (10%) (hypoadrenal state) give corticosteroids.
9. Post op:

Care in ICU.

Complications:
1) HTN: residual circulating CAs pulm edema, LV failure, stroke.
2) HypoTN (catecholamine withdrawal).
3) Hypoglycemia.
4) Somnolence.

ORTHOPEDICS
1)
2)
3)
4)
5)
6)

Cement implantation $.
Pulmonary fat embolism (pelvic surgery &long bones).
DVT pulmonary embolism.
Tourniquet (precautions, comoplications, contraindications).
Malignant hyperthermia.
Hypotensive anesthesia.

VASCULAR
Carotid Endarterectomy
1) Pt = IHD + stroke.
2) Monitoring: all CVS + all CNS monitors (esp. awake, distal stump pr).
3) Br protection:
1. MAP.
2. Hypothermia.
3. PaO2.
4. PaCO2.
5. Hct = 30%
6. Bl sugar (normoglycemia).
7. Drugs: anticonvulsant, CCB (nimodipine).
8. Thiopentone.
9. Volatiles: isoflurane.

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by Doaa Kamal

4) B4 anastomosis: ABP.
5) After anstomosis: ABP.
6) Postop complications:
1.
2.
3.
4.
5.
6.

Hyper-reperfusion $.
Delayed recovery.
Stroke.
Damage of carotid body: resting PaCO2.
HTN: d.t. Damage of carotid baroreceptors.
Surgical:
Pneumothorax.
Recc laryngeal N palsy.
Phrenic N injury.
Airway edema.

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

Thoracic/abdominal aortic surgery:

1)
2)
3)
4)
5)
6)
7)
8)

Monitoring: SSEP, renal (UOP).

One lung ventilation.
Aortic cross clamp.
Bypasses &shunt.
Spinal cord protection.
Renal protection.
Declamping (Hypotension, Hyper K+, metabolic acidosis).
Postop complications:
A. Paraplegia.
B. Renal failure.
9) Bloody surgery.
Lengthy surgery.
Myocardial protection (dt. Severe HTN above clamp).
Brain protection.

CARDIAC SURGERY
CPB
A. PREBYPASS:
1) Hemodynamic changes.
2) Bleeding prophylaxis.
3) Anti-coagulation.
B. BYPASS:
1) Myocardial protection: cardioplegia, hypothermia.
2) Renal protection.
3) Cerebral protection [total hypothermic circulatory arrest].
4) Flow & MAP.
5) Monitoring.
6) Anesthesia during CPB.
C. WEANING:
1) Rewarming.

10

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by Doaa Kamal

2) De-airing.
3) Declamping.
4) Weaning & difficult weaning.
D. POSTBYPASS:
1) Reversal of anti-coagulation (heparin reversal).
2) Control of bleeding.

Pediatric CPB
1)
2)
3)
4)

Circuit priming: blood.

Pump flow: 150-200 ml/min ().
1ry pump failure: incidence (uncommon).
Hemostatic defects: incidence (common).

Causes of 1ry pump failure / difficult weaning off bypass

(A) Surgical / technical causes:
1) Graft kink, spasm, occlusion.
2) Prolonged bypass time (cross clamp).
3) Excessive cardioplegia.
4) Air embolism.
5) Valvular dysfunction.
6) Cardiac tamponade (postop).
(B) Myocardial:
1) Stunning.
2) Ischemia.
3) Reperfusion injury.
(C) Metabolic:
1) Acidosis.
2) K+ heart block, K+.
3) Ca.
4) Residual anesthetic effect (volatiles, thiopental).
(D) Medical:
1) Arrhythmias: Eg. heart block, rapid AF, V-tach, VF.
2) SVR.
3) PVR.

THORACIC SURGERY
Thoracotomy (pneumonectomy)
1)
2)
3)
4)
5)

Predicted post op FEV1.

Lateral/ prone.
One lung ventilation.
Thoracic epidural.
Post op complications:
Resp: pulm edema, ARDS, brochopleural fistula, pl effusion, bronchial
stump disruption, bronchial torsion.
CVS: arrythmias, herniation of the heart, shock.
CNS: paraplegia, recurrent laryngeal N, phrenic N.
6) Bloody & lengthy surgery.

Esophageal surgery
1) One lung ventilation.
11

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by Doaa Kamal

2) Thoracic epidural (advantages).

Pulm: respiratory complications.
CVS: coronary VD, preload, afterload.
post op ileus.
Early ambulation.
hypercoagulable state: DVT pulm embolism.
ICU stay.
3) Bloody.
4) Lengthy.
5) Complications.

N-M DISEASE
Myasthenia
1) Preop Leventhal score (to predict requirement for post op mechanical ventilation):
duration (6yr), dose (pyridostigmine750mg/day), COPD, vital capacity < 2.9L.

2) Preop preparation: steroid cover, plasmapharesis.

3) Preop pyridostigmine ( dose or miss last dose).
4) Regional preferred: AVOID high blocks, AVOID: ester LAs (dt. Anticholinesterases &
plasmapharesis toxicity).

5) AVOID: ms relaxant (resistant to sux, sensitive to NDMR) if needed use

minimal dose (10% of the usual dose), guided by N(+).
6) Criteria of extubation.
7) Post op MV.
8) If in labor: Neonate of myasthenic mother mechanical ventilation (3 wks).

Ms dystrophies (eg. Duchene, Becker)

1)
2)
3)
4)
5)

Malignant hyperthermia (associated).

Cardiomyopathy.
Kyphoscoliosis (restrictive lung disease, pulm HTN).
Regional preferred.
AVOID: sux (hyperKalemia VF, malignant hyperthermia) & NDMR.

Myotonia
1)
2)
3)
4)
5)

Malignant hyperthermia (associated).

Difficult intubation (trismus).
Difficult mechanical ventilation.
CVS: Cardiomyopathy, cor pulmonale, arrhythmias.
AVOID: sux, NDMR, neostigmine (ms spasm), postop shivering.

OBESITY (BARIATRICS)
Definitions: Morbid obesity, Ideal BW, Lean BW, Adjusted BW.
Formulae: BMI = Wt (kg)/ Ht (m)2 Brocas formula: = Ht (cm) 100 = Ht (cm) 105

Pathophysiological changes (metabolic $)

1) Respiration:
a. Restrictive lung disease.
b. V/Q mismatching.
c. OSA.
d. Difficult intubation/ mask ventilation.
2) CVS: HTN, IHD, pulm HTN Cor plumonale (RVF).
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3) GIT: delayed gastric emptying, regurgitation, aspiration.

4) Blood: incidence DVT.
5) Metabolic: hyperglicemia (DM), hyperlipidemia.

Anesthesia for morbid obese pts (Bariatric surgery)

1) Regional light GA (preferred technique).
Adv of RA: 1- opioid consumption 2-Early recovery& ambulation 3- post op
pulm complications 4- post op DVT & pulm embolism.
2) Difficult intubation (Ramped position), mask ventilation, mechanical
ventilation (restrictive lung disease).
3) DVT prophylaxis.
4) Aspiration prophylaxis.
5) Drug dosing adjustment:
Lipid soluble: total BW (d.t large volume of distribution).
Hydrophilic: lean/ ideal BW (d.t small volume of distribution).
6) Mechanical ventilation: 7-10 ml/kg of Ideal BW.
7) Post op:
Analgesia: regional (GOOD analgesia esp. upper abdominal surgery).
Complications: pulmonary complications, DVT pulm embolism, post op
wound dehiscence.
OSA: CPAP.

OSA/ OSH

Def: sleep disorder cc by:

OSA: complete cessation of air flow
OSH: 50% air flow
10 sec
10 sec
5 times/hr
5 times/hr

Pathophysiology: as morbid obese +
Chronic hypoxemia, hypercapnia polycythemia, pulm HTN Cor
pulmonale
Daytime somnolence

Choice of anesthesia:
REGIONAL preferred.
If GA: AVOID sedation, use SHORT-acting opioids.

Difficult intubation: (algorithm).

Difficult extubation: (precautions).

Post op monitoring in ICU: it is a contra-indication for day case surgery.

Pre & post op CPAP mask: (pneumatic airway splinting).

BLOOD
Sickle cell anemia
1) AVOID:
1. HypoTN.
2. Hypothermia.
3. Hypoxia.
4. Acidosis.
5. Dehydration.
6. Stasis (tourniquet).
2) Crises (4) & ttt

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3) Preop exchange transfusion HbS<30% HbA>60%.

4) Difficult intubation.
5) Repeated bl transfusion (HBV, HCV, HIV).

Hemophilia
1) Preop: F8=100%, F9>30%
by FFP, Cryo, F8 concentrate (/12 hr), F9 (/24 hr), desmopressin DDAVP.
Bethesda unit of inhibition: if highly +ve ttt:
Massive F8.
Porcine F8.
F9.
F7 (Novoseven).
Plasmapharesis.
2) AVOID regional anethesia: ABSOLUTE CI#.
3) HBV, HCV, HIV (repeated bl & plasma transfusion).
4) Measures to bl loss intraop.
5) CI# nasal intubation, gentle oral suction under vision.
6) Postop: maintain F8>50% 2 wks postop.

PEDIATRICS
Physiology
1)
2)
3)
4)
5)
6)
7)
8)

CVS: HR-dependent (bradyshock).

CNS: MAC.
Resp: airway: large prominent occiput, floppy epiglottis, narrowest subglottic.
Liver: immature HYPOGLYCEMIA, immature drug metabolism,
incidence of halothane hepatitis.
Kidney: immature must give Na (obligate Na losers) but Na load.
Blood: physiological anemia (HbF HbA), bl.vol=85 ml/kg.
Metabolic: HYPOGLYCEMIA (<40mg/dl), rapid fluid turnover (TBW= 70% of
body weight) rapid dehydration.
HYPOTHERMIA ( body fat, surface area).

GA Management
1)
2)
3)
4)
5)
6)
7)
8)

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

Prematurity
1)
2)
3)
4)

CVS: persistent fetal circulation (PDA, PFO e Rt to Lt shunt).

CNS: kernicerus, ICHge.
Resp: RDS, apneic spells.
Metabolic: hypoglycaemia, hypothermia.
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5) ROP: retinopathy of premature.

Congenital diaphragmatic hernia

1) C/P:
A. Resp: hypoxia (Alveolar-arterial gradient), hypercapnia, resp&metabolic acidosis.

B. CVS: pulm HTN, persistent fetal circulation (PDA, PFO, RVF).

2) Preop preparation: NPO (IV fluids), NG tube (ryle): to deflate intestine.
3) Awake intubation (AVOID +ve pr ventilation gastric inflation, more
hypoxia).
4) Ventilation: RR, TV (permissive hypercapnia) Avoid pneumothx on healthy
side.
5) AVOID factors w cause pulmonary VC ( PVR): hypoxia, hypercapnia,
acidosis, hypothermia, histamine release, catecholamine release (stress, pain),
N2O.
6) Post op:
ECMO.
Tolazoline.
Pulm VD: NO, PGI2.

CHPS
1) C/P:
Dehydration & shock.
Metabolic: early alkalosis, late acidosis (severe dehydration) paradoxical
aciduria.
Electrolytes: Na, K, Cl.
2) Evacuate stomach by NG tube.
3) Rapid sequence crash induction sux & cricoid pr /awake intubation.

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

Cleft lip & palate

1)
2)
3)
4)
5)
6)
7)
8)

URTI.
Difficult intubation &mask ventilation.
Gauze in cleft.
ETT: armoured/ RAE oral.
Dinghman retractor complics: tube kinking, slippage.
Epinephrine injection.
ORAL PACK.
Eye protection.

Cerebral Palsy
1)
2)
3)
4)

Chest infection.
Ms relaxant: dantolene, baclofen pump.
Difficult intubation (rigidity).
Anti-epileptics.

Fetal surgery (open)

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3)
4)
5)

by Doaa Kamal

GA: volatile 2 MAC.

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

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

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

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

AMBULATORY
A. Surgery: duration, not lengthy, not bloody, not major.
B. Pt: contraindications #.
C. Anesthesia:
1) Regional.
2) Drugs.
3) Airway mgt.

Post op complications: pain (mgt), PONV (mgt), bleeding.

Discharge criteria: for GA & regional. Scores: 1-modified Aldrete, 2-postanesthesia discharge score.

TRAUMA
Golden hour.
Permissive hypotension: CI# 1- head trauma 2- pregnancy.
PRIMARY SURVEY: A B C D (disability) E (exposure from head to toe).
SECONDARY SURVEY: (workup)

hd trauma & cx spine.

Chest trauma.

Abdominal trauma.

Orthopedics.

Airway trauma.

+ History of medical illness &last meal (in relation to trauma).
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Airway Trauma

Types of airway trauma: maxilla, mandible, fr base, larynx, trachea, bronchi.

C/P: of airway obstruction (= resp distress).
Assessment of airway.
Intubation.
Extubation. Precautions for difficult extubation.

Mass Casualty

Definition: no. of casualties the ability of a community to meet the needs of its victims

Causes: natural disasters (earthquake, tsunami, floods), war.

Role of anesthetist: triage. A B C.
Types of trauma: polytrauma, blast injuries, burns, toxic: (chemical, biological).

Chemical weapons: organophosphates, cyanide, vesicants (arsenic), pulmonary

intoxicants (sulfur). Biological: anthrax, small pox.

Anesthesia for field hospitals:
Sources of O2.
Types of Anesthesia Machine for such conditions: portable unit, draw over vaporizer
Monitoring equipment.
Anesthetic management:
1) A B C (as management of polytraumatized pt).
2) Regional anesthesia.
3) Analgesics: NSAIDS, opioid agonist-antagonist, opioids, ketamine, Entonox.
4) Anesthetic agents: IV (diazepam, midazolam, propofol, ketamine) Volatiles.
5) Airway management: airway, LMA, ETT, cricothyrotomy (difficult airway mgt)

MUSCULO-SKELETAL DISEASE
Scleroderma
1)
2)
3)
4)
5)
6)

Difficult cannulation.
Difficult intubation.
Steroid cover.
CVS: HTN, pulm HTN, pericarditis, CHF, arrhythmias.
Pulm: IPF, pulm HTN.
Renal: RF.

Kyphoscoliosis
1)
2)
3)
4)
5)
6)
7)

Malignant hyperthermia.
Difficult intubation.
Restrictive pulm disease (PFTs).
Pulm HTN.
One lung ventilation.
SSEP, MEP, intraop wake up test.
Bloody & lengthy surgery.

Dwarfism
Proportionate: hypogonadism, panhypopituitarism, cretinism.
Disproportionate: Achondroplasia, MPS (mucopolysaccharidosis), osteogenesis imperfecta.

1)
2)
3)
4)

Difficult intubation.
Atlanto-axial instability sublaxation quadriplegia.
Malignant hyperthermia.
Dilated cardiomyopathy: AR, MR, TR.

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5) Kyphoscoliosis.
6) Restrictive lung disease pulm HTN corpulmonale.
7) ICT (problems: spinal herniation, epidural further ICT).
8) Hepatomegally liver impairment.
9) Renal impairment.
10) Pathological fractures.

NEURO-PSYCHIATRIC DISEASE
Stroke
1) Anti-plt.
2) Sux hyperkalemia.

Epilepsy
1)
2)
3)
4)

Anti-epileptic side effects.

Carbamazepine, phenytoin = Enz(+), valproate = enz(-) serum level.
AVOID: ketamine, pethidine, atracurium, enflurane.
It fits occur: ttt

Parkinsonism ( Dopamine, A.Ch)

1)
2)
3)
4)
5)
6)
7)
8)

AVOID: metoclopramide (D2 blocker crosses BBB).

Can give: anticholinergics, neostigmine (cannot cross BBB).
Adverse effects of L-dopa: CNS, CVS: tachy, arrhythmias, GIT: N&V.
Difficult intubation (ms rigidity).
Difficult ventilation (ms rigidity).
Difficult regional anesthesia (ms rigidity).
Auntonomic dysfunction: HTN.
Sux may hyperkalemia.

TRANSPLANTATION
Anesthesia for pt transplanted organ
1)
2)
3)
4)
5)

Complete aseptic conditions.

Steroid cover.
Adverse effects of immunosuppressives.
Organ protection.
Dennervated: Ht, Lung.

Anesthesia for pt transplanted lung

1)
2)
3)
4)
5)
6)
7)

Preop bronchiolitis obliterans (most common complication).

Loss of lymphatics extravascular lung water fluid restriction.
Monitor: biphasic capnography.
REGIONAL: recommended.
Cuff of ETT: avoid suture line.
Ht + Lung transplant: fluid mgt = challenging.
+ Others: (steroid cover, immuno suppressives, complete aseptic conditions).

Anesthesia for pt transplanted heart

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

3) + others: (steroid cover, immuno suppressives, complete aseptic conditions).

MISCELLANEOUS
Porphyrias
1)
2)
3)
4)
5)

AVOID: drugs precipitate attack (see table).

AVOID: dehydration attack (preop fasting for too long: give IV fluids).
Bl loss liberal transfusion stragtegy (Hct > 30%) since anemia attack.
REGIONAL : recommended.
C/P of acute attack, diagnosis & ttt.

Anesthesia for pt HIV

1)
2)
3)
4)
5)

Complete aseptic conditions.

Guard against HIV transmission to OR personnel.
C/P: CVS, CNS, Renal, Blood.
Mediastinal L-adenopathy (mediastinal $, SVC $).
Adverse effects of: antivirals, antifungals, antibiotics.

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

Precautions for Bloody surgery

A. To Blood loss:
1)
2)
3)
4)

Hypotensive anetshesia.
Tourniquet.
Local infiltration of adrenaline.
Elevation 10-15.

B. To give blood rapidly

1)
2)
3)
4)
5)
6)

Preop autologous blood donation.

Normovolemic hemodilution.
Cell saver devices.
Wide bore cannulae.
Type-specific cross matched blood.
Rapid infusion devices.
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7) Blood warmers.
8) Antifibrinolytic agents: aprotinin, Epsilon Amino Caproic Acid,
tranexamic acid.
9) Blood substitutes.
10) Normothermia.
11) Calcium to prevent citrate toxicity & aid coagulation.

Precautions for Lengthy surgery

1) To hypothermia:
I. Warm IV fluids.
II. Ambient room temp.
III. Warm blanket/ mattress.
IV. Warm humidified inspired gases.
V. Low flow anesthesia.
VI. Cotton wrapping of the limbs.
VII. Blood warmers.
VIII. Warm irrigating fluids.
IX. Monitoring by temp probe.
2) DVT prophylaxis.
3) Pressure sore prophylaxis.
4) Avoid N2O: peripheral neuropathy, agranulocytosis.
5) Use Isoflurane (more rapid recovery).
6) High volume low pr ETT cuff ( frequent monitoring of intracuff pr).
7) IV fluids: physiological salt solution.

ANY ORGAN TRANSPLANTATION

Indications: end stage organ failure & (its causes)
CIs #: age >65, other end organ failure, malignancy (metastasis), psychiatric probs (pt
non-compliance), HIV +, active infection, + sth special for each organ:

Liver: alcoholic.

Renal: Glomerulonephritis, oxaluria, reversible RF.

Ht: pulm HTN (combined Ht & lung).

Pancreas: morbid obesity.
Donor Criteria: ABO compatible, HLA (not for liver), healthy organ.
Recipient C/P
Organ: preservative solution (UW solution), cold &warm ischemic time.
Anesthetic Mgt:
A. Preop:

C/P: organ failure.

Preparation (pt optimisation).

IMMUNOSUPRESSIVES: methyle prednisolone + .

ABs: 1-cephazolin/ imepenem 2-antifungal: fluconazole 3-antiviral:acyclovir,
gancyclovir 4-pneumocystis carnii: sulfamethoxazole trimethoprim (SMZ-TMP)

Complete aseptic conditions.
B. Intraop:

Graft: source: cadaver/ living related, preservative solution, warm&cold ischemia
time, orthotopic/paratopic.

Monitoring.

Surgical technique: (organ & vessel anastomosis).

IMMUNOSUPRESSIVES: b4 declamping: methyl prednisolone +

Graft reperfusion: DECLAMPING problems [hypoTN, hyper K+, metabolic
acidosis + others].

Monitoring of new graft func, hyperacute rejection, early graft dysfunction & ttt.

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by Doaa Kamal

Postop: ICU
Pain Mgt.
Monitoring.
IMMUNOSUPPRESIVES.
Complications:
a) ORGAN: failure (1ry organ failure), acute rejection & management.
b) Lumen: leakage, stricture.
c) BVs: hge, hematoma, thrombosis (arterial, venous) prophylaxis & ttt.
d) Infections & complications of immunosupressives: opportunistic infections.
e) Surgical complications.
f) Others:

Qs related to transplants:
1) Anesthetic mgt of organ transplantation?
2) Anesth mgt of pt transplanted organ? (eg. presenting for lap cholecystectomy).
3) Postop mgt of pt transplanted organ?
4) Preop preparation for organ transplantation?

IMMUNOSUPPRESSIVES
A. STEROIDS.
B. CALCINEURIN INHIBITORS:
1. Cyclosporine (Neural): adv effects:

HTN.

Nephrotoxic.

Neurotoxic: fits, coma.

Hepatotoxic.
2. Tacrolimus (FK 506): (the same) + hyperglycemia. Used in cyclosporine-resistant
acute rejection.
C. PURINE SYNTHESIS INHIBITORS:
1. Azathioprine: adv effects:

Anemia.

Thrombocytopenia.

Leukopenia.

Hepatotoxicity.
2. MMF (mecophenolate mophetil): the same.
D. ANTI T-CELL ANTIBODIES:
1. Monoclonal (OKT 3): used in steroid resistant acute rejection. Adv effects:

Bronchospasm.

Pulm HTN.

Resp failure.

$ of cytokine release: fever, chills, flushing, chest pain.

Prophylaxis & ttt: anti-H diphenhydramine, hydrocortisone, methyl prednisolone.
2. Polyclonal (Thymoglobulin).
+ All cause opportunistic infections.

*************** Thank You

You ***************

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