Contents

Anaesthesia Revision - 1  1

Anaesthesia Revision - 2  7

Anaesthesia Revision - 3  18

Anaesthesia Revision - 4  23

Anaesthesia Revision - 5  27

Anaesthesia Revision - 6  34

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 Anaesthesia Revision - 1 1

ANAESTHESIA REVISION - 1 ----- Active space -----

PAC : Past Medical & Personal History [Link]

Pre Anaesthesia check-up (PAC).

Past Medical History :
Co-morbid conditions Treatment plan prior to surgery
Continue antihypertensives till day of Sx.
Hypertension • Exceptions : ACE-I & ARBs (Cause severe hypotension).
• Minor surgeries (Minimal blood loss) : Continue ACEI & ARBs.

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• Discontinued :
- OHA & Insulin : On surgery day (Risk of hypoglycemia).

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Diabetes mellitus

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- SGLT-2 inhibitors : 24 hrs prior (Risk of eugylcemic ketoacidosis).

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• Intra-op Start regular short acting insulin.
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• Continue antiepileptics till day of Sx.
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Epilepsy (Triggers : hypoxia, hypercarbia, acidosis, can precipitate seizures).

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• Obtain baseline LFT.

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Continue medications till day of Sx.

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Thyroid disorder • Hypothyroidism : May cause delayed recovery d/t ↓BMR.

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• Hyperthyroidism : To prevent thyroid storm (Tachycardia, SVT).

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Continue antipsychotics.
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Exceptions :
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• MAO inhibitors : Stopped 3 weeks prior.

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Interacts with Synthetic opioids (Meperidine) Hypertensive crisis.

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Psychiatric problems
• Lithium/Mg :2+

- Stop 24-48 hours prior if used along with long acting muscle relaxants
(Prolong their action).
- Can be continued with short acting muscle relaxants like Mivacurium & Atracurium.

Medications Treatment plan prior to surgery

• Estrogen : ↑DVT risk.
- Low risk (Young/immediate mobilization) : Continue.
Oral contraceptive pills
- High risk (Old/long bone fractures/↑bed-rest) : Stop.
• Progesterone : No risk.
Herbal medicine • Check LFT : If abnormal Delay by 1-2 weeks.
Anti-tubercular therapy • Continue ATT (Stopping drug ↑MDR TB).
(ATT) • Check LFT (ATT : Enzyme inducers).
Sildenafil • Stop 24-48 hours prior (Risk of hypotension).

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 2 Anaesthesia

----- Active space ----- Medications Treatment plan prior to surgery

• Stop (May cause electrolyte imbalance/hypotension)
Diuretics
- Exception : Thiazides.
• During regional anaesthesia (RA) Bleeding in closed cavities

Nerve compression
(Permanent damage).
• Anticoagulants discontinued prior to RA :
- Aspirin : Continued/stopped 3 days prior if ↑risk of bleeding.
Anticoagulants - Clopidogrel
5-7 days prior.
- Warfarin
• Bridging with LMWH to prevent re-infarction :
- LMWH Prophylactic dose : Stop 12 hours prior.
Therapeutic dose : Stop 24 hours prior.
- Regular heparin : Stop 6 hours prior.

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• Topical anesthesia : Continue anticoagulants.

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Personal History :
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Condition Features
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• Stopped 3-4 weeks prior (Ideally 6-8 weeks).

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• ↑ Risk of bronchospasm :
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- Clinical features :
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Sudden tachycardia, HTN, ↑airway resistance, wheeze + ..

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- EtCO2 : Shark fin pattern.

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Smoking - Rx : Bronchodilators.
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• ↑Risk of laryngospasm (On extubation) :

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- Clinical features : Stridor, ↓rapid SpO2, paradoxical chest movements/

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no air entry into lungs.

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- Rx : 100% O2 f/b Propofol If uncontrolled Add succinylcholine.

Alcohol 24-48 hours prior.
Tobacco chewing Chances of difficult intubation (D/t restricted mouth opening).

PAC : Family & Allergy History [Link]

Family History :

Malignant hyperthermia :
• Etiology : All inhalational agents & Succinyl choline.
• Risk factor : Strong family h/o muscular dystrophies.
• Pathophysiology : R yanodine receptor mutation (Sarcoplasmic reticulum)

Vigorous muscular contractions.

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• Clinical presentation : ----- Active space -----

- Initial : Locked jaw (Masseter spasm).
- Sudden tachycardia, HTN, ↑body temperature.
- ↑EtCO2 (Most sensitive).
- Ventricular arrhythmias (Hyperkalemia) & cardiac arrest.
• Mx :
- 100% O2 (1st step).
- DOC : Dantrolene sodium (2.5 mg/kg diluted in distilled water).
- Hyperkalemia Mx : Calcium gluconate Insulin + dextrose or Salbutamol.
- Hyperventilation & acidosis Mx : Sodium bicarbonate.
- Post-operative complication :
Acute tubular necrosis (Myoglobin release) : Monitor urine output.

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Allergy History :

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Causes anaphylactic shock (Histamine : vasodilator & bronchoconstrictor).

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Etiology : r@
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Antibiotics > latex > muscle relaxants > local anaesthetics.

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Clinical presentation :
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• Sudden tachycardia, hypotension.

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• Wheeze (D/t ↑airway resistance).

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• Edema (Lips/face/airway).
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Mx :
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• Adrenaline (DOC) : Dosage based on route (1 mL = 1 mg = 1 : 1000).

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- IV dose : 1 mL of 1 : 10000.
- IM / SC dose : 0.5 mL of 1 : 1000.
• Hydrocortisone.
• Adequate fluids.

Airway Examination [Link]

Risk Factors :
• H/o difficult intubation.
• Airway anomalies.

Finger breadth technique

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----- Active space ----- Assessment :

Examination Inference
• Mnemonic : OBESE • Pregnancy
- Obesity • Long upper incisors
Predictors for difficult - Bearded • Inability to protrude lower jaw
intubation (DI) - Elderly • Small mouth opening
- Short • High arched palate
- Edentulous
Mouth opening Finger breadth technique (Normal = 3 fingers)
• Normal : 12-35˚
Atlanto-occipital/C-spine mobility
• Neck circumference (>43 cm) DI
Thyromental distance Normal : >6.5 cm (<6 cm DI)
Sternomental distance Normal : 13 cm (<12 cm DI)

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Thyromental distance
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Sternomental distance
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Mallampati scoring :
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Mallampati scoring
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Grades Structure seen

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Grade I Uvula hanging freely Uvula

Grade II Tip of uvula not visible
Grade III Half of Uvula not visible
Grade IV Hard palate
Difficult (Introduced by Only hard palate visible
intubation (D1) Sampson Young)
Grade 0 Clear glottic opening with large Mallampati scoring
epiglottis

ASA Grading & Pre-operative Investigations [Link]

ASA Grading :
Based on functional capacity.

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----- Active space -----

Grade Characteristics Examples

I Healthy patient • Normal BMI, non-smoker, occasional alcohol use
• Medical disease under control (HTN, DM,epilepsy)
• Smoker, BMI = 30-40
II Mild disease with no functional limitation
• Pregnancy
• Mild - moderate obesity
• Medical diseases with poor control (HTN, DM, epilepsy)
III Severe disease with functional limitation • CKD, CLD, COPD
• Morbid obesity (BMI >40)
IV Severe disease with threat to life • Recent MI, CVA, unstable angina
V Moribund patient • Death <24 hours
VI Brain dead patient -

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Investigations :

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Minimum laboratory parameters for various scenarios :
Parameters r@ Value
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Minimum acceptable Hb before elective surgery 8 g/dL

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Minimum acceptable Hb before elective surgery with comorbid conditions 10 g/dL

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Minimum acceptable Hb before elective surgery in critically ill patients 12 g/dL

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Minimum acceptable platelet count for invasive procedure (Central line/liver biopsy) 50,000
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Minimum acceptable platelet count for central neuraxial block 1 lakh

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Minimum acceptable platelet count for peripheral neuraxial block 80,000

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Indications for ECHO vs ECG :

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ECHO ECG
• Dyspnoea of unknown origin. • K/c/o IHD.
Mandatory • Heart failure patients with worsening • Significant arrythmia PAD, CVD.
dyspnoea. • Significant structural heart disease.
May be • Past h/o LV dysfunction not • Major Sx in asymptomatic patients
done evaluated since l yr. without h/o coronary heart disease
Not • Asymptomatic patients.
• As routine investigation.
performed • Low risk surgical procedures.

Risk Stratification [Link]

Cardiac risk stratification :

ACC/AHA guidelines.
High risk surgery :
• Surgery above umbilicus/emergency surgery.
• Proceed with surgery.
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----- Active space ----- Elective surgery : Thoroughly evaluate for the following & then do Sx
• ACS. • Significant arrhythmias.
• Decompensated HF. • Valvular heart disease.
Risk assessment for developing MI :
Parameter Score Score Risk of cardiac complication
High risk surgery 1 0 0.4 %
H/o ischemic heart disease 1 1 1.0 %
H/o congestive cardiac failure 1 2 2.4 %
H/o cerebrovascular accident 1 ≥3 5.4 %
H/o diabetes mellitus requiring insulin 1
Serum creatinine >2.0 1

Stress testing : Perform if functional capacity <4 METS.

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Criteria for performing Sx after coronary stenting :

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• Bare metal stent : Wait for 1 month.
• Drug eluting stent (M/c) : Wait for 6 months. r@
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Criteria for giving infective endocarditis prophylaxis :

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• Previous history. • Unrepaired/repaired (Residual defect) CHD.

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• Prosthetic valves. • Cardiac transplant.

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Pulmonary risk stratification :

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Patient related Procedure related Laboratory test

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• Old age • Aortic aneurysm repair • Albumin concentration <3.5 g/dL

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• Cigarette smoker • Upper abdominal Sx • Chest radiograph abnormalities

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• Abnormal findings on CXR • Emergency Sx

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Pre-operative Instructions [Link]

Pre-medications : Fasting guidelines before Sx :

• Anxiolytic : Short acting • Adult : 6-8 hours.
benzodiazepines (Midazolam). • Children :
• Anti-emetic (Ondansetron). - 2 hours : Clear liquids.
• Anti-sialogogues : - 4 hours : Breast milk.
- Atropine/Glycopyrrolate. - 6 hours : Non-human milk, solids
- Indication : Children, intellectual - 8 hours : Heavy fatty meal.
disability, head & neck Sx.
• Analgesia :
Short acting opioids (Fentanyl).
• Antibiotics :
Cephalosporin for cardiac Sx.
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ANESTHESIA REVISION - 2 ----- Active space -----

Monitoring of Patient : CNS, CVS, RS  [Link]

CNS Monitoring
Depth of anesthesia (Absence of awareness) is monitored.

Bispectral Index :
• Analyzes EEG waveforms.
• 40 to 60 : Recommended range for GA. Bispectral Index

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CVS Monitoring :

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HR BP ECG Central venous Pulmonary Echocardiography
• Arrhythmias : Lead II r@
pressure Capillary Wedge
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• Ischemia
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Pressure
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(PCWP)
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Non-Invasive : Invasive (M/c : Radial) :

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Sphygmomanometer • Major Sx.

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• Palpation. • Allens test : Ensures

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• Auscultatory.
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adequate collateral
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• Oscillatory.
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circulation
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(Automatic)
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Allens Test (AT) : Modified AT :

• Compress B/L radial • Compress both
A. with 2 hands. radial & ulnar A.
• Negative : Normal. • Positive : Normal.
Central Venous Catheter vs. Pulmonary Artery Catheter :
Central Venous Catheter Pulmonary Artery Catheter
• Measures : Right heart functioning
CVP • Measures : Left heart functioning
(Normal : 0-5 cm H2O) PCWP
• Monitor fluid status :
Features - ↓CVP + ↓BP Rx : Fluids.
- ↑CVP + ↓BP (Pump failure) Don’t administer Normal : ↑ : LV
fluids. 12-16 mmHg dysfunction
• Long term IV cannulation for : TPN, inotropes, • Reduntant method
cardiac medications.
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----- Active space -----

Central Venous Catheter Pulmonary Artery Catheter

• Arrhythmias : M/c
Complications Arrhythmias (M/c)
• Pulmonary capillary rupture : Most dreaded

Triple lumen
Image • Size : 7 Fr (20 cms)
• Inserted in IJV.

CV Catheter Swan-ganz catheter

RS Monitoring :

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Pulse Oximeter :

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• Measures oxygenation. • Limitations :

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• Principle : Beer Lambert’s law. - CO poisoning : SpO2 falsely↑
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• Emits : - Meth Hb, dyes : SpO2↓
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Absorbed by
- Red light (660 nm) Reduced Hb.
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Absorbed by
- Infrared light (940 nm) Oxygenated Hb.
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Capnography :
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• Monitors exhaled CO2

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• Principle : Infra red spectroscopy.

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• Normal EtCO2 : 35-45 mmHg.

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Main stream capnography Side Stream Capnography

Waveforms :
Normal : Top hat shape.

Phase III Exhaled EtCO2

Phase Characteristics
measured
I Exhaled from dead space (No CO2)
α β II Expiratory upstroke (Gases exhaled by upper alveoli)
Phase II Phase IV
III Alveolar plateau phase (Gases exhaled from middle &
(Phase 0)
lower alveoli)
Phase I IV Inspiratory downstroke

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Abnormal Waveforms : ----- Active space -----

Expired CO2

Expired CO2
Time Time
Bronchospasm/Partially obstructed ET tube Cardiogenic oscillations
• Increased upstroke of phase III. Physiological in children (D/t thin chest wall).
• Shark fin pattern.

Expired CO2
Expired CO2

Curare cleft

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Time Time

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Recovering from the effect of muscle Hypoventilation
Seen in opium poisoning (CNS depressant)
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relaxant
If curare cleft seen :
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- During Sx : Supplement with muscle relaxant.

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- End of Sx : Start reversal.

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Expired CO2

Step ladder pattern

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Time
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Malignant hyperthermia Malignant hyperthermia

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Expired CO2

Expired CO2

Elevated
Time Time
Leaky sampling line baseline Rebreathing of CO2
Dual plateau sign. Exhausted soda lime/inadequate fresh gas flow
A B
Expired CO2
Expired CO2

β
6
4
2
0

Time
Time
Incompetent inspiratory valve Single lung transplant
Slaying of phase IV. 2 peaks in phase III
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----- Active space -----

Expired CO2
50
37
CO2 (mmHg)

0
Time Time
Sudden zeroing of EtCO2 Intubation into esophagus
• Accidental extubation/circuit disconnection (M/c)
• Venous air embolism

Monitoring of Patient: Neuromuscular & Temperature [Link]

Neuromuscular Monitoring :
Use : To check adequate muscle relaxation after Sx.
Train Of Four (TOF) stimulation :

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• Muscle contraction noted on 4 equal

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supramaximal stimulus. Ulnar nerve monitoring (M/c)
• TOF ratio (4th stimulus/1st stimulus) : > 0.9 r@ (Adductor policis muscle)
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Safe to extubate (Fully recovered from muscle relaxant).

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Constant diminution response

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Normal DMR (Phase 1)

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Gradual fade response

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(Also in Phase II block of DMR)

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Normal NDMR
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Temperature Monitoring :
Hypothermia : Hyperthermia :
• D/t depressed hypothalamus, Malignant hyperthermia, sepsis.
chilled OT & IV fluids.
• Under anesthesia : ↓Shivering threshold.
Monitoring :
Site Areas for measurement
Neuro Sx Tympanic membrane, nasopharynx
Core body temperature Cardio Sx Pulmonary artery (Most accurate)
Other Sx Lower esophagus (M/c done)
Intermediate Rectum (Wards, casualty)
Not reliable Skin, Axilla

Note : Bladder temperature Not performed since values affected by urine flow.
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Airway Management & Equipments [Link] ----- Active space -----

Pre-oxygenation :

Anatomical face mask :

100% O2 with tight fitting mask Time
Normally 10-12 L (↑Apnea time up to 10 min) 3 min
Anatomical face mask
Preferred : 8 Vital Capacity (VC) breaths 1 min
Emergency
Least preferred : 4 VC breaths 30 sec
• Position : Slight head up.
• Triple manoeuvre Head tilt
(Prevents tongue Chin lift
Jaw thrust

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falling back)

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Jaw thrust

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Recent updates : Head tilt & chin lift

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r@ O2 ↑Apnea time by
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Trans-nasal Humidified Rapid Insufflation 60 L for 3

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13 minutes
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Ventilatory Exchange (THRIVE) min

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NO DESAT : Directly to pharynx 15 L/min 9 minutes

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Guedel’s airway :
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• Prevents tongue fall back.

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• Disadvantage : Stimulates Gag reflex.

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• Size : Angle of mouth to tragus/mandible.

Guedel’s airway
Nasopharyngeal airway:
• Prevents collapse of pharynx.
• Contraindications :
- Children with adenoids.
- Base of skull fracture (Raccoon’s eye).
- Coagulopathy. Nasopharyngeal airway

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----- Active space ----- Laryngoscopy :

Head & neck position :

Neck extension
Oral axis is Scissor’s method
aligned with the (To extend the lower jaw)
other 2 axes.

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10-15 cm pillow/head

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ring behind the occiput

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Helps align pharyngeal &
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laryngeal axes.
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Sniffing of morning air/Drinking of pint beer position

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• Flexion : At lower cervical spine

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• Extension : At atlanto-occipital joint

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Laryngoscopes :
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Macintosh/Curved blade Miller’s/Straight blade

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Used in Adults Children.

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Hold laryngoscope in left hand

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Same as adults except :

Insert from right corner of mouth
• Inserted from center
Method of oral cavity
Push tongue to side till blade reaches its base
• Include epiglottis,
while lifting the hand
On visualising epiglottis (Don’t include) : Lift hand using triceps & deltoid
Note : Do not bend at wrist joint. (Causes upper teeth injury.)
Visualisation Indirect Direct

Image

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Corkmack lehane grading : ----- Active space -----

To assess visibility of glottic opening after laryngoscopy.

Grade 1 : Grade II : Grade III : Grade IV :

Complete laryngeal Only posterior portion of Only epiglottis seen Epiglottis not seen
aperture seen laryngeal aperture seen

ETT & Miscellaneous Equipments for Intubation [Link]

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Endotracheal Tube (ETT) :

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Types :

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Murphy’s eye : A lternate
ventilation r@
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Pilot balloon :Inflates

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cuff
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Guide : Crosses vocal cords

Uncuffed ETT
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Cuffed ETT
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(Prevents aspiration)
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Types of Cuffed ETT ↓Pressure, ↑Volume (PVC)

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↑Pressure, ↓Volume (Red rubber) Disadvantage :

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Pressure >25 cmH2O

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damages tracheal mucosa.

↑Pressure, ↓Volume cuff

Narrowest part of larynx :

• Glottis : Adults Cuffed ET tube.
• Subglottis : Children Microcuffed (Recent recommendation) : Distal placement.
Uncuffed

Microcuffed ETT
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----- Active space ----- Modification :

Flexometallic/Armoured tube : Double lumen ETT : Used in lung Sx
Use :
• Head & neck Sx.
• Prone position Sx.

RAE ETT :
• South facing : Cleft lip surgeries. • North facing : Lower lip Sx

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Accessory Gadgets :
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• Passed in ETT • Direct tracheal insertion • For foreign body removal

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Stylet Bougie Magill’s forceps

Advanced Gadgets :
Flexible fiber optic bronchoscope :
• Gold standard for ETT position.
• Used in restricted mouth opening & lung Sx.

Note : Capnography Surest sign of intubation. Flexible fiber optic bronchoscope

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----- Active space -----

Video laryngoscope Airtraq laryngoscope Bullard laryngoscope

Health care worker protection : D/t
↓chances of aerosol contamination

Supraglottic Airway Devices [Link]

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LARYNGEAL MASK AIRWAY (LMA) :

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First Generation :
Classical LMA : (Made of Latex) r@ LMA Unique :
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• Made of PVC.
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• Advantages : Easy to use, minimal neck movement.

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• Disadvantages : D oesn’t prevent aspiration. • Single use.

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Avoid in : Emergencies, Prone position,

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Laparoscopy, Pregnancy.
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Superior part :
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Base of tongue
Intubating LMA
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Lateral walls :
On pyriform fossa
Tip :
Above esophageal sphincter

Second generation :
D/t drain tube (For removal of aspirate).
Proseal LMA : LMA Supreme : IGEL :
Drain tube
Drain
tube Drain tube

• Made of PVC (Better sealing pressure) • Made of silicon gel. (Mimics

• Used in laparoscopic Sx & pregnancy. shape of pharynx.)
(But intubation preferred) • No pilot balloon.
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----- Active space ----- Modifications for Intubation [Link]

Manual in-line stabilization : ↓Neck movement after RTA.

Rapid sequence/Emergency intubation :

Sellick’s Maneuver : Applying pressure on
cricoid cartilage
(Esophageal lumen occlusion). Ramp position
(For obese patients)

Feature RSI Modified RSI

Induction agent & muscle relaxant administered quickly

Cricoid pressure applied (30 N)

Procedure

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Cricoid pressure removed after :

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Intubation & cuff inflation.

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Selick’s Maneuver

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Muscle relaxant Succinylcholine (Short acting) Rocuronium
Induction AOC Thiopentone sodium r@
Propofol
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PPV C/I (↑Risk of aspiration) Gentle PPV (<20 cm) permitted

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Awake intubation :
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• Superior laryngeal nerve block • Glossopharyngeal nerve block

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• Transtracheal injection :
Blocks recurrent laryngeal nerve

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Failed Intubation Algorithm [Link] ----- Active space -----

Plan A :
Facemask ventilation Succeed Tracheal intubation
Laryngoscopy
& tracheal intubation
Failed intubation

Plan B :
Maintaining oxygenation : Supraglottic Succeed Stop and think :
SAD insertion Airway Device Options (Consider risks & benefits)
(SAD) 1. Wake the patient up.
2. Intubate trachea via the SAD.
3. Proceed without intubating the trachea.
4. Tracheostomy/cricothyroidotomy.
Failed SAD ventilation

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Plan C :

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Final attempt at face Succeed

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Facemask ventilation Wake the patient up

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mask ventilation
Can’t Intubate, Can’t r@
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Oxygenate (CICO)
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Plan D :
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Emergency front Cricothyroidotomy

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of neck access
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----- Active space ----- ANAESTHESIA REVISION - 3

Drugs in General Anaesthesia (GA) :

Intravenous Inhalational Muscle relaxants Analgesics

induction agents induction agents & reversal

Intravenous Induction Agents [Link]

Induction agents : Depressants.

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• Act on GABA receptors : ↑Chloride conductance Membrane hyperpolarization.

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BARBITURATES
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Good antiepileptic action (Except Methohexital).
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Thiopentone Sodium :
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General properties : Yellow powder of pH 10.5 (Most alkaline) with garlic/onion smell.
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Onset : 15 sec (Arm brain circulation time).

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Metabolism :
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• Highly lipophilic.
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• Termination of action by redistribution (Brain Fat).

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- Patient will have a hangover effect.

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Dose : 3-5 mg/kg.

Use :
• AOC :
- Neurosurgeries (Max. ↓ICP). - Hyperthyroidism
• Truth serum.
Complication :
• Accidental intraarterial administration : Pain, pallor, edema, gangrene.
Mx : Retain cannula (To prevent vasospasm).
- Saline/heparin flush.
- Stellate ganglion block (Lower cervical sympathetic ganglion).

Methohexital :
Disadvantage : Proconvulsant (Avoided in neurosurgeries).
Indication : Electroconvulsive therapy.
Dose : 1-1.5 mg/kg (More potent than thiopentone).
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 Anaesthesia Revision - 3 19

NON BARBITURATES ----- Active space -----

Propofol Etomidate Ketamine

Form : • White : Egg lecithin (Used within 6

(Oily hours). Oily preparation :
Phencyclidine derivative
• Oily preparation : Soya bean oil. Propylene glycol.
Painful
• Mixed with lignocaine to ↓pain.
injection)

• Dissociative anaesthesia,
Depressant (In vivo).
Properties Antiemetic & antipruritic Most cardiostable
• NMDA receptor antagonist
(↑Catecholamine release).
• IV : 1-2 mg/kg.
Dose 1-2.5 mg/kg 0.2-0.3 mg/kg
• IM : 4-6 mg/kg.

om
Onset 15 sec - -

l.c
ai
Intrathecally used with

gm
Duration 8-10 min (Without hangover) -
r@
jja LA to ↑duration
• Day care/ambulatory Sx &
gu

• Shock (↑HR & BP).

ar

monitored anaesthesia care.

• Asthma/COPD : Good
nw

• Ophthalmic Sx (Max ↓IOP). • Cardiac &

bronchodilator.
pa

Agent of • LMA insertion & Rx of laryngospasm aneurysm Sx.

h

• Tetralogy of Fallot.
is

choice (↓ reflexes). • DC
an

• Low resource settings

• Total IV anaesthesia. cardioversion.
m

(Burns, I & D).

• Office based anaesthesia :
|

• Paediatric Sx.
w

Endoscopy & colonoscopy.

ro
ar

• ↑Oral secretions
M
©

(Rx : Atropine/
Propofol infusion syndrome • Myoclonus
Glycopyrrolate).
(On prolonged infusion) : • Emetic &
• Unpleasant hallucinations/
Side • Green urine, severe metabolic Epileptogenic.
Emergence (Reduces with
effects acidosis, asystole. • Inhibits
midazolam).
• Addictive d/t pleasant adrenocortical
• C/I :
hallucinations. synthesis.
- HTN & cardiac conditions.
- Ocular Sx (↑IOP)

Inhalational Induction Agents [Link]

Characteristics :
• Maintain depth of anaesthesia.
• Induce sleep (Paediatric).
• Depressants.
• Enter & exit the circulation via lungs.

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 20 Anaesthesia

----- Active space ----- Classification :

Newer agents (Non flammable) : Older agents (Flammable) :

• Halothane. • Ether.
• Isoflurane. • Chloroform.
• Desflurane. • Trilene.
• Sevoflurane. • Cyclopropane.
Meyer Overton Rule :
Potency ∝ lipid solubility.

Minimum alveolar concentration (MAC) :

• Minimum amount of drug required to produce immobility to painful stimulus.
1

om
• Potency ∝ .

l.c
MAC values

ai
gm
Least MAC Highest MAC
r@
jja
gu

Most potent Methoxyflurane Halothane Isoflurane Sevoflurane Desflurane N2O Least potent
ar
nw

FACTORS AFFECTING UPTAKE

pa
h

Machine to Alveoli :
is
an

a. Concentration effect :
m
|

• Higher inspired concentration Quicker induction.

w
ro
ar

b. Second gas effect (Augmented in flow effect) :

M

• In presence of one gas (N2O) Concentration of IA increases.

©

• Reason : Rapid diffusion of N2O from alveoli to pulmonary circulation.

Both effects seen simultaneously at start of surgery.

Note :
Diffusion hypoxia/Fink effect (End of Sx) :
• Rapid diffusion of N20 from pulmonary circulation Dilution of O2.
• Mx : 02 supplementation.

Alveoli To Pulmonary Circulation :

Blood gas partition coefficient : Concentration of agent in blood
(B/G ratio) Concentration of agent in alveoli
↑ B/G ratio ↑Concentration in blood ↑ Solubility in blood Delayed induction

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 Anaesthesia Revision - 3 21

----- Active space -----

Least B/G ratio Highest B/G ratio

Fastest Xenon Desflurane N2O Sevoflurane Isoflurane Halothane Methoxyflurane Slowest

induction (Ideal agent) induction

Systemic Effects Of Inhalational Agents [Link]

Halothane Isoflurane Desflurane Sevoflurane

• Maximum AOC :
bronchodilation. • Paediatric
• Pungent : • Irritant :
• Sweet scent Sx (Sweet

om
Pulmonary Avoid in Avoid in
(2nd choice in children) scene).

l.c
system : asthmatics. asthmatics.

ai
Note : Contains thymol • Daycare Sx.

gm
↓RR (Preservative) • Lung injury.
• ↓ Pulmonary vascular resistance. r@
jja
• Mild hypoxic pulmonary vasoconstriction.
gu
ar

• AOC : Cardiac • Avoided

nw

• Max ↓ HR patient in cardiac

pa

(Bradyarrhythmias) (↓Preload & patients

h
is

CVS : AOC for cardiac

• Sensitises
an

afterload) (↑HR
↓HR, ↓BP patients
m

myocardium to • Complication : temporarily)

|

adrenaline. Coronary steal

w
ro

phenomenon.
ar
M

CNS : The rise in ICP is countered by hyperventilation

• Max ↑CBF, ↑ICP.
©

↑ Cerebral (↓EtCO2 = ↓ICP).

• C/I in neurosurgery
blood flow Used in neurosurgery.
(CBF)
Note : Enflurane causes seizures.
↑ ICP.
• Max ↓LBF.
Minimally
GIT, liver and • Metabolite causes - -
metabolised.
biliary tract : Halothane hepatitis in
↓Liver blood old age, female,
flow (LBF) 40 yrs, obese, multiple Hepatic insufficiency : Either of 3 used
exposure.

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 22 Anaesthesia

----- Active space ----- Halothane Isoflurane Desflurane Sevoflurane

• Max fluoride ions.
Renal system : • Prolonged use of
Best agent :
Fluoride ions Sevoflurane (High. conc.) +
- Desflurane > Isoflurane
(Added to make it soda lime = Compound A
(Least metabolized)
non inflammable) (Nephrotoxic in lower
Causes nephrotoxicity. animals).
Note : Max nephrotoxicity Methoxyflurane.
Reproductive system Good uterine relaxants (↑risk of PPH).
Ocular ↓ IOP
• Minimal
Metabolism Max - • Green -
house gas

om
Note : Trilene Only analgesic.

l.c
ai
gm
Effects of N2O :
• Proven teratogen. r@
jja
gu

• Disrupts Vit B12 metabolism :

ar

- Megaloblastic anemia.
nw
pa

- Subacute combined degeneration of spinal cord.

h
is

• C/I in :
an
m

- Pneumothorax/pneumomediastinum.
|

- Middle ear & retina sx.

w
ro
ar
M
©

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 Anaesthesia Revision - 4 23

ANAESTHESIA REVISION - 4 ----- Active space -----

Muscle Relaxants : DMR [Link]

Aids in intubation/Surgical relaxation.

Depolarizing Muscle Relaxants (DMR) : Succinylcholine

Succinylcholine (2 molecules of ACh)
Dosage 1-2 mg/kg
Duration <10 minutes
Onset of action 30 seconds

om
l.c
AOC Difficult intubation/rapid sequence intubation

ai
gm
• Non competitive blockade : Ach receptor.
Mechanism of action
• Metabolised by pseudocholinesterase. (PSE : Produced by liver).
r@
jja
• Bradyarrhythmia (Rx with Atropine/Glycopyrrolate).
gu

• Muscle fasciculations :
ar

Systemic effects - Post-operative myalgia.

nw

- ↑ICP, ↑IOP, ↑Intragastric pressure (↓Chances of aspiration)

hpa

• Anaphylaxis
is
an

• Family h/o malignant hyperthermia & muscular dystrophies.

m

• Preexisting hyperkalemia.
|
w

• Burns.
ro

C/I
• Acute liver failure.
ar
M

• Sepsis.
©

• Hemiplegia/paraplegia.

Reasons for prolonged duration of action :

↓Concentration of PCE : ↓PCE enzyme activity : Phase II block :

• Acute liver failure. Atypical pseudocholinesterase. • Succinylcholine >5mg/kg :
• Neonates, pregnancy. Receptor damage.
• Drugs : • Rx : Mechanical ventilation.
- Pyridostigmine. • Resembles NDMR block,
- Organophosphate poisoning. but Neostigmine is C/I.

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 24 Anaesthesia

----- Active space ----- Atypical pseudocholinesterase :

• Qualitatively assessed by dibucaine number.
(↑Affinity to pseudocholinesterase).
• Rx :
- Continue Mechanical ventilation.
- Fresh frozen plasma.
Type of Pseudocholinesterase Dibucaine number Duration of action
Normal 80 : 20 <10 min
Heterozygous variant 50 : 50 45 min - 1 hour
Homozygous variant 20 : 80 6 - 8 hours

Muscle Relaxants : NDMR [Link]

om
Non Depolarizing Muscle Relaxants (NDMR)

l.c
ai
gm
Types :
: Steroidal compounds. r@ : Benzylisoquinolone compounds.
jja
gu

Properties Advantages Disadvantages

ar
nw

• Avoid in day-care Sx
pa

Pancuronium Excretion : Kidney AOC : Shock

• C/I : HTN & cardiac patients (↑HR & BP)
h
is

Vecuronium Excretion : Bile AOC : Cardiac & neuro Sx Avoid in hepatic insufficiency
an
m

• Onset : 30 sec. AOC :

|

Rocuronium • Duration 30 min. • Rapid Sequence Intubation. -

w
ro

• Dose : 0.6-1.2 mg/kg. • Day Care Sx.

ar
M

Metabolism :
• Anaphylaxis (D/t histamine release).
©

Hoffman’s degradation AOC : Liver & renal transplant/

Atracurium • Seizures (D/t laudosine released on
(Non-enzymatic/non organ failure patients.
prolonged infusion)
dependant clearance)
Cisatracurium • Similar to atracurium.
Preferred over Atracurium
(Isomer of • No histamine & minimal -
(D/t lesser S/E)
atracurium) laudosine release.
• Onset : 2-3 sec.
• Duration : 10 minutes
• Day-Care Sx :
Mivacurium (Shortest). -
2nd preferred AOC.
• Metabolism : Plasma
esterases.
Reversal Of Block :
Neostigmine :
• Dose : 0.05 - 0.07 mg/kg.
• Administered on spontaneous breathing (EtCO2 : Curare cleft).
• Side effect : Bradycardia/↑Oral secretions Rx : Atropine/Glycopyrrolate.
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 Anaesthesia Revision - 4 25

Sugammadex (New reversal agent) : ----- Active space -----

• Cyclodextrin molecule. • Side effects :
• Used for reversal of Vecuronium/Rocuronium - Anaphylaxis
(In day care Sx). - Contraceptive failure.
Signs of adequate reversal :
• Regular respiration & adequate tidal volume. • Able to hold tongue depressor b/w
• Spontaneous eye opening. central incisors.
• Spontaneous limb movement. • Train of four ratio > 0.9 : Guaranteed
• Able to protrude tongue, cough (No cyanosis). recovery.
• Able to lift head >5 sec (Most reliable bedside test).

Paediatric Surgeries [Link]

om
l.c
Preoperative Preparation :

ai
gm
To ↓anxiety :
• Benzodiazepine syrup (Midazolam). r@
jja
Children > 6 months age
gu

• Ketamine IM : 4-6 mg/kg.

ar

• Parental accompaniment in OT.

nw
pa

Fasting guidelines :
h
is
an

• 2 hours : Clear liquids. • 6 hours : Solids (Except breast milk).

m

• 4 hours : Breast milk. • 8 hours : Heavy fatty meal.

|
w
ro
ar

Note : EMLA Cream Eutectic mixture

M

• Lignocaine (2.5%) + Prilocaine (2.5%).

©

• Used for superficial procedures (IV cannulation).

Intraoperative Considerations :
Inhalational.
Induction of anaesthesia
AOC : Sevoflurane > Halothane (Inhalational agents).
AOC : Vecuronium/Atracurium.
Muscle relaxant
Avoid : Succinylcholine in <1 year (D/t undiagnosed myopathy).
Analgesic : Fentanyl 1-2 mcg/kg (Short acting agent).
ETT : Microcuffed > Uncuffed ETT.
Airway Management
Laryngoscope : Miller’s blade.
OT temperature : 27-28˚C.
Prevention of hypothermia
Warm fluids & heating devices.

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 26 Anaesthesia

----- Active space ----- Post-Operative Analgesia :

Caudal anaesthesia :
• No risk of spinal cord injury.
• Administered only in postoperative phase
in children.
• ↑Risk of infection (D/t bowel & bladder
immaturity).
Caudal anaesthesia :
Insertion at S4-S5 vertebral junction
& directed towards S2 segment.

Day Care Anaesthesia [Link]

• Same day admission, operation & discharge.

om
• ↓ Risk of hospital infection.

l.c
• All regional anaesthesia procedures can be done in day care setting.

ai
gm
r@
Prerequisites : jja
Patient factors :
gu

I & II.
ar

• Consider ASA grades

nw

III (In well-controlled diseases).

pa

• Avoid extreme ages : Premature babies/>85 years.

h
is

• Stays near the hospital & has a responsible attender.

an
m
|

Procedure factors :
w
ro

• Indications : Laparoscopic Sx.

ar
M

Procedures anticipating post-op complications.

©

• C/I
Duration >90 minutes.
Anaesthetic factors :
Agent of choice (Short acting with no residual effects)
IV induction Propofol
Inhalational Sevoflurane (Sweet smelling) > Desflurane (Irritant)
Muscle relaxant Rocuronium & Sugammadex > Mivacurium
Opiod Remifentanyl (Shortest), Fentanyl (India)
Local anaesthesia Chlorprocaine (Shortest)

Post Operative Considerations :

Discharge of patient : Modified Aldrette Scoring System Fit for discharge if >9.

Complication :
• M/c : Drowsiness, nausea & vomiting.
• M/c cause for readmission : Hemorrhage.
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ANAESTHESIA REVISION - 5 ----- Active space -----

Regional anaesthesia :

Central nerve blocks Peripheral nerve block

Spinal Epidural Caudal Any nerve blocks

Spinal Anaesthesia/Subarachnoid Block [Link]

Indications :

om
Below umbilical surgeries.

l.c
ai
Absolute C/I :

gm
r@
• ↑ICP. • Severe hypovolemia.
jja
• Bleeding tendencies. • Severe mitral & aortic stenosis.
gu
ar

• Local site infection. • Drug allergy.

nw

• Patient refusal.
hpa
is

Site :
an
m

• Adults : L3 - L4.
|
w

• Children : L4 - L5.
ro
ar
M

Procedure :
©

• Preparation : Strict aseptic precaution.

• Position : Sitting/left lateral/prone.
• Projection of needle :
Layers encountered : Skin Subcutaneous tissue Supraspinous ligament
Arachnoid mater Dura mater Ligamentum flavum Interspinous ligament
Needles :

Based on action on dura Based on needle

circumference (Gauge) :
Dura cutting : Dura splitting :
↓Gauge Thicker needle ↑PDPH.
• ↑PDPH. • ↓PDPH.
• Technically easier. • Technically difficult.
• Examples : Quincke (M/c). • Example : Whitacre, Sprotte.

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 28 Anaesthesia

----- Active space ----- Post Dural Puncture Headache (PDPH) :

Incidence : M/c after LSCS.
Characteristics : Mx :
• Dull boring type with mild - • Adequate bed rest + Plenty oral
moderate intensity. fluids.
• Seen 24 to 48 hours after Sx at • Analgesia : Caffeine + paracetamol.
occipital & frontal region. • Severe cases : Epidural blood patch.
• Aggravating factors : Change in
posture.

Factors Affecting Level of Anaesthesia (LOA) :

Patient factors :
• Height ∝ 1/LOA. • CSF ∝ 1/LOA.

om
• Pregnancy : ↑Intraabdominal pressure ↑Subarachnoid &

l.c
epidural venous pressure.

ai
↑Blockade d/t

gm
Progesterone (Nerves become sensitive).
Procedure factors : r@
jja
Position : Related to baricity.
gu
ar
nw

Drug Trendelenburg (Head down) Reverse Trendelenburg (Head up)

pa

Hyperbaric Higher level of block Lower level of block

h
is
an

Hypobaric Lower level of block Higher level of block

m

Drug factors :
|
w

• Volume & level of injection ∝ Level of anaesthesia.

ro
ar

• Baricity of drug = Density of drug compared to CSF.

M
©

- Hypobaric (Drug floats) : ↑Blockade.

- Hyperbaric (Drug settles down) : ↓Blockade.
Side Effects :
Spinal anaesthesia Sympathetic blockade.
Side effects of spinal anesthesia
1. ↓HR (Rx : Atropine/glycopyrrolate)
2. ↓BP :
CVS a. Prevention : Preloading IV fluids
b. Rx : Pregnant Phenylephrine (DOC)
Non-pregnant Ephedrine (DOC)/mephentermine
Respiratory 1. Low LOA : No effect
system 2. High LOA : Only Intercoastal muscles paralysed (C/o shortness of breath)
GIT Sphincters relaxed Reverse peristalsis
• Urinary retention (M/C) Rx : Foley’s catheter
GUT
• Penile enlargement
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 Anaesthesia Revision - 5 29

Epidural Anaesthesia [Link] ----- Active space -----

Technique :
Loss of resistance (LOR) technique.

Tuhoy needle

LOR syringe

Epidural catheters

Epidural catheter Set

Advantages :

om
• ↑Duration of anaesthesia.

l.c
ai
• Used in post-op analgesia.

gm
• No risk of PDPH (As long as dura is not accidentally punctured).
r@
jja
• Stable hemodynamics.
gu
ar

Disadvantages :
nw
pa

• Technically difficult & not suitable for emergencies.

h
is

• Inadequate blockade.
an

• Severe PDPH if accidental dural puncture.

m
|

• Accidental catheter migration Subarachnoid Space : Total spinal anaesthesia (Mx : Intubation).
w
ro

Blood vessel : Local anesthesia toxicity.

ar
M
©

Peripheral Nerve Block [Link]

Brachial Plexus Block :

X

Interscalene approach Supraclavicular approach Infraclavicular approach

Axillary approach

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 30 Anaesthesia

----- Active space ----- Indications Disadvantages

• Horner’s syndrome
Interscalene
Shoulder & upper arm Sx • Phrenic nerve is blocked
(Root)
• Ulnar N. spared
Supraclavicular • Horner’s syndrome
Distal arm & forearm Sx
(Distal trunk) • Pneumothorax
Sparing of :
Axillary Forearm & hand Sx
• Musculocutaneous N.
(Nerves) (No risk of pneumothorax)
• Intercostobrachial N. (T2)
Infraclavicular Arm & hand Sx Requires peripheral nerve
(Cords) (Includes musculocutaneous & axillary N.) stimulator

Local Anesthetics [Link]

om
Classification :

l.c
Amides

ai
Esters

gm
• Stable solution • Unstable solution
r@
Physical property
• ↓Incidence of allergic reaction • ↑Incidence of allergic reaction
jja
gu

In liver By plasma esterase

Metabolism
ar

Except : Articaine Except : Cocaine.

nw

• Lignocaine
pa

Examples • Procaine
•
h

Bupivacaine
is
an

MoA :
m

• Voltage gated sodium channel blockade.

|
w
ro

• Action of LA↓ in infected areas (↓pH Ionized form of LA Poor penetrance).

ar
M

Sequence of Blockade :
©

Regional anesthesia : B > C = Ad > Ag > Ab > Aa

Autonomic > Sensory > Motor

Experimental model : A > B > C.
Characteristics :
Factors
Quicker onset :
Onset • Small myelinated fibers
• Addition of NaHCO3 (↑pH Non-ionized form Quick onset of action)
Absorption Intercostal N. block : Maximum absorption (Risk of toxicity)
↑by :
• Addition of adrenaline (1 : 200,000) ↓Systemic absorption
Duration - Don’t inject in end arteries (Causes gangrene)
(Fingers, toes, tip of nose, ear lobule, circumcision Sx involve end arteries)
• Addition of opioids (Morphine, fentanyl)
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 Anaesthesia Revision - 5 31

Max. dose : ----- Active space -----

• Lignocaine : 3-4.5 mg/kg.
• Bupivacaine & ropivacaine : 2-3 mg/kg.
• Lignocaine + adrenaline : 7 mg/kg.

Toxicity :
Lignocaine : Seizures mainly.
Mx : Midazolam.
Bupivacaine : Ventricular arrhythmias mainly.
Rx : 20% Intralipid (1.5 ml/kg bolus, 0.25 ml/kg/hr infusion).
Cocaine : ↑BP & causes angina.
Rx : Nitroglycerine.
Prilocaine : Methemoglobinemia d/t ortho-toluidine..

om
l.c
Applications :

ai
gm
EMLA Cream : 2.5% lignocaine + 2.5% prilocaine (IV Cannulation).
r@
jja
Bier’s block :
gu

• IV regional anaesthesia with tourniquet.

ar
nw

• Drugs :
pa

- Approved : Lignocaine 0.5%.

h
is
an

- C/I : Bupivacaine.
m

• Indication : Short procedures (Long procedures : Tourniquet pain).

|
w

• C/I : Sickle cell anemia.

ro
ar
M

Labour Analgesia :
©

Bupivacaine 0.125% : Ad & C fibers blockade.

0.25% : Ab & Aa fibers blockade.

Anaesthesia Workstation [Link]

Designed by Sir Henry Edmund Gaskin Boyle.

ZONES
• High pressure (Main : Gas cylinders).
• Intermediate pressure.
• Low pressure.

High Pressure Zones : Gas Cylinders

Classification : • Liquifiable : N2O
• Non-liquifiable : O2 Work station

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 32 Anaesthesia

----- Active space ----- Identification :

Gas Cylinder
O2 Black body with white shoulder
CO2 Grey
N2O Blue
He Brown
N2 Black
Air White body with black shoulder
Cyclopropane Orange
Entonox Blue body with white shoulder

Material used : Measurement :

om
• Molybdenum steel alloy. Non-liquifiable gas : Bourdon’s pressure gauge.

l.c
• Aluminum (For use in Liquifiable gas : Manually weighing the cylinder.

ai
gm
MRI rooms).
r@
jja
Safety features :
gu

Non-liquifiable cylinders : Service pressure.

• Markings (Prevents explosions)
ar

Liquifiable cylinders : Filling ratio/density.

nw
pa

• Pin Index Safety System (PISS) : To prevent wrong connections of cylinders.

h
is
an

Cylinder Pin index value

m

Air 1, 5
|
w
ro

O2 2, 5
ar
M

N2O 3, 5
©

CO2 <7.5% 2, 6
PISS
CO2 >7.5% 1, 6
Cyclopropane 3, 6
Entonox 7

• Bodock’s Pressure Seal (Gasket) : To prevent gas leakage.

Intermediate Pressure Zone :
40 - 55 psi

Pipeline
pressure
indicator

Pipelines Diameter index safety system O2 flush valve (O2+)

• 35 - 75 L O2/min.
• Disadvantage : Barotrauma.
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 Anaesthesia Revision - 5 33

Low Pressure Zone : ----- Active space -----

• 10 - 15 PSI.
• O2 flow meters are always downstream.
• Safety feature : Link 25 system.

BREATHING CIRCUITS
Mapleson’s/Semi Closed Circuits :
Advantage : Easy transportation. APL Valve
Disadvantage : Heavy FGF. Co-axial circuit

om
Patient end

l.c
Reservoir bag

ai
Types :

gm
Bain’s circuit

r@
jja
Adjustable pressure
gu
ar
nw

Corrugate tube
pa

Reservoir
h
is

bag Patient
an
m

Mapelson A Mapelson D Mapelson F

|

• AKA Magill’s circuit • M/c type • AKA Jackson Rees circuit

w
ro

• FGF = Minute ventilation (MV) • FGF = 1.6 x MV • Use : Pediatric Sx

ar

• Use : Spontaneous ventilation •

M

Use : Control ventilation

©

Note : MV = VT (Tidal volume) x RR • Modification : Bain’s circuit

Closed Circuit/Circle Systems :

• Gases are recycled.
- Reabsorption of CO2 with soda lime.
• Composition :
Absorbent Ca(OH)2 NaOH KOH H2O
Classic soda lime (In %) 80 3 2 16
• Disadvantage : Bulky (↑Chance of disconnection).

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 34

----- Active space ----- ANAESTHESIA REVISION - 6

Basic Life Support (BLS) Algorithm [Link]

om
l.c
Put pt. in left Normal No normal

ai
lateral position & breathing breathing

gm
and but

r@
pulse felt pulse felt
Using ambu bag
jja
gu
ar
nw

High quality CPR :

pa

• Push hard (2 inches/5 cm) &

h
is

fast on the lower sternum.

an

No breathing/
• Ensure adequate chest recoil.
m

only gasping and no

|

pulse felt • Only compressions

w
ro

(If alone) can be at

ar

high-quality a rate of 100-120/min.

M

CPR • CPR quality can be assessed

©

by quantitative waveform
capnography.

Rhythm is Rhythm is
shockable not shockable

resume Resume CPR immediately

CPR for 2 minutes

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 Anaesthesia Revision - 6 35

Advanced Cardiac Life Support (ACLS Algorithm) [Link] ----- Active space -----

1
� Start CPR
� Give Oxygen
� Attach defibrillator

Rhythm shockable?

Yes No

2 9
VF/pVT Asystole/PEA

om
10
3 Defibrillate � Intravenous/intraosseous access

l.c
� Epinephrine ASAP & 1 mg every

ai
4
� Resume CPR x 2min 3-5 min.

gm
� (Even if defibrillation worked) � CPR x 2min

r@
� Intravenous/interosseous
intraosseous access
access jja � ET intubation
gu

Post cardiac Yes Yes Post cardiac

ar

Rosc
ROSC Rosc
ROSC
nw

arrest care arrest care

No No
hpa

Asystole/PEA Yes Management of

is

Rhythm shockable? No Rhythm shockable?

Management VF/PVT
an

Yes
m

No
|

5 Defibrillate 11
w

� CPR 2 min
ro
ar

6 � Treat reversible causes

� CPR X 2min
M

� Epinephrine 1 mg every 3-5min

©

� Consider advanced airway Yes Post cardiac

Rosc
ROSC arrest care
No
Post cardiac Yes
Rosc
ROSC Yes Management of
arrest care Rhythm shockable?
No VF/PVT
Asystole/PEA
Rhythm shockable? No No
Management 12
Yes

7 Defibrillate

8 PEA : Pulseless electrical activity

� CPR X 2min
VF : Ventricular fibrillation
� Amiodarone / lidocaine
PVT : Pulseless ventricular tachycardia
� Treat reversible causes
ROSC : Return of spontaneous circulation

Post cardiac Yes

Rosc
ROSC
arrest care

No

Anaesthesia Revision • v4.0 • Marrow 8.0 • 2024

 36 Anaesthesia

----- Active space ----- Shock energy for defibrillation :

• Biphasic : 120 - 200 J.
• Monophasic : 360 J.

Drug therapy :
• Epinephrine IV/10 dose : 1 mg every 3-5 minutes (1 : 1000).
• Amiodarone IV/10 doses :
- First dose : 300 mg bolus.
- Second dose : 150 mg or,
• Lidocaine IV/IO :
- First dose : 1-1.5 mg.

Reversible cause :

om
• Hypovolemia.

l.c
• Hypoxia.

ai
gm
• Hydrogen ion (Acidosis). 5 Hs
• Hypo/hyperkalemia. r@
jja
gu

• Hypothermia.
ar
nw

• Tension pneumothorax.
pa
h

• Cardiac Tamponade.
is
an

• Toxins. 5 Ts
m

• Thrombosis (Pulmonary).
|
w
ro

• Thrombosis (Coronary).
ar
M

Indications that resuscitation was successful :

©

• ROSC (Return of spontaneous circulation).

• Monitor pulse & blood pressure.
• Abrupt sustained increase in PETCO2 (Typically 40 mmHg).
• Spontaneous : BP tracing.
Indications to stop BLS & ACLS :
• Cardiac arrest not witnessed.
• No ROSC after 20 mins of CPR. BLS
ACLS
• AED unavailable/not delivered.
• Bystanders CPR not provided.

Anaesthesia Revision • v4.0 • Marrow 8.0 • 2024

 Anaesthesia Revision - 6 37

Adult Tachycardia with Pulse [Link] ----- Active space -----

Assess responsiveness (HR ≥ 150) Note :

• Tachycardia : HR ≥ 100 bpm.
• Check Airway, Breathing, Circulation. • Tachyarrhythmia : HR ≥ 150 bpm.
• Connect ECG, and IV access.
• Identify and treat underlying cause. 5 features of hemodynamic instability :
• ↓BP.
• Shock.
Persistent tachyarrhythmia
• Altered mental status.
• Ischemic chest discomfort.
Assess hemodynamic stability • Acute heart failure.
Unstable Stable

• Synchronised cardioversion/ Check if wide QRS complex

DC shock (50 J) Yes No
• Consider adenosine if

om
narrow QRS complex. • Antiarrhythmic infusion. • Vagal maneuvers.

l.c
ai
• Consider adenosine only if • Adenosine.

gm
regular and monomorphic. • β blockers/ Ca2+ channel blockers.
r@
jja
Antiarrhythmic infusion :
gu
ar

• Procainamide :  • Sotalol :
nw

- 20-50 mg/min until arrhythmia is - 100 mg (1.5 mg/kg) over 5 minutes.

hpa

suppressed. - Avoid if prolonged QT.

is
an

- Maximum dose : 17 mg/kg. • Adenosine :

m
|

- Maintenance infusion : 1-4 mg/min. - First dose : 6 mg rapid IV push then

w
ro

- Avoid if prolonged QT or CHF. NS flush (Peripheral line).

ar
M

• Amiodarone : - Second dose : 12 mg.

©

- First dose : 150 mg over 10 mins.

- Repeat if VT recurs.
- Maintenance : Infusion of 1 mg/min
for first 6 hrs.
Note : Synchronised cardioversion, shock is synced with “R” wave.
Adult Bradycardia [Link]

Bradycardia
Note :
Hemodynamically stable Hemodynamically unstable • Bradycardia :
HR <60 bpm.
Monitor & observe. • Atropine IV 1 mg bolus • Bradyarrhythmia :
• Repeat every 3-5 mins HR <50 bpm.
• Maximum dose : 3 mg
not effective
Transcutaneous pacing/Dopamine infusion/Epinephrine infusion.
Anaesthesia Revision • v4.0 • Marrow 8.0 • 2024