anesthesiapocketbook for medical students

8/21/2019 AnesthesiaPocketbook for Medical Students

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The Medical Student’s AnesthesiaPocketbook

University of Texas Health Science Center Houston


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Table of ContentsACKNOWLEDGEMENTS...........................................................................................................................2

ANESTHESIA OVERVIEW.........................................................................................................................3

INTRODUCTION...........................................................................................................................................3PREOPERATIVE HISTORY AND PHYSICAL.................................................................................................3IV’S AND PREMEDICATION.........................................................................................................................R OOM SETUP AND MONITORS...................................................................................................................INDUCTION AND INTUBATION.....................................................................................................................!MAINTENANCE.........................................................................................................................................."#EMERGENCE..............................................................................................................................................""PACU CONCERNS......................................................................................................................................"$

COMMONLY USED MEDICATIONS......................................................................................................13

VOLATILE ANESTHETICS.........................................................................................................................."3IV ANESTHETICS......................................................................................................................................."%LOCAL ANESTHETICS..............................................................................................................................."&

OPIOIDS....................................................................................................................................................."&MUSCLE R ELAXANTS................................................................................................................................"R EVERSAL AGENTS/ ANTICHOLINERGICS..............................................................................................."

PHARM CHARTS.......................................................................................................................................18

INHALATIONAL ANESTHETICS.................................................................................................................."'MAC.........................................................................................................................................................."'INTRAVENOUS ANESTHETICS...................................................................................................................."!

IV FLUIDS....................................................................................................................................................2

ASA CLASSIFICATION.............................................................................................................................21

MALLAMPATI CLASSIFICATION.........................................................................................................22

!UICK REFERENCE/REVIEW...............................................................................................................23

PROCEDURE CHECKLIST......................................................................................................................2"

INTUBATION...............................................................................................................................................$(IV LINE PLACEMENT.................................................................................................................................$(BAG MASK VENTILATION........................................................................................................................$(VENTILATOR SETTINGS............................................................................................................................$'ARTERIAL LINE PLACEMENT...................................................................................................................$'CENTRAL LINE PLACEMENT....................................................................................................................$'SPINAL.......................................................................................................................................................$!EPIDURAL..................................................................................................................................................$!

RESOURCES................................................................................................................................................3

NOTES...........................................................................................................................................................31

C#$%&'()%#&*: Trent Bryson MS4, Tanner Baker MS4, Claudia Moreno MS4, Darrell Wilcox MS3, and Allison DeGreeff MS3


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Ackno)led*e+ents

,e the contributors )ould first and fore+ost like to thank the faculty at the University of Texas at Houston for their su--ort *uidance and teachin*s in hel-in* us create this -ocket book. ,e )ould also like to thank the residents for their contributions to our learnin* and skill develo-+ent as )ell as in hel-in* us revise the content to be asdetailed succinct and accurate as -ossible.

$


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Anesthesia /vervie)Ada-ted fro+ 0A Medical Student’s Anesthesia Pri+er1 by 2oy . Soto M4 5roysoto6ucla.edu7

I$%+),%'#$

8n +any -ro*ra+s across the country +edical students are only ex-osed to t)o )eeks of

anesthesiolo*y durin* their third or fourth year. The student often attends daily lecturesand +i*ht be told to 9read Miller:s ;asics of Anesthesia9 but often by the ti+e thestudent has finally fi*ured out )hy )e are doin* )hat )e:re doin* the rotation is overand he or she leaves )ith only a +ini+u+ of anesthesia kno)led*e.

This -ri+er is intended to *ive a brief overvie) of )hat )e do )hen )e do it and )hy)e do it for standard unco+-licated cases ... the ty-es that you are bound to see durin*your rotation. ;y no +eans is the infor+ation contained co+-rehensive or intended toallo) you to -ractice anesthesia solo but it is intended to *ive an overvie) of the 9bi* -icture9 in a for+at that can be


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%eflux Disease @ Present or not AnesthetiBed and relaxed -atients are -rone tore*ur*itation and as-iration -articularly if a history of reflux is -resent. This is usuallyan indication for ra-id se


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+ulti-le factors are taken to*ether the -redictive value is increased. The follo)in* so+es-ecific as-ects of the headFneckFu--er air)ay exa+ )hich can be used to hel- -redictdifficulties that +ay be encountered.

HeadFIeckFU--er Air)ay exa+

(acial trau!a or defor!ities@ +ay +ake it difficult to -erfor+ laryn*osco-y.

De$iated septu! or nasal polyps@ can -ose difficulty )ith nasal intubation or )ithinsertin* a naso*astric tube -ossibly resultin* in bleedin*.

)eck ran&e of !otion@ the -atient needs to be able to assu+e the sniffin* -osition5cervical flexion and atlanto@occi-ital extension7 so that the oral -haryn*eal andlaryn*eal axes are ali*ned )hich )ill facilitate vie)in* the *lottic o-enin*. Ior+al -atients should achieve 3& de*rees or +ore of atlanto@occi-ital extension )hich canassessed by observin* the an*le traversed by the occlusal surface of the +axillary teeth)hen the head is fully extended fro+ the neutral -osition. 4ifficulty )ith intubation +ay

be -redicted by a si*nificant reduction in the ability to achieve this de*ree of extension or if the -atient ex-eriences any -ain tin*lin* or nu+bness durin* this +ove+ent.

TM* !o'ility and de&ree of !out openin& @ this is i+-ortant for deter+inin* theade


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The siBe of the +andible can be assessed by +easurin* the thyro+ental distance. This isthe distance fro+ the +entu+ of the +andible to the thyroid cartila*e. A thyro+entaldistance of c+ 5a--roxi+ately 3 fin*er breadths7 or less as often seen in -atients )ith arecedin* +andible or a short neck +ay indicate a -ossible difficult intubation.Alternatively the sterno+ental distance 5fro+ +entu+ to sternal notch7 can also be used)hich assesses the siBe of the +andible and neck. A sterno+ental distance of J "3 c++ay also -oint to difficulty )ith intubation.

inally a -hysical status classification is assi*ned based on the criteria of the A+ericanSociety of Anesthesiolo*ists 5ASA"@&7 )ith ASA@" bein* assi*ned to a healthy -erson)ithout +edical -roble+s other than the current sur*ical concern and ASA@& bein* a+oribund -atient not ex-ected to survive for +ore than t)enty four hours )ithoutsur*ical intervention. An 9D9 is added if the case is e+er*ent. The full details of theclassification scale are also detailed later.

IV’* $+ P&-4-+',%'#$

The t)o skills you should take the o--ortunity to -ractice )hile on your rotation are 8Linsertion and air)ay +ana*e+entFintubation. Dvery -atient 5)ith the exce-tion of so+echildren that can have their 8L:s inserted follo)in* inhalation induction7 )ill re


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The +onitors that )e use on +ost -atients include the -ulse oxi+eter blood -ressure+onitor and electrocardio*ra+ all of )hich are ASA re


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,hen it co+es to dra)in* u- the initial dru*s there are % cate*ories of dru*s that should be ready for each case? induction a*ents sedationFanal*esia dru*s reversal a*ents ande+er*ency dru*s. At ti+es the s-ecific dru*s +ay vary de-endin* on the case but thefollo)in* are +ost co++only used. The first 3 cate*ories should be dra)n u- in -re-aration for the case but the e+er*ency dru*s are often already -re-ared.

-nduction A&ents

idocaine 5"7 5"#+*F+7 E 4ra) u- in a &cc syrin*ePro-ofol 5"#+*F+7 E 4ra) u- in a $#cc syrin*e2ocuroniu+ 5"#+*F+7 E 4ra) u- in a &cc syrin*e

Sedation+Anal&esia Dru&s

Lersed 5"+*F+7 E 4ra) u- in 3cc syrin*eentanyl 5+c*F+7 E 4ra) u- in &cc syrin*e

%e$ersal A&ents

Ieosti*+ine 5"+*F+7 E 4ra) u- in &cc syrin*elyco-yrrolate 5#.$+*F+7 E 4ra) u- in &cc syrin*e

.!er&ency Dru&s 5QAt Her+ann these dru*s are already -re-ared and should be foundin -lastic ba*7

QPhenyle-hrine 5"##+c*F+7 E 8n "#cc syrin*eQD-hedrine 5&+*F+7 E 8n "#cc syrin*eQSuccinylcholine 5$#+*F+7 E 8n "#cc syrin*eAtro-ine "+*F+ E 8n 3cc syrin*e /ther -re-arations that can be done before the case focus on -atient -ositionin* andco+fort since anesthesiolo*ists ulti+ately are res-onsible for intrao-erative -ositionin*and resultant neurolo*ic or skin inOuries. Heel and ulnar -rotectors should be available asshould axillary rolls and other -ads de-endin* on the -osition of the -atient.

'


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I$+),%'#$ $+ I$%)(%'#$

Nou no) have your sedated -atient in the roo+ )ith his 8L 5*ender selected at rando+ ...you *enerally anesthetiBe +en and )o+en the sa+e7 and he:s co+fortably lyin* on theo-eratin* table )ith all of the afore+entioned +onitors in -lace and functionin*. 8t isno) ti+e to sto) your tray tables and brin* your seats to the full u-ri*ht -osition

because it:s ti+e for take@off. 8ndeed +any -eo-le co+-are anesthesia )ith flyin* anaircraft since the take@off and landin* can be


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relaxer7 or vecuroniu+ 5or any of the other @oniu+s or @uriu+s )hich are all nonde-olariBin* relaxers7. A t)itch +onitor is usually used to ascertain de-th of relaxationand )hen the t)itch has sufficiently di+inished intubation can be atte+-ted. Iote thatthe above induction a*ents usually last for less than ten +inutes so +any of us )ill turnon a volatile anesthetic a*ent )hile )e are +ask ventilatin* and )aitin* for the +uscle

relaxant to take effect. Try to kee- a *ood +ask seal so you don:t anesthetiBe yourself ...

/nce the -atient is ade


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is al)ays -ayin* attention to the tone of the -ulse oxi+eter or the slur-in* of blood intothe suction canister. Li*ilance is key to a *ood anesthetic.

/ne can also -re-are for -otential -ost@o-erative -roble+s durin* the case by treatin*the -atient intrao-eratively )ith lon*@actin* anti@e+etics and -ain +edications.

E4-&5-$,-

Usin* our analo*y of flyin* an air-lane a -oor landin*Fe+er*ence can be disastrous.=no)in* )hen to turn do)nF off your anesthetic a*ents co+es )ith ex-erience andattention to the -ro*ress of the sur*ical case. D+er*ence isn:t as easy as it +i*ht at firstsee+ since very i+-ortant ste-s have to take -lace before a -atient can be safelyextubated.

,hen usin* nonde-olariBin* neuro+uscular blockin* a*ents such as 2ocuroniu+ or Cisatracuriu+ a -eri-heral nerve sti+ulator is used to +onitor the -har+acolo*icaleffects of these dru*s and the dosa*e can be titrated to effect. Iear the end of the case

the nerve sti+ulator is used to assess the de*ree of s-ontaneous recovery fro+ thesedru*s. Ieosti*+ine an anticholinesterase dru* is ty-ically used as a reversal a*ent)hen the s-ontaneous recovery is occurrin* as deter+ined by the -resence of t)itchesinduced by the nerve sti+ulator. ,hen utiliBin* a train@of@four sti+ulation the *reater the nu+ber of visible +uscle t)itches the *reater the de*ree of s-ontaneous recoverythat has occurred. A lack of +uscle t)itches indicates the blockade at the neuro+uscular Ounction is still too intense and the ad+inistration of neosti*+ine is not likely to facilitatereversal. 8t is also i+-ortant to note that even )ith % t)itches and the return of s-ontaneous breathin* the -atient +ay still have u- to (& of the IMK rece-torsoccu-ied by the blockin* a*ent. The ade 5 cc/kg

• TV/RR > 10

•

PaO2 > 65-70 mmHg on FiO2 < 40%• PaO2 < 50 mmHg

• H!mo"#namic $ai'i#

• T!m(!)a*)! a '!a$ 35

• +,F > -20

Suction +ust al)ays be close at hand since +any -atients can beco+e nauseous after extubation or si+-ly have co-ious oro-haryn*eal secretions. /nce the -atient is

""


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reversed a)ake suctioned and extubated care +ust be taken in transferrin* hi+ to the*urney and oxy*en +ust be readily available for trans-ortation to the recoveryroo+FPost@Anesthesia Care Unit 5PACU7. inally re+e+ber that )henever extubatin* a -atient you +ust be fully -re-ared to reintubate if necessary )hich +eans havin* dru*sand e


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Co++only Used Medications

V#%'- A$-*%-%',*

• All are 'roncodilators, except for desflurane /ic is irritatin& and !ay

cause 'roncospas!0 Ad!inistered alone 1i0e0, /itout narcotics2, inaled

anestetics increase respiratory rate 'ut decrease tidal $olu!e0

• .xcept for alotane, inaled anestetics are not !eta'olied 'y te 'ody and

are eli!inated 'y $entilation0

• All $olatile anestetics 1'ut not nitrous oxide2 are capa'le of tri&&erin&

!ali&nant yperter!ia 1MH20

• Wile in !any cases $olatile anestetics are used for !aintenance of

anestesia, in so!e circu!stances tese dru&s !ay 'e cosen to induce

anestesia suc as in pediatrics cases in /ic te cild !ay not tolerate -

place!ent a/ake0

HalotanePro? Chea- nonirritatin* so can be used for inhalation inductionCon? on* ti+e to onsetFoffset Si*nificant Myocardial 4e-ressionSensitiBes +yocardiu+ to catechola+ines Association )ith He-atitis

-sofluranePro? Chea- excellent renal he-atic coronary and cerebral blood flo) -reservationCon? on* ti+e to onsetFoffset irritatin* so cannot be used for inhalationinduction

Desflurane

Pro? Dxtre+ely ra-id onsetFoffset

Con? Dx-ensive Sti+ulates catechola+ine release Possibly increases -osto-erative nausea and vo+itin* 2e


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IV A$-*%-%',*

• Most sedati$e ypnotics /ork trou& te ini'itory &a!!a5a!ino'utyric

acid 1GABA2 neurotrans!itter syste! in /ic increased clorideconductance leads to neuronal ini'ition0 Most - induction a&ents 'ind to a

specific site called GABA A for tis ini'itory effect, and tey a$e a rapid

onset due to lipopilic properties /ic allo/ te! to 6uickly partition intote i&ly perfused lipopilic 'rain and spinal cord0 Tey also a$e sort

duration of action, /it teir ter!ination of effect due to redistri'ution into

less perfused tissues suc as !uscle and fat0

Bar'iturates 1e0&0, tiopental2

4ecrease 8CP by decrease in cerebral oxy*en consu+-tion. Since cerebral -erfusion is -reserved desirable dru* for neurosur*ery cases. Causesres-iratory and cardiac de-ression.Pro? Dxcellent brain -rotection Sto-s seiBures Chea-Con? Myocardial de-ression Lasodilation Hista+ine release Can

-reci-itate -or-hyria in susce-tible -atients 7ropofol 8n adults induction dose ".& to $.& +*Fk* )hile continuous infusion of "## to $## +icro*ra+sFk*F+in +aintains unconsciousness. These valuesdiffer for children and for the elderly.Pro? Prevents nauseaFvo+itin* uick recovery if used as solo anesthetica*entCon? Pain on inOection Dx-ensive Su--orts bacterial *ro)th Myocardialde-ression 5the +ost of the four7 Lasodilation cross reactivity in -atients)ith e** aller*y.

.to!idate

Mini+al de-ression of cardiovascular and -ul+onary function. 8deal for -atients )ith CL4 or he+odyna+ic instability. 8nduction dose of #.$ to#.% +*Fk* that causes -ain on inOection and +yoclonus. Su**ested that it+ay su--ress cortisol synthesis.Pro? east +yocardial effect of 8L anestheticsCon? Pain on inOection Adrenal su--ression 5 si*nificance if used onlyfor induction7 Myoclonus IauseaFLo+itin*

"eta!ine

,orks via anta*onis+ of the I@+ethyl@4@as-artate rece-tor channelco+-lex. Mini+ally de-resses the cardiores-iratory syste+. 8nductiondose of " to $ +*Fk* in adults. 4irectly sti+ulates SIS and increases ;P

and heart rate. 8ncreasin* de+and on the heart and is not a *ood choice for CA4 -atients.Pro? ,orks 8L P/ P2 8M @ *ood choice in uncoo-erative -atient )ithout

8L Sti+ulation of SIS → *ood for hy-ovole+ic trau+a -atients often

-reserves air)ay reflexesCon? 4issociative anesthesia )ith -osto- dys-horia and hallucinations

8ncreases 8CPF8/P and CM2#$ Sti+ulation of SIS → bad for -atients

)ith co+-ro+ised cardiac function increases air)ay secretions

"%


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Dex!edeto!idine

Selective al-ha@$ adrener*ic a*onist )hich is used in the o-eratin* roo+as an adOunct to *eneral anesthesia or to -rovide sedation for a)akefibero-tic intubation or for re*ional anesthesia. 8t is *enerally *iven as aloadin* dose of #.&@" +c*Fk* over "# +inutes follo)ed by an infusion of

#.$ to #.( +c*Fk*Fhr. 8t -roduces sedative@hy-notic and anal*esic effects)ithout causin* res-iratory de-ression. Benodiaepines 1BD82

Usually -rovided as -re+edication for sedation and anxiolysis before*eneral anesthesia. Pro-erties include anxiolytic effects to sedation andunconsciousness at hi*her doses. MidaBola+ 5Lersed7 induction dose of #." to #.$ +*Fk* and infusion rates of #.$& to " +icro*ra+Fk* -er +inute.;4Vs -roduce res-iratory cardiovascular and u--er air)ay reflexde-ression and in the -resence of hy-ovole+ia +ay cause si*nificanthy-otension. 2eversal of the sedative action of these co+-ounds )ith theco+-etitive anta*onist flu+aBenil.

L#, A$-*%-%',*

.sters @ MetaboliBed by -las+a esterases @ one +etabolite is PA;A )hich cancause aller*ic reactions. Patients )ith 9aller*y to novacaine9 usually do )ell )itha+ides for this reason. All have only one 9i9 in their na+e e*. ProcaineTetracaine Chlor-rocaine.

A!ides @ MetaboliBed by he-atic enBy+es. All have at least t)o 9i9s in their na+e e*. idocaine 2o-ivicaine ;u-ivicaine

O'#'+*

Morpine E de-resses breathin* -rinci-ally by i+-airin* the +edullary res-onseto C/$. Also tri**er the che+orece-tor tri**er Bone 5CTV7 )hich +ay lead tonausea and +ay in turn sti+ulate the vo+itin* center and -roduce e+esis. Also+or-hine decreases 8 +otility and -ro-ulsion -roduces urinary retention andreleases hista+ine by sti+ulatin* baso-hils in the lun*s and +ast cells in the skin.8n the CLS +or-hine +ay -roduce vascular dilation decrease SL2 and overall

hy-otension. 8t is lon* actin* > renally excreted → active +etabolite has o-iate

-ro-erties therefore be)are in renal failure

De!erol @ eu-horia sti+ulates catechola+ine release so be)are in -atients usin*MA/8:s renally active +etabolite associated )ith seiBure activity therefore

be)are in renal failure

"&


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(entanyl+Alfentanil+Sufentanil+%e!ifentanil @ More -otent than +or-hine )ithSufentanil bein* the +ost -otent 5u- to "###x as -otent7. 8n addition all areshorter actin* than +or-hine )ith 2e+ifentanil bein* the shortest. /ften used toattenuate the stress res-onse to sur*ical sti+ulation. o) doses -roduce brief effect but lar*er doses are lon* actin* increased incidence of chest )all ri*idity

vs. other o-iates no active +etabolites usually safe in -atients )ith +or-hinealler*ies.

M)*,- R-7$%*

D-#&''$5

Succinylcoline @ inhibits the -ost@Ounctional rece-tor and -assivelydiffuses off )ith increased 8CPF8/P +uscle fasciculations and -osto-+uscle aches tri**ers MH increases seru+ -otassiu+ es-ecially in -atients )ith burns crush inOury s-inal cord inOury +uscular dystro-hy or disuse syndro+es. 2a-id and short actin*.

N#$+-#&''$5Many different kinds all endin* in 0oniu+1 or 0uriu+1. Dach has adifferent +etabolis+ onset and duration +akin* choice de-end ons-ecific -atient and case. So+e exa+-les? 7ancuroniu! @ Slo) onsetlon* duration tachycardia due to va*olytic effect0 Cisatracuriu!@ Slo)onset inter+ediate duration Hoff+an 5nonenBy+atic7 eli+ination soattractive choice in liverFrenal disease. %ocuroniu! @ astest onset of nonde-olariBers +akin* it useful for ra-id se


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Atropine @ used in conOunction )ith Ddro-honiu+ crosses the ;;;causin* dro)siness so +aybe bad at end of sur*ery for reversal so+e useas -re+ed for all children since they tend to beco+e bradycardic )ithintubation and -roduce co-ious drool

Glycopyrrolate @ used in conOunction )ith neosti*+ine does not cross;;;

Central Anticholiner*ic Syndro+e? ;lind as a bat 5;lurred vision7 2ed as a beet 5lushin*7 4ry as a bone 5Anhydrosis7 ast as a hare 5Tachycardia7 Mad as a hatter 54eleriu+7

"(


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Phar+ Charts

I$%'#$ A$-*%-%',*

I$%'#$

A$-*%-%',*

M9#& A+0$%5-* P&'4& U*- T#7','%/,#$,-&$*

N'%)* O7'+- Io odor ast induction and recoveryMini+al cardio-ul+onaryde-ressionood anal*esic

Minor sur*eryUsed in co+bination )ith*eneral anesthetics for*eneral anesthesia

Acute@IFLChronic@inhibition of ;"$+etabolis+ and inductionof ;"$ 4D8C8DICN

H #%$- Pleasant odor Slo)er induction and recovery

Most )idely used -edianesthetic )orld )ide.Asth+a -atients 5no

bronchoconstriction7

Slo) inductionFrecoverySensitiBes +yocardiu+ tocatechola+inesLent.

Arryth+ias H e-atotoxicity

E$6)&$- Pleasant odor ess S.D. than Halothane

Adults Hy-otensionSeiBures 6 hi*h W X

Ie-hrotoxicity

I*#6)&$- Stable cardiac rhyth+2a-id onsetFrecoveryMini+al +etabolis+lo) tox

-otentialDxcellent Muscle relaxant

Most )idely usedanesthetic in adults.

Pun*ent odor 5not *reat for kids7;roncho@irritant

D-*6)&$- 2a-id onsetFrecoveryHi*h -otency 5least soluble7Dven less +etabolis+

A+bulatory sur*ery 5forra-id recovery7

Lery -un*ent8rritatin* to air)aysA2NI/SPASMDx-ensiveYYY

S-0#6)&$- ast inductionFrecoveryHi*h -otency 5least soluble7

Ionirritatin* va-or

/ut-atient anesthesia8nhalation 8nduction5es-ecially children7

M-%#76)&$- 2enal Toxicity

Iitrous /xide 4esflurane Sevoflurane Dnflurane 8soflurane Halothane Methylfurane

ASTDST S-eed of /nset S/,DST

/,DST Potency H8HDST

Hi*h MAC o) MAC

5"#%7 57 5$.$7 5".&7 5#.'7

MACMini+u+ Alveolar Concentration E defines the a+ount of anesthetic necessary toachieve no res-onse to sur*ical sti+ulus. The nu+bers listed above are theconcentrations necessary to achieve " MAC or no res-onse in of the -o-ulation. AMAC of ".3 is $ standard deviations u- or )here !& don’t res-ond. A MAC of ".& isthe MAC ;A2 )here sy+-athetic outflo) is co+-letely blocked. ,hen usin* +ulti-lea*ents MAC’s are additive i.e. Z MAC of nitrous 5&$7 Z MAC of Sevo 5"."7 ise


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I$%&0-$#)* A$-*%-%',*

I$%&0-$#)*

A$-*%-%',*

O$*-% E'4'$%'#$ P&4,#:'$-%',* A+0$%5-*/

U*-

D'*+0$%5-*

B&('%)%-* 5H>A7@Thio-ental@Methohexital@Thia+ylal

3#@%#sec

@"#@"$ hrs@ 3@ hrs

2edistribution 2a-id onsetast recovery

Anesthesia for short -rocedures.

Io anal*esiaAlkalineFTissue8rritant.2es- > CLde-ressiono) T8 /4 risk

B-$#+'-'$

-*

5H>A7@4iaBe-a+@MidaBola+@oraBe-a+

3@& +in

@$#@%# hrs@$@ hrs

4e+ethelated in theiver.5-rolon*ed t"F$ )ithcirrosis etc7

2elative ra-idonsetMini+al res-and CLde-ression

Preanesthetic

Iot a *oodanal*esicCan’t -roducesur*ical anal*esia

D'**#,'%'0-

5H>A7

@=eta+ine

@$@3 hrs 8ntenseanal*esia and

a+nesia

2adiolo*ical -rocedures inchildren;ronchodilator

4issociativeanesthesia 5887

un-leasantrecovery )Fhallucinationsand ni*ht+ares

M'*,-$-#)*

5H>A7@Dto+idate@Pro-ofol

[" +in%#@sec

%@'hrs3@hrs ar*e volu+e of

distribution hi*hlyli-o-hilic

Prevents IFL


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8L luids

H#= M),>

Ty-e \ H2 " $ 3 %

Maintenance -er hour 5% $ " rule or k* %# in anyone over $# k*7

" " " "

4eficit5Hrs IP/ x Maintenance7

"F$ "F% "F% @

8nsensible oss53@"& ccFhr ? case de-endent7

Dsti+ated blood loss5"?" colloid 3?" crystalloid7

A#=(- B##+ L#**

The allo)able loss is calculated by +ulti-lyin* the blood volu+e 5;L7 by the -ercentfro+ startin* he+atocrit 5HCTs7 to threshold he+atocrit 5HCTt7 for transfusion.

A; ] ;L x 55HCTs@HCTt7FHCTs7

;lood volu+e is deter+ined by +ulti-lyin* the )ei*ht by a constant. Ieonates ] !# ccFk*8nfants ] '# ccFk*Adult +en ] # ccFk*Adult )o+en ] ccFk*

E74-

A k* )o+an co+es in after fastin* for "$ hours for elective sur*ery. Her -re@o-he+atocrit )as 3&. Nou decide that in order to transfuse she +ust have a he+atocrit lessthan $&. /ver the course of the sur*ery she loses $ cc’s of blood each hour for 3 hours.She has only +ini+al blood loss durin* the last hour of her % hour sur*ery.

Ty-e \ H2 " $ 3 %

Maintenance -er hour 5% $ " rule /2 k* %# in anyone over $# k*7

!# !# !# !#

4eficit5Hrs IP/ x Maintenance7

"$ x !# ] "#'#

&%# $(# $(# @

8nsensible oss53@"& ccFhr ? case de-endent7

' ' ' '

Dsti+ated blood loss5"?" colloid 3?" crystalloid7

Col E $C&*? @

Col E $C&*? @

Col E $C&*? @

@

Total crystalloid "3'' """# """# !'

Additionally she should be transfused as she -assed her threshold for transfusion durin*the third hour. Since that -oint )as close to the end of sur*ery transfusion -robablycould be held off until arrival at PACU since transfusion reaction is not easily noticed)hile under *eneral anesthesia.

$#


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ASA Classification

The -ur-ose of the *radin* syste+ is si+-ly to assess the de*ree of a -atient’s 9sickness9or 9-hysical state9 -rior to selectin* the anesthetic or -rior to -erfor+in* sur*ery.4escribin* -atients’ -reo-erative -hysical status is used for recordkee-in* for co++unicatin* bet)een collea*ues and to create a unifor+ syste+ for statisticalanalysis. The *radin* syste+ is not intended for use as a +easure to -redict o-erativerisk.

The +odern classification syste+ consists of six cate*ories as described belo).

ASA P*', S%%)* ;PS< C**'6',%'#$ S*%-4

ASA PS C%-5#& P&-#-&%'0- H-%

S%%)*

C#44-$%* E74-*

ASA PS " Ior+al healthy -atient Io or*anic -hysiolo*ic or -sychiatric disturbance^excludes the very youn*and very old^ healthy )ith*ood exercise tolerance

ASA PS $ Patients )ith +ild syste+icdisease

Io functional li+itations^has a )ell@controlled

disease of one body syste+^controlled hy-ertension ordiabetes )ithout syste+iceffects ci*arette s+okin*)ithout chronic obstructive -ul+onary disease 5C/P47^+ild obesity -re*nancy

ASA PS 3 Patients )ith severesyste+ic disease

So+e functional li+itation^has a controlled disease of+ore than one body syste+

or one +aOor syste+^ noi++ediate dan*er of death^controlled con*estive heartfailure 5CH7 stablean*ina old heart attack -oorly controlledhy-ertension +orbidobesity chronic renal

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failure^ bronchos-asticdisease )ith inter+ittentsy+-to+s

ASA PS % Patients )ith severesyste+ic disease that is aconstant threat to life

Has at least one severedisease that is -oorlycontrolled or at end sta*e^ -ossible risk of death^unstable an*inasy+-to+atic C/P4sy+-to+atic CHhe-atorenal failure

ASA PS & Moribund -atients )ho are

not ex-ected to survive)ithout the o-eration

Iot ex-ected to survive

$% hours )ithout sur*ery^i++inent risk of death^+ultior*an failure se-sissyndro+e )ithhe+odyna+ic instabilityhy-other+ia -oorlycontrolled coa*ulo-athy

ASA PS A declared brain@dead -atient )ho or*ans are bein* re+oved for donor

-ur-oses

ASA PS ,**'6',%'#$* 6 %- A4-&',$ S#,'-% #6 A$-*%-*'##5'*%*

Malla+-ati ClassificationThe Malla+-ati Classification is based on the structures visualiBed )ith +axi+al +outho-enin* and ton*ue -rotrusion in the sittin* -osition 5ori*inally described )ithout -honation but others have su**ested +ini+u+ Malla+-ati Classification )ith or )ithout -honation best correlates )ith intubation difficulty7.

Class 8? soft -alate fauces uvula -illars

Class 88? soft -alate fauces -ortion ofuvula

Class 888? soft -alate base of uvula

Class 8L? hard -alate only

$$


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uick 2eferenceF2evie)• Pre@Anesthesia Dvaluation

o Cardiac Patient E decreased exercise tolerance i+-ortant si*n^ if able to

cli+b $ fli*hts of stairs cardiac reserve -robably intact

Post@M8 E infarction risk stabiliBes at &@ after +onths• Perio-erative M8 +ortality $#@

• 8f no -rior M8 -erio-erative risk #."3

• /ccur in %'@($ hrs -ost@o-

• Io elective sur*ery )ithin +onths of M8

Prior Cardiac Sur*ery or PTCA is not contraindication to sur*ery

Contraindication to sur*ery ] M8 J" +onth unco+-ensated CH

severe AS or MS Dvaluation

• MaOor risk E unstable coronary syndro+e

•

8nter+ediate risk E +ild an*ina -rior M8 CH 4M• Minor risk E a*e abnor+al D= arrhyth+ia decreased

functional ca-acity stroke uncontrolled HTI Studies E D= Holter stress test technetiu+ !!+ thalliu+

i+a*in* coronary an*io*ra-hyo C/P4

Dx-lain obstruction

4eter+ine severity and res-onsiveness to albuterol *et PT’s

C2 if hi*hly sy+-to+atic 8ncreased risk if -re@o- PT’s J -redicted

Also hel-ful to deter+ine ho+e /$ re


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• Mali*nant Hy-erther+ia E skeletal +uscle hy-er+etabolic syndro+e

o Tri**erin* anesthetics E halothane esflurane isoflurane desflurane

sevflurane succinylcholine

o ene E Ca channel of skeletal +uscle sarco-las+ic reticulu+ )ithdecreased reu-take of Ca

o Sy+-to+s E increased H2 increased breath rate increased etC/$ 5+ost

sensitive7 unstable ;P cyanosis coca@cola colored urine ate si*ns 5@$% hrs7 E increased te+-erature +uscle s)ellin*

heart failure 48C liver failureo Confir+ dia*nosis by lar*e difference bet)een venous C/$ and arterial

C/$o abs E 2es-iratory and +etabolic acidosis hy-oxia hy-erkale+ia

hy-ercalce+ia hi*h +yo*lobin hi*h CP= +yo*lobinuriao 8ncidence E "?$$####^ "?%#### )ith succinylcholine

o Mortality E "# overall (# )ithout dantroleneo uture anesthesia E no -retreat+ent )ith dantrolene flush anesthesia

+achineo T

" @ Call for hel-$ @ Sto- volatile anesthetic3 E "## /$% E Manually hy-erventilate& E S)itch to a clean breathin* circuit E Sto- sur*ery +aintain on sedative@hy-notic anesthesia( E 4antrolene $.&+*Fk* 5+ixed )ith sterile )ater7 < "# +inutes to+ax dose of "#+*Fk*. Maintenance dose at "+*Fk* < hrs for ($hours.' E Correct +etabolic acidosis )ith IaCH/3 "@$+*Fk* Correct hi*h=! E Cool -atient )ith iced 8L IS and cold fluids in *astric lava*e in -eritoneal or thoracic cavity if o-en and P2 "# E Maintain urine out-ut )ith +annitol or lasix. 4o not use CC;’

o 8L luids 52 IS7

o Maintenance 5%$"7 IP/ ti+e 5Maintenance Q G hrs7 Dva-orative

loss 5"@'ccFk*Fhr7

•

ocal Anestheticso Dsters E 1 0i1 in na+e 5i.e. novocaine7 +etaboliBed by -las+a

-seudocholinesterases. /ne of its +etabolites is PA;A )hich causesaller*ic reactions 5i.e. )ith Procaine and Tetracaine7. CS has noesterases. Sulfa aller*ic -atients.

o A+ides E 2 0i1s in na+e 5ie. idocaine ;u-ivicaine7 +etaboliBed by

liver enBy+es +ay cause +ethe+e*lobine+ia 5-rilocaine bu-ivicaine7aller*ic reaction rare so+e bad hy-eractivity reactions

$%


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o Mechanis+ E decrease -er+eability to Ia ions binds to Ia channel in

inactivated state no threshold -otential reached affects ra-id firin* nervesfirst +yelinated un+yelinated

o Contraindications E hy-ersensitivity severe heart block ,P, syndro+e

o Toxicity E often follo)s -redictable -attern of tinnitus -erioral nu+bness

and tin*lin* sense of doo+ seiBure co+a. Cardio E decreased -hase 8L de-olariBation increased P2 )ide

2S Pul+onary E -hrenicFintercostal nerve -aralysis

CIS E diBBiness circu+oral nu+bness tinnitus blurred vision

excitatory si*ns CIS de-ression

Muscle E toxic inOected 8M

idocaine kno)n to decrease coa*ulation

• Air)ay Mana*e+ent

o MA E sub for DT tube as lon* as inflation^ +ay be used as *uide for

intubation Pro-ofol used for induction E relaxes Oa)

=ee- in -lace until -atient o-ens +outh on arousal

Co+-lications E as-iration +ucosa inOury laryn*os-as+Fcou*hin*

Contraindication E risks for *astric as-iration such as D24

-re*nancy recent +eal

• Mendelssohn’s Syndro+e

o As-iration -neu+onia secondary to as-iration of *astric contents

o T E su--ortive ad+ission to 8CU continued intubation res-iratory

thera-y suctionin* /$ no antibiotics


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&. Pass tube E i++ediately follo)in* fasiculations fro+ succinylcholine. Post@tube +ana*e+ent E ta-e tube o-ioids etc etc.

• Dxtubation Criteria

o Tidal volu+e &ccFk*o 2es-irations s-ontaneous and 'F+in

o I8 of @"# to @"&

o Patient sho)in* -ur-oseful +ove+ent

o Te+-erature of 3& C or *reater

o He+odyna+ic stability

o Pa/$ _ # on i/$ %# Pco$ ` && ++H*

• aryn*os-as+

o Children at es-ecially hi*h risk

o Try to break first by *ivin* hi*h -ositive -ressure

o 8f cannot break +ust use succinylcholine to -aralyBe -atient to ba*@+ask

or re@intubate.

Pre@o- 2oo+ Pre- ChecklistMachine E +achine checkout /$ calibration *as levelSuctionMonitors E A line central line Pulse /x ;P D= ;8SAir)ay E laryn*osco-e oral air)ay +ask tube / Te+- -robeIL E alcohol needle flush on he-lock ta-e 8LDru*s E -ro-ofol eto+idate -aralytic narcotic versed -henytoin atro-ine e-ine-hrinesuccinylcholineS -ecial Seat

Labs E ty-e and cross H>H coa*s

$


28/33

Procedure Checklist

The -ur-ose of this section is to -rovide you )ith a list of -rocedures you +ay bere


29/33

V-$%'%#& S-%%'$5*

A&%-&' L'$- P,-4-$%

C-$%& L'$- P,-4-$%

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S'$

E'+)&

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31/33

2esources

The follo)in* are a short list of additional resources that you +i*ht find hel-ful durin*your anesthesia +onth in findin* +ore in de-th details about anesthesia.

T-7%

Mor*an D Mikail MS Murray MK. 0Clinical Anesthesiolo*y1 Mcra) Hill Medical.$##& 5Y(&7

lidden 2S. 0IMS Anesthesiolo*y1. i--incott ,illia+s > ,ilkins. $##3. 5Y$#7

W-(

Lirtual Anesthesia Text ;ook htt-?FF))).virtual@[email protected]+Findex.sht+l

,orld Anaesthesia /nline htt-?FF))).nda.ox.ac.ukF)fsaFindex.ht+

3#

http://www.virtual-anesthesia-textbook.com/index.shtmlhttp://www.nda.ox.ac.uk/wfsa/index.htmhttp://www.virtual-anesthesia-textbook.com/index.shtmlhttp://www.nda.ox.ac.uk/wfsa/index.htm


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Iotes

3"


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anesthesiapocketbook for medical students

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