Summary of Anesthesia minor

‫يريد نيل المجد والسيف مغمد‬

 ‫ويأمل ادراك العال وهو نائم‬
Done by :
 Razan Yaseen
 Abrar Ramadan
 Sara Irshedat
 Juhainah Hazaymeh
 Pre-operative evaluation

 hx , PE , investigations ( if needed)
 -hx »»
1) pt profile .. age , wt , height is very imp. bcz most of the doses depend on them
2) current problem
3) systemic review
4) past medical:
 if there is hx of arrythmia , ischemic heart disease , valvular diseases .. most of
anesthetic drugs are cardio suppressant
 if there is HTN…… to know the baseline
 current URTI »» delay the surgery unless its emergency
 asthma or COPD »» dry cold anesthetic drugs trigger the condition also we use spinal
anesthesia instead of GA in CS , hernia ...
 hx of epilepsy .. avoid enflurane
 DM » more risk of hypotension , infections , silent MI and sudden death , and
hypoglycemia during operation
 hypothyroidism » exaggerated CVS depression
 hyperthyroidism .. more risk of thyroid storm..
 GERD »» pre op give anti H1
5) past surgical : previous surgery , hx of anesthesia , is there any complications after
these surgeries!

6) drug hx :

 is there is any allergies for penicillin , latex ( found in gloves ) , propofol ( founds in
eggs )
 oral hypoglycemic agents are withheld
7) family hx ::hx of problems with anesthesia .. hx of prolonged apnea suggests
pseudocholinesterase deficiency and an unexplained death suggests maliganant
hyperpyrexia

8) social hx :smoking hx ,, chronic smokers encouraged to abstain from smoking for at

least 8 weeks prior to operation

9) NPO status..
 8 h after heavy meal as meat..
 6 h after light meal as toast crackers or formula milk in infants 🍼
 4 h after breast milk
 2h after clear fluid as water , coffee

 PE »»
 vital signs
 physical and mental assessment
 airway assessment
¤teeth

¤TMJ mobility

¤mallampati criteria ‫😇موجودات من قبل‬

¤deviation of trachea

¤mobility of cervical spine ( flexion + extension (

¤thyromental distance .. less than 7 cm suggests difficult intubation

¤wilson score : increase in weight, decrease in head and neck movement, reduced
mouth openning , presence of receding mandible or buck teeth…all suggests difficult
intubations. ..

¤calder test : The patient is asked to protrude the mandible as far as possible. The
lower incisors will lie either anterior to, aligned with or posterior to the upper incisors.
The latter two suggest reduced view at laryngoscopy. (inability to protrude the lower
incisors in front of the upper)

 exam RS and CVS

 check for IV access

-investigations: could be nothing or every things 😁😈

 CBC .. anemia , thalassemia..
 LFT
 KFT
 ECG
 chest X ray ... etc
 Risk assessment
 complications of anesthesia
#minor : nausea , vomiting , headache , urinary retention .. etc

#major : aspiration , allergy , MI , pneumonia , PE .. etc

- antiemetic as meteclopromide or hyosicine , anti histamines can be used in laparoscopy

and vomiting risk

‫هسا راح أحطلكم العديد من الجداول…جدا مهمات لالوال‬

The 4 classes are:-

• class I (0–5 points) __ 1%

• class II (6–12 points) __ 5%

• class III (13–25 points) __ 16%

• class IV (=26 points) __ 56%

% of preoperative cardiac event

>25 points – only live saving procedures

(13-25) – were advised to have preoperative medical consultations to lower their

morbidity and mortality
 ANATOMY OF AIRWAY AND INTUBATION
 Lung Volumes
.... ‫ترتيبهم ع الشكل هيك‬
 IRV: the maximal volume that can be inhaled after normal inspiration
 TV : volume of air moved into or out of the lungs during quiet breathing – 0.5 L
( intra-op any pt need 6-10ml/kg of O2)
 ERV : maximal volume of air that can be exhaled after normal expiration
 RV : the volume of air remaining in the lungs after a maximal exhalation
 Capacity ( sum of more than 2 physiologic volumes)
 VC : the volume of air breathed out after the deepest inhalation. (IRV + TV + ERV )
 IC : maximum amount of air that can be inspired (IRV + TV)
  FRC : volume in the lungs after normal expiration ( ERV + RV )
 TLC : the volume in the lungs at maximal inflation
 OXYGEN-HAEMOGLOBIN DISSOCIATION CURVE
Factors affecting this curve
I. Rt shift …… less affinity of Hb to O2 …..more unloading to tissue …..
Hyperthermia, ↑ 2,3-DPG, ↑ CO2 , ↓pH
II. Lt shift …..more affinity
Hypothermia , ↓ 2,3-DPG, ↓ CO2, ↑pH ، co
 preoxygenation is the process of administering oxygen to a patient prior to intubation, so
as to extend ‘the safe apnea time’ from 1 min to 8 min ….by administering 100% O2 and
denitrogenation of the lungs

 INSTRUMENTS
 Face mask : used for inhalational induction , maintenance ,preoxygenation, select
appropriate size to ensure gas tight seal , hold in place using C on E technique , stridor
and suprasternal retraction suggest airway obstruction ( oral /nasal airway prevent this
obstruction while using the face mask)
 Laryngoscope
 Laryngeal mask airway (LMA) :
*Indications : maintain patent airway w/o need to hold the mask ( free the anesthetist
hands) , less invasive than ETT , when suspect difficult intubation , inserted blindly
without laryngoscopy , decrease risk of aspiration of regurgitated gastric content but
dose not eliminate it completely

*Contraindications : full stomach , at risk of regurgitation ( pregnancy, hiatal hernia) ,

prone / lateral decubitus position , head and neck or thoracic surgery

 Endotracheal Tube :

 Classified according to its shape

1) Reinforced OR unkinkable ( used in head and neck surgery , in surgery
w.prone position , CPR )
2) Kinkable
3) RAE tube : used for better access : for ENT , ophthalmic or jaw surgery
 either w. cuff(decrease the risk of aspiration and more fixation ) OR w.o cuff
 According to the type of the cuff….There are two types
 1. High volume low pressure…most commonly used …less risk of ischemia
to mucosa
2. low volume high pressure…more risk of ischemia to mucosa
 The size of the tube( the internal diameter)….For adult male require “8.0-9.0
mm ID “ and For adult female normally “7.0-8.5 mm”. But For pediatric can be
calculated from the formula (age/4) + 4mm
 For oral intubation the length should be 20-23cm…. But For pediatric can be
calculated from the formula (age/2) + 12cm

 Methodology of intubation :
* either under GA : iv or inhalational plus minus Relaxant such
suxamethonium ( use relaxant in case of abdominal/thoracic / cranial surgery ,
for prolonged operations , for prolonged ventilation)
*or Awake intubation under local anesthesia ( topical or endotracheal spray)

 Technique of Tracheal Intubation

1. Positioning the patient…. Sniffing position… to align the axes of mouth,
pharynx and larynx for direct visualization during laryngoscopy…
Contraindicated in known OR suspected C-spine fracture OR instability
2. Opening the patient’s mouth… Left hand for holding laryngoscope ……Right
hand for opening the mouth and insertion of tube
3. Performing Laryngoscopy
4. Insertion of the ETT through the vocal cords and removing the
laryngoscope…. Tip of ETT should be located at the midpoint of trachea, at
least 2 cm above carina ….if deep ..it will be inserted into the RT bronchus

 Indications for ETT : any c/I for LMA that mentioned above , chest /abdomen
or cranial surgery , ventilates and protect the healthy lung ( hemoptysis ,
pulmonary abscess) , respiratory failure , when positive pressure ventilation is
required , during CPR , when muscle relaxant is required .

 Confirmation of correct ETT placement

 Direct Visualization : Observing the tube passing through the vocal cords
and presence of vapor on the tube
 Capnography : gold standard , Measuring the carbon dioxide in expired gas
  chest movement with positive pressure ventilation( symmetrical )
 Listening to the apex and base of each lung for breath sounds with
ventilation( bilateral equal good air entry ) …listening to epigastrium also
 X-RAY
 Fibro-optic laryngoscope

 COMPLICATIONS OF INTUBATION :
*Early :
 Hypoxia: due to esophageal intubation, Failed intubation, Failed
ventilation after intubation( kinking of tube …)or Aspiration of gastric
contents.
 Trauma : Direct (During laryngoscopy and insertion of tube
….Damage to lips, teeth, tongue, pharynx, larynx, trachea, nose
(epistaxis ) ) OR Indirect ( To the recurrent laryngeal nerves, and the
cervical spine and cord).
 Reflex activity : Hypertension and arrhythmias ,vomiting and
laryngeal spasm when attempting to intubate the pt during the light
plane of anesthesia
*Late : tracheal necrosis and stenosis , hoarseness of voice due to vocal
cord damage .
AIRWAY OBSTRUCTION
 The most common cause of airway obstruction in an unconscious supine patient
 is falling back of the tongue into the hypopharynx
 managed by
 Clearing the airway of any foreign material.
 Using a chin lift maneuver…. when spinal injury is NOT suspected
 Using a jaw thrust maneuver. when spinal injury is suspected( cervical disc OR
atlantoaxial instability )
 Inserting artificial airways:
 Oropharyngeal airway
o To maintain the airway in the unconscious patient during bag and mask
ventilation as well as during CPR and for persons with a large tongue
o Inserted upside down until the tip is beyond the end of the tongue then
rotated 180 degrees .
  nasopharyngeal airway
o used by in situations where an artificial form of airway maintenance is
necessary but tracheal intubation is impossible or inadvisable…check the
patency of the Rt nostril , the size is assessed by nostril diameter….no gag
reflex (vs oral airway)SO it can be used in conscious pts
o Nasal airways are contraindicated in-patients with severe trauma to the
head and/or face due to the possibility of direct intrusion into brain tissue
 laryngeal mask airway.

 1-2-3’ Test: for airway assessment

 TMJ mobility … space created between the tragus of the ear and the mandibular
condyle should be approximately one fingerbreadth in width.
 Mouth opening and tongue protrusion …
 Ask the patient to open mouth maximally…..The aperture of the patient's
mouth should admit at least 2 fingers between his teeth, otherwise … It
will be difficult to insert the laryngoscope blade
 Mallampati Classification….The visualized structures upon mouth
opening :
Class I: hard and soft palate, fauces, uvula, tonsillar pillars
Class II: hard and soft palate, fauces, uvula .
Class III: hard and soft palate, base of uvula
Class IV: hard palate only
 Thyromental distance ….from tip of chin to thyroid cartilage….must be more
than 3 fingerbreadth ..if less ..difficult intubation .

General Anesthesia
There are four types of anesthesia that may be employed alone or in combination :
 Local
 sedation
 regional
 general
General Anesthesia :pharmacologically induced reversible state of unconsciousness ,amnesia
and analgesia .
* Muscle relaxant may needed .
* Premedication with anxiolytic may needed .
Four A’s of general Anesthesia : lack of Awareness , Amnesia , Analgesia , Akinesia

Stages of general anesthesia :

1) induction of anesthesia :
 Either intravenous (mainly) or inhalational in certain situations:
Young children , upper or lower airway obstruction such epiglottis , goiter or
foreign body aspiration , bronchopulmonary fistula plus minus empyema ,
inaccessible veins .
 Methodology of inhaled induction:
1. Initially 70% N2O in O2 used followed by 1-3% halothane to deepens the
anesthesia , monitoring of the pt is essential ( skin color , O2 sat , pulse , ECG)
2. Establish an airway ( Oral airway , LMA or ETT )
 Disadvantages of inhaled induction : slow ,may induce bronchospasm or
laryngospasm , theater pollution .
*Rapid sequence induction used in pt with high risk of regurgitation :
( pre-oxygenation- cricoid pressure – induction agent – succinylcholine – tracheal
intubation and cuff inflation)

2) maintenance of anesthesia :
 Through inhalational agent ( Sevoflurane, Isoflurane or Halothane in mixture of
70% N2O in O2 ) , this method of maintenance used in : superficial/minor
procedures which produce little pain or reflexes , when profound muscle relaxant
is not required.
 or IV agents
 or IV opioids (fentanyl)
*Total intra-venous anesthesia (TIVA) =propofol + fentanyl
 Complications of anesthesia maintenance : airway obstruction, laryngospasm
(due to stimulation during light plane of anesthesia , management: stop the
stimulant ( extubation ) -100% O2 mask – deepen the anesthesia - suxamethonium
- re-intubation) , bronchospasm ( increase anesthesia depth , bronchodilator ,
endotracheal lidocaine) , Malignant hyperthermia , increased ICP

3) Emergence and recovery :

 stop all drugs delivery
 Reversal of muscle relaxant action ( neostigmine + atropine)
 Place the pt in the recovery position ( left lateral decubitus ) especially for who at
risk of regurgitation
  100% O2 replaces the anesthetic gases to prevent diffusional hypoxia and to
provide pulmonary reservoir
 Tracheobronchial suction then follow
 Extubation during inspiration
 Ensure from the pt ability to maintain the airway and form intact respiratory
reflexes .
 Complications of extubation : laryngospasm , aspiration , tachycardia and transient
HTN , voice changes due to glottic edema.

Intravenous anesthetic agents

Ideal intravenous anesthetic agent :
 rapid onset : un-ionized , lipid soluble
 rapid offset : redistribution from brain to muscles and fat
 analgesic and anti- emetic effects
 non excitatory ( coughing , purposeless movement) , no RS or CVS depression , no
nightmares , no interaction w. muscle relaxants .
 not induce hypersensitivity or histamine release , no pain or thrombosis at injection
site , no stimulation of porphyria .
 Non toxic to organs
 Long shelf life

IV anesthetic agents are either barbiturate or non barbiturate .

1) barbiturate : sodium thiopental

 Hypnotic , highly bounded to albumin ( renal and hepatic diseases associated
with low albumin level so higher unbound thiopental may cause toxicity).
 Arm brain circulation time = 30-60 sec ( need this time to start action) and last 5-
10min
 Dose : 3-6mg/kg ‫حفظ‬
 Effects on CNS : decrease dissociation of GABA from its receptors resulting in
depression of reticular activating system causing loss of consciousness (LOC) and
profound CNS depression ( dec cerebral metabolic rate , dec ICP , dec IOP and dec
pain threshold so anti-analgesic effect)
 CVS : dose related depression of myocardial contractility ( dec CO and SV ) ,
decrease venous tone so hypotension + reflex tachycardia .
  RS : depress rate and depth of breathing leading to brief period of apnea , light
level of thiopental dose not blunt airways response to manipulation (Intubation)
so coughing , hiccoughing , laryngospasm and bronchospasm all may occurs .
 arterial injection produce necrosis.
 No effects on kidney , uterus or fetus
 Indications :
1) induction of anesthesia
2) maintenance of anesthesia for short procedures
3) anticonvulsant
4) for regional anesthesia
 Absolute C/I : hypersensitivity , porphyria , airway obstruction .
 Cautious to use for pt in shock , cardiac , hepatic and renal diseases .

2) non barbiturate agents

1) propofol :
 Hypnotic
 Highly lipid soluble , combined with egg white and soya bean oil for IV
administration
 No effects on muscle relaxants
 Mild anti emetic properties ( so low incidence of N&V) , not induce histamine
release nor malignant hyperthermia.
 Dose : 2.5-3mg/kg for induction ‫حفظ‬
 CNS effects : decrease cerebral metabolic rate and decrease ICP
 CVS : decrease systemic vascular resistance so hypotension (more severe than
caused by thiopental ), no reflex tachycardia ( vs thiopental) .
 RS : profound respiratory depression with brief apnea , effectively blunts airways
response to manipulation thus hiccoughing , bronchospasm rarely seen ( vs
thiopental)
Respiratory depression and hypotension are More profound with
Propofol Than thiopental
 burning sensation when injected so give along lidocaine and in proximal large
vein
 Indications : induction and maintenance of GA , sedation for ( conscious
sedation ,ICU intubated pt , along regional anesthesia, for Painful procedure such
endoscopy)
  C/I : soya bean and Egg allergy (very rare) , shock and in case where hypotension
can’t be tolerated such in severe aortic /mitral stenosis or cardiac tamponade ,
inability to maintain a patent airway or lack of resuscitation equipments.

2) ketamine
 Dissociative anesthetic
 Arm brain circulation time = 20 sec and last ~ 10-15 minutes
 MOA : Acts on numerous CNS receptors including NMDA receptor.
 Dose : 1-2mg/kg ‫حفظ‬
 CNS effects : produce dissociative anesthesia (state of unconsciousness and
intense analgesia however the pt's eyes remain open and their limbs may move
purposelessly) , increase cerebral metabolic rate and increase ICP , unpleasant
dreams and hallucinations ( so give with midazolam)
 RS : respiratory drive is maintained so apnea is rare , preserves laryngeal and
pharyngeal reflexes so cough and swallow may occurs , increase sympathetic tone
cause bronchodilation , increases airway secretions .
 CVS : increase sympathetic outflow so increase HR , BP and CO
 Increase muscles tone and the effects of muscle relaxant (vs propofol)
 Cross the placenta
 Indications:
 induction for hemodynamically compromised pt ( pt in shock) .
 induction for severe asthmatic cases .
 For sedation during painful diagnostic procedures .
 C/I : allergic , psychiatric disorders , CVA , raised ICP , coronary ischemia, for
whom HTN is hazardous , inability to maintain patent airway or lack of
resuscitation equipment.

Anxiolytic ( benzodiazepine )
 Used as adjuvant IV anesthetic agents because they are agonist at GABA
receptors so provide : sedation , amnesia , anticonvulsant effect , muscle
relaxation and anxiolytic
 minimal RS/CVS depression .
 used as premedication to decrease anxiety , induce amnesia and sedation
 Midazolam vs diazepam
 Midazolam: more potent , more rapid onset , greater amnestic effects , shorter
DOA , water soluble so less pain at injection site vs diazepam .
 Antidote is flumazenil
 Analgesic ( narcotics)
 Acts on mu / kappa receptors
 CNS effects : dec pain perception , unconsciousness at large doses , induce
chemotrigger zone so N&V
 RS : dose related depression ( reversed by naloxone)
 CVS : little myocardial depression , decrease sympathetic tone and induce
histamine release (especially Morphine) so peripheral vascular resistance
decreases causing hypotension .
 GIT : N&V , biliary spasm , constipation , urinary retention , muscle rigidity .
 Fentanyl :
 most narcotic agent used during induction of anesthesia ( only used intra-op)
due to its rapid onset of action.
 DOA = 30 min , very potent (used in micrograms)
 Dose :0.5 – 3 microgram/kg ‫حفظ‬
 pre and post-op use morphine or Pethidine (meperidine)
 Antidote : naloxone (high doses associated with abrupt return of pain so : HTN ,
tachycardia, arrhythmia, cardiac arrest )

Inhalation anesthetic agent

 Inhaled anesthetic mainly used for maintenance of GA .
 Continue to be the mainstay for induction in pediatrics .
 MAC : the concentration of inhaled anesthetic in the alveoli necessary to prevent
movement of 50% of pts when a standard incision is made
 The lower the MAC the higher the potency .
 Factors lower the MAC : advanced age , hypothermia, hypothyroidism , acute ethanol
intoxication , opioids and pregnancy.
 Factors increases the MAC : pediatrics , hyperthermia , hyperthyroidism , chronic
ethanol intoxication and amphetamine
 Gender , duration of anesthesia , pH , HTN and hyperK have no role in MAC value .
 The higher the concentration , flow rate and minute ventilation the faster the agent
reach the alveoli .
 Blood flow rate , solubility of the agent , differences in the agent level btw arterial and
venous all affect the rate of brain delivery .
 1) nitrous oxide (N2O)
 Good analgesic but weak anesthetic (MAC = 105%) ‫حفظ‬
 Either used as adjuvant to other anesthetic or in dental and obstetric procedures
 Side effects :
 Dec BP and HR , inc ICP , expands any gas containing spaces ( pneumothorax ,
distended bowel loop , cranium , middle ear)
 Diffusional hypoxia : seen during emergence from N2O - rapid outpouring of
insoluble N2O displace alveolar O2 - hypoxia , so all pts should receive O2 at the
end of anesthesia .
 Contraindications : bowel obstruction , pneumothorax , increased intracranial pressure .

2) Halothane

 The most potent inhaled anesthetic : MAC = 0.75% ‫حفظ‬

 Rapid induction and recovery , used also for maintenance ( along O2 or O2 + N2O )
 Cause inhibition of salivary and bronchial secretions
 Bronchodilation , respiratory depression
 Hypotension , bradycardia and myocardial relaxation : so beneficial to use in pts with
CAD .
 Induce muscles relaxation
 Poor analgesic
 Arrhythmigenic ( very common) : sensitize myocardium to catecholamine
 Decrease GI motility : cause severe post-op N&V
 Uterine relaxation : C/I in obstetrical anesthesia due higher risk of post-partum
hemorrhage
 Post-op shivering is common
 Hepatotoxic
 Photosensitive : preserved in amber colored glass bottle
 Associated with Malignant hyperthermia

3) Enflurane

 MAC = 1.68% ‫حفظ‬

 Epileptogenic
 Potent CVS depressant
 4) Isoflurane

 Pungent odor : irritant to airway so not used for inhaled induction

 MAC : 1.2%
 Not used for CAD pts due to coronary vasodilation which cause coronary steal
syndrome : atherosclerotic plaque in selected coronary artery causes narrowing of the
lumen so the distal arterioles compensate by vasodilation , upon administration of
coronary vasodilator such Isoflurane , the whole coronary arteries vasodilated result in
shunting away of blood from the ischemic zone result in further ischemia ....
 Increase ICP
 Dose dependent muscle relaxant even the uterus

5) Sevoflurane
 Pleasant smell so non-irritant : the fastest for induction ( Agent of choice for
inhalational induction )
 MAC = 2% ‫حفظ‬
 most commonly used one for maintenance
 Non arrythmogenic ( vs Halothane)
 Less potency vs others
 Uterine relaxant
 Post-op agitation
 Bronchodilation , hypotension
 Nephrotoxic , hepatotoxic , neurotoxic due compound A production .

6 ) desflurane
MAC = 6% ‫حفظ‬

# all flurane group associated with malignant hyperthermia.

 Muscle relaxant
 Neuromuscular junction :
1) pre-junctional membrane ( motor nerve ending ) containing Ach vesicles
2) synaptic cleft
3) post-junctional membrane ( motor end plate) containing on its surface Ach receptors

 Muscle relaxants :
1) depolarizing non competitive agonist ( succinylcholine)
2) non depolarizing competitive antagonist (Tubocurarine)

 When to use muscle relaxant??

1) in intra-abdominal / thoracic / orthopedic or intra-cranial surgery
2) facilitate endotracheal Intubation

1) depolarizing muscle relaxant :

Succinylcholine (suxamethonium or scholine) :
 Ultra-short acting muscle relaxant ( DOA=5-10min)
 30-60 second to act
 Dose : 1-2 mg/kg ‫حفظ‬
 bind to nicotinic cholinergic receptors so depolarizing the post-junctional membrane ,
since scholine not degraded by Ach esterase , scholine result in continuous receptors
stimulation manifested by initial fasciculations and subsequent desensitization and
paralysis
 Action can’t be reversed with choline esterase inhibitors
 Scholine diffuse away to plasma and degraded by hydrolysis through the action of
plasma pseudocholinesterase .
 Pseudocholinesterase deficiency can be qualitative (genetic) or quantitative ( as a
consequence of liver disease , pregnancy or various medications such
cyclophosphamide and monoamine oxidase inhibitors)
 Effects of scholine :
 Cns : increase both ICP and IOP
 because of cross-reactivity at muscarinic receptors , scholine have the following
effects on CVS and RS :
 cvs : arrhythmia , bradycardia , sinus arrest
 RS : bronchospasm and excessive salivation
 Post-op myalgia is common
 Scholine is a potent trigger of malignant hyperthermia
  Scholine elevate serum potassium ~0.5 mEq / l in normal pts , but exaggerated
release in selected cases leading to fatal hyperkalemia and cardiac arrest .

 Indications to use scholine :

1) full stomach : emergency , Cesarean section
2) for rapid sequence induction for who at risk of regurgitation
3) suspected difficult intubation
4) when muscle relaxation is required for short duration operations
5) before electroconvulsive therapy

 Absolute contraindications :
1)Inability to maintain airway
2)Malignant hyperthermia history
3)Allergic
4)Myotonia
5)Cases at risk of exaggerated release of potassium :
 Third degree burn
 Severe Intra-abdominal infection
 Close head injury
 UMN lesion
 Muscular dystrophy
 Recent paralysis ( CVA , spinal cord injury )
 Relative contraindications :
1)Familial periodic paralysis
2)Pseudocholinesterase deficiency
3)Myasthenia graves
4)open eye surgery

2) non depolarizing muscle relaxants :

 Competitively block post-junctional nicotinic receptors so prevent depolarization and
subsequent paralysis.
 Since it a competitive inhibitors , block can be overcome by increase concentration of
Ach at synaptic cleft by using Ach esterase inhibitors
 All given IV and not cross BBB or placenta
 Acidosis , hypothermia , old ages , hypokalemia , hypocalcemia , inhalational agents all
extend its action .

Vecuronium :
 Intermediate acting
 No CVS side effects

Rocuronium :
 Intermediate acting
 Relaxant of choice for short / intermediate procedures
 Fast onset : suitable for rapid sequence induction( alternative to scholine)
 No CVS side effects

Cisatracurium :
 Intermediate acting
 Not cause histamine release ( vs atracurium)
 Relaxant of choice for pts with renal and hepatic insufficiency

Pancuronium :
 Long acting
 Not cause histamine release
 Cause cvs side effects: increase HR , BP , CO
 Dependent on renal excretion so caution to use for who have renal insufficiency
( prolonged blocking )

Reverse of muscle relaxant blocking done through Ach esterase inhibitors . But we only
want to reverse the nicotinic blockage and to prevent muscarinic receptors stimulation
we give also anticholinergic drugs .

Ach esterase inhibitors :

Neostigmine
 Reversible inhibitor
 Side effects due parasympathetic stimulation : meiosis , hyper-secretion , inc Gi motility
, flushing , bradycardia
Anticholinergic drugs :
Atropine :
 Competitive antagonist for muscarinic receptors
 Cross BBB
 Actions : tachycardia ( paradoxical bradycardia at suboptimal doses) , mydriasis , dec
secretions , constipation , urinary retention , bronchodilation
 Overdose : hyperthermia , xerostomia , delirium , tachycardia , flushing .
 Clinical uses : cycloplegic , antispasmodic , block secretions prior to surgery , enuresis ,
organophosphate antidote , along neostigmine for muscle relaxant action reversal .
 C/ I : BPH ,Closed angle glaucoma

Scopolamine :
 Same as atropine but with more cns action : used for motion sickness , sedation ,
amnesia

Glycopyrrolate
 Not cross BBB
 Less cvs side effect than atropine

IV fluid
 Total Body Water (TBW) : dec if person has more fat

-60% in adult M -55% in adult F -75% in infant

 fluid compartments :
 -ECF 1/3 TBW ( ¾ interstitial fluid , 1/4 plasma , 0.5 L transcellular fluid )
 -ICF 2/3 TBW
 in ECF : main cation is Na 142mEq/l , main anion Cl 103 mEq/l
 in ICF main cation K 140 mEq/l
 IV solutions
1. crystalloids replaced by 3: 1 rule ( 3ml crystalloid for each 1ml loss)
 isotonic : same osmolality to plasma
 0.9% NS ( 154 mmol/L Na , 154mmol/L Cl )
- after 15-30 min ,only 25-30% of volume remains intravascular
- used for:
 1st line emergency fluid resuscitation & perioperative period.
 hypovolemic resuscitation.
 replacing electrolyte-rich GI losses.
- Risk of hyperchloremic metabolic acidosis
 Ringer’s lactate ( Hartmann’s solution )
- contain : 131 Na , 112 Cl , 29 HCO3 , 5 K , 4 mmol/L Ca
- used for:
 1st line emergency fluid resuscitation & perioperative period. (used more
than NS)
 reduce iatrogenic hyperchloremic metabolic acidosis.
 - not in case of hyperkalemia or with citrated blood transfusions because of K
& Ca
 Hypotonic solution : 5% Dextrose (D5W)
- NOT routinely used because glucose metabolized result in free H2O so dilute
the electrolytes ; risk of hypoNa .
- used to treating dehydration as a result of water losses.
1. Effect of large volume crystalloid infusion

1- extravascular accumulation in skin, connective tissue, kidney.

2-inhibition of GI motility
3-delay healing of anastomosis
4-large volume ,Rapid infusion cause hypercoagulability.

2. Colloids :
 are homogenous, non-crystalline substances consisting of large molecules or
ultramicroscopic particles, which persist in the vascular compartment to expand
the functional plasma volume (lasting several hours to several days)
 2 types : Natural (albumen) & Synthetic .
 plasma expanders : so given in a volume similar to the estimated deficit ( 1 : 1 rule
)
 commonly used types :

1. Human Albumin Solution ( MW 70000 )

*4.5% solution for hypovolemia

* salt-poor 20% solution for hypoalbuminemia

2. Gelatins :

 Rarely lead to histamine release /anaphylaxis ( bronchospasm, urticarial rash,

hypotension, and tachycardia)
 No limit on total volume that may be administered (vs starch )

3. Hydroxyethyl starches : The best colloid

 limited total volume only up to 30-50 ml/kg

 S/E :
  Anaphylactoid reactions: hypersensitivity, mild influenza-like symptoms,
tachycardia, bronchospasm
 non-cardiogenic pulmonary edema , renal impairment , itching after their
use
 Decrease in hematocrit , disturbances in coagulation and bleeding

4) Dextran :
 given 20ml/kg for the 1st 24 hours and 10ml/kg thereafter for 5 days only
 Dextran 70 :Better volume expander.
 Dextran 40:Improves blood flow through microcirculation
 Use for vascular surgery – prevent thrombosis
 Can cause mild-moderate anaphylactic reactions
 Infusions more than 20 ml/kg/d can interfere with blood typing, renal failure,
prolong Bleeding Time (Dextran 40).

Crystalloid Colloid
Cheap Expensive
Low MW High MW
½ life 15-20 min ½ life 2-3 hr
1:3 rule 1:1 rule
Risk of allergy

 intra-op fluid requirements

1- compensatory intravascular volume expansion (CVE)

 to compensate anesthetic vanodilation and cardiac depression , we give 5 mL/kg of RL

before or simultaneous with the onset of anesthesia .
 risk of post-op hypervolemia in pt w. cardiac or renal problems .

2- Maintenance fluids

*"4-2-1" rule /hour or "100-50-20" rule/day

 4 ml/hr for 1st 10 kg

 2 ml/hr for 2nd 10 kg
 1 ml/hr for remaining kg

3- Preoperative deficits : either due to

  *NPO deficit ( maintenance * NPO hours )
 pre-op GIT losses ( vomiting or diarrhea)
 *blood loss :
 if less than 15 % use crystalloid “ becz it’s safer “
 15-30% use colloids “becz more effective “
 more than 30% loss in healthy young adult use blood ( Hb less than 7-8 g/dl)
 in Children start blood transfusion if 10% blood loss
 elderly + preexisting disease start blood transfusion at 20% blood loss. ( Hb 10 g/dl or
less )

4- ongoing surgical Losses:

1. Evaporation

2. Blood loss : estimated through thorough inspection of blood in the field around the
pt , count the number of gauze used , volume of blood inside suction device , use of
irrigation

*Allowable blood loss = 3×( RBC volume at preoperational hematocrit level – RBC
volume at hematocrit level of 30% )

*given that the total blood volume = 75ml×weight for males and 65ml×weight for
females.

3. Third space loss : replaced through ( 4-6-8 ml/kg/hr ) rule for minor , moderate ,
major surgery respectively .

* sum all the requirement & give ½ the amount in the 1st hr , ½ remained in the following 2
hrs

*Monitoring Adequacy of Fluid Replacement: vital signs , urine output should be 1ml/kg/hr ,
hemoglobin /hematocrit levels , invasive monitoring ( central venous pressure)

Blood transfusion..
 Blood groups
ABO system..
 Determined by presence OR absences of A OR B RBC surface Ag
 Ab( IgM) against the missing Ag is produced naturally within the first year of life ( A...
Has A Ag... Has anti B Ab) ...
Rh system
  Persons w. D Rhesus Ag are considered Rh positive AND person lacking this Ag are
called Rh negative
 Vs ABO groups.... Rh negative pts usually develop Ab against the D Ag only after an Rh
positive transfusion OR w. Pregnancy ( mother is Rh - and baby is Rh +)
other RBC Ag system.. Like Lewis, Duffy....
Fortunately... Only ABO and Rh systems are imp in the majority of blood
transfusion.
 Compatibility Testing: The purpose of compatibility testing is to predict and to prevent
antigen–antibody reactions as a result of red cell transfusions
 ABO–Rh Testing
 The most severe transfusion reactions are due to ABO incompatibility( Ag and Ab
interaction …activate C system …intravascular hemolysis )
 The patient’s red cells are tested with serum known to have antibodies against A and
against B to determine blood type. …..confirmation of blood type is then made by
testing the patient’s serum against red cells with a known antigen type.
 If the subject is Rh-negative, the presence of anti-D antibody is checked by mixing the
patient’s serum against Rh positive red cells….
 Antibody Screen
 The purpose of this test is to detect in the serum the presence of the antibodies that
are most commonly associated with non-ABO hemolytic reactions.
 The test (also known as the indirect Coombs test) requires 45 min.
 Crossmatch
 donor red cells are mixed with recipient serum.
 Confirms ABO and Rh typing ,Detects antibodies to the other blood group systems OR
antibodies in low titers … SO it assures optimal safety.
 Because it is time-consumed (45 min), crossmatches are often now performed before
the need to transfuse only;
- when the patient’s antibody screen is positive
- when the probability of transfusion is high
- when the patient is considered at risk for alloimmunization.
 Emergency Transfusions
 blood type is known, an If the patient’s abbreviated crossmatch, requiring less than
5 min, will confirm ABO compatibility.
 If the recipient’s blood type and Rh status is not known , type O Rh-negative
(universal donor) red cells may be used.
 Blood Bank Practices
  One unit of blood ( 450 ml + 50 ml of preservative- anticoagulant solution " CPDA-1...
citrate, phosphate, dextrose and adenosine "... So total unit now is 500ml) ... Can be
preserved for 35 days...
 Then it will be typed... Screened for Abs,...tested for HCV, HBV, HIV and syphilis....
 Now We want to separate the whole blood into its components..
 centrifugation of blood ..... give
1. packed RBC.... 250ml per unit...we add a saline preservative.. So it becomes 350 ml..
Stored at 1-6 C BUT it can be frozen in hypertonic glycerol for up to 10 y ( for rare
blood groups and it is so expensive)
2. supernatant ...further centrifugation... Yield.
- Platelets... )50-70 ml pf plasma for each unit ) stored at room temperature for 5
days... (Most platelets are now obtained from donors by apheresis, and a single platelet
apheresis unit is equivalent to the amount of platelets derived from 6–8 units of whole
blood)
- Plasma .. Then frozen to yield FFP( 200 ml per unit) ... If we slow thawing of FFP... It
will give us... Gelatinous precipitate ( cryoprecipitate.. Contains high concentration of
factor 8 and fibrinogen)
 The use of leukocyte-reduced ( leukoreduction ) blood products has been rapidly
adopted by many countries….in order to decrease the risk of transfusion-related
febrile reactions, infections, and immunosuppression.
 Intraoperative Transfusion Practices
1. Packed Red Blood Cells….Prior to transfusion, each unit should be carefully checked
against the blood bank slip and the recipient’s identity bracelet….then warmed to 37 c
to prevent hypothermia… and The transfusion tubing should contain a 170-μm filter to
trap any clots or debris.
2. Fresh frozen plasma
 (FFP)…. contains all plasma proteins, including most clotting factors.
 Transfusions of FFP are indicated
 in the treatment of isolated factor deficiencies
 the reversal of warfarin therapy
 the correction of coagulopathy associated with liver disease.
 patients who have received massive blood transfusions
 Pt continue to bleed following platelet transfusions.
 Patients with antithrombin III deficiency or thrombotic thrombocytopenic purpura
3. Platelet transfusions
 should be given to patients
 with thrombocytopenia
 dysfunctional platelets.
  Prophylactic in patients with platelet counts below 10,000–20,000 × 10^9 /L
because of an increased risk of spontaneous hemorrhage
 Administration of a single unit of platelets may be expected to increase the
platelet count by 5000–10,000 × 10 9 /L which survive only 1–7 days following
transfusion.
4. Granulocyte transfusions
 prepared by leukapheresis, may be indicated in neutropenic patients with bacterial
infections not responding to antibiotics…..have a very short circulatory life
span….Irradiation of these units decreases the incidence of graft –versus host
reactions, pulmonary endothelial damage. BUT The availability of (G-CSF) and (GM-
CSF) has greatly reduced the use of granulocyte transfusion
 Changes that happen to old blood units:
 Increased 2,3 DPG that reduce the affinity of hemoglobin to oxygen (right shift of O2-Hb
dissociation curve)
 Hyperkalemia …. metabolic acidosis
 Decreased or no platelets at all due their short half life (which is about 7 days)
 Deficient coagulation factors( so the pt will bleed out )
 Complications of blood transfusion
1) Allergic Reaction(Troubled breathing ,Fever, chills, flushing ,Tachycardia or low
blood pressure ,Nausea)
2) Viruses and Infectious Diseases:(HIV, Hepatitis B and C.)
3) Fever:. Ttt by antipyretics.
4) Iron Overload ( in chronic blood transfusions which can damage your liver, heart,
and other parts of your body.) ….ttt by iron chelation therapy.
5) hemolytic reaction:
 Acute : is very serious, but also very rare. …..It occurs if the blood type during a
transfusion doesn't match. The symptoms include chills, fever, nausea, pain in
the chest or back, and dark urine….. managed by Stopping the transfusion and
then re- crossmatch …
 Delayed
 Massive blood transfusion :
 transfusion of one blood volume (or >10 units) within 24 hours OR of more than
50% of a patient's blood volume (or >5 units) in 2-4 hours in adults
 complications : coagulopathy like DIC , acidosis ,hypothermia ,hypocalcemia,
hyperkalemia , impaired O2 diffusion

Monitoring....
What things we need to monitor and what the equipments we use ??
1. o2 sat by pulse oximetry... ( spo2 = oxyHb /( oxyHb + deoxyHb) .... 95-100%...
2. ECG... Look for heart rate, rhythm, sinus or not ( every p wave is followed by QRS
complex) ....
3. blood pressure measurement ... By
 invasive ….By
 Arterial blood pressure...
 Cath in radial artery mostly OR brachial, femoral and dorsalis pedis...
 indication... imp …imp
- Rapid moment to moment BP changes
- Frequent blood sampling
- Major surgeries (cardiac, thoracic, vascular)
- Circulatory therapies: vasoactive drugs, deliberate hypotension
- Failure of indirect BP: burns, morbid obesity
- Sever metabolic abnormalities
- Major trauma
 Central venous line...
 good estimation for RA and RV pressure... Mostly in Rt internal jugular vein (
easily accessible, identifiable anatomical landmarks and short course to SVC)
BUT can be complicated by bleeding, injury to carotid artery, pneumothorax
and arrhythmia... Also subclavian artery( higher pneumothorax risk) and
external jugular vein ( higher bleeding risk) can be used...
 normal pressure is 1-10 mmhg
 indication... imp …imp
- CVP monitoring provides Right Atrial and Right Ventricle pressures
- Advanced Cardiopulmonary disease + major operation
- Secure vascular access for drugs
- Secure access for fluids + traumatic pts
- Aspiration of entrained air: sitting craniotomies
- Inadequate peripheral IV access
 non- invasive method... by Automated methodology... automated inflation of cuff
every 3-5 min and take the readings for SBP, DBP, HR and MAB... Rapid and
accurate....
4.capnography...
 Measures end tidal CO2.. Normally range b.w 35-45...
 Very imp to identify any respiratory compromise like pE, obstruction...
  Any problem in CO2 production OR elimination can affect its reading...

5.cyanosis...
 Defined as the presence of 5 gm/dL of deoxygenated hemoglobin (deoxy Hb).
 Oxygen hemoglobin dissociation curve

... 😌😌‫ لو تتوفوا مش كاتبيتهم‬..‫شرحنا عنه كثير‬..

6. temperature..
 Measured by thermostat...
 Sites: nasopharynx , tympanic, esophagus and rectum...
 Normal heat loss during anesthesia averages 0.5 - 1 C per hour
 Hypothermia... Mostly occur in.. elderly, burn patients, neonates, spinal cord
injuries
 Causes of hyperthermia.
 Malignant hyperthermia : treated with dantrolin , cooling and FFP
 Endogenous pyroxenes (IL1)
 Excessive environmental warming
 Increases in metabolic rate secondary to:….Thyrotoxicosis,
Pheochromocytoma…..
 (local anesthetic(
 Block of propagation of action potential through nerve fibers in circumscribed area of
the body.
 All LA have : tertiary amine + aromatic ring +intermediate chain ( ester or amide)
 Order of sensation which lost by local anesthesia : pain –temperature –touch –
pressure –motor .
 2classes
1) esters : not used any more due to dependence

¤as cocaine , procaine.

¤unstable in solution

¤rapidly hydrolyzed in the body by plasma Pseudocholinesterase

¤para amino benzoate " breakdown product " associated with allergic phenomena
and hypersensitivity reactions

2) amides :

¤like lidocaine , prilociane , bupivaciane , etidocaine , mepivacaine

¤stable in solution

¤slowly metabolized by hepatic amidases

¤hypersensitivity is rare

 MOA: LA enter the nerve fibers as neutral free base then the cationic part form and
block inner surface of Na+ channels so prevent Na+ influx so no impulse propagation.
 Since most LA cause vasodilation (except cocaine) , vasoconstrictors are frequently
added to intermediate acting LA to 1) enhance their potency 2) prolong their duration
of action 3) reduce systemic absorption and toxicity 4) maximize safe dose ( for
lidocaine dose increases from 3 to 7mg/kg)

*Vasoconstrictor not given with bupivacaine which is long acting LA and

vasoconstrictor dose not prevent the systemic absorption and toxicity

 Absolute C/I for adrenaline containing local anesthatic agents:

 1) infiltration around end arteries bcz this lead to severe ischemia and necrosis .. as in
ring block of fingers , penis..
1) IV regional anesthesia ) bier's block)

 Relative C/I :

2) Pt with severe HTN

3) general anesthesia with halothane

 toxicity from local anesthetic may occurs due to accidental rapid IV injection , rapid
absorption in highly vascularized area such MM and overdose
 signs and symptoms of toxicity :
* mainly on CNS , CVS and RS are lately involved
*CNS : dizziness , tinnitus , perioral numbness .. may tonic clonic seizures , coma :
managed with ABCD and midazolam
*CVS : bradycardia, hypotension and arrhythmia all seen if the LA not combined with
adrenaline : managed with IV fluid and atropine, ephedrine or adrenaline ,
antiarrhythmic respectively
*RS : depression

Types of local anesthetic

1)Infiltration therapy : anesthesia of subcutaneous tissue for minor surgical

procedures , action on unmyelinated nerve endings

2) peripheral nerve blockade .. minor block as radial nerve block or major block as
brachial plexus block

3) Neuroaxial block ( spinal , epidural)

4) IV regional anesthesia (Bier`s block ) :

 Bier`s block is indicated to any procedure below the elbow or below the knee that is
completed within 40-60min
 Mainly used for upper limb ( ganglion , carpal tunnel), lower limb have strong muscles
so difficult arterial compression
 No need for muscle relaxant
 Contraindications : severe Raynaud`s or homozygous sickle cell disease , crush injury
need caution.
 prilocaine is the DOC in bier's block » the least toxic local anesthetic , largest
therapeutic index
 dose : 40 ml of 0.5% prilocaine (Prilocaine is the Best for Biers block )
 bupivacaine and etidociane should not be used because both are highly proteins
binders so more cardiotoxicity risk after tourniquet release
 Technique of bier's block :

1) Apply the double tourniquet

2) Use Esmarch rubber bandage to exsanguinate the limb from blood
3) Inflate proximal tourniquet 100mmHg above pt systolic Bp
4) Remove rubber bandage
5) Inject LA
6) Inflate distal tourniquet and deflate proximal one and start the surgery
7) Don’t deflate before 20-30 min passed away since the La injection to prevent
systemic toxicity

lidocaine

 Dose : 0.2 – 2% ( 2% lidocaine means that 2g /100ml = 2000mg/ 100ml = 20mg/ml)

 Carful titration allow for differential block ( block only pain sensation but not motor
one)
 also it is antiarrhythmic drug
 Neuraxial anesthesia ( spinal , epidural )
Spinal anesthesia :
Definition: injection of local anesthetic in subarachnoid space
Level of injection : Bellow L2 ( spinal cord end btw L1/L2 in adult and btw L2/L3 in children )
, iliac crest roughly corresponding to the body of L4
Position :
 sitting : neck flexion till the chin touch the chest + back bending forward.
 Lateral : fetal position
Drug used :
 Up to 3ml of 0.5% hyperbaric bupivacaine (marcaine) : 2-3 hrs. duration ‫حفظ‬
 Up to 3ml of 5% hyperbaric lidocaine last 45-90 min (2 ml of adrenaline 1:1000 may
added to extend the duration )
Onset of action : within 2-5min
Speed of action depends on :
 Baricity : hyperbaric is the best ( move down with gravity)
 Position of the pt : should be either supine or head up
 Dose : single shot , low dose , high density ( vs epidural dose)
 Level and speed of injection
Advantages : cheap , minimal RS depression , pt remain awake so can maintain patent
airway and can be aware of hypoglycemia symptoms , lower risk of regurgitation and
aspiration ,no need for muscle relaxant , low risk of bleeding intra-op , increase gut motility
and blood flow ( low risk of anastomosis dehiscence and ileus), lower risk of DVT and PE .
Indications :
 Pt preference
 Bellow umbilicus operations ( CS , hernia , genitalia , perineum , lower limbs surgery
except amputation)
 COPD , asthma , URTI
 hepatic, renal diseases , DM
 elderly
Contraindications :
 Pt refusal
 Uncooperative pt
 Increase in ICP
 Sever aortic stenosis
 Bleeding disorders
 Hypovolemia
 Septicemia
 Localized infection over the spine
 Anatomical deformity
 Neurological diseases
Structures that will be passed : skin - subcutaneous tissue - supraspinous lig - interspinous
lig - ligamentum flavum - epidural space - dura - subarachnoid space ( containing the CSF so
once you in , CSF should leak out )
Complications :
Early :
 Multiple failed trials
 N&V
 Hematoma formation
 Nerve injury
 Accidental venous injection : suspected if the pt complaining of ( dizziness , tinnitus ,
lightheadedness , circumoral numbness or lingual sensation )
 Hypotension :
 More rapid than epidural
 due to decrease sympathetic outflow , treated by IV fluid , legs raising , vasoconstrictor
such ephedrine , Atropine , if pregnant : change position to lateral decubitus to prevent
aortocaval compression syndrome by gravid uterus .
Late :
 Meningitis
 Urinary retention
 Paralysis
 Post dural puncture headache :
 Start after 12-24 hrs and may last weeks
 Positional headache : when upright , relieved while supine
 Occipital headache , N&V , neck stiffness
 More severe if occurs after trumatic dural puncture during epidural anesthesia ( larger
needle so more CSF leak )
 Treatment
 Conservative if <1week : Bed rest + caffeine intake + simple analgesic + increase oral
water intake + compressive bandage around the abdomen to increase intra-abdominal
pressure so less leaking .
 If the headache last >1 week : blood patch : use the epidural needle to inject 10-15 cc of
pt blood in the epidural space - clotting - no leak - headache stop immediately

Epidural anesthesia:

Definition : technique whereby a local anesthetic drug is injected through a catheter placed
into the epidural space
Level of injection : cervical , thoracic or lumber
Drug used : 15-20ml of 0.5% isobaric bupivacaine or 2% lidocaine ‫حفظ‬
Dose : single shot or continuous infusion through indwelling catheter, high dose , low
density .
Onset of action : within 15 - 20 min
Method : loss of resistance technique using low resistance syringe
Indications : same as spinal + pain management such lower back pain , used in vaginal
delivery to prevent pain sensation while maintaining the ability to contract pelvic muscles
Complications : same as spinal but no headache except if traumatic puncture of dura by
the epidural syringe.
the eye couldn't resist the spear without being pierced , and the hand couldn't
grasp the sword without being cut off
So... if you fight for Ur dreams as much as you can....you will achieve them
sooner or later
JUST DON'T give up and carry on..

Special thanks for Razan Yaseen ….

For perfect editing and correction .
😍😍😍😍😍.