ANESTHESIOLOGY

medpgnotes

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY

CONTENTS
ANESTHESIOLOGY INSTRUMENTS................................................................................................................................. 4
GENERAL FEATURES OF ANESTHETIC INSTRUMENTS ............................................................................................... 4
ANESTHETIC CYLINDERS ............................................................................................................................................ 4
PIN INDEX .................................................................................................................................................................. 4
ANESTHETIC GASES ................................................................................................................................................... 4
ANESTHETIC MACHINES AND CIRCUITS .................................................................................................................... 5
MAPLESON SYSTEM .................................................................................................................................................. 5
OXYGEN CONTROL DEVICES ...................................................................................................................................... 5
DEVICES FOR CO2 ABSORPTION ............................................................................................................................... 6
DEAD SPACE .............................................................................................................................................................. 6
ENDOTRACHEAL TUBE .............................................................................................................................................. 7
LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION ............................................................................................... 7
NASOTRACHEAL INTUBATION ................................................................................................................................... 9
LARYNGEAL MASK AIRWAY ....................................................................................................................................... 9
TRENDELENBERG POSITION ...................................................................................................................................... 9
GENERAL FEATURES OF MONITORING DURING ANESTHESIA .................................................................................. 9
CENTRAL VENOUS PRESSURE MONITORING .......................................................................................................... 10
PULMONARY ARTERY CATHETER ............................................................................................................................ 10
CAPNOGRAM .......................................................................................................................................................... 11
ANESTHETIC COMPLICATIONS .................................................................................................................................... 11
AIR EMBOLISM ........................................................................................................................................................ 11
RESPIRATORY COMPLICATIONS .............................................................................................................................. 11
MALIGNANT HYPERTHERMIA ................................................................................................................................. 12
INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS .................................................................................... 12
RESUSCITATION....................................................................................................................................................... 13
MENDELSON SYNDROME........................................................................................................................................ 13
HYPOTHERMIA IN ANESTHESIA............................................................................................................................... 14
CLINICAL ANESTHESIA ................................................................................................................................................. 14
HISTORY OF ANESTHESIA ........................................................................................................................................ 14
STAGES OF ANESTHESIA .......................................................................................................................................... 14
PREANESTHETIC ASSESSMENT ................................................................................................................................ 14
PEDIATRIC ANESTHESIA .......................................................................................................................................... 15
www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY

ANESTHESIA IN HEAD INJURY ................................................................................................................................. 15

CARDIOVASCULAR ANESTHESIA.............................................................................................................................. 15
ANESTHESIA IN ENT ................................................................................................................................................ 16
OBSTETRIC ANESTHESIA .......................................................................................................................................... 16
ANESTHESIA IN ORTHOPEDICS ................................................................................................................................ 16
RESPIRATORY ANESTHESIA ..................................................................................................................................... 16
DAY CARE ANESTHESIA ........................................................................................................................................... 17
DRUGS OF ANESTHESIA .............................................................................................................................................. 17
PREANESTHETIC DRUGS .......................................................................................................................................... 17
GENERAL FEATURES OF ANESTHETIC DRUGS ......................................................................................................... 17
INHALATIONAL ANESTHETICS ..................................................................................................................................... 18
MINIMUM ALVEOLAR CONCENTRATION ................................................................................................................ 18
PARTITION COEFFICIENT ......................................................................................................................................... 18
GENERAL FEATURES OF INHALATIONAL ANESTHETICS........................................................................................... 18
XENON..................................................................................................................................................................... 19
NITROUS OXIDE ....................................................................................................................................................... 19
TRILENE ................................................................................................................................................................... 20
ETHER ...................................................................................................................................................................... 20
HELIUM ................................................................................................................................................................... 20
CHLOROFORM ......................................................................................................................................................... 20
HALOTHANE ............................................................................................................................................................ 20
ENFLURANE ............................................................................................................................................................. 21
ISOFLURANE ............................................................................................................................................................ 22
DESFLURANE ........................................................................................................................................................... 22
SEVOFLURANE ......................................................................................................................................................... 22
METHOXYFLURANE ................................................................................................................................................. 23
INTRAVENOUS ANESTHETICS ...................................................................................................................................... 23
GENERAL FEATURES OF INTRAVENOUS ANESTHETICS ........................................................................................... 23
PROPOFOL ............................................................................................................................................................... 24
KETAMINE ............................................................................................................................................................... 24
THIOPENTONE ......................................................................................................................................................... 25
ETOMIDATE ............................................................................................................................................................. 26
LOCAL ANESTHETICS ................................................................................................................................................... 26
GENERAL FEATURES OF LOCAL ANESTHETICS......................................................................................................... 26
www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY

BUPIVACAINE .......................................................................................................................................................... 28
LIGNOCAINE ............................................................................................................................................................ 28
PRILOCAINE ............................................................................................................................................................. 29
COCAINE .................................................................................................................................................................. 29
PROCAINE................................................................................................................................................................ 29
BIERS BLOCK/IVRA ................................................................................................................................................. 29
PERIBULBAR AND RETROBULBAR BLOCK ................................................................................................................ 30
STELLATE GANGLION BLOCK ................................................................................................................................... 30
BRACHIAL PLEXUS BLOCK ........................................................................................................................................ 30
CELIAC PLEXUS BLOCK ............................................................................................................................................. 30
NEUROMUSCULAR BLOCKERS .................................................................................................................................... 31
GENERAL FEATURES OF NEUROMUSCULAR BLOCKERS .......................................................................................... 31
DEPOLARISING MUSCLE RELAXANTS SUCCINLY CHOLINE ................................................................................... 31
FEATURES OF NON DEPOLARIZING MUSCLE BLOCKERS ......................................................................................... 33
D-TUBOCURARINE ................................................................................................................................................... 33
PANCURONIUM ...................................................................................................................................................... 33
VECURONIUM ......................................................................................................................................................... 34
MIVACURIUM.......................................................................................................................................................... 34
ATRACURIUM .......................................................................................................................................................... 34
GALLAMINE ............................................................................................................................................................. 34
ALCURONIUM ......................................................................................................................................................... 35
SPINAL, EPIDURAL AND CAUDAL ANESTHESIA and pain management ...................................................................... 35
SPLANCHNIC BLOCK ................................................................................................................................................ 35
NEURAXIAL BLOCKADE............................................................................................................................................ 35
SPINAL ANESTHESIA ................................................................................................................................................ 35
EPIDURAL ANESTHESIA ........................................................................................................................................... 37
CAUDAL ANESTHESIA .............................................................................................................................................. 37
OTHER BLOCKS ........................................................................................................................................................ 38
PAIN ............................................................................................................................................................................ 38
GENERAL FEATURES OF PAIN .................................................................................................................................. 38
ASSESSMENT OF PAIN ............................................................................................................................................. 38
ANALGESIC DRUGS .................................................................................................................................................. 39

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY

ANESTHESIOLOGY INSTRUMENTS
GENERAL FEATURES OF ANESTHETIC INSTRUMENTS
Rotameter
Rotameter
MC cause of inaccurate reading in Rotameter
Wright spirometer
Types of Pneumatographs measuring airway resistance
Used to protect airway
Least damage to blood elements

Constant pressure, variable orifice, flow meter for gases

and liquids
Height of bobbin rise indicates flow rate
st
nd
1 Static Electricity, 2 Dirt
Used for calculation of expired volumes
Fleischs type, Venturi type, Turbine type
LMA, endotracheal tube, combitube
Membrane oxygenator

ANESTHETIC CYLINDERS
Filling ratio of anesthetic cylinder

Filling ratio is the weight of the fluid in

the cylinder divided by weight of water
required to fill the cylinder
Black cylinder with white shoulders
Purple
Blue
Orange

Color of oxygen cylinder

Color of ethylene cylinder
Color of nitrous oxide cylinder
Color of cyclopropane cylinder

PIN INDEX
Pin index of nitrous oxide
Pin index
System preventing Incorrect gas Cylinder attachment

3,5
Pin is present on machine, not effective if wrong gas is
filled in cylinder, hole position on cylinder valves
Pin Index Safety system

ANESTHETIC GASES
Gas filled as liquid in cylinders
Gas stored in liquid form
Nitrous oxide
Tare weight is used for
For high pressure storage of gases, cylinders are made
of
Pressure of N2O at 20*C
High pressure in gas cylinder indicate
Critical temperature of air
Critical temperature of oxygen
Critical temperature of N2O

CO2, N20, cyclopropane

N2O
Cylinder blue in color, MAC 105
Gas Cylinders
Molybdenum steel
745 psi
Impurities in N2O
-140.6*C
-119*C
36.5*C

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY

ANESTHETIC MACHINES AND CIRCUITS

Anesthesia breathing circuit
Boyles machine
Boyles law
High pressure system in anesthesia machine is delivered
by
Principle of Boyles apparatus
Heidbrink meter in Boyles apparatus
Bernoulli principle
Modified bernoulli
Clayton is used in closed breathing circuit as

Cylinder is a part of high pressure system, O2 flush

delivers < 35 liters
Continuous flow, low resistance
At constant temperature, volume of a given mass varies
inversely with its absolute pressure
Hanger yoke
Continuous Flow
Indicates flow of gases
In laminar flow, velocity of flow through a tube is
inversely related to its pressure against the size of tube
Pressure change = 4 * (velocity)^2
Indicator

MAPLESON SYSTEM
Most efficient anesthetic circuit for GA with
spontaneous respiration
Air flow in Magills circuit (Mapleson A)
Magills circuit

Mapleson A

NOT suited for both controlled and assisted ventilation

No corrugated tube in
Bain circuit
Bain circuit

Mapleson system used in children

Ayres T piece
Features of Ayres T piece
Most appropriate circuit for ventilating spontaneously
breathing infant during anesthesia
Rebreathing prevention valve
Rebreathing circuit

Equal to minute volume

Ideal for adults, semiclosed, spontaneous breathing is
must
Mapleson A
Mapleson C
Mapleson type D, can be used for both controlled and
spontaneous ventilation
Inner tube for inspiration, circuit of
choice for controlled ventilation, light
weight, fresh gas flow should be 1.5 times of
minute volume
Ayer T tube
Mapleson E
No reservoir bag, no expiratory valve
Jackson Rees modification of Ayres T piece
Light, well designed, used at expiratory end of tube
To and fro circuit, circle system, water system

OXYGEN CONTROL DEVICES

Assessment of oxygen in a cylinder attached to
anesthesia machine
Used for proper oxygen flow to patient
System Maintaining O2 concentration by limiting N2O
flow

Bourdon pressure gauge

Proportionator between N2O and O2 control valve,
different pin index, calibrated oxygen corrected analysis
Pneumatic Interlock Oxygen Ratio Monitor Controller
(ORMC)

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY
System Maintaining 25% O2 concentration and
Maximum N2O:O2 flow ratio of 3:1
Safety measures to prevent delivery of hypoxic mixture
to patient
Oxygen concentrator
Oxygen content in anesthetic mixture
Fixed performance oxygen provided by
Delivery of oxygen in basic life support
Humidification of air is needed in
Oxygen delivery regulated by
Maximum O2 concentration achieved in venturi mask
Side effects of oxygen therapy

Oxygen given during anesthesia to prevent

90% oxygen by
Safe oxygen concentration in therapy is to achieve
Humidity of dry 100% oxygen
Artificial nose

Link 25 Proportion Limiting system(Datex Ohmeta

System)
Location of oxygen valve after N2O valve, location of fail
safe valve downstream from nitrous oxide supply
source
Zeolite activation, delivers O2,requires power supply
33%
Venturi mask
Through mask
Face mask
Oxygen tent, oxygen apparatus, poly mask, venti mask
60%
Absorption atelectasis, decreased pulmonary
compliance, decreased vital capacity, endothelial
damage
Hypoxia
Non rebreathing mask
PaO2 > 50 mm Hg
0 mg H2O litre
Heat and moisture exchanger

DEVICES FOR CO2 ABSORPTION

CuSO4 present in
Ba (OH)2 present in
Decrease CO2 absorption
Decreases CO2 absorption
Increases CO2 absorption
Soda lime is used to absorb CO2 in
Reacts with soda lime
Main component of soda lime in closed circuit
Composition of soda lime
NOT a component of sodalime
Soda lime does NOT contain
NOT true about soda lime
Water is used for hardening in
Color change in Mimoza 2
Signs of soda lime exhaustion

Amsorb
Baralime
High flow, medium granule, No resistance in circuit
Increased tidal volume, increased dead
space
Resistance in circuit
Closed circuit system
Trilene
Calcium hydroxide
90% Ca(OH)2 + 5% NaOH + 1% KOH
Ba OH2
CaCl
Used in treatment of alkalosis
Soda lime
Red to white
Change of color of granules, rise in ETCO2
in capnography, rise in BP followed by
fall, rise in pulse rate, deepening of
spontaneous respiration, increased oozing
from wound, increased sweating

DEAD SPACE
Normal dead space

30% of tidal ventilation

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY
Anatomical dead space is increased by
Dead space is increased by
Physiological dead space is decreased by
Anatomical dead space in Supine position
Anatomical dead space decreased by
Dead space NOT increased by
Least amount of CO2 present in

Atropine, Halothane, Inspiration

Anti cholinergic drugs, standing, hyperextension of neck
Neck flexion
Decreases
Massive pleural effusion
Endotracheal intubation
Anatomical dead space - end inspiration phase

ENDOTRACHEAL TUBE
Size of endotracheal tube in 1 6 months
aged
Size of endotracheal tube in 6 months to 1
year aged
Size of endotracheal tube in 1 6 years
Size of endotracheal tube more than 6
years
Length of endotracheal tube in neonate
Length of endotracheal tube in elder
children
Reasonable size of endotracheal tube in 3 year old
Curved blade in adult laryngoscope is
Endotracheal cuff
Size of endotracheal tube in children less than 6 years
Diameter and length of endotracheal tube in full term
infant
McIntosh tube for
Magills tube
Armoured endotracheal tube is used in
RAE endotracheal tube
RAE tube is used in
Diameter of ET tube in child less than 1000 g
Direct laryngoscope in right handed person
Type of endotracheal tube and blade in children
Cuff pressure in ET tube should not exceed

2 4 mm
3.5 4.5 mm
[Age/3] + 3.5
[Age/4] + 4.5
10 11 cm
[age/2] + 12
4.5 mm
Macintosh
High volume low pressure, low volume high pressure
(Age/3.5)+3.5
3.5 mm and 12 mm
Adults
Children
Neurosurgery
Red
LASER surgery
2.5,3
Left hand
Uncuffed tube with straight blade
23 mm Hg

LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION

High airway resistance seen in
Airway assessment

LEMON law
Normal thyromental distance
Mallampatti grading for

Main bronchus
Mallampatti grading, Cormack and
Lehare (based on laryngoscopy), Wilsons
scoring, LEMON law
Look externally, evaluate 3-3-2 rule,
Mallampatti, Obstruction, Neck mobility
>6.5 cm
Inspection of oral cavity before intubation
www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY
Mallampatti classification is based on
Clinical predictor of a difficult intubation
is postulated to be responsible for a grade
III Mallampatti view of oral cavity
NOT an indication for endotracheal intubation
Both orotracheal and nasotracheal intubation is
contraindicated in
Difficulty in intubation
Features of difficult airway
Used in difficult intubation
Maneuver performed during laryngoscopy and
intubation

Endotracheal intubation in children

NOT seen during laryngoscopy
Sellicks original description of cricoid
pressure
Sellick maneuver is used to prevent
Sellick maneuver is effective in prevention
of
NOT a maneuver performed during laryngoscopy
Effective adjuvant in attenuating
hypertension and tachycardia associated
with laryngoscopy and intubation
High potassium level with scoline for
intubation occurs with
Most accurate measurement of correct placement of ET
tube
Correct placement of endotracheal tube judged by
Speedy intubation, breath sounds were observed to be
decreased on left side and high end tidal CO2
Laryngoscopy and intubation is associated with
Endotracheal intubation
A child has been intubated and connected to anesthesia
machine. A problem has occurred in anesthesia
machine and the child collapsed after 2 minutes. What
to do next
Laryngeal complication of Prolonged ET intubation
Prevention of intubation induced
laryngeal spasm
Drug that can precipitate reflux
Treatment of severe tracheal stenosis due to
endotracheal intubation for more than 2 weeks

Opening of mouth
Large tongue

Pneumothorax
Acute laryngotracheobronchitis
Burns in head and neck, Stills disease, Downs
syndrome
Millers sign, TMJ ankylosis, micrognanthia and
macroglossia
Helium O2 mixture, entoxon, sevoflurane
Flexion of neck, extension of head at atlantooccipital
joint, in straight blade laryngoscope epiglottis is lifted
by tip, upper incisors are most vulnerable to damage by
laryngoscopy so laryngoscope should not be levered
against them
Small morbidity on prolonged intubation
Hypotension
Extending head
Gastric aspiration
Passive regurgitation and subsequent
aspiration
Laryngoscope is lifted upwards levering over the upper
incisors
Succinylcholine

Chronic paraplegia
End Tidal CO2
Arterial CO2, Breath sounds, Chest X ray
Endobronchial intubation
Hypertension and tachycardia, raised IOT, raised ICT,
decreased lower esophageal sphincter tone, arrhythmia
Reduces normal anatomical dead space
Increase the flow

Stenosis, Ulceration, Abductor paralysis

Local anesthesia, fentanyl, diltiazem
Promethazine
Tracheal resection and end to end anastomosis

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY
Surgery for extensive tracheal stenosis

Grillo or Barclay procedure

NASOTRACHEAL INTUBATION
Merits of nasotracheal intubation
Nasal intubation is contraindicated in

Good oral hygiene

CSF rhinorrhoea

LARYNGEAL MASK AIRWAY

Supraglottic type of airway management
NOT a definite airway
NOT an advantage of laryngeal mask airway
Laryngeal mask airway NOT used for
Laryngeal mask airway is used for
Laryngeal mask airway

LMA
Plan C of anesthetic airway management

Laryngeal mask airway

Laryngeal mask apparatus
Aspiration is prevented
Large tumor in oral cavity
Maintenance of airway
More reliable than face mask, alternative to
endotracheal tube, does NOT require laryngoscope and
visualization
Intubation can be done, size 1 for neonates, size 3 for
adults
Insertion of laryngeal mask airway and fibroptic
bronchoscopy

TRENDELENBERG POSITION
Maximum vital capacity decreased in
Trendelenberg position decrease
Trendelenberg position does NOT cause decrease in
Position with least vital capacity in GA

Trendelenberg position
Vital capacity, FRC, compliance
Respiratory rate
Trendelenberg

GENERAL FEATURES OF MONITORING DURING ANESTHESIA

Individual operative awareness by
Organ at greatest risk of ischemia under
conditions of normovolemic hemodilution
Best to monitor intraoperative myocardial ischemia
Most sensitive and practical technique to detect
myocardial ischemia in perioperative period
5th vital sign
Pulse oximetry
Pulse oximetry detects inaccurately in presence of
Inadequate ventilation during intraoperative period is
best assessed by
Beer Lambert Law

Bispectral imaging
Heart
Transesophageal echocardiography
Regional wall motion abnormality detected with help of
2D transesophageal echocardiography
Pulse oximetry
At 660 nm, oxyhemoglobin reflect more light than
deoxyhemoglobin, reverse is true at 940 nm
Nail polish, methemoglobinemia, skin pigmentation
Pulse oximetry
Pulse oximetry

www.medpgnotes.com

ANESTHESIOLOGY INSTRUMENTS

ANESTHESIOLOGY
Oxygen saturation is measured by
Used to monitor respiration in non intubated neonate
Non ventilated baby is in incubator, best way to
monitor babys breathing and detect apnea
A postoperative patient with pH 7.25 MAP 60 mm Hg
treated with
Least affected during anesthesia
Somatosensory evoked potential is
important during
MC nerve used for monitoring during anesthesia
Modality best utilized for neuromuscular
monitoring during maintenance of
anesthesia
NOT a cause of bacterial sepsis in ICU patient on
invasive monitoring

Pulse oximeter
Impedance pulmonometry
Impedance pulmonometry
Fluid therapy with CVP monitoring
Brainstem auditory evoked potential
Thoracic and abdominal aorta surgery
Ulnar nerve
Train of four

Humidified air

CENTRAL VENOUS PRESSURE MONITORING

MC vein for CVP monitoring
While inserting CVP, patient developed respiratory
distress
MC complication of central venous catheter
Complications of CVP line
CVP monitoring is most useful in
In a patient with multisystem trauma, presence of
hypotension with elevated CVP is suggestive of
CVP does NOT indicate

Right Internal Jugular Vein

Pneumothorax
Catheter related infection
Airway injury, hemothorax, septicemia, air embolism,
pulmonary edema
Guiding hemodynamic therapy
Cardiopulmonary problem
Tissue perfusion

PULMONARY ARTERY CATHETER

Swan Ganz catheter measure
While introducing Swan Ganz catheter, its placement in
pulmonary artery can be identified by
Swan Ganz catheter is used to measure

Pulmonary wedge pressure is indirectly

Measurement of intravascular pressure by pulmonary
artery catheter
Left atrial filling pressure closely
resembles

PCWP, mixed venous oxygen saturation, Right atrial

pressure
PA pressure tracing has dicrotic notch from closure of
pulmonary valve > diastolic pressure is higher in PA
than in RV
Pulmonary artery pressure, pressure of
cardiac chambers, pulmonary capillary
wedge pressure, cardiac output and
cardiac index, blood sample for mixed
venous oxygen saturation, to measure
temperature of pulmonary artery
Left atrial pressure
At the end of expiration
Pulmonary capillary wedge pressure

www.medpgnotes.com

10

ANESTHETIC COMPLICATIONS

ANESTHESIOLOGY

CAPNOGRAM
Capnography is based on
NOT a cardiovascular monitoring technique
Flat capnogram

Luft principle
Capnogram
Disconnection of anesthetic tubing, accidental
extubation, mechanical ventilation failure
Phase 0 inspiratory phase, phase 1 dead
space and little or no CO2, phase 2
mixture of alveolar and dead space gas,
phase 3 alveolar plateau with peak
representing end expiratory and end tidal
CO2

Phases of capnogram

ANESTHETIC COMPLICATIONS
AIR EMBOLISM
End tidal CO2 decreased during surgery
Significant air embolism occurs with volume
Diagnosing air embolism with tracheoesophageal
echocardiography
Factors favoring embolism is a patient with major
trauma
Air embolism in neurosurgery is maximum in
Most sensitive investigation for air embolism
Known case of thyrotoxicosis posted for
abdominoperineal resection. sudden drop in BP and
end tidal CO2, Mill Wheel murmur
Most serious complication of sitting position
Transesophageal echocardiography

Air embolism
100 cc
Very sensitive investigation, continuous monitoring to
detect venous embolism, interferes with Doppler when
used together
Mobility of fracture, diabetes
Sitting position
Transesophageal echo > Doppler ultrasound
Air embolism

Air embolism
Can quantify the volume of air embolised, Very
sensitive investigation, Continuous monitoring is
needed to detect venous embolism

RESPIRATORY COMPLICATIONS
Anesthetic complication with respiratory infection
Aspiration pneumonitis

Obstruction of respiration in comatose patients is

mainly due to
NOT a cause of respiratory insufficiency in immediate
post operative period

Bacteremia, Increased mucosal bleeding, laryngospasm

Affected by volume of aspiration and pH of aspiration
fluid, increased incidence during induction,
inflammation, infection
Falling back of tongue
Mild hypovolemia

www.medpgnotes.com

11