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Anesthesia HQ
Anesthesia Review
for board preparation
6th Edition
ANESTHESIA HQ 2009 ! 1
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Notice of Rights
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Group, LLC
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The study guide is still organized by topics and chapters in an easy to read outline format,
which also will provide you with the opportunity to add your own knowledge, thoughts, and
comments throughout the review process. The study guide is intended as a supplement and
an aid to your previous years of study, diligence, and hard work. From the moment you begin
preparing for the anesthesia board exam, you should read, reread, and review again, all of the
topics and information contained in the study guide, web site, and additional textbooks.
My goal is to provide you with the tools to prepare, organize, and ultimately pass the
anesthesia board exams. I wish you good luck and success in your studies and career.
Michael K Loushin, MD
Founder
Anesthesia HQ
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Dedication
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Notice of Liability
The information contained herein is only to be used as a study aide in preparation for the
anesthesia board exams. Such information is not to replace any medical education, clinical
experiences, or the study of textbooks and medical journals. The actual use of this
information, including any medical concepts, facts, drug dosages, and methods, therefore is
at the reader!s own risk. We assume NO responsibility for any injury or damages to any
person or property that may result from such reliance on or use of any of this information.
We have taken all reasonable precautions to confirm the accuracy of the information
presented herein and to describe generally accepted practices. However, we are not
responsible for any inaccuracies, errors, and/or omissions or for any consequences from the
use or application of any of the information contained herein and make no promise or
warranty, express or implied, with respect thereto.
We have taken all reasonable precautions to ensure that the drug selection and dosages set
forth in this text are in accordance with recommendations and practice current at the time of
writing. However, in view of ongoing research, changes in government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is solely
responsible for reviewing and following the package insert for each drug for any change in
indications and dosage and for any warnings and precautions. This is particularly important
when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It therefore is
the sole responsibility of the reader to ensure that the applicable health care provider has
ascertained the FDA status of each drug or device planned for use in their clinical practice.
THE READER ASSUMES ANY AND ALL RISKS ASSOCIATED WITH THE ACTUAL USE
AND/OR RELIANCE ON ANY OF THE INFORMATION CONTAINED HEREIN THAT
DEVIATES IN ANY WAY FROM THE INTENDED PURPOSE OF SUCH INFORMATION AS
ONLY A STUDY AIDE IN PREPARATION OF THE ANESTHESIA BOARD EXAMS. TO THE
EXTENT THE READER ULTIMATELY RELIES ON AND/OR OTHERWISE USES ANY SUCH
INFORMATION FOR ANY OTHER PURPOSE, WHETHER INTENDED OR OTHERWISE,
THE READER AGREES TO INDEMNIFY AND HOLD US HARMLESS FROM ANY AND ALL
INJURIES, DAMAGES, COSTS, FEES AND EXPENSES (INCLUDING ATTORNEYS! FEES
AND EXPENSES) THAT MAY OR DOES IN ANY WAY RESULT FROM SUCH ACTUAL USE
AND/OR RELIANCE.
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Table of Contents
Anesthesia Circuits and Machines" 13
Bellows" 25
Vaporizers" 29
Scavenger System" 37
E Cylinders" 43
Carbon Dioxide Absorbers" 47
Electricity " 51
Capnography " 57
Blood Pressure Monitoring" 69
Central Venous Pressure Monitoring" 77
Pulmonary Artery Catheter" 85
Cardiac Output & Cardiac Index Monitoring" 95
Pulse Oximetry " 101
Mixed Venous Saturation Monitoring" 105
Cardiac Pressure-Volume Curves" 109
Inhalational Anesthetics" 117
Neuromuscular Blockers" 133
Local Anesthetics" 145
Obstetric Anesthesia: An Overview " 153
Obstetric Emergencies" 163
Pre-eclampsia" 171
Fetal Heart Tracing" 175
Myocardial Ischemia & Myocardial Infarction" 185
Valvular Diseases" 195
Pacemakers & Automated Implantable Cardiovertor Defibrillators" 209
Anesthetic Management of Pacemakers & AICDs" 215
Cardiac Reflexes" 219
Heart Transplant" 221
Abdominal Aortic Aneurysm" 223
Thoracic Aortic Aneurysm" 229
Intra-aortic Balloon Pump" 235
Cardiopulmonary Bypass Circuit" 239
Respiratory: An Overview" 245
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Hypoxemia" 259
Pulmonary Embolism" 263
Thoracic Anesthesia" 265
Mediastinoscopy" 275
Cystic Fibrosis" 277
Obstructive & Restrictive" 279
Lung Diseases" 279
Aspiration" 289
Acid-Base: An Overview" 293
Metabolic Acidosis" 301
Metabolic Alkalosis" 307
Respiratory Acidosis" 311
Respiratory Alkalosis" 317
Alpha-stat & pH-stat" 319
Blood Gas Management" 319
Neuroanesthesia" 321
Evoked Potentials" 333
Carotid Endarterectomy " 337
Arnold-Chiari Malformation" 341
Venous Air Embolism" 343
Spine Anatomy" 347
Spinal Cord Injury & Spinal Shock" 355
Tourniquet Pain" 359
Pediatric Anesthesia & Physiology " 361
Congenital Heart Disease" 371
Congenital Diaphragmatic Hernia" 377
Necrotizing Enterocolitis" 379
Ligation of a Patent Ductus Arteriosus" 381
Pyloric Stenosis" 385
Retinopathy of Prematurity " 389
Tracheo-esophageal Fistula" 391
Gastroschisis & Omphalocele" 395
Extracorporeal Membrane Oxygenation" 397
Ophthalmology & Eye Physiology " 399
Retrobulbar Block" 405
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Naloxone" 632
Nicardipine" 633
Nitric Oxide" 634
Nitroglycerin" 635
Nitroprusside" 636
Norepinephrine" 638
Phentolamine" 639
Phenylephrine" 640
Prazosin" 641
Propofol" 642
Succinylcholine" 644
Sufentanil & Remifentanil" 646
Sympathomimetics" 647
Trimethaphan" 648
Vasopressin" 649
Index" 653
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A. Circle systems are complex anesthesia circuits where the components are arranged in a
circle. Circle systems are utilized to prevent rebreathing of carbon dioxide (CO2) during
low fresh gas flow. They also allow good conservation of respiratory heat and humidity.
B. Circle systems prevent rebreathing of carbon dioxide by means of a CO2 absorber. They
allow rebreathing of exhaled gases (oxygen and anesthetic gases). A scavenger system
removes any waste gases from the circle system.
E. A semi-open system does not allow rebreathing of gases and requires high fresh gas flow.
1. Mapleson systems are semi-open systems.
2. Semi-open systems are associated with increased loss of heat and humidity due to
high fresh gas flow rates and absence of rebreathing.
3. It is difficult to scavenge waste gases with a semi-open system.
4. Since they do not contain valves, semi-open systems have less resistance to
spontaneous breathing.
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Chapter: Anesthesia Circuits and Machines "
F. A closed system has fresh inflow gas which nearly equals the amount of gas taken up by
the patient.
1. The amount of inflow gas that needs to be replaced is the amount of oxygen
consumed by the patient and the amount of anesthetic gas absorbed by the patient!s
body and the anesthesia circuit.
2. There is complete rebreathing of gases (oxygen and inhalational anesthetic) after
removal of CO2 by the carbon dioxide absorber.
3. There is no gas exiting through the scavenger.
4. The APL valve is also closed, preventing overflow of gases.
5. Some of the semi-closed systems may be turned into closed systems by turning the
APL valve to the off/closed position.
6. Since there is nearly complete rebreathing of gases, a closed system offers maximum
conservation of heat and humidity.
7. A change in gas concentration occurs very slowly, due to low fresh gas flows.
H. The components of the circle system may be arranged in multiple ways, but certain criteria
must be met in order to prevent rebreathing of carbon dioxide.
1. The fresh gas inlet must be between the CO2 absorber and inspiratory valve. It cannot
be on the expiratory limb.
2. The adjustable pressure limiting valve (APL) must be between the CO2 absorber and
expiratory valve. It cannot be in the inspiratory limb.
3. The unidirectional valves must be present between the reservoir bag/bellows and the
patient (Y-piece).
4. Other components of the circle system may have varying configurations.
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Chapter: Anesthesia Circuits and Machines "
K. During spontaneous ventilation with a circle system, the APL valve is fully open.
L. In a circle system, the ventilation dead space is distal to the Ypiece of the breathing
circuit.
1. The length of the separate inspiratory and expiratory limbs of the tubing does not affect
dead space caused by the anesthesia circuit.
2. For example, increasing the length of the inspiratory and expiratory limbs does not
increase the dead space distal to the Y-piece.
M. The compliance of the circuit tubing will affect the tidal volume that is delivered to the
patient. A portion of a set tidal volume can be lost to distending the circuit tubing.
1. A less compliant tubing results in smaller distention of the circuit tubing with each
inspiratory volume.
a. Pediatric and neonatal circuit tubing are less compliant. This minimizes the
amount of tidal volume lost to distending the tubing with each delivered ventilation.
b. Anesthesia circuit tubing with low compliance should be used for neonates and
infants.
2. For example, if the circuit tubing has a compliance of 5 mL/cm H2O, and the inspiratory
pressure is 20 cm H2O, the amount of volume lost to distending the tubing is 100 mL (5
mL/cm H2O multiplied by 20 cm H2O).
a. One can see from the above example how tubing compliance can cause
hypoventilation issues in small children and neonates. Depending on the
compliance of the lungs, majority of the set tidal volume may be used to just
distend the tubing.
b. Using the above example, let!s say a neonate required a tidal volume of 80 mL.
Since 100 mL is lost to distending the tubing, the neonate may not receive any lung
ventilation. Instead, the set tidal volume would only distend the circuit tubing.
3. Some of the newer anesthesia machines compensate for tubing compliance. The
compensatory mechanism allows better matching of set tidal volume to actual
delivered tidal volume.
N. Oxygen flush valve is connected inline with the inspiratory limb of the breathing circuit.
1. When the oxygen flush valve is open, fresh gas (oxygen) flows at approximately 50 psi
and greater than 30 L/min.
2. Opening the oxygen flush valve can result in the following:
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Chapter: Anesthesia Circuits and Machines "
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Chapter: Anesthesia Circuits and Machines "
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Chapter: Anesthesia Circuits and Machines "
O. Currently used anesthesia machines have evolved from simple anesthesia delivery
machines into complex ventilators with specialized anesthetic delivery mechanisms that
are controlled by powerful computers.
1. Even with the evolution of the complex anesthesia machine, the basic components of
an anesthesia machine have not significantly changed. The basic components include
the following:
a. Gas supply (oxygen, nitrous oxide, air) is provided by central and E-cylinder
sources.
b. Pressure regulators to control the supply of gases from the central and E-cylinder
gas sources.
2. The central gas supply has a safety device called a diameter index safety system
(DISS) that helps prevent connection of improper gas lines to the central gas supply
source.
a. For example, the DISS helps prevent connection of the oxygen gas line to the
nitrous oxide central gas supply. Connection of the nitrous oxide line to the oxygen
central supply is also prohibited.
3. All E-cylinders also have a safety system that helps prevent connection of the incorrect
gas cylinder to the anesthesia machine. This is called the pin index safety system
(PISS).
4. The pressure regulators in the anesthesia machine lower the pressure of the delivered
gases prior to administration to the patient.
a. Low pressure system includes the components of the flow meters, control valves,
and vaporizer to the common gas outlet to the patient.
(1) Recall, the normal pressure from the oxygen E-cylinders is approximately 2200
psi and the nitrous oxide pressure is about 740 psi.
(2) The oxygen line from the high pressure wall supply is about 50 psi.
5. The fail-safe valve is one of the key safety components of an anesthesia machine.
The purpose of the fail-safe valve is to help detect and protect from the delivery of
hypoxic mixtures of gases. The 2000 ASTM F1850-00 standard requires the following
for all anesthesia machines: the delivered oxygen concentration shall not decrease
below 19% at the common gas outlet; an alarm shall activate within five seconds when
pressure decreases below manufacturers specified threshold. Current anesthesia
machines have alarms that activate when the pressure falls below 30 psi. There are
two types of fail-safe valves, depending on the manufacturer of the anesthesia
machine.
a. The Datex Ohmeda anesthesia machines utilizes a pressure sensor shut off valve.
With this system, the fail-safe valve is either open or closed. When the pressure of
oxygen falls to a set threshold (20 psi), the valve closes and shuts off flow of all
gases except oxygen to help detect and protect from the delivery of hypoxic
mixture of gases.
(1) The Datex Ohmeda machines also have a second-stage oxygen regulator that
allows flow of oxygen from the flow valve control to be constant when the
pressure is greater than 12-14 psi.
(1) The proportioning system decreases the supply of nitrous oxide as the
pressure of oxygen supply decreases. At a critical level, the nitrous oxide
supply is shut off.
c. The fail-safe valve does not prevent the delivery of an hypoxic mixture of gases.
The oxygen analyzer on the distal end of the anesthesia circuit is the last line of
defense in detecting the delivery of hypoxic mixture of gases.
d. Recall that the fail-safe monitor is pressure sensitive and not flow sensitive.
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Chapter: Anesthesia Circuits and Machines "
! E Cylinders
A. Anesthesia machines have backup gas cylinders (E cylinders). The E cylinders connect
directly to an anesthesia machine and are available in the event of a central gas supply
failure.
B. The intrinsic pressures of the E cylinders (oxygen ~2200 psi; nitrous oxide ~745 psi) are
regulated down to approximately 45 psi by pressure regulators on the E cylinders and
anesthesia machine.
1. The down-regulated E cylinder pressure is less than the central gas pressure, which
allows preferential gas flow from the central gas source.
2. When the central gas pressure falls below 45 psi, the E cylinder gas becomes
available to the anesthesia machine.
3. All E cylinders must be checked prior to each anesthetic.
C. The Pin Index Safety System (PISS) was developed to safeguard against connecting
incorrect E cylinders to the anesthesia machine.
1. For example, an oxygen E cylinder cannot be easily connected to the E cylinder yolk
for nitrous oxide on the anesthesia machine.
D. Critical temperature for a gas is the temperature at which a gas can be liquefied under
pressure. Above the critical temperature, a gas cannot be liquefied regardless of
pressure; distinct gas and liquid states do not exist.
1. For example, the critical temperature for oxygen is 119o C. This means that oxygen
can be liquefied under pressure if the temperature is colder than -119o. Above this
temperature, it exists only as a gas.
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Chapter: E Cylinders"
2. The critical temperature for nitrous oxide is 36o C. This explains why nitrous oxide
exists as a liquid at room temperature.
E. Nitrous oxide exists as a liquid at room temperature and the volume of gas remaining in
the cylinder is not proportional to the cylinder pressure.
1. The nitrous oxide tank pressure usually does not begin to decrease until the liquid is
exhausted and only gas remains in the tank.
2. When only N2O gas exists in the tank, there is usually less than 400 L of gas
remaining.
3. The most accurate way to determine remaining N2O volume is to weigh the E cylinder.
a. The tare weight (empty weight) is stamped on the cylinder.
b. The volume of nitrous oxide can be calculated by knowing the three components:
(1) the mass (g) of nitrous oxide in the cylinder,
(2) molecular weight of nitrous oxide (44 g/mol), and
(3) one mole of gas at standard temperature and pressure is 22.4L.
c. A simple estimate is that 1000g (1kg) of nitrous oxide is about 550 L of free gas at
20oC. (At STP, the volume would be about 512 L)
A nitrous oxide E cylinder has a tare weight of 7 kg. The pressure gauge reads 740
psi and now weighs 8.8 kg. How many liters of nitrous oxide are remaining in the
cylinder at standard temperature and pressure (STP)?
F. Boyle!s Law describes the relationship between pressure (P) and volume (V) of a gas.
1. At a constant mass of gas and temperature, the product of pressure and volume is
constant (P1V1 = k).
2. As the volume of gas decreases, the pressure inside the E cylinder also decreases in
proportion to the volume of gas.
a. The exception is nitrous oxide, since it is both liquid and gas inside an E cylinder.
G. Charles! Law describes the relationship between volume and temperature. Charles! Law
states that V/T = k at a constant pressure and quantity.
1. Under constant pressure and quantity, the volume of a gas varies directly with
temperature (degrees Kelvin).
2. As the temperature of a gas increases, the volume also increases.
H. The Boyle!s and Charles! laws can be combined. The combined gas law is as follows:
(P1V1)/T1 = (P2V2)/T2
I. Dalton!s Law states that total pressure is equal to the sum of the partial pressures.
J. Recall that standard temperature and pressure (STP) are assumed for these equations.
The standard temperature is 273oK (0oC) and pressure is 14.7 psi. Normal room
temperature is around 20oC or 293oK.
Gas Laws
Pressure Conversions
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Chapter: E Cylinders"
One can calculate the availability of a gas from an E cylinder by utilizing the the gas laws.
A previously full oxygen E cylinder with an initial pressure of 2000 psi now reads
1000 psi. How long will the oxygen last when the patient is receiving 6 L/minute via
a face mask?
P1V1 = P2V2
P1 = 1000 psi
V1 = 5 L (approximate internal volume of an E cylinder)
P2 = 14.7 psi (atmospheric pressure)
V2 = needs to be solved with the above equation