Basics of anaesthesia REVISION NOTES ANESTHESIA
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anesthesia machine PIN index cylinder capnography oxygen therapy mapleson circuit stages of anaesthesia boyles apparatus rotameter flow meter breathing circuits mapleson circuits anaesthesia revision notes for neet pg preparation with high
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Basics of anaesthesia REVISION NOTES ANESTHESIA
- 1. Basics of anaesthesia TONY SCARIA 2010 KMC
- 4. Boyles apparatus Continuous flow system TONY SCARIA 2010 KMC
- 6. Cylinders are made up of molybdenum steel • MOST COMMONLY USED IS SIZE E TONY SCARIA 2010 KMC
- 8. PIN INDEX • TO PREVENT INCORRECT GAS CYLINDER ATTACHMENT TONY SCARIA 2010 KMC
- 9. DIAMETER INDEX SAFETY SYSTEM (DISS) FOR CONNECT CONNECTION OF CYINDER TO MACHINE TONY SCARIA 2010 KMC
- 10. GAS FILLED AS LIQUID IN CYLINDER • N2O • CO2 • CYCLOPROPANE TONY SCARIA 2010 KMC
- 11. O2 therapy • O2 therapy Delivers O2 more than 29 % (at room 0229 %) • Indications • Recovery from GA • a/c respiratory failure • ARDS • a/c severe BA • severe pneumonia • a/c exacerbation of COPD • Pulmonary thromboembolism • CVA IHD ILD • Shock • O2 delivery devices TONY SCARIA 2010 KMC
- 12. • Nasal prongs • Simple face mask • Partial rebreather • Non breather • Venturi mask • O2 hood in neonate TONY SCARIA 2010 KMC
- 14. Simple oxygen mask • r TONY SCARIA 2010 KMC
- 15. AMBU BAG mapleson C TONY SCARIA 2010 KMC
- 17. High performance fixed performance TONY SCARIA 2010 KMC
- 19. • Stage III plane 3 surgical anaesthesia TONY SCARIA 2010 KMC
- 25. Boyles apparatus : anaesthetic machine • High pressure low resistance continuous flow TONY SCARIA 2010 KMC
- 26. Rotameter Bobbin flow rate of gases N20 & O2 act as carriers for halothane vapours TONY SCARIA 2010 KMC
- 27. Flow meters/Thorpe tube • Variable orifice with smallest diameter at the base TONY SCARIA 2010 KMC
- 28. • HEIGHT TO WHICH BOBBIN RISES FLOW RATE • CAUSES OF INACCURATE READING • STATIC ELECTRICITY • DIRT • NONVERTICAL TUBE • BACK PRESSURE BY VENTILATOR • TONY SCARIA 2010 KMC
- 29. LINK 25 TO PREVENT HYPOXIATONY SCARIA 2010 KMC
- 30. IN A 3 GAS MACHINE SAFEST CONFIGURATION IS WHEN OXYGEN IS LOCATED IN DOWNSTREAM AFTER BOTH GASES TONY SCARIA 2010 KMC
- 32. PRESSURE SYSTEM TONY SCARIA 2010 KMC
- 33. PRESSURE SYSTEM HIGH • FROM CYLINDER TO PRIMARY PRESSURE REGULATOR • cylinder • yoke assembly • oxygen assembly • 1st pressure reducing valve INTERMEDIATE • 1ST PRESSURE REDUCING VALVE TO FLOW CONTROL VALVE • Pipeline source • Flow control valve • 2nd pressure reducing valve LOW • DOWNSTREAM TO FLOW CONTROL VALVE • Rotameter TONY SCARIA 2010 KMC
- 34. Fail safe valve in case of hypoxia shuts off & decreases supply of nonoxygen gases increasing delivery of O2 Oxygen enters downstream TONY SCARIA 2010 KMC
- 35. Hypoxia prevention • Oxygen flail valve • Low pressure oxygen alarm • oxygen is located at downstream position TONY SCARIA 2010 KMC
- 36. Cylinders • Made of chromium molybdenum steel TONY SCARIA 2010 KMC
- 37. Pin index system TONY SCARIA 2010 KMC
- 39. Carbon dioxide 1 ,6 Single central holeTONY SCARIA 2010 KMC
- 42. Gas Pin index Colour of cylinder Air 1,5 02 2,5 Black body ,white shoulder Nitrous oxide 3,5 blue C02 1,6 Grey Cyclopropane 3,6 Orange Entonox 7 Blue body with Blue Quartered Shoulders Ethylene red halothane Amber helium Brown TONY SCARIA 2010 KMC
- 45. O2 cylinders • Black with white shoulder • Pressure -2000 psi • As liquid O2 • Size from AA to H • Most commonly used is E TONY SCARIA 2010 KMC
- 46. N2O cylinder • Blue • 760 psi • liquid gas TONY SCARIA 2010 KMC
- 49. Gas pipes • Seamless copper tubing • Pressure is 50 psi (4 bar) TONY SCARIA 2010 KMC
- 52. Mapleson A /magill • System of choice in spontaneous breathing TONY SCARIA 2010 KMC
- 53. Mapleson B • Not used clinically TONY SCARIA 2010 KMC
- 54. Mapleson c • Operative recovery room • Not used TONY SCARIA 2010 KMC
- 55. Mapleson D / bain co-axial system • Best for controlled ventilation TONY SCARIA 2010 KMC
- 56. Mapleson E/ Ayres tube • Jackson rees modification of t piece • Best circuit for children in spontaneous and assisted ventilation • Infants & young children TONY SCARIA 2010 KMC
- 58. Circuit type type F (Ja Required fresh gas flow Comments Spontaneous Controlled Type A (magill) Equal to minute volume Very high & difficult to predict • Circuit of choice for spontaneous ventilation • Not used for controlled ventilation Type B 2*minute volume 2-2.5 times minute volume Type C 2* minute volume 2-2.5 times minute volume • AMBU bag • Co-axial system Type D (bain circuit) 2-3 times minute volume 1-2 times minute volume • Circuit used for controlled ventilation • Most commonly used circuit • Can also be used for spontaneous ventilation Type E (Ayre T piece) 2-3 times minute volume 3 times minute volume • Circuit of 2nd choice in children Type F(Jackson rees ) 2-3 times minute volume 2times minute volume • Circuit of choice in children TONY SCARIA 2010 KMC
- 60. Mapleson a • Best for spontaneously breathing patient • Prevent rebreathing Gas from patient is expelled through valve TONY SCARIA 2010 KMC
- 62. Bain circuit /mapleson d best circuit for both controlled & spontaneous breathing TONY SCARIA 2010 KMC
- 63. Bain circuit coaxial system TONY SCARIA 2010 KMC
- 64. Mapleson D TONY SCARIA 2010 KMC
- 66. Mapleson f • Used in infant • Jackson rees modification of Ayres t piece • Light weight • Fresh gas flow is close to respiratory tract • No valves low resistance • High gas flow hence CO2 does not accumalate • Drying of respiratory epithelium TONY SCARIA 2010 KMC
- 68. Mapleson C • Used for emergency resuscitation TONY SCARIA 2010 KMC
- 70. C02 absorbents • Circle systems • From expired gas CO2 is absorbed by C02 absorbents and then recirculated in to the patient • Soda lime • Baralyme • Amsorb plus TONY SCARIA 2010 KMC
- 72. Soda lime • Most commonly used • 94% ca hydroxide • 5% NaOH • 1% KOH • Silica to provide hardness & prevent alkaline dust formation • Size 4-8 mesh • Clayton yellow pH indicator • As more CO2 is absorbed colour , pink yellow/white TONY SCARIA 2010 KMC
- 73. Drugs contraindicated in circle systems • Trichloroethylene • Sevoflurane • Methoxyflurane • chloroform TONY SCARIA 2010 KMC
- 74. Baralyme • BaOH (instead of NaOH )5% • 80% ca hydroxide • 6% KOH • Less heat caustic and less heat prdn • No silica is necessary to produce hardness • Indicator • Mimiza Z and ethyl red as indicator • Pink red TONY SCARIA 2010 KMC
- 75. Amsorb plus • Calcium hydroxide • Calcium chloride • Water • Hardness caso4 & polyvinyl pyrrolidine TONY SCARIA 2010 KMC
- 77. Guedels staging of anaesthesia for ether • Stage 1 (stage of analgesia) • Hearing is last sense to be lost • Stage 2 stage of delirium • Stage 3 stage of surgical anaesthesia • Entire relaxation • No muscular rigidity • Deep regular breathing • Satge 4 stage of medullary paralysis (respiratory paralysis) TONY SCARIA 2010 KMC
- 80. ASA physical scale TONY SCARIA 2010 KMC
- 81. MONITORING OF ANAESTHESIA TONY SCARIA 2010 KMC
- 82. Monitoring of depth of anaesthesia • Bispectral index : most commonly used • Electrode strip placed on forehead electrical activity recorded in the form of EEG TONY SCARIA 2010 KMC
- 85. 60-40 surgical anaesthesia TONY SCARIA 2010 KMC
- 86. Other methods • Raw EEG • power spectral analysis • Auditory evoked potentials • Tunstalls isolated forearm technique • Lower esophageal contractility TONY SCARIA 2010 KMC
- 88. 4 PHASE & 2 ANGLES PHASE 1 INSPIRATORY BASELINE DEVOID O CO2 αANGLE 110*c TRANSITION FROM DEAD SPACE TO ALVEOLI GASES β ANGLE= 90 * DEAD SPCE GAS TONY SCARIA 2010 KMC
- 89. ETCO2 • Normal = 35 -45 mmHg • 2-5 mmHg LOWER THAN ARTERIAL PaCO2 • ETCO2 at end expiration • Inversely proportional to alveolar CO2 • Uses • Malignant hyperpyrexia (first indicator) • Degree and adequacy of alveolar ventilation • Correct placement of endotracheal tube (best indicator) • In esophageal intubation • Absence of CO2 in exhaled air or <10 mm TONY SCARIA 2010 KMC
- 90. ETCO2 • Circuit Disconnection indicator • Sudden cessation of CO2 in expiratory phase • Indicator of degree of rebreathing (presence of CO2 in inspired air) • Massive fall of ETCO2 • Air embolism • Indicator of cardiac output • Hypovolemia • Pulmonary embolism (following craniotomies major complication) • Cardiac arrest TONY SCARIA 2010 KMC
- 99. Pulse oximeter • O2 saturation of Hb TONY SCARIA 2010 KMC
- 100. Pulse oximeter TONY SCARIA 2010 KMC
- 101. Deoxy Hb red light oxy Hb IR light TONY SCARIA 2010 KMC
- 102. PRINCIPLE OF PULSE OXIMETRY • AMOUNT OF LIGHT ABSORBED α CONCENTRATION OF LIGHT ABSORBING SUBSTANCE BEERS LAW • LIGHT ABSORBED IS PROPORTIONAL TO DISTANCE TRAVELLED (LENGTH) LAMBERTS LAW TONY SCARIA 2010 KMC
- 103. PULSE OXIMETRY DETECTS ONLY PULSATILE BLOOD TONY SCARIA 2010 KMC
- 104. Error in SpO2 • COHb • methHb • Intravasular dye(methylene blue) • Low blood volume (hypovolemia) • Nail polish • Ambient pressure • MOVEMENT OF LIMB TONY SCARIA 2010 KMC
- 105. Central venous pressure • CVP parallels right atrial P • Normal 5-10 cm of H2o(2-7 mmHg) • Veins used (seldinger technique) • Right internal jugular V*** • Short straight and valveless • Tip of catheter should be at junction of SVC and RA • Subclavian • Femoral • Antecubital TONY SCARIA 2010 KMC
- 106. MEASUREMENT OF CENTRAL VENOUS PRESSURE: MANOMETRY When the stopcock is turned to direct flow of fluid to the patient, the manometer is bypassed. TONY SCARIA 2010 KMC
- 107. To measure central venous pressure, first turn the stopcock to fill the manometer to 25 cm H2O. TONY SCARIA 2010 KMC
- 108. Next, open the stopcock to the patient and the manometer. Allow the column of water in the manometer to fall and stabilize before a reading is taken. Note that the zero mark must be horizontally aligned with the tricuspid valve (which is estimated as the midaxillary line in a supine patient) TONY SCARIA 2010 KMC
- 109. Indications for CVP • TPN • Open heart surgeries • Shock (fluid management) • Major surgeries • Apirating air embolus TONY SCARIA 2010 KMC
- 110. Increased CVP • Fluid overload • RV failure • Pulmonary embolus • Hemothorax • Cardiac tamponade • Constrictive pericarditis Decreased CVP • Hypovolemia & shock • Venodilaton TONY SCARIA 2010 KMC
- 111. Hypothermia • Temp monitoring in skin rectum nasopharynx • Hypothermia causes • delayed metabolism of drugs & delayed awakening • Shivering • Increased o2 consumption • Shift of ODC to left • Temperature is maintained TONY SCARIA 2010 KMC
- 112. Neuromuscular blockade is monitored at • Ulnar nerve TONY SCARIA 2010 KMC
- 113. By assessing movement of thumb TONY SCARIA 2010 KMC
- 114. • No twitches 100 % blockade TONY SCARIA 2010 KMC
- 115. TONY SCARIA 2010 KMC
- 116. Monitoring of neuromuscular blockade • Tetany: A sustained stimulation (5 s) • Train-of-four (TOF): Four pulses in rapid succession • Double-burst stimulation (DBS): A series of 3 pulses followed after a pause by 2 or 3 pulses. • Post-tetanic potentiation: When a pulse is sent after a tetanic stimulation, it will bring on a stronger twitch than at first. • non-depolarizing muscle blockers, there is a fade phenomenon where twitch amplitude decreases from the first stimulationTONY SCARIA 2010 KMC
- 117. TONY SCARIA 2010 KMC
- 118. Train of four TONY SCARIA 2010 KMC
- 119. Train of four • Used for neuromuscular monitoring • 4 stimuli each of 2 Hz& each for 2second • Ratio of T4 to T1 is taken • With depolarisers all 4 ampitudes are of same in phase I(T4:T1=1) • In phase II & in nondepolarising block • Decrease proportionately in response to T1 • Fading • Raito of 0.3 required for most surgeries • Ratio of 0.7 for reversal TONY SCARIA 2010 KMC
- 120. • Adductor pollicis (ulnar nerve) • Used for monitoring • Paralysis of adductor pollicis adequate blockade of laryngeal & pharyngeal muscle neuromuscular blockade • Absence of activity in orbicularis oculiblockade in laryngeal muscle • Diaphragm requires 90%of recptor occupation while for Sx only 70 - 75 % is needed TONY SCARIA 2010 KMC
- 121. Myasthenia gravis • Anaesthesia of choice • Isoflurane,propofol • Muscle relaxant • Atracurium /cisatracurium (1st choice) ,mivacurium,rapacurium • myasthenia is resistant to depolarising muscle relaxant • Myasthenia is sensitive to nondepolarising Contra indicated • Aminoglycosides • Tertacycline • Polypeptide Abx • Procainamide • Pencillamine • B blockerTONY SCARIA 2010 KMC
- 122. Porphyrea Safe • Inhalational • N2O,halothane,cyclopropane • IV agents • Propofol • NM blocking agents • dTC ,suxmethonium,pancuronium • NM reversing agents • Atropine,gycopyrrolate ,neostigmine • LA safe • Lignocaine,bupivacaine,prilocaine,tertrac ine Contraindicated • IV agents • barbiturates.,etomidate • LA • Ropivacaine • Analgesic • Pentazocin TONY SCARIA 2010 KMC
- 123. Porphyrea Contraindicated • Thiopentone • Methohexitone • Etomidate • Ketorolac • Phenacetin • Pentazocine TONY SCARIA 2010 KMC
- 124. Day case surgery • DOC for induction propofol • Muscle relaxant Sch,mivacurium TONY SCARIA 2010 KMC
- 125. Mnemonic day case surgery • Manmohan Singh Is A Prime Minister • Mivacurium • SCh • Isoflurane • Alfentanyl • Propofol • Midazolam TONY SCARIA 2010 KMC
- 126. Liver failure Drugs used • Isoflurane (hepatic blood flow is least affected) • NM blockercisatracurium Contraindicated • Halothane TONY SCARIA 2010 KMC
- 127. Renal failure Drugs used • Isohurane • Halothane • Desflurane Contraindicated • Methoxyflurane • Morphine • Gallamine TONY SCARIA 2010 KMC
- 128. Status asthmaticus • Children halothane • Adults ketamine TONY SCARIA 2010 KMC
- 129. Pediarics • Inhalation agent of choice sevoflurane TONY SCARIA 2010 KMC
- 130. Malignant hyperthermia drugs used • NODDLE Piza Kake • N20 • Opiate • Diazipine • Droperidol • LA • Etomidate • Propofol • Ketamine TONY SCARIA 2010 KMC
- 131. Ischemic heart disease • Barbiturate • Propofol • Etomdate TONY SCARIA 2010 KMC
- 133. TONY SCARIA 2010 KMC
- 134. MORPHINE • Poisoning • Pinpoint pupil • Respiratory depression death • Rx • Naloxone 0.6mg IV repeated every 3 mins till rr peaks up • No agonistic action and no resp depression • Morphine tolerance except for miosis & constipation • Morphine withdrawal • Rhinorrhea,hyperhidrosis,sweating,diarrhea,goose flesh • Withdrawal of morphine substitute with oral methadone & gradual withdrawal of methadone TONY SCARIA 2010 KMC
- 135. Morphine • IM /IV/SC/epidurally/rectally • Effective against visceral and myocardial ischemic pain TONY SCARIA 2010 KMC
- 136. • Opiods spasm of sphincter of oddi & increase biliary P TONY SCARIA 2010 KMC
- 137. • Opiod with high protein binding • Alfentanyl,sufentanyl • Very high lipid solubility • Sufentanyl,fentanyl • With very high ionized fraction • Alfentanyl TONY SCARIA 2010 KMC
- 138. Remifentanyl • Ultrashort acting opiod • Metabolised by RBC and tissue esterases • Not influenced by heptic or renal clearance TONY SCARIA 2010 KMC
- 139. Oculocardiac reflex • Trigemino vagal reflex • Traction on extraocular muscle bradycardia • Afferent trigeminal • Efferent vagal TONY SCARIA 2010 KMC
- 140. TONY SCARIA 2010 KMC
- 142. Modes of ventilation • Non invasive ventilation • Face mask /nasal cannula • Invasive ventilation • Mechanical ventilation • With endotracheal intubation TONY SCARIA 2010 KMC
- 143. Mechanical ventilation • Indications • Hypoxemic respiratory failure • Most common indication • ARDS, HF with pulmonary edema ,pneumonia • Hypercarbic respiratory failure • COPD ,neuromuscular disease TONY SCARIA 2010 KMC
- 144. • Positive pressure ventilation • Positive • Air pushed in to trachea • Most commonly used • Negative pressure ventilation • Negative pressure is created in alveoli • Air is sucked in to lung • Not used TONY SCARIA 2010 KMC
- 145. Ventilator • Volume preset time cycled • Delivers fixed tidal volume at regular intervals • Most commonly used • Pressure preset time cycled TONY SCARIA 2010 KMC
- 146. Modes of ventilation • Total ventilator support • Ventilator provides mechanical breath , patients effort is NIL • Patient is passive…ventilator is active • Intermittent positive pressure ventilation • Volume controlled mechanical ventilation (CMV) • Flow delivery is governed by preset flow rate and volume • Pressure controlled ventilation • Flow delivery is governed by preset inspiratory pressure • Partial ventilator support TONY SCARIA 2010 KMC
- 147. Partial ventilator support • Assisted mechanical ventilation (AMV) • Ventilator assists a breath initiated by patient • Assist contolled mechanical ventilation • Intermittent mandatory ventilation (IMV) • Synchronised intermittent mandatory ventilation (SIMV) • Pressure support ventilation TONY SCARIA 2010 KMC
- 148. Typical ventilator setting • Tidal volume -10 ml/kg • Inspn /expn – 1:2 • Frequency- 10-12 breaths /min • Inspiratory flow rate - 60-80L/min • PEEP – 3-5 cm H2O • FiO2- 50% TONY SCARIA 2010 KMC
- 149. Positive airway pressure ventilation • PEEP • Positive pressure applied at the end of expiration • Used during mechanical ventilation • CPAP • During both expiration and inspiration • During spontaneous respiration TONY SCARIA 2010 KMC
- 150. Indications for CPAP • Abnormal physical examination • Increased work of breathing, • Substernal & suprasternal retraction,grunting, nasal flaring ,cyanosis , increases RR • Inadequate ABG • Abnormal CXR • Poorly infiltrated/abnormal infiltration TONY SCARIA 2010 KMC
- 151. CPAP • Pulmonary edema • Weaning from ventilator • Sleep apnea • Tracheomalacia • Respiratory distress syndrome TONY SCARIA 2010 KMC
- 152. Weaning from ventilator • Discontinuing the ventilator support • From any mode possible but not from control mode ventilation • Because in CMV patient support is nil and Tidal volume is delivered by ventilator TONY SCARIA 2010 KMC
- 153. Weaning from ventilator • Modes used are • SIMV • IMV • Assisted controlled ventilation(ACV) • Pressure support ventilation (PSV) • SIMV+PSV • T piece • CPAP TONY SCARIA 2010 KMC
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