World Anaesthesia Day : October 16, 1846 William T.G.

Morton demonstration
of ether as an anaesthetic

1. General Anesthesia (GA): Loss of consciousness (LOC) +ve

2. Regional & Local Anesthesia(LA): LOC –ve, Don’t cross BBB

Local Anesthesia
 Loss of sensation from specific area
 MOA : blocking f a s t v o l t a g e g a t e d Na+ Channel

Most commonly used is Lidocaine/Lignocaine, used with vasoconstrictor like

Adrenaline, Excreted by kidneys
Long Acting = Dibucaine > Bupivacaine(cardiotoxic)

Structures pierced from outside to inside during SPINAL ANESTHESIA /

LUMBAR PUNCTURE SS 3 LIGA DAP (MENINGES)
1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Epidural space
7. Duramater
8. Arachnoid mater(Last structure to be pierced before spinal anaesthesia)
9. Subarachnoid space (contain CSF, Inject Agent here in spinal)
1.Spinal Anaesthesia: more potent than Epidural
Causes :- Hypotension and headache due to CSF LEAK
 Uses: Prostate surgery ( TURP) , During Delivery, Limb Sx
 Except : a) aorta/cardiac surgery, Organ transplant etc

2.Epidural Anesthesia :- Below Umbilical surgery

→Site :Thoracic/Lumbar Vertebra
→ Pierce till → Ligamentum Flavum
→ Indication -Same as spinal anesthesia
 Needle used - Touhy Needle
 Doesn’t cause hypotension, shock
 Analgesic
 Increased dose needed

General Anaesthesia
 →Can cross BBB
 → Loss of consciousness
 ABOVE UMBLICAL REGION SURGERY
Eg:- Laproscopic surgery ( renal sx, neuro sx, CABG , transplant sx)
All GA Act by GABA (CNS inhibition) except KETAMINE & XENON act via NMDA
Glutamate Antagonism

 Components of G.A
1. LoC
2. Loss of Reflex
3. Amnesia (No Memory)
4. Muscle Relaxant
5. Analgesia (No Pain)

Steps
→3-5 min give 100%O₂ first
1.Indication → IV/Inhalational Agent (IA)
2.Maintenance →Continue GA
3.Reversal →Stop giving Ga, Reversible Agents Eg. Flumazenil
TIVA = TOTAL I.V. ANESTHESIA

PIN Index Safety System

 The medical gas pin-index safety system ensures that the correct medical
gas cylinder is hung in the correct yoke.
 5 6 7

1,5 AIR 1,6 CO2 > 7% ENTONOX

2,5 OXYGEN 2,6 CO2 <7% 50% O2%

50% N2O
3,5 NITROUS 3,6 CYCLOPROPANE
OXIDE
HELIUM  NO PIN ( BROWN)
HELIOX  2,4
ETHYLENE  1,3

INHALATIONAL ANAESTHETICS

MINIMUM ALVEOLAR CONCENTRATION (MAC)

 The MAC of an inhaled anaesthetic is the alveolar concentration that
prevents movement in 50% of patients in response to a standardized
stimulus (eg, surgical incision)
 Lower the MAC higher is the potency.
 Order of potency (increasing order of MAC values)
 Methoxyflurane (0.16) [most potent]> halothane (0.74)> > isoflurane (1.15)
>Enflurane (1.68) > ether (1.92) > sevoflurane (2.0) > desflurane (6.6) > >
xenon (70) > N2O (104) [least potent]
 Most potent inhalational anaesthetic: methoxyflurane
 Least potent inhalational anaesthetic: nitrous oxide
NITROUS OXIDE
 Good Analgesic Agent but Poor GA
 Max MAC & least potency (MAC 104)
 N2o is Having SO LESS POTENCY , Hence it Fails To Cause GA Alone

 It takes help of Other Inhalation Agent like Halothane to produce effects

it fails to Cause GA alone.

IS KNOWN AS 2ND GAS EFFECT

 So When N20 + HALOTHANE Goes out From body they take O2 with
them Which Cause Diffusional Hypoxia- This is known as 3rd Gas
Effect or FINK EFFECT

Contain O2 so can cause fire C/I in LASER Sx

Increase pressure of air filled cavities, avoid in pneumothorax, small bowel
obstruction, middle ear surgery etc

BLOOD-GAS SOLUBILITY : opposite of SPEED

High blood solubility means that a large amount of inhaled anesthetic must be
dissolved (i.e., undergo uptake) in the blood before equilibrium with the gas
phase is reached. So, Higher BGS means slower Induction and Recovery

Xenon:
 LOWEST BGS, FASTEST IA
 Pure inert gas, It is an odourless, nonexplosive
 Closest to being an ideal anaesthetic agent.
 ADVANTAGE: FAST ONSET AND RECOVERY , ANALGESIC, NEURO AND
CARDIO PROTECTIVE
 DISADVANTAGE: HIGH COST , AND LOW POTENCY.( MAC= 70%)

Halogenated IA
- Release fluoride Fl-
- Act via GABA Mechanism and inhibit CNS
- End with – FLURANE, except Halothane
METHOXYFLURANE
 Most potent but not used as it Causes vasopressin resistant high output
renal failure (max fluoride release on metabolism
Most Potent H I S D (Least Potent)
Min BGS D I S H (SLOWEST)

A. HALOTHANE: RED COLOUR

 Stored In =Amber Colored Bottle

 Heart =Arrhythmic, Max fluoride release
 Hepatotoxic =Liver
Lung =Bronchodilation useful in Asthma

Sweet smelling liquid

2nd preffered in children


B. ISOFLURANE :
 Irritable ( Not used in Children And Asthmatics)
 Agent of choice for cardiac and neurosurgeries

C. DESFLURANE:
 The low solubility of desflurane in blood and body tissues causes a very rapid
induction of and emergence from anesthesia.
 Pungency and airway irritation can be manifested by Dyspnoea, salivation,
breath-holding, coughing, and laryngospasm.
 Laryngospasm , least metabolized preferred in elderly liver diseases

D. SEVOFLURANE
 Sweet smelling
 1st preferred in children
 Agent of Choice for the day Care Anesthesia
 Avoid in Renal Surgeries

 Sevoflurane is agent of choice for asthmatics, cardiac Surgeries,

neurosurgery and Liver Surgery .
Day Care Anesthesia : DIS MAP (propofol best)
I. V AGENTS
A. Thiopentone: Barbiturates
 It is available as a yellow amorphous powder having 6% anhydrous sodium
carbonate.
 This preparation is high alkaline (pH 10.5-11) so should not be
reconstituted in acidic solution like RL.
 Dose 3-5 mg/kg, adequate induction dose leads to loss of eye lash reflex
 Smell =Garlic
 Agent of choice for Neuro Surgery
CI= In Prophyria, Hypotension,Heart Block

 Colour =Yellow colour amorphous powder

B. PROPOFOL
 Propofol : (2,6-diisopropylphenol)
 Highly lipid-soluble drug results in rapid onset of action that renders the
patient unconscious within approximately 30 seconds.
 Decreases the incidence of nausea and vomiting.
 available as a 1% propofol (oil in water emulsion) that appears milky white
in colour & contains:
 10% soybean oil, 2.25% glycerol, 1.2% egg phospholipid emulsifier

Uses:
1: Most common induction agent used nowadays
2: Agent of choice for patients with malignant hyperthermia, open eye injury,
neurosurgery, hepatic disease\failure, office based procedures, rigid
bronchoscopy.
3: can be used in liver/kidney disease patiwnts also
4: used for procedural & ICU sedation.
Side Effects:
1: pain on injection.
2: Hallucinations, sexual fantasies, and opisthotonos can occur.
3: green coloured urine after prolonged infusion
C. KETAMINE ( CUT MIND)
 M.OA. – NMDA ANTAGONIST
 ketamine Is a “complete” anaesthetic as it induces analgesia, amnesia, and
unconsciousness.
 It causes dissociative anesthesia ( AWAKEN BUT NO PAIN) meaning patient
appear to be conscious but not responding to sensory stimulation.
 C.I IN NEUROSURGERY, post op HALLUCINATIONS
 Increase Symp. Activity and all pressures(BP,IOP, ICP)
 Increased skeletal muscle tone, Corneal, cough, and swallowing
reflexes all may be present.
USES
 DOC for unstable cardiovascular patients suffering from hypovolemia,
haemorrhagic shock, or cardiovascular depression in sepsis.
 DOC for patients with reactive airway disease (bronchodilation and
profound analgesia) For ASTHMA PATIENT

D. ETOMIDATE (OPIOID)
 Most Cardio Stable , hence, Agent of Choice for cardiac surgeries (
Angioplasty, aneurysm clipping).

 It is painful on injection, can cause involuntary muscle tremors, has

higher rates of nausea and vomiting, and can increase the risk of
seizures in patients with decreased thresholds

MALIGNANT HYPERTHERMIA :

 Malignant hyperthermia (MH) is a rare genetic Autosomal Dominant

hypermetabolic muscle disease.

 Cantrigger malignant hyperthermia FLURANES SUCKS LIGNO

Inhaled general anaesthetics : ether, halothane, all fluranes
Nondepolarizing muscle relaxants : Succinylcholine
LIGNOCAINE

PATHOPHYSIOLOGY
 The mechanisms of MH has been the gene for the ryanodine (Ryr 1)
receptor, located on chromosome 19.
 There is sudden excess release of calcium from sarcoplasmic reticulum
resulting in sustained muscle contraction
 Patient shivers on OT table, increase body temperature, high ETCO2 more
than 80-120 mmHg,
 Immediate cause of death : Arrhythmia
 Late cause: kidney failure due to myoglobinuria

Dantrolene Therapy :
 The dose is 2.5 mg/kg intravenously every 5 min until the episode is
terminated (upper limit, 10 mg/kg).
NEUROMUSCULAR BLOCKING DRUG
→Relax the muscle

Depolarizing NMBDs Nondepolarizing NMBDs-

Interfere with the actions of Ach.
-mimic the actions of Ach:
 Long acting : Pancuronium
Succinyicholine  Short acting : Mivacurium
 Briefly Contract
 Then Relax  No contraction only relaxation
 Muscle pain +nt
 Muscle pain +nt
 Train of Four +nt
 Train of Four ⊙
 Can be short or Long acting
 Short acting  Antidote =Neostigmine,
 No Antidote Pyridostigmine

NONDEPOLARIZING MUSCLE RELAXANTS

 Based on their chemical structure, they can be classified as
benzylisoquinolinium, steroidal,or other compounds.
 Steroidal compounds can be vagolytic, most notably with pancuronium but
inconsequentially with vecuronium or rocuronium. Benzylisoquinolines
tend to release histamine
MIVACURIUM:
 Only NDMR which is metabolized by pseudocholinesterase enzyme.
 Therefore, doesn’t need reversal with anti-cholinesterase agents (AOC for
Day Care surgery patients)
 Shortest acting NDMR available for use
 Releases histamine

ATRACURIUM
 Racemix mixture of isomers of atracurium
 Metabolism by non-specific hydrolysis (75%) &Hoffman’s elimination (25%)
 Releases histamine on fast administration(avoided in asthamatics)
 Less potent than Cisatracurium
 Risk of laudonosine toxicity (seizure potential)

CISATRACURIUM:
 Stereoisomer of atracurium that is four times more potent
 Isomer Of Atracurium Without Much Side effect
 No Histamine Release
 Minimal / No Laudosine
PANCURONIUM
 Metabolized (deacetylated) by the liver to a limited degree.
 Used only in Patient with Shock
 Symptomatic activity : increased Heartrate , Blood pressure
 Excretion : primarily renal (40%),some of the drug is cleared by the bile
VECURONIUM ROCURONIUM
 Metabolized to a small Onset of Action : 60 sec
extent by the liver. Good Alternative for Rapid Squences
 MOST CARDIO STABLE intubation wherever Sch is
used for Cardiac And Neuro contraindicated.
Surgeries Duration of Action : 30 mins
 Excretion : Depends The effects can be reversed with
primarily on biliary SUGAMMADEX
excretion and secondarily Agent of choice for day Care
on renal excretion Anesthesia
( Rocuronium + Sugammadex)
It has slight vagolytic tendencies
TUBOCURARNE:
 1st muscle relaxant to be used clinically
 Associated with histamine release
DOXACURIUM:
 Longest acting NDMR, Highly potent, Exclusive renal excretion
ASA I I.
Healthy Without comorbidities
ASA II II.
Milder systemic diseases , no functional
limitation ( under control)
ASA III III. Moderate systematic diseases with
functional limitation
ASA IV IV. Severe diseases i.e. Threat to life
ASA V V. Moribund Patient
ASA VI VI. Brain Dead Patient
Cormack and Lehane’s laryngeal grades of the airway

◆ INTUBATION POSITION

CHIN-LIFT AND HEAD-TILT MANOUVER :

 THYROMENTAL DISTANCE (TMD) (PATIL’S TEST)-
defined as the distance from the chin (mentum) to the top of the
notch of the thyroid cartilage with the head fully extended and can be
measured with a ruler for accuracy.
  ATLANTO-OCCIPITAL (AO) JOINT EXTENSION-

The sniffing or Magill position is considered the optimal “classical”

position of the head and neck for facilitating tracheal intubation.
 Any reduction in extension is
 expressed in grades:
• Grade I: >35 degrees
• Grade II: 22 to 34 degrees
• Grade III: 12 to 21 degrees
• Grade IV: <12 degrees
AIRWAY EVALUATION
1: Factors Causing Difficult Bag and Mask Ventilation (BMV)
 MNEMONIC “OBESE“
 O: Obese (BMI > 30 kg\m2)
 B: Bearded individual
 E: edentulous individual ( no teeth)
 S: history of Snoring ( Obstructive Sleep Apnea)
 E: Elderly (age >55 years)

A. AIRWAY EVALUATION
MallamPati classification

Used to predict the ease of endotracheal intubation(difficult airway).

 class I - soft palate, fauces, entire uvula, pillars;
 class II - soft palate, fauces, portion of uvula;
 class III - soft palate, base of uvula;
 class IV - hard palate only.
2: Factors Causing Difficult Laryngoscopy & Intubation
 MNEUMONIC LEMON:
 L = Look externally (facial trauma, large incisors, beard or moustache,
large tongue,
 high arched palate)
 E = Evaluate the 3-3-2 rule
 M = Mallampati (Mallampati score > 3)
 O= Obstruction (epiglottitis, peritonsillar abscess, trauma).
 N = Neck mobility (limited neck mobility)

MONITORING OF ANESTHESIA AND ITS EQUIPMENT

ANESTHESIA MONITOR

PULSE OXIMETER
Non invasive, in vivo, and
continuous assessment of
functional SaO2 (SpO2).
Based on BEER LAMBERT
LAW

NON INVASIVE BLOOD

PRESSURE
Choose correct cuff size,
initiate cuff inflation. Can
be automated, for routine
monitoring, measures
mean pressure

GUEDEL’S AIRWAY
 GUEDEL’S AIRWAY
 An oral airway is a
device used to
maintain an open
airway in a patient
who is at risk of
airway obstruction.

 It is commonly used
during anaesthesia,
sedation, or in
emergency situations
to facilitate breathing.

Laryngoscopes
used for visualizing the glottis to facilitate intubation

MCCOY
It has got a movable lip, which
can be used to manoeuvre the
glottis
Macintosh
 most commonly used.
 has curved blade available
in 4 sizes
 smallest for children
 largest for adults with long
necks.

Miller
 It has a straight blade with
curve at the tip.
 USED CHILDREN

Oxford infant blade

 Used for Infants

Flexible
Laryngoscopes/Bronchoscopes
(Fibreoptic)

 Gold standard technique for

the management of difficult/
failed intubation.

 It is less traumatic, does not

require any specific position
of neck and can be
performed in awake
patients.

Bullard Laryngoscope
 The prototypical
anatomically shape rigid
fiberscope.
 Accessories include hollow
tracheal
tube stylet, a single-use
blade
extender, and an external
light source cable
adaptor.
 Paediatric and adult sizes
are
available
Endotracheal Tubes

An endotracheal tube is a specific type of tracheal tube that is nearly

always inserted through the mouth (orotracheal) or nose
(nasotracheal).

CUFFED ENDOTRACHEAL TUBE

LMA CLASSIC ( FIRST also called as Brain Mask.
GENERATION ) placed blindly in oropharynx and
the cuff is inflated
with large volume of air (30 to 40
mL for adult size).
Advantage
 -Easy to insert
 -Does not require any
laryngoscope and muscle
relaxants.
 -Less sympathetic
stimulation as compared to
intubation.
 -Reusable (up to 40 times)
Disadvantage
 Increases the risk of
aspiration.
 Can cause laryngospasm
and airway Obstruction
LMA FLEXIBLE

 The tube of LMA is enforced

with a wire making it
flexible(non kink able
making it useful for head
and neck surgeries.)
DOUBLE LUMEN ( COMITUBE)  double-lumen airway
composed of a pharyngeal
lumen and a
tracheoesophageal lumen.

 Used for Lung Sx

 Provide Single Lung
ventilation

Cuffed Endotracheal Tube Best because it presents

aspiration,

 It is reasonable to choose
cuffed ETTs over uncuffed
ETTs for intubating infants
and children.

 When a cuffed ETT is used,

attention should be paid to
ETT size, position, and cuff
inflation pressure (usually
<20-25 cm H2O).

SECOND GENERATION=> provides better seal thereby decreasing

the chances of aspiration
Intubating LMA

Also called as LMA Fastrach

Up to 8 no. endotracheal tube
can be guided through it.

Proseal LMA

 It also Incorp- rates a

gastric drainage tube that
allows for gastric access
with an orogastric tube and
channels

 any regurgitated gastric

contents away from the
airway, effectively isolating
the respiratory and
gastrointestinal tracts.

Supreme LMA

 Supreme LMA is like

proseal LMA with a bite
block to avoid damage to
LMA tube, if the patient
bites. available in adult
sizes 3 to 5

I-GEL
 The cuff is prefilled with gel
avoiding the complications
of air filled cuff such as cuff
leakage, damage and
puncture.

 Like Proseal, I-gel also

contains a drain tube,
which can be used to
deflate the stomach
 Flexometallic Tube
 Used for Sx of head and
neck,Prone position Sx

PERIPHARYNGEAL
AIRWAY(COBRA-PLMA)

 It has high volume oval cuff,

which seals the
hypopharynx while patient
can be ventilated through
the ventilation slots
at the tip

MONITORING GENERAL ANESTHESIA

1.ECG
2.BP
3.Pulse Oximetry
4.Capnography ETCO2: 35-45 mmHg

5.Temperature
CIRCUIT BREATHING SYSTEM
TYPES OF CIRCUITS :

1. OPEN CIRCUIT: Also known as a “rebreathing circuit,”

this system allows the exhaled gases to escape into the room and not be
recycled.

2. CLOSED CIRCUIT: Also known as a “non-rebreathing circuit,” this system

recycles the exhaled gases and conserves heat and moisture. It consists
of a carbon dioxide absorber (SODA LIME), unidirectional valves, and
tubing.
3. Mapleson circuit / Semiclosed circuits :
 Named after the British anaesthetist, Jack Mapleson, these circuits are
classified from Type A to Type E.

 They are categorized based on the location of the fresh gas inlet and the
patient’s expiratory valve.

 MAPLESON A / MAGILL’S CIRCUIT  Preferred in adults – for

Spontaneous ventilation
 MAPLESON D / BAIN’S CIRCUIT  Preferred in adults – for Controlled
ventilation
 MAPLESON F/ JACKSON REES CIRCUIT/ AYRES T PIECE  Preferred in
paediatrics for : Spontaneous ventilation And Controlled ventilation.
 AMBU BAG RESUSCITATOR

 AMBU - artificial manual

breathing unit.
 available in a capacity of
I,200 mL for adults,
 500 mL for children
 250 mL for newborns.
 100% oxygen can be
delivered by AMBU bag by
attaching O2 source and O2
reservoir

Venturi mask
 Supplemental
oxygensupplementation via
nasal cannula or Venturi
mask must be administered
to maintain oxygen
saturation (SpO2) between
92 to 96% (< 88-90% if
COPD).

 OXYGEN DELIVERY SYSTEMS ARE CLASSIFIED AS

1. LOW FLOW SYSTEM :NASAL PRONGS ( MAX : 6L)
2. RESERVOIR SYSTEMS : Face mask And Face mask With Reservoir Bag
3. HIGH FLOW SYSTEM: Air entertainment Mask or heated , Humified O2
delivered through Nasal prongs

OXYGEN DELIVERY FLOW RATE APPROXIMATE O2

DEVICES
NASAL CANULA 1-6 0.24—0.44
SIMPLE FACE MASK 5-8 .40—0.60
PARTIAL 6-10 0.60—0.80
BREATHING MASK
NON BREATHING 10-15 0.90—1.00
MASK
VENTURI MASK 2-15 0.24—0.60
REGIONAL ANESTHESIA INSTRUMENTS

1. SPINAL NEEDLE – QUINCKE

1. A spinal needle is a long, thin needle with a bevelled tip that is used to
puncture the dura mater of the spinal cord and access the cerebrospinal
fluid (CSF) for diagnostic or therapeutic purposes.
2. Most commonly used spinal needle is the Quincke
Babcock cutting needle

2. Epidural Needle
1. An epidural needle is a long, thin needle with a blunt or rounded tip that
is used to puncture the
ligamentum flavum and access the epidural space.
Epidural needles are identified by presence of flange / wings for better
support while holding needle. Most commonly used types is Tuohy’s needle

COLOUR OF VAPORIZER INHALATION AGENT

RED HALOTHANE
BLUE DESFLURANE
YELLOW SEVOFLURANE
PURPLE ISOFLURANE
Medications need to be stopped
MAO A inhibitors  (3 weeks before)
Oral anticoagulants  (Warfarin 4 days prior)
Heparin  (Low molecular weight 12
hours before)

Anti platelets except aspirin  (Clopidogrel 7 days prior)

Thrombolytic  (10 days prior)
NSAIDs  (48 hours prior if used with
other antiplatelet
Disulfiram  10 days prior)

All herbal medications  (7 days before)

Smoking  (8 weeks before)

ANTI HYPERTENSIVE  ACE-I AND ARBs ARE

omitted , rest are Continued
On Day of Surgery
Unfractionated Heparin  Last dose – 4 hour Prior To
Surgery
Anti TB DRUGS  Continue on day of surgery
and do the liver function test
OHA And insulin  Omitted on day of Surgery
as patient is fasting
Warfarin  Stop 5 days prior to Surgery
All psychiatry Medication  Continued on day of surgery
EXCEPT MAO Inhibitors