Anaesthesiology OSCE

Gabriel Banini
Medical Student, Class of 2022

1
Content
• Tools • ASA Classification
• Oxygen Therapy and Oxygen • Premedication
Delivery Devices • Difficult Airway
• Muscle Relaxants • Fasting Guidelines
• Inhalational Agents • Rapid Sequence Induction
• Intravenous Agents • Triple Manoeuvre
• Fluid and Electrolyte Therapy
• Safe Dose Calculation for Local
Anaesthesia
2
Tools

3
Self Inflating Bag Valve Mask

4
Uses/Indications
• Bag valve mask may be used for emergency ventilation. e.g. during
CPR.
• Bag and valve may be used to ventilate patients with an ET tube or
LMA
• Alternative for failed intubation

5
Contraindications
• Complete upper airway obstruction
• After induction – risk of aspiration
• Severe facial trauma
• Foreign body in the airway. Eg gastric content

6
Complications
• Lung injury from over stretching
• Inflated air in stomach
• Aspiration

7
Management of Difficult Mask Ventilation
• Jaw thrust
• Placement of an oral airway
• Two-person mask ventilation

8
Oropharyngeal Airway
• A curved plastic device that is designed to go over the back of the tongue.
• Estimating the right size: From angle of mouth to the angle of mandible

9
Uses/Indications
• To maintain the airway in unconscious patient by preventing the
tongue from occluding airway
• Aids in airway suctioning
• Conduit for passing devices into the oropharynx
• Prevents tongue bite

10
Contraindications
• Intact gag reflex (conscious or semi-conscious patients) – vomiting
and aspiration
• Oropharyngeal growth

11
Complications
• Vomiting and aspiration in patients with intact gag reflex
• Very long ones can cause airway obstruction
• Trauma to airway

12
Nasopharyngeal Airway
• Estimating the right size: From
the tip of the nose to the tragus
of the ear

13
Uses/Indications
• To maintain the airway patency
• To suction secretions
• Can be used to guide NG tube placement

14
Contraindications
• Bleeding disorder/ History of nosebleed
• Anticoagulation
• Basilar skull fracture
• Growths in the nose or nasopharynx. Eg polyp

15
Complications
• Nasal bleeding
• Injury to turbinates
• Sinusitis

16
Advantages of NPA over OPA
• Better tolerated in patients with intact gag reflex
• Can be used in the setting of restricted mouth opening. Eg oral
trauma, trismus

17
Laryngeal Mask Airway

18
Uses/Indications
• To maintain airway
• Used as an alternative to bag-mask ventilation
• Can be used to guide intubation
• Used as an alternative when endotracheal intubation is not successful

19
Contraindications
• Patients at risk of aspiration
• Abnormal lesions or deformities of the supra glottis
• Complete upper airway obstruction
• Restricted mouth opening. Eg oral trauma, trismus

20
Complications
• Laryngospasm
• Aspiration – Gagging

21
Advantages of LMA over ET
• Insertion requires less skill
• Dose not require NMB drugs
• Does not require laryngoscopy
• Emergence is smooth

22
Magill Forceps
Uses
• To remove FB from oral cavity
• To pack the throat during oral or
pharyngeal surgery
• To guide ET and NG tube

Complications
• Local trauma esp uvula
• Can burst cuff of ET tube during
passage

23
Nasogastric Tube
Uses
• Gastric decompression
• Gastric lavage
• Delivering medication
• Feeding of unconscious patients

24
Nasogastric Tube
Contraindication Complications
• Recent nasal surgery • Bleeding
• Severe midface trauma • Oesophageal injury
• Coagulopathy/History of • False passage into trachea
nosebleed
• Oesophageal varices

25
Laryngoscope
Parts
- Blade
- Handle

26
Laryngoscope
Uses/Indications Contraindications
• Direct laryngoscopy • Epiglotitis – Airway obstruction
• Aid in tracheal intubation • Coagulopathy
• Passing orogastric tubes • Craniofacial trauma

27
Spinal Needle
Uses/Indications
• Spinal anaesthesia for surgery
• LP for meningitis
• Delivering antibiotics
• Delivering contrast media for
myelography

28
Structured Traversed in Spinal Anesthesia:
Posterior to Anterior
• Skin
• SC fat
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Epidural space
• Dura and arachnoid
• Subarachnoid space

29
Spinal Needle
Contraindications Complications
• Infection over site • Infection
• Increased ICP • Bleeding
• Coagulopathy • Post dura puncture headache
• Allergy • Cerebral herniation
• Patient’s refusal

30
Post Dura Puncture Headache
Prevention Treatment
• Use of smaller gauge spinal • Patient should be kept supine
needles • Adequate hydration
• Use of pencil tip needles • Analgesics. Eg NSAIDs
• Adequate hydration • Caffeine → increases CSF prodn
• Epidural blood patch: injection
of 5 – 20ml of autologous blood
into epidural space at the
puncture site

31
Central Venous Catheterization Set
Insertion sites
• Internal jugular vein : B/n the
medial and lateral heads of the
sternocleidomastoid muscle and
lateral to the carotid artery

• Subclavian vein
• Femoral vein

32
Central Venous Catheterization Set :
Components

Central Line

33
Uses/Indications
• Measurement of CVP
• Limited vascular access
• To administer multiple drugs at same time
• To administer blood and blood products
• To administer parenteral nutrition
• To administer vaso-irritating drugs as KCL, 50% Dex etc
• For taking blood samples

34
Complications
Acute Delayed
• Arrhythmias • Sepsis
• Bleeding • Thrombosis
• Pneumothorax
• Damage to thoracic duct,
oesophagus, carotid artery
• Cardiac puncture
• Catheter embolization

35
Contraindications
• Uncooperative patient
• Skin infection over puncture site
• Coagulopathy
• Distortion of anatomic landmark
• Thrombus in the intended vein

36
 IV Cannulae

Colour Size
Orange 14
Grey 16
Green 18
Pink 20
Blue 22
Yellow 24

Mnemonic: Organic Gardens Get Perfect Background Yield

37
IV Cannulae
Uses Complications
• Deliver IVF • Infection
• Deliver blood and blood • Injury
products
• Taking blood samples
• Emergency relieve of tension
pneumothorax

38
Endotracheal Tube

39
ET- Parts and Functions
• Bevel: The slant portion found at the tip of the tube. The bevel is
usually left-facing. This helps in easy visualization of the vocal cords
and easy access into the trachea during intubation
• Murphy’s Eye: An opening at the side of the ET that functions as a
vent and prevents complete obstruction should the primary distal
opening of the ET tube gets blocked.
• Cuff: Prevents aspiration by occluding the airway
• Pilot line/Inflating tube: Serves as a conduit for air into the cuff.

40
ET- Parts and Functions
• Pilot balloon: This is a small bulb with a one way valve to allow air
from the syringe into the cuff through the pilot tube/line. Used to
indicate if the cuff is properly inflated.
• Radiopaque line: For X-ray visualization
• Universal connector: Connect the ET tube to the breathing or
anesthesia systems.
• Stylet: Gives the tube rigidity so that it can be easily placed into the
trachea. It must be removed once the tube has been successfully
passed.

41
Endotracheal Tube

42
Endotracheal Tube
Indications
• To secure the airway and reduce risk of aspiration
• To deliver inhalational anaesthetic agents
• To deliver oxygen
• Positive pressure ventilation

43
Confirming Correct Endotracheal Intubation
• Direct visualization
• Chest movement on ventilation
• Breath sounds on auscultation
• Misting sign
• Capnography – Gold standard
• Bronchoscophy
• Chest X-ray
• O2 Saturation

44
Anesthesia Machine

45
Anesthesia Machine
Components and Function
• Oxygen Tank: This used oxygen that is delivered to the patient.
• Reservoir Bag: Acts as a reservoir of gases for the patient to breathe.
It can also be used to manually ventilate the patient should it be
necessary.
• Oxygen Flow Meter: Used to regulate the amount of oxygen supplied
to the patient.
• Vapourizer: This takes the liquid form of the inhalational agent and
transforms it into vapour.

46
Anesthesia Machine
Components and Function
• Breathing circuit (Hose & Face mask): Used to deliver the inhalational
agent and oxygen from the machine to the patient. It also carries the
expired gases away from the patient.
• Soda Lime Canister: This absorbs the CO2 and water vapour expired
by the patient.
• Pressure Manometer: Indicates the pressure that is within the
breathing circuits
• Display Monitor: Helps the technicians to track the flow of the agent
and to make sure it is consistent

47
Oxygen Therapy
• Oxygen therapy is the administration of oxygen at concentrations greater than
that of the surrounding air to patients with breathing disorders who aren’t able to
get them naturally.

• Indications include:
-COPD
-Asthma
-Trauma to respiratory system
-Head trauma
-Heart failure
-Pneumonia
-etc
48
Oxygen Delivery Devices

49
Nasal Prongs
• Flow rate
- 44% O2 at 6L/min

• Advantages
-Patients can eat, drink and talk while
using them.
-They reduce the risk of carbon dioxide
rebreathing.

• Disadvantage
-Nasal irritation and mucosal drying
50
Simple Face Mask/Rebreather Mask
• Flow rate
- 60% O2 at 7 - 8L/min

• Advantages
-Can provide increased delivery of
oxygen for short periods of time.
-Can be used in patients with nasal
irritation or epistasis.

• Disadvantages
-Increases dead space
-Uncomfortable for patients while
eating or talking
51
Non Rebreather Mask With Reservoir Bag
• Flow rate
- 70% O2 at 10L/min

• Advantage
-Can provide high concentration of
oxygen for short periods of time.
-Can be used in patients with nasal
irritation or epistasis.

• Disadvantage
-Increases dead space
-Uncomfortable for patients while
eating or talking
52
Muscle Relaxants

53
Suxamethonium/ Succinylcholine
Class: Depolarizing NMBD
Dose: 1-1.5mg/kg
Advantages Disadvantages
• Fast onset • Muscle pain
• Has short duration of action so • Hyperkalemia → cardiac arrest
can be used for procedures that • ↑↑ intra-ocular, intra-cranial and
intra gastric patients
require only a brief duration of
muscle relaxation • Prolonged neuromuscular block in
some patients (both inherited and
• Effective relaxation acquired)
• Risk of malignant hyperthermia

54
Suxamethonium/ Succinylcholine
Contraindications
• Burns patients (hyperkalemia)
• Spinal cord injuries (hyperkalemia)
• Glaucoma (↑ intra-ocular pressure)
• Extensive muscle injury (hyperkalemia)

55
Atracurium
Class: Non-depolarizing NMBD
(Benzylisoquinolinium)
Advantages Disadvantages
• Spontaneous degradation • Release histamine → bronchospasm,
(Hoffmann elimination) hence skin reactions
can be used in patients with
organ failure. Eg: Liver and
Kidney failure patients
• Neuromuscular block can be
reversed with Neostigmine

56
Atracurium
Contraindications
• Asthma patients
• Peptic ulcer

57
Pancuronium & Vecuronium
Class: Non-depolarizing NMBD (Aminosteroid)

Advantages Disadvantages
• Dose not release histamine • Metabolized in end organs
hence can be used in asthma hence cannot be used in
and peptic ulcer patients. patients with organ failure. Eg
• Neuromuscular block can be Liver and Kidney failure patients
reversed with Neostigmine

58
Pancuronium Vs Vecuronium Vs Atracurium
• Pancuronium is mainly eliminated by the kidneys hence it is
contraindicated in patients with kidney pathologies. However it may
be used in patients with liver pathologies.
• Vecuronium is mainly metabolized and eliminated by the liver hence
it is contraindicated in patients with liver pathologies. However it may
be used in patients with kidney pathologies.
• Atracurium is eliminated by Hoffmann Elimination (spontaneous
degradation) and plasma esterases hence it can be used in patients
with both liver and kidney pathologies.

59
Inhalational Agents

60
Halothane
Disadvantages
• Arrhythmogenic
Advantages
• Decreases blood pressure
• Pleasant smell
• Sensitizes myocardial conduction
• Bronchodilation→ good for system to the action of
asthma and COPD patients catecholamines therefore, it
cannot be used with epinephrine
• Does not cause mucus during surgery
production in the airways • Post-operative shivering common
• Non-emetic. • Uterine relaxation →post-partum
• Non-flammable hemorrhage
• Hepatotoxicty
• Increases intra-cranial pressure
61
Isoflurane

Advantages Disadvantages
• Coronary vasodilatation → Good • Pungent smell
for patients with coronary artery
disease • Decreases BP
• No increase in ICP → Excellent • Ventilatory depressant
for Neurosurgery.
• Rapid recovery
• Not arrhythmogenic
• Fairly good muscle relaxation
62
Intravenous Agents

63
Thiopental/ Thiopentone/ Pentothal
Class: Barbiturate
Dose: 4-5mg/kg
Advantages Disadvantages
• Bacteriostatic • Poor analgesic
• Decreases BP
• Dose not increase ICP
• Releases histamine
• Potent anticonvulsant • Not suitable for laryngeal mask
• Low incidence of nausea and airway b’cos the airway reflexes are
preserved.
vomiting • Respiratory depression
• Can precipitate porphyrias. This is
due to increased expression of ALA
Synthase. (NB: Barbiturates are
enzyme inducers)
64
Propofol
Class: Phenol
Dose: 2-2.5mg/kg
Advantages Disadvantages
• Does not increase ICP • Painful on injection
• Rapid recovery • Decreases BP
• Antiemetic • Respiratory depression
• Excellent for LMA as it reduces
the airway reflexes
• Safe in porphyria

65
Etomidate
Class: Imidazole
Dose: 0.3mg/kg
Advantages Disadvantages
• Very stable on the • Causes cough and hiccups
cardiovascular system • Adrenal suppression
• Causes less respiratory • Can precipitate porphyrias
depression.
(↑↑ALA Synthase)
• Fast onset of action

66
Ketamine
Class: Phencyclidine
Dose: IV 1.5 -2mg/kg, IM 4-10mg/kg
Advantages Disadvantages
• Can be administered through • Slow onset
various routes
• Prolonged recovery with
• Produces anterograde amnesia hangover effects
• Good analgesic • Increases ICP
• Does not reduce BP
• Emergence phenomena
• Produces bronchodilation
→ good for asthma and COPD
patients

67
Midazolam
Class: Benzodiazepine
Advantages Disadvantages
• Produces anterograde amnesia • Slow onset
• Has mild effects on the • Injection site reactions → pain,
respiratory and cardiovascular swelling, etc
system
• Can be reversed by Flumazenil
in case of overdose

68
Sample Question (2020 OSCE)
An asthmatic patient is to undergo anesthesia for a surgical procedure. The
drugs to be used include:

[Pancuronium, Atracurium, Vecuronium, Pethidine, Diclofenac, Ketamine,

Propofol, Halothane, Isoflurane]

Choose from the list the most appropriate drug for:

(i) Induction
(ii) Maintenance
(iii) Muscle relaxation
(iv) Analgesia

69
 My Answers and Reasons for Choosing them
• Induction: Ketamine (NB: IV agents are usually used for induction)
-Ketamine produces bronchodilation and therefore suitable for an asthmatic patient.

• Maintenance: Halothane (NB: Inhalational agents are used for maintenance)

-Halothane produces bronchodilation and therefore suitable for an asthmatic patient

• Muscle Relaxation: Pancuronium or Vecuronium

-Atracurium causes the release of histamine and therefore not suitable for asthmatic
patients

• Analgesia: Pethidine (Opioid)

-NSAIDs(Diclofenac) are contraindicated in asthma b’cos they cause bronchospasm due to
increased synthesis of leukotrienes 70
Fluid and Electrolyte Therapy
• Correction of Pre-existing deficits • Third space losses
- Use the 4:2:1 rule -Minimal surgical trauma: 2ml/kg/hr
Eg. herniorraphy, head and neck surgeries,
• Maintenance fluid requirement during knee surgeries
surgery
- Use the 4:2:1 rule -Moderate surgical trauma: 6ml/kg/hr
Eg. cholecystectomy, hysterectomy, chest
• Blood loss during surgery, replace with: surgeries
- Same volume of blood/colloid
- 3 x the volume of cystalloid -Severe surgical trauma: 10ml/kg/hr
Eg. laparotomy, major bowel resection,
nephrectomy, abdominal aortic aneurysm
repair

71
Fluid and Electrolyte Therapy
Sample Question with Solution
Calculate the fluid management for an elective hernia repair using the
following information

• Age: 68 years
• Gender: Male
• Weight: 50kgs
• Nil per os for 8 hours
• Duration of operation: 2 hours
• Total blood loss during surgery: 500ml

72
Fluid and Electrolyte Therapy
1.Correction of Pre-existing deficits
Maintenance fluid requirement for 50kg:
(4 x 10) + (2 x 10) + (1 x 30)
= 40 + 20 + 30
= 90ml/hr

Patient was NPO for 8 hours

Therefore Pre-operative deficit
= Number of hours NPO x Maintenance fluid requirement
= 8 x 90
= 720ml

This must be given before the surgery

73
Fluid and Electrolyte Therapy
2.Maintenance fluid requirement during surgery
Maintenance fluid requirement for 50kg:
(4 x 10) + (2 x 10) + (1 x 30)
= 40 + 20 + 30
= 90ml/hr

Duration of surgery is 2 hours

Therefore total maintenance for 2 hours = 90 x 2 = 180ml

This is given during the surgery

74
Fluid and Electrolyte Therapy
3.Third space losses
Hernia repair is a minimal trauma surgery (2ml/kg/hr)
= 2 x 50
= 100ml/hr

Duration of surgery is 2 hours

Therefore total requirement for 2 hours = 100 x 2 = 200ml

This is given during the surgery

75
Fluid and Electrolyte Therapy
4.Replacement of blood lost during surgery,
Total blood loss during surgery is 500ml. This can be replaced with:

• 500ml blood
• 500ml colloid
• 1500ml crystalloid

76
Safe Dose Calculations with Local Anesthesia
• LIDOCAINE: 1-2%
Dose:
- Plain: 3mg/kg
- With adrenaline: 7mg/kg

• BUPIVACAINE: 0.25-0.5%
Dose: 2.5mg/kg

77
Safe Dose Calculations
• Is it safe to give 12ml of 1% plain lidocaine to a 70kg patient? [Plain
lidocaine = 3mg/kg]

1%(w/v) = 1000mg/100ml =10mg/1ml

OR
1% = 1 x 10 = 10mg/1ml
Safe dose for patient in mg = 70kg x 3mg/kg = 210mg
Safe dose for patient in ml = 210mg/10mg x 1ml = 21ml

*It is safe to give the patient 12ml because the maximum dose that can be
given is 21ml

78
Safe Dose Calculations
• Is it safe to give a 70kg patient 30mls of 2% lidocaine with adrenaline?
[Lidocaine with adrenaline = 7mg/kg]

2%(w/v) = 2000mg/100ml =20mg/1ml

OR
2% = 2 x 10 = 20mg/1ml
Safe dose for patient in mg = 70kg x 7mg/kg = 490mg
Safe dose for patient in ml = 490mg/20mg x 1ml = 24.5ml

*It is not safe to give the patient 30ml because the maximum dose that can
be given is 24.5ml

79
Safe Dose Calculations
• What will be the safe dose in ml for use of 0.5% Bupivacaine for a 30kg
child [Bupivacaine = 2.5mg/kg]

0.5%(w/v) = 500mg/100ml =5mg/1ml

OR
0.5% = 0.5 x 10 = 5mg/1ml
Safe dose for patient in mg = 30kg x 2.5mg/kg = 75mg
Safe dose for patient in ml = 75mg/5mg x 1ml = 15ml

*The safe dose/maximum dose of 0.5% Bupivacaine for a 30kg child is 15ml
80
 ASA CLASSIFICATION
ASA DEFINITION EXAMPLES
ASA I Healthy patient with no Healthy, non-smoking, no or
systemic disease minimal alcohol
ASA Patient with mild systemic Current smoker, social
II disease, no functional alcohol drinker, pregnancy.,
limitations obesity (<40), well-
controlled HPT/DM
ASA Patient with moderate to MI, CVA, TIA (>3months),
III severe systemic disease with alcohol, dependence, poorly
some functional limitations controlled HPT/DM,
BMI≥40, ESKD on regular
scheduled dialysis,
premature neonate
81
 ASA CLASSIFICATION

ASA DEFINITION EXAMPLES

ASA IV A patient with severe systemic Recent (<3months) MI, TIA, CVA,
disease that is a constant threat to ESKD not on regular dialysis, severe
life valvular dysfunction, sepsis, DIC
ASA V A moribund patient who is not Ruptured thoracic/abdominal
expected to survive 24h without aneurysm, massive trauma,
operation intracranial bleed with mass effect,
ischemic bowel disease with cardiac
pathology or multiple organ
dysfunction
ASA VI Brain stem dead patient whose
organs are being removed for
donor purposes

Add E to denote emergency eg ASA IIE

82
Premedication
• Premedication refers to the administration of medication before the
induction of anesthesia.
• These medications are neither part of the patients usual medical
regimen nor are they part of the anesthetic.

83
Aim of Premedication
• To allay anxiety: Benzodiazepines eg. Midazolam
• To reduce secretions in the airway: Anticholinergics eg. Atropine,
Hyoscine
• To produce amnesia: Benzodiazepines eg. Midazolam
• To increase stomach pH and reduce the risk of aspiration
pneumonitis: Sodium citrate, Ranitidine
• To reduce nausea and vomiting: Metoclopramide
• To control pain: NSAIDs (avoid the use of NSAIDs in asthmatic and
peptic ulcer patients)

84
Identification of Difficult Airway
• Patient’s Past Medical & Surgical History
• Physical Examination
• Thyromental Distance
• Mallampati Classification

85
Past Medical & Surgical History
• Neck surgeries
• Cervical fixation devices
• Acromegaly
• Ankylosing spondylitis
• Rheumatoid arthritis
• Reduced jaw mobility
• Epiglottitis

86
Physical Examination
• Thick short neck
• Stiffness of cervical spine
• Limited mouth opening
• Growth in the oropharynx, airway, neck
• Prominent upper incisors
• Receding chin
• Deviation of the trachea
• Abnormally large breast

87
Thyromental Distance
• Measure from upper edge of thyroid cartilage to chin with the head
fully extended.
• Less than 3 finger breadths (<6cm) is a sign of difficult airway

88
Mallampati Score

Class 1 Entire uvula and tonsillar

pillars visible
Class 2 Tip of uvula and pillars
hidden by tongue
Class 3 Only soft and hard palate
visible
Class 4 Only hard palate visible

Class 3 & 4 associated with difficult airway

89
Fasting Guidelines

Ingested Material Minimum Fast Period

Clear liquids 2 hours

Breastmilk 4 hours

Non-human milk and Solid 6 hours

food

90
Rapid Sequence Induction
This is a method of inducing anesthesia in patients who are at high risk
of aspiration of gastric contents into the lungs. The steps involved are:

• Preoxygenation: with 100% oxygen

• Rapid IV induction: IV Thiopental (ultra-short acting barbiturate) can
be used.
• Application of cricoid pressure: to occlude the esophagus
• Intubation

91
Rapid Sequence Induction
Indications
• Abdominal pathology: Ileus
• Delayed gastric emptying: Trauma, Opioids, Vagotomy
• Incompetent lower esophageal sphincter: GERD, Hiatus hernia
• Pregnancy
• Impaired consciousness → loss of airway reflexes

92
Triple Manoeuvre

• Head tilt
• Chin lift
• Jaw Thrust

Technique used to maintain a patent

upper airway in functional airway
obstruction (ie. depressed level of
consciousness, loss of airway muscle
tone, falling of tongue posteriorly)
93
Thank You!
“Champions do not become champions when they win the event, but
in the hours, weeks, months and years they spend preparing for it. The
victorious performance itself is merely the demonstration of their
championship character.”

― Alan Armstrong

94