STAGES OF ANAESTHETICS

Stage of analgesia Starts from beginning of anaesthetic inhalation and lasts upto the loss of
consciousness. Pain is progressively abolished. Patient remains conscious, can hear and see, and
feels a dream like state; amnesia develops by the end of this stage. Reflexes and respiration remain
normal. Though some minor operations can be carried out during this stage, it is rather difficult to
maintain—use is limited to short procedures.

Stage of delirium From loss of consciousness to beginning of regular respiration. Appa-rent excitement is
seen—patient may shout, struggle and hold his breath; muscle tone increases, jaws are tightly closed,
breathing is jerky; vomiting, involuntary micturition or defecation may occur. Heart rate and BP may rise
and pupils dilate due to sympathetic stimulation. No stimulus should be applied or operative procedure
carried out during this stage. This stage is inconspicuous in modern anaesthesia

Surgical anaesthesia Extends from onset of regular respiration to cessation of spontaneous breathing. This
has been divided into 4 planes which may be distinguished as: Plane 1 Roving eyeballs. This plane ends
when eyes become fixed. Plane 2 Loss of corneal and laryngeal reflexes. Plane 3 Pupil starts dilating and
light reflex is lost. Plane 4 Intercostal paralysis, shallow abdominal respiration, dilated pupil. As anaesthesia
passes to deeper planes, progressively—muscle tone decreases, BP falls, HR increases with weak pulse,
respiration decreases in depth and later in frequency also— thoracic lagging behind abdominal.

Medullary paralysis Cessation of breathing to failure of circulation and death. Pupil is widely dilated,
muscles are totally flabby, pulse is thready or imperceptible and BP is very low. Many of the above indices
have been robbed by the use of atropine (pupillary, heart rate), morphine (respiration, pupillary), muscle
relaxants (muscle tone, respiration, eye movements, reflexes) etc. and the modern anaesthetist has to depend
on several other observations to gauge the depth of anaesthesia
PREANAESTHETIC MEDICATION

Preanaesthetic medication refers to the use of drugs before anaesthesia to make it more
pleasant and safe. The aims are: 1. Relief of anxiety and apprehension preoperatively and to
facilitate smooth induction. 2. Amnesia for pre- and postoperative events. 3. Supplement
analgesic action of anaesthetics and potentiate them so that less anaesthetic is needed
4. Decrease secretions and vagal stimulation caused by anaesthetics. 5. Antiemetic effect
extending to the postoperative period. 6. Decrease acidity and volume of gastric juice so that it
is less damaging if aspirated.
Myasthenia gravis
Myasthenia gravis is an autoimmune disorder affecting about 1 in 10,000 population, due to development of
antibodies directed to nicotinic receptors (NR) at the muscle endplate → reduction in number of free NM
cholinoceptors to 1/3 of normal or less (Fig. 7.3) and structural damage to the neuromuscular junction →
weakness and easy fatigability on repeated activity, with recovery after rest. Neostigmine and its congeners
improve muscle contraction by allowing ACh released from prejunctional endings to accumulate and act on
receptors over a larger area, and by directly depolarizing the endplate. Treatment is usually started with
neostigmine 15 mg orally 6 hourly; dose and frequency is then adjusted according to response. However, the
dosage requirement may fluctuate from time to time and there are often unpredictable periods of remission and
exacerbation. Pyridostigmine is an alternative which needs less frequent dosing. If intolerable muscarinic side
effects are produced, atropine can be added to block them. These drugs have no effect on the basic disorder
which often progresses; ultimately it may not be possible to restore muscle strength adequately with antiChEs
alone. Corticosteroids afford considerable improvement in such cases by their immunosuppressant action. They
inhibit production of NR-antibodies and may increase synthesis of NRs. However, their long term use has
problems of its own (see Ch. 20). Prednisolone 30–60 mg/day induces remission in about 80% of the advanced
cases; 10 mg daily or on alternate days can be used for maintenance therapy. Other immunosuppressants have
also been used with benefit in advanced cases. Both azathioprine and cyclosporine also inhibit NR-antibody
synthesis by affecting T-cells, but response to the former is slow in onset (takes upto 1 year), while that to the
latter is relatively quick (in 1–2 months). Removal of antibodies by plasmapheresis (plasma exchange) is
another therapeutic approach. Dramatic but short lived improvement can often be achieved by it in myasthenic
crisis.
Myasthenic crisis is characterized by acute weakness of respiratory muscles. It is managed by tracheal
intubation and mechanical ventilation. Generally, i.v. methylprednisolone pulse therapy is given while anti-
ChEs are withheld for 2–3 days followed by their gradual reintroduction. Most patients can be weaned off the
ventilator in 1–3 weeks. Plasmapheresis hastens recovery. Thymectomy produces gradual improvement in
majority of cases. Even complete remission has been obtained. Thymus may contain modified muscle cells with
NRs on their surface, which may be the source of the antigen for production of anti-NR antibodies in
myasthenic patients.
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[End Time]>[Start Time]

0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
0

"Good"
0

"Good"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[End Time]>[Start Time]

Today()

"Good"

0
0

No
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[Subtotal]+[Tax]
0

No
[End Date]>[Start Date]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
=Today()
[Delivery Date]>=Today()
No

"Not Started"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Full-time"
[Unit Price]*[Quantity]*(1-[Discount])

0
0

"None"
=Today()

0
[End Time]>[Start Time]
[End Date]>=[Start Date]

"Not Submitted"
=Today()

No
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[Subtotal]+[Tax]+[Shipping]

0
0

0
[Original Contract Sum]+[Change Orders]

[Completed Previously]+[Completed This Period]

([Completed Previously]+[Completed This Period])*0.05

([Completed Previously]+[Completed This Period])-(([Completed

Previously]+[Completed This Period])*0.05)+[Tax]
(([Completed Previously]+[Completed This Period])-(([Completed
Previously]+[Completed This Period])*0.05)+[Tax])-[Previous Payments]

0
Today()
"1 - New"

"1 - Critical"

=Today()

Make sure the Status and Resolution fields are in sync

[Status]="3 - Resolved"

[Resolution] Is Null

If the Status is Resolved but the Resolution is not

specified, raise an error to prevent the data from being
saved

You must select a resolution.

[Status]="4 - Closed"
[Resolution] Is Null

If the Status is Closed but the Resolution is not specified,

raise an error to prevent the data from being saved

An issue must be resolved before it can be closed.

[Resolution] Is Not Null

If the Status is not Resolved and not Closed but a

Resolution is specified, clear the resolution

Resolution

Null
Make sure the Status and Resolution fields are in sync

[Status]="3 - Resolved"

[Resolution] Is Null

If the Status is Resolved but the Resolution is not

specified, raise an error to prevent the data from being
saved

You must select a resolution.

[Status]="4 - Closed"

[Resolution] Is Null
If the Status is Closed but the Resolution is not specified,
raise an error to prevent the data from being saved

An issue must be resolved before it can be closed.

[Resolution] Is Not Null

If the Status is not Resolved and not Closed but a

Resolution is specified, clear the resolution

Resolution

Null
0
"Good"
0
0

0
IIf([Returned Date] Is Null,"Checked Out","Returned")

Today()
IIf([Returned Date] Is Null,"Checked Out","Returned")

Today()
IIf([Returned Date] Is Null,"Loaned","Returned")
Today()
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
0
0

No
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[Unit Price]*[Quantity]*(1-[Discount])

0
"None"
IIf([Status]="Completed",No,Yes)

=Today()

"New"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])
Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
1

No
0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
"Open"
0

No

0
IIf([Status] In ("Completed","Deferred"),No,Yes)

[End Date]>=[Start Date]

"2 - Medium"

"Not Started"

Now()
Not Update([Changed Date])

Changed Date

Now()
0

0
0
=Today()

0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
[Quantity]*[Unit Price]

0
0
[Unit Price]*[Quantity]*(1-[Discount])

0
0

"None"
IIf([Status]="Completed",No,Yes)

=Today()

"New"
Concat([Budget Year]," - ",[Budget Quarter])
DateDiff(MONTH,[Start Date],[End Date])*[Rental Rate]

[End Date]>=[Start Date]

0
2
0
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
0

No
[End Time]>[Start Time]
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
"On Track"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])
Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
IIf([Status] In ("Completed","Deferred"),No,Yes)

[Percent Complete] Between 0 And 1

"2 - Medium"

"Not Started"
This data macro makes sure the Status is set correctly if the Percent
Complete is updated or it makes sure the Percent Complete is set
correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

[Percent Complete]=0

Percent Complete is default - check Status

[Status]="Completed"

If Status is changed to Completed set Percent Complete to

100%

Percent Complete

[Percent Complete]=1
If Percent Complete is 100% set Status to Completed

[Status]

"Completed"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100% and the

Status is either Completed or Not Started, set Status to In
Progress

Status

"In Progress"
This data macro makes sure the Status is set correctly if the Percent
Complete is updated or it makes sure the Percent Complete is set
correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

Update([Percent Complete])

[Percent Complete]=1

If Percent Complete is changed to 100% and Status is not

set to Completed, set Status to Completed

[Status]<>"Completed"

Status

"Completed"
[Percent Complete]=0

If Percent Complete is changed to 0% and Status is

Completed, set Status to Not Started

[Status]="Completed"

Status

"Not Started"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100% and the
Status is either Completed or Not Started, set Status to In
Progress

Status

"In Progress"

Update([Status])

[Status]="Completed"

If Status is changed to Completed and Percent Complete is

not 100%, set Percent Complete to 100%

[Percent Complete]<>1
Percent Complete

[Status]="Not Started"

If Status is changed to Not Started and Percent Complete

is not 0%, set Percent Complete to 0%

[Percent Complete]<>0

Percent Complete

0
[Percent Complete]=1

If Status is changed to something other than Completed

and the Percent Complete is 100%, set Percent Complete
to 0%

Percent Complete

0
IIf([Status] In ("Completed","Deferred"),No,Yes)

[Percent Complete] Between 0 And 1

"2 - Medium"

"Not Started"

This data macro makes sure the Status is set correctly if the Percent
Complete is updated or it makes sure the Percent Complete is set
correctly if the Status is updated.
Percent Complete: 0=0%, 1=100%

Update([Percent Complete])
[Percent Complete]=1

If Percent Complete is changed to 100% and Status is not

set to Completed, set Status to Completed

[Status]<>"Completed"

Status

"Completed"

[Percent Complete]=0

If Percent Complete is changed to 0% and Status is

Completed, set Status to Not Started
[Status]="Completed"

Status

"Not Started"

[Status]="Completed" Or [Status]="Not Started"

If Percent Complete is between 0% and 100% and the

Status is either Completed or Not Started, set Status to In
Progress

Status

"In Progress"
Update([Status])

[Status]="Completed"

If Status is changed to Completed and Percent Complete is

not 100%, set Percent Complete to 100%

[Percent Complete]<>1

Percent Complete

1
[Status]="Not Started"

If Status is changed to Not Started and Percent Complete

is not 0%, set Percent Complete to 0%

[Percent Complete]<>0

Percent Complete

[Percent Complete]=1
If Status is changed to something other than Completed
and the Percent Complete is 100%, set Percent Complete
to 0%

Percent Complete

0
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
0

=Today()
[Sunday]+[Monday]+[Tuesday]+[Wednesday]+[Thursday]+[Friday]+
[Saturday]
([Sunday]+[Monday]+[Tuesday]+[Wednesday]+[Thursday]+[Friday]+
[Saturday])*[Pay Rate]

0
0
0
DateDiff(DAY,[Start Date],[End Date])

[End Date]>=[Start Date]

"Pleasure"
Coalesce([First Name]+" "+[Last Name],[Last Name],[First Name],[Email],
[Company])

Coalesce([Last Name]+" "+[First Name],[Last Name],[First Name],[Email],

[Company])

Coalesce([First Name],[Last Name],[Email],[Company]) Is Not Null

"Business"
Today()

"Best Way"
0
0