DRUG Inducting dose Stock dose ASA CLASSIFICATION

(mg/kg) (mg/mL) 1 Normal, healthy, (-) smoker/alcohol drinker

Midazolam 0.02-0.2 5 (dilute) 2 Mild to moderate systemic disease, well-controlled. No
Diazepam 0.3-0.6 5 organ dysfunction nor functional limitation (ex. Smoker
Fentanyl 0.7-2 mcg 50 mcg >10 pack yrs, social alcoholic drinker, pregnant, BMI 30-
Lidocaine 1-1.5 20 40, Well controlled DM/HPN, mild lung dse, Asthma)
Propofol 1.5-2.5 10 3 Severe systemic disease w/ functional limitations (ex.
Atracurium 0.3-0.5 10 Poorly controlled DM/HPN, COPD, morbidly obese (BMI
Rocuronium 0.6-1.2 10 >40), Active Hepa, alcohol dependence/abuse, moderate
Suxamethonium 1-1.5 20 reduced EF (30-39%), ESRD w/ regular sched HD,
Ephedrine 0.1-0.2 50 (dilute) implanted pacemaker, premature infant PCA <60 wks, >3
Atropine 0.01 1 mos hx of MI/CVA/TIA/CAD/stents, stable angina)
Paracetamol 15-20 1gm/vial 4 Severe, life threatening (ex. Recent <3 mos
300mg/amp MI/CVA/TIA/CAD/stents, ongoing cardiac
Nalbuphine 0.1-0.2 10 ischemia/severe valve dysfunction, severe rEF (<30%),
Morphine 0.025-0.1 10 (dilute) sepsis, DIC, ARF/ESRD + non-compliant dialysis
Ketorolac 0.5-0.75 30 5 Moribund, not expected to survive w/o OR (ex. Ruptured
abdominal/thoracic aneurysm, AIDS, massive trauma,
Dexamethasone 0.1-0.6 4
intracranial bleeding w/ mass effect, ischemic bowel in
Diphenhydramine 0.5-1 50
the face of cardiac pathology or multiple organ/systemic
Ketamine IM 5-10 50 dysfuction)
Ketamine IV 1-2 50 6 Brain dead, for donor - organ transplant
Thiopental 5-7 (pedia), 20 E Emergency
3-5 (adult)
Etomidate 0.2-0.3
Bupivacaine 5 STAGES OF GENERAL ANESTHESIA
Tramadol 50 I Disorientation, altered consciousness
Butorphanol 2 II Excitatory stage, delirium, uncontrolled movement,
Noradrenaline 1 mcg/kg/min irregular RR = *DON’T EXTUBATE = Laryngospasm
III Surgical anesthesia, return of regular RR
Plane 1 – light anesthesia
CRITERIA FOR EXTUBATION Plane 2 – loss of blink reflex, reg RR *(DEEP
SUBJECTIVE EXTUBATION – If w/ hx of laryngospasm)
§ Breathing spontaneously Plane 3 – deep anesthesia, shallow RR, assisted
§ Follows commands ventilation. Level of anesthesia for painful surgery
§ 5 seconds sustained head lift Plane 4 – diaphragmatic RR, assisted ventilation, CV
§ Intact gag reflex impairment
§ Airway clear of debris IV Too deep, overdose & anesthetic crisis. Stage between
§ Adequate pain control respiratory arrest & death d/t circulatory collapse
§ Minimal end-expiratory concentration of inhaled
anesthetics
OBJECTIVE LMA INTUBATION
§ Vital capacity ≥10 mL/kg Indications: elective, fasting, CPR, difficult airway, rescue
§ Peak voluntary negative inspiratory pressure >-20cmH2O device alternative to mask ventilation/ ET intubation
§ Tidal volume >6mL/kg Contraindications:
§ 5 seconds sustained tetanic contraction § Risk of aspiration (full stomach/GERD/pregnant)
§ T1/T4 ratio >0.7-0.8 § ↓ respiratory compliance d/t low pressure seal of LMA
§ Alveolar-arterial PaO2 gradient <350 mmHg (on FiO2 of § cuff will leak at ↑ inspiratory pressure > gastric
1) during weaning from mechanical vent insufflation. *Peak inspiratory pressure maintained ≥20
§ Dead space to tidal volume ratio ≤0.6 during weaning cmH2O to ↓ cuff leaks & insufflation
from mechanical vent § Long term mechanical ventilator support anticipated
§ Intact upper airway reflexes = laryngospasm
§ Morbidly obese (BMI >40)
MALLAMPATI CLASSIFICATION § >14 wks AOG
1 Tonsillar pillars (P) + Uvula (U) + Soft palate (S) + Hard
Palate (H)
2 USH BALANCE ANESTHESIA
3 SH 1. Anxiolysis & Anterograde Amnesia – Midazolam (0.02-
0.2)
4 H
2. Analgesia
MODIFIED CORMACK LEHANE GRADE
a. Fentanyl (0.7-2 mcg/kg)
1 Full view of glottis
b. Lidocaine (1-1.5): local anesthesia to painful
2a Partial view of the glottis Propofol d/t EDTA, anti-arrhythmic class IB, blunts
2b Arytenoids or posterior part of the vocal cords sympathetic response
3 Only epiglottis c. Paracetamol (20 – analgesia, 15 – antipyretic)
4 Neither glottis nor epiglottis visible. (+) Soft palate 3. Unconsciousness / Sedation
a. Propofol (1.5-2.5)
ESTIMATED BLOOD VOLUME b. O2 + Sevoflurane
4. Immobility – NMB
Female: 65 x kg Newborn term: 90
a. Atracurium (0.3-0.5, 3-5 mins onset)
Male: 75 x kg Newborn preterm: 100-120
b. Rocuronium (0.6-1.2, 1-3 mins) = RSI 1.2, 1 min
Child: 70 x kg Infant (3-12 mos): 80
c. Suxa (RSI 1-1.5, 1-1.5 min onset)
Spinal target Bupivacaine Surgical procedure MORPHINE PUSH ORDERS
level (mg) BP: Ø Patient seen & examined
T4 (nipple) 12 - *20 § CS (12.5-13.5 mg 0.75% HR: Ø Morphine 2mg in 10 cc pNSS OR in
hyperbaric) RR: 0.125% isobaric Bupivacaine given
§ upper abdominal sx (20
UO:>0.5cc/kg/hr via epidural catheter. NEXT DOSE at
hyperbaric)
T6-T7 *15 § AP/inguinal hernia (12-15 VAS: /10 o Date & time
(xiphoid)/ ≥T8 hyperbaric) ( ) N/V Ø Monitor v/s q15 mins for the 1st hr
§ BTL (10-12 hyperbaric) ( ) generalized then q1h thereafter until stable
≥T10 *10 - 15 § TURP (7.5 isobaric or severe Ø Monitor I&O qhourly & record
(umbilicus) /hyperbaric) pruritus Ø WOF signs of opioid toxicity:
§ cystoscopy (2.5-5 o BP <90/60 mmHg, HR <60
iso/hyperbaric) o O2 sat <95%
§ penile prosthesis (12-15 o Severe nausea & vomiting
hyperbaric) o Generalized pruritus
§ cervical cerclage (5-7.5
hyperbaric) o Decrease sensorium
≥T12 § Hip fx (15-20 isobaric in o UO <0.5 cc/kg/hr
sitting or lateral w/ operative Ø Give PRN meds as ordered
side up) Ø Refer accordingly
§ knee replacement (12-15
hyperbaric) ANESTHESIA TECHNIQUE
§ knee arthroscopy (5-7.5 RA-SAB (AP, CS, upper abdominal)
iso/hyperbaric)
§ ankle sx (7.5 hyperbaric) v LLDP/RLDP. Asepsis & antisepsis. Local infiltration w/
L1-L3 (inguinal ligament) § Lower extremity sx Lidocaine 2%. Spinal needle G25 (orange)/ G26 (brown)
L2-L3 (knee) § Foot sx inserted at L3-L4 IVS midline/paramedian approach. (+)
S2-S5 *5 v Hemorrhoidectomy (5- clear, free flowing CSF. Atraumatic. No paresthesia.
7.5mg hyperbaric for Bupivacaine 0.5% (H) 20mg given intrathecal. Sensory
lithotomy / 2.5-5 for prone) block up to T4 Modified Bromage score 3/3.
v VBAC (5 mg)
CLEA/CTEA
v LLDP/RLDP/Sitting. Asepsis & antisepsis. Local
PRE-OP ORDERS (NIMO)
infiltration w/ Lidocaine 2%. Tuohy needle G18 inserted
Ø Pre-anesthesia assessment done OR
at L3-L4/C6-C7 IVS midline/paramedian approach. (+)
§ Patient seen & examined
§ History, PE, and chart reviewed LORTA. Epidural catheter inserted with ease
Ø Anesthesia plan explained, understood, and accepted by cephalad/caudal, (-) test dose, (+) Trojanowsky sign,
the patient secured and taped.
Ø Please secure consent OR Informed consent obtained CSEA (Double level)
Ø If PAY: Dr. (name) informed v LLDP/RLDP/Sitting. Asepsis & antisepsis. Local
Ø NPO post midnight infiltration w/ Lidocaine 2%. Tuohy needle G18 inserted
Ø IVF: pLR 1L x MF, *for DM pts: D5NSS 1L x MF at L3-L4/C6-C7 IVS midline/paramedian approach. (+)
Ø Meds:
§ Omeprazole 40mg IV OD while on NPO LORTA. Epidural catheter inserted with ease
§ If (+) wheezes: Salbutamol neb 30 mins prior to OR cephalad/caudal, (-) test dose, (+) Trojanowsky sign.
§ *DM: HOLD all oral antihyperglycemics Spinal needle G25 (orange)/ G26 (brown) inserted at L3-
§ *HPN: HOLD ACEi & ARBS, continue CCB & BB L4 IVS midline/paramedian approach. (+) clear, free
Ø Others: flowing CSF. Atraumatic. No paresthesia. Bupivacaine
§ Pls relay all labs once available (CBC PC, Na, K, BUN, 0.5% (H) # mg given intrathecal. Sensory block up to T
Crea, ECG, CXR, PT/PTT) Modified Bromage score 3/3.
§ For Hgb <100:
GETA
o For anemia correction
v X: Preoxygenation. Midazolam 1-2 mg IV. Fentanyl 50-
o Pls secure # ‘U’ pRBC, properly typed and
crossmatched for possible OR use 75 mg IV. Lidocaine 60 mg IV. Propofol mg IV.
§ For K correction if K ≤3, Na correction ≤140 O2+Sevoflurane via face mask. Atracurium or
§ For IM-RS (for ≥40 y/o) Rocuronium mg IV.
§ *If with abnormal PE findings or labs: Refer to IM- v T: Direct laryngoscopy using Mac/Miller blade #.
Cardio/Pulmo/Endo/Nephro Cormack Lehane grade #. ETT size # mm ID inserted at
o Liver enzymes/Crea 2x ↑ level # cm. cuffed and secured. (+) SCE, CBS. Eyelids
§ Pre-op meds stop prior to OR taped.
§ *DM: CBG monitoring q6h while on NPO
§ Encourage full oral & body hygiene prior to OR GA-Double Lumen Tube (DLT)
§ Refer accordingly v X and T: Direct laryngoscopy using Mac/Miller blade #.
Cormack Lehane grade #. DLT inserted at level # cuffed
WARD CALL INTUBATION ORDERS & secured. (+) SCE, CBS. Placement confirmed using
§ Patient was referred for ANESTHESIA NOTES FOB.
intubation Ø Intubated using ETT size GA-LMA
§ GCS, BP, O2 sat 7.0mm ID inserted up to
§ Post intubation O2 sat, BP level # cm depth v X and T: LMA supreme/king size # inserted with ease. (+)
Ø For CXR-PA, ABG tracheal sounds with good air entry. (+) SCE, CBS.
Cuffed and secured. Eyelids taped
ESTIMATED BLOOD LOSS
GA-TT
§ BKA/AKA: % of limb loss based on burn rule of nines x
v X + Hooked to Tracheostomy tube and secured. (+) SCE,
estimated blood loss
§ Fully soaked lab pack: 30cc CBS. Eyelids taped
§ Kidney basin: 30 (small), 500 (big) v Use ED95 of Rocuronium or Atracurium
§ Clots x 3, wash: 120 cc
 POST-OP ORDERS (TOMDRIMO) PACU ENDORSEMENT
Ø To PACU (main OR) / RR (OB) PACU #
Ø O2 at: § Name, Age/Sex
§ Neuroaxial: 2 LPM via nasal cannula § s/p (procedure) secondary to (diagnosis)
§ GA/LMA: 5 LPM via face mask
o Jehovah’s witness
Ø Monitor v/s q15 mins x 1 hr, q30 mins for 2nd hr then q1h
o ABL, EBL, # BT transfused/ colloids used
thereafter until stable
Ø Diet: § PACU Day #, Post-op day #
§ DAT w/ SAP once fully awake (extremity/sx w/o abdominal § GCS (E V M )
manipulation) § VS: BP, HR, RR, Temp, O2 sat
§ NPO temporarily (CS/abdominal/pedia/upper airway) § UO (cc/kg/hr), VAS
Ø Regulate present IVF at maintenance fluid (MF) § If w/ MV: AC mode or SIMS, TV, PEEP,BUR, FiO2
§ pLR 1L x MF § FASTHUG
§ CS/Assisted NSD: D5LR 1L x 20 ’U’ Oxytocin x 8 hrs o Feeding (NPO/DAT) /Fluid (Present IVF)
§ Ongoing BT: pNSS 1L x KVO + 1 ‘U’ pRBC o Analgesics
Ø IVF to ff:
§ pLR 1L x MF o Sedation
§ OB: D5LR 1L + 10 ’U’ Oxytocin x 8 hrs ff by D5LR 1L + o Thromboembolic prevention
10 ’U’ Oxytocin x 8 hrs o Head (flat/elevated)
Ø Meds: o Ulcer prevention (turning q2h, Omeprazole/Rani)
§ Central acting o Glucose monitoring q6h w/ latest CBG (time)
o Butorphanol drip: Butorphanol 6mg in 500cc D5W IV § Others:
to run for 24-48 hrs OR # of cycle o Awaiting labs
o Tramadol drip: Tramadol 300mg in 500cc D5W IV to o New labs
run for 24-48 hrs x # of cycle o ABG (time): pH, paCO2, HCO3, ABE, interpretation
o Diclofenac drip: Diclofenac 150mg in 500cc D5W IV
to run for 24-48 hrs
o *Chole/Mastectomy/CTEA: Morphine 2mg in 10 cc
pNSS OR in 0.125% isobaric Bupivacaine via PRE-OP ENDORSEMENT
epidural catheter x 4 doses c/o AROD (indicate exact § PAY: 1st case, time, at OR/DR, under (name of attending
date & time q12h then write on white board) surgeon) for (procedure)
• 0.25% iso Bupi: 5cc Bupi + 5cc pNSS § Name, Age/Sex
• 0.125% iso Bupi: 2.5cc Bupi + 7.5cc pNSS § For (procedure) secondary to (diagnosis)
o *NSD/BTL: Mefenamic Acid 500mg/tab q6h x 2 days § ASA # for (history, PE, labs)
+ Tramadol 50mg IV q8h prn for breakthrough pain § PE: stable v/s, GCS, TMD, neck mobility, unremarkable
o Fentanyl infusion via EZ pump: Fentanyl 500 mcg in cardiopulmonary and abdominal PE
100cc pNSS to run for 52 hours
§ OB: FHT, IE
§ Peripheral acting
§ Significant lab results
o Ketorolac 30 mg SIVP q6h x 8 doses ( ) ANST
o Diclofenac 75mg IV q12h x 4 doses § IM RS, IM cardio granted with date and expiration (pedia)
o Paracetamol 1gm IV q8h x 3 doses § Plan (if pay, ask the consultant their plan. Don’t suggest)
§ PRN for Breakthrough pain § *ER PAY: Write at white board
o Butorphanol 0.5mg IV q6h o Room #, full name, age/sex
o Tramadol 50mg SIVP q8h o Procedure
o Fentanyl 50 mcg IV q2h (Rescue dose) o Dr. (surgeon)/Anesth – inf
§ Others o Scheduled date & time/ if no time yet (NTY)
o Omeprazole 40mg IV OD while on Ketorolac/Diclo
o Not yet in (NYI)
o *If on Tramadol/Morphine PRN for VOMITING
• Metoclopramide 10mg IV q8h
• Ondansetron 4mg q8h RTC x 48 hrs then shift
ENDORSEMENT
to prn
o Tranexamic Acid 500mg IV q8h x 3 doses § Name, Age/Sex
o *for Morphine: Diphenhydramine 50mg IV q12h prn § Procedure secondary to dx
for severe pruritus § ASA # for (history, PE, labs)
o Antibiotics c/o main service § Preinduction v/s, FHT ( OB)
Ø Others: § Induced via GETA/GETA-RSI/RA-SAB
§ Position § Intraop BP & HR range
o Spinal: Flat on bed for 6-8 hrs (post cutting) § Hypotensive episodes, Infused # units of pRBC/fluids
o GA/Epidural: mod to high back rest § # of hours tourniquet
o Optha/vitreous: prone
§ OB: pt gave birth to live Bb Girl/Boy w/ AS of
§ Keep patient well thermoregulated and comfortable
§ Encourage deep breathing exercises § EBL, ABL (CS 1L, NSD 500)
§ If estimated blood loss exceeds allowable: rpt CBC § Transfer to RR/PACU w/ stable vs & AVM
§ If ongoing BT: rpt CBC 6 hrs post BT
§ Monitor I&O qshift/q1h & record (if on Morphine) MODIFIED BROMAGE SCORE
§ *if Morphine was given: WOF signs of opioid toxicity:
0: No motor block
o BP <90/60 mmHg, HR <60, O2 sat <95%
o Severe nausea & vomiting 1: Inability to raise extended leg BUT ABLE to move knees
o Generalized pruritus and feet
o Decrease sensorium 2: Inability to raise extended leg and move knees BUT ABLE
o UO <0.5 cc/kg/hr to move feet
o Standby Naloxone 1 amp 3: Complete block of motor limb
§ Referrals: IM Cardio/Endo/Nephro/Pulmo for additional
findings if not yet referred
§ For major cases: rpt all labs (CBC,S. Na, K, Ca, Mg, Cl,
BUN, Crea, PT, aPTT) TEST DOSES
§ Refer accordingly
0.9 cc pNSS + 0.1 cc NSAID
Omeprazole – pedia skin test
 DRUG WHEN TO STOP WHEN TO RESTART
CONTINUE ON DAY OF SURGERY Antiplatelets
§ Clonidine (patch if NPO), antiarrhythmics *Dipyridamole 2 days N/A
§ Anti-hypertensives, Beta blocker *Clopidogrel 7 days 12-24 hrs
§ GERD meds: Omeprazole, Ranitidine, Motilium Anticoagulants
§ Seizure and anti-Parkinsons meds *Warfarin 5 days 24 hours
§ Benzodiazipines – risk of withdrawal when abruptly stopped *IV Heparin 4 hours 2 hours
& ↓anesthetic need infusion
§ Antipsychotics (including MAOI) - ↓seizure threshold + risk *SC Heprin BID 8-10 hours 2 hours
of Neuroleptic Malignant syndrome & TID
§ Anti-depressants *Dabigatran 4-6 days
§ Asthma meds: Bronchodilators *Rivaroxaban 3 days
§ OCPs – unless stopped for DVT prevention *Apixaban 3-5 days
§ Estrogen if used for birth control or cancer tx (unless high *Fibrinolytics 48 hours 48 hours
risk for thrombosis) *LMWH 12 hours 4 hrs (low risk) OR 12-
§ Corticosteroids (oral/inhaled) (prophylactic) 24 hrs (intermediate risk
§ Rheuma agents, Thyroid meds, HIV meds *LMWH 24 hours to high risk ORs)
§ Acetaminophen, opiates (therapeutic) 24 hours
§ Statins Vitamin K ü Recheck INR 24
§ Warfarin – cataract surgery antagonist hours prior
§ Clopidogrel – drug-eluting stents for <6 months, bare metal *initial INR >3.0 5 days ü Single dose of 1-5
stents <1 month, prior cataract surgery mg Vit K PO for
INR >1.5
§ Aspirin – vascular d/o, previous cardiac stents, prior
cataract/vascular sx, for secondary prophylaxis)
§ Autoimmune (Methotrexate if NO risk of renal failure) FOOD/FLUID MINIMUM EXAMPLES
§ Diuretics: Triamterene, hydrochlorothiazide INTAKE FASTING PERIOD
§ Eye drops Clear liquids 2 hours Water, fruit juices
§ Opioid w/o pulp, sports
§ Insulin: drinks, carbonated
o T1DM: 1/3 of intermediate to long acting (NPH, Lente) drinks, tea, coffee
o T2DM: 1/2 long acting (NPH) or combination (70/30) Breast milk 4 hours
preparations Infant formula 6 hours
o Glargine (Lantus): ↓ only if dose is ≥1 unit/kg
Non-human milk 6 hours Cow, goat, soy
o With insulin pump: continue lowest nighttime basal rate
o HOLD if CBG <100 milk
Light meal 6 hours Toast, clear
HOLD ON DAY OF SURGERY liquids, non-
§ ACEI, ARBs 12-24 hrs prior OR alcoholic drinks
§ Loop diuretics Full meal 8 hours Fried/fatty foods,
§ Weight loss meds meat, alcoholic
§ Vitamins, mineral, iron drinks
§ Oral antihyperglycemics
§ Insulin:
o Basal insulin (Lantus) taken at half dose FLUID LOSSES STRESS (+ EBL)
o Bolus insulin (Lispro) while on NPO Major sx 2-4% OR 6-8 mL/kg
o Regular insulin (exception: insulin pump, continue Moderate sx 4-6% OR 4-5 mL/kg
lowest basal rate generally nighttime dose) Minor sx 6-8% OR 3-4 Ml/kg
§ Aspirin: 5-7 days prior
o Serious bleeding > risk of thrombosis
o Primary prophylaxis (no known vascular disease) OPIOID DEMAND LOCKOUT BASAL
§ Autoimmune DOSE (mins) INFUSION
o Methotrexate (if risk of renal failure) Morphine 1-2 mg 6-10 0-2 mg/hr
o Entanercept, Infliximab, Adalimumab (NOT STOPPED Fentanyl 20-50 mcg 5-10 0-60 mcg/hr
for IBDs) Sufentanil 4-6 mcg 5-10 0-8 mcg/hr
§ OCPs (if high risk of thrombosis) Tramadol 10-20 mg 6-10 0-20 mg/hr
§ Clopidogrel Hydromorphone 0.2-0.4 mg 6-10 0-0.4 mg/hr
o Not included in group for continuation
o Drug-eluting stents for 3-6 months if risk of delaying
surgery is greater than risk of stent thrombosis
§ Estrogen if used for menopause or osteoporosis ABSOLUTE CONTRAINDICATION FOR RA-SAB
§ Antacids (Tums) § Patient refusal
§ Herbals & non-vitamin supplements: 7-14 days prior § Localized sepsis
§ Topical creams and ointments § Allergy to drugs
§ Viagra – 24 hours prior § ↑ ICP
§ Warfarin – 5 days prior if normal INR is required § Inability to maintain stillness during needle puncture
RELATIVE CONTRAINDICATION FOR RA-SAB
NSAIDS § Myelopathy or peripheral neuropathy
§ D/C for 5 half-lives of the drug § Spinal stenosis
§ Short acting: stop 1 day prior OR
§ Spine surgery
o Diclofenac, Ibuprofen, Ketorolac
§ Multiple sclerosis
o Indomethacin – 2 days prior
§ Mid acting: stop 4 days prior § Spina bifida
o Diflusenal, Naproxen, Sulindac, Meloxicam § Aortic stenosis or fixed cardiac output
§ Long acting: stop 10 days prior § Hypovolemia d/t vasodilation
o Nabumetone, Piroxicam § Thromboprophylaxis and Anti-coagulants
§ COX2 Inhibitors (Celecoxib): stop 2 days prior § Inherited coagulopathy
§ Infection
 ANESTHETHIC TECHNIQUE FOR OBESE PATIENT VT = Wt (kg) x 6-8, 1 lung 4-6
§ Premed antacid & analgesia Bag size = wt (kg) x 60 (vital capacity)
§ Glucose monitoring & control IDEAL BODY WEIGHT (Broca’s formula)
§ DVT prophylaxis § Female: 45.5 + 0.41 (ht in cm – 152) OR ht (cm) - 100
§ Self-position on operating table
§ Male: 50 + 0.41 (ht in cm – 152) OR ht (cm) - 105
§ Preoxygenate & intubate in ramped (tragus level with sternum)
or sitting position
§ CPAP and HFNO
ANTERIOR PERIPHERAL BLOCK
§ Minimal induction to ventilation time
§ Commence maintenance promptly § PEC BLOCKS – breast sx, anterior chest sx
§ Tracheal intubation o 1 = bet pectoralis major & minor (10 mg
§ Caution w/ supraglottic airway devices in BMI >40 Bupivacaine)
§ Avoid spontaneous ventilation. Use PEEP o 2 = 1+ bet pectoralis minor & serratus anterior
§ Short acting inhalations or TIVA (10+20 mg Bupivacaine)
§ Short acting opioids & multimodal analgesia
§ PONV prophylaxis § SERRATUS ANTERIOR BLOCK
§ Ensure full NMB reversal
o Clavicle – no conduction beyond the bone
§ Awake extubation & recover sitting up
o 0.25% Bupivacaine 20 cc

DOSING FOR ANESTHETIC DRUGS IN OBESE § MRM – for periop pain management
LEAN BW ADJUSTED BW TOTAL BW o PEC 2
(males max 100kg, (Ideal +
o Serratus anterior block + PEC 1
females max 70kg) 40% excess)
§ Propofol § Propofol § Suxamethonium POSTERIOR PERIPHERAL BLOCK
induction infusion § LMWHs (titrate § TRANSVERSUS ABDOMINAL PLANE (TAP) BLOCK
§ Thiopental § Neostigmine dose with Xa o 1 = external oblique, internal, transversus abdominis
§ Fentanyl (max 5 mg) levels) 2 = aponeurosis (near quadratus 5umborum) (20 cc
§ Alfentanil § Antibiotics § Midazolam Bupivacaine)
§ Morphine § Sugammadex § Fentanyl/sufenta § The more posterior, the better
§ Rocuronium § Paracetamol? § Cistracurium § NPO patient = Bull’s eye sign
§ Cistacurium § LMWH? induction § Stomach – is above aorta
maintenance § Sugammadex
§ Paracetamol § Neostigmine § RECTUS ABDOMINIS BLOCK
§ Bupivacaine § Mivacurium o Inguinal hernia to ↓ MAC
§ Lidocaine o Start at the middle
o Insert needle at aponeurosis at far end between
PONV PROPHYLAXIS BASED ON APFEL SCORE external and transversus abdominis
Risk score Prevalence Prophylaxis § Darkest – transversus abdominis
0 9% ± Ondansetron 4 mg § Thickest – external abdominis
1 20% Ondansetron 4 mg
± Dexamethasone 4 mg § PARAVERTEBRAL BLOCK
2 39% Ondansetron 4 mg o Cover 1-2 levels above & 1-2 levels below
+ Dexamethasone 4 mg § ERRECTOR SPINAL BLOCK
± Propofol infusion o On top of the bone
3 60% Ondansetron 4 mg § *Indicator that the block is correct the lungs will go up
+ Dexamethasone 4 mg
+ Propofol infusion
± Scopolamine patch EPIDURAL TEST DOSE
4 78% Ondansetron 4 mg ü 9.5cc Lidocaine (ampule) + 0.5 cc cocktail (1 cc syringe: 0.1cc
+ Dexamethasone 4 mg epinephrine + 0.9cc lidocaine)
+ Propofol infusion ü Epinephrine: 1:200,000 dilution
+ Scopolamine patch ü Top up dosing (mg): from insertion site (L3-L4/C6-C7) to target
sensory block (L3-T4: 10mg)
SIMPLIFIED APFEL SCORE PONV RISK % 30-45 mg Lidocaine OR 5-10 mg Bupivacaine
§ Female = 1 point § 1 risk factor = 20% § (+) signs of subarachnoid anesthesia
§ Non-smoker = 1 § 2 risk factor = 40% o 2-3 mins: warmth or tingling sensation on legs/feet,
§ History of PONV = 1 § 3 risk factor = 60% sensory block to cold & pinprick, motor block
§ Post-operative opioids = 1 § 4 risk factor = 80% § 2 limitations of lidocaine in pregnant:
TOTAL: 0-4 o Warmth in legs and motor weakness after injection
o Extensive sensory and sympathetic block
o High subarachnoid block
LMA SIZE = WEIGHT
§ 1,2 = pedia Lidocaine + 15 mcg Epinephrine IV
§ 3 = 30-50 kg § (+): ↑HR by at least 10 bpm & SBP 15 mmHg
§ 4 = 50-70 kg § Seizure, cardiac arrest
§ Blunt these responses: sedation, general anesthesia, β-
§ 5 = 70-90 kg blockade, elderly, and pre-existing neuraxial block
§ PRESSURE: not more than 60
DLT (Ht) Laboring women
§ MALE: >140 cm = Fr. 41, <170 cm = Fr. 39 § Pain-induce tachycardia can confuse with + epinephrine
§ FEMALE: >160 cm = Fr 39, <160 = Fr 37 response
§ Bilateral sensory change & analgesia 20-30 mins after 10-15 Ml
ETT SIZES DEPTH
of dilute local anesthetics or dilute opioid
§ Pedia uncuffed: Age (yrs)/4 + 4 § Age + 10
§ >2 y/o cuffed: Age (yrs)/4 + 3.5 § Age/2 +12 Surgical patients
§ <2 y/o cuffed: Age (yrs)/4 + 3 § ETT size x 3 § 2-chloroprocaine/ Lidocaine: warmth and numbness 5 to 10
§ Adult Female: size 7-8 § 18-20 mins after
§ Male: size 8-9 § 20-22 § Bupivacaine/ Ropivacaine: 15 to 30 mins after
 MAINTENANCE FLUID DIFFICULT MASK VENTILATION (MOANS)
SHORTCUT (24 hrs cycle) Mask seal inadequate
§ Wt (kg) + 40 Obesity/ Obstruction
HOLLIDAY-SEGAR Age >55
§ 1st 10 kg: 100 mL/kg No teeth
§ 2nd 10 kg: 50 mL/kg Stiff lungs/ Sleep apnea
§ Remaining kg: 20 mL/kg
FOR 24 HR CYCLE DIFFICULT LARYNGOSCOPY (LEMON)
§ 1st 10 kg: 4 mL/kg/24 hr = 40 Look externally: beard, small chin, buck teeth, facial trauma,
§ 2nd 10 kg: 2 mL/kg/24 hr = 20 airway bleeding
§ Remaining kg: 1 mL/kg/24 hr Evaluate 3-3-2:
FLUID DEFICIT § Inter-incisor <3
FD = [MF x NPO (hrs)] – [Input (IVF,BT) + Output (UO,edema)] § Mentohyoid <3
1st hr = FD/2 + MF § Thyrohyoid <2 fingerbreadths
2nd – 3rd hr = FD/4 + MF Mallampati score >3
4th hr = MF + Fluid loss stress Obesity/ Obstruction
Neck pathology (immobilization/surgery)
SPINAL COCKTAIL
§ 0.9 cc Bupivacaine + 0.1 cc Morphine DIFFICULT SUPRA GLOTTIC AIRWAY INSERTION
o 100 mcg/mL dilution (RODS)
o 2-3 drops Morphine Restricted mouth opening
o Usually 200-300 mcg/mL dilution Obstruction
Distorted anatomy (surgery/infection/trauma/tumor)
Stiff lungs
POST-OP CARE FOR OBESE
PACU discharge: DIFFICULT SURGICAL CRICOTHYROIDOTOMY (SHORT)
§ Discharge criteria met
Surgery to neck
§ SpO2 maintained at pre-op levels w/ minimal O2 therapy
§ No evidence of hypoventilation Hematoma to neck
OSA or Obesity Hypoventilation Syndrome: Obesity
§ Sit up and avoid sedatives and post op opioids Radiotherapy to neck
§ Reinstate patient’s own CPAP if applicable w/ additional Tumor
time in recovery until free of apneas w/o stimulation
§ Untreated, intolerant of CPAP or ineffectively treated EQUIPMENT FOR OBESE
(persistent symptoms) are at risk for hypoventilation § Suitable bed/trolley & OR table
§ IV opioids should be avoided, but if warranted, continue § Gel padding
SpO2 monitoring and level 2 care must be considered. § Wide strapping
§ Table extension/arm boards
§ Forearm cuff or large BP cuff
FACTORS ↑ MAC § Step for anesthetist
§ Acute use of amphetamine § Difficult airway equipment
§ Cocaine § Video laryngoscope
§ Ventilatory with PEEP & pressure modes
§ Ephedrine
§ Hover mattress
§ Chronic use of Ethanol § Long spinal, regional, and vascular needles
§ Highest at 6 months old § Ultrasound machine
§ Hypernatremia § Appropriately sized calf compression devices
§ Hyperthermia § Depth of anesthesia monitoring
§ Red hair § Neuromuscular monitoring
§ Sufficient staff to move the patient
FACTORS ↓ MAC § Ramping
§ Propofol o Tragus level with sternum
§ Etomidate o Reduces risk of difficult laryngoscopy
§ Barbiturates o Improves ventilation and pre-oxygenation
§ Benzodiazepine
§ Ketamine GENERAL GOOD WARD LEVEL PRACTICE
§ α2-Agonist (Clonidine, Dexmedetomidine) § Multimodal analgesia
§ Acute use of Ethanol § Caution with long-acting opioids and sedatives
§ Local anesthetics § Early mobilization
§ Opioids § Robust thromboprophylaxis regimen
§ Chronic use of amphetamine § Experienced consultant review
§ Lithium
§ Verapamil
THYROIDECTOMY
§ Elderly
§ Hyponatremia ü Vocal cord paralysis d/t accidental cut of recurrent
§ Anemia (Hgb <5 g/dL) laryngeal nerve
§ Hypercarbia ü Check vocal cord via laryngoscopy prior extubation
§ Hypothermia ü If with paralysis = can delay extubation
§ CNS hyperosmolality ü Repeat serum Calcium 6 hrs post specimen out
§ CNS depressants, Tranquilizers, Narcotics (indicate time)
§ Hypoxia
§ Pregnancy
 INNERVATION OF THE LARYNX
NERVE SENSORY MOTOR PHYSIOLOGIC CHANGES OF PREGNANCY AT TERM
Internal superior § Epiglottis Plasma volume ↑ 40-50%
laryngeal nerve § Base of tongue Total blood volume ↑ 25-40%
§ Supraglottic Hemoglobin ↓ 11-12 g/dL
mucosa NONE Fibrinogen ↑ 100%
§ Thyroepiglottic Serum cholinesterase ↓ 20-30%
joint
Systemic vascular resistance ↓ 50%
§ Cricothyroid
joint Cardiac output ↑ 30-50%
External superior Anterior subglottic Cricothyroid Systemic blood pressure ↓ slight
laryngeal nerve mucosa membrane Functional residual capacity ↓ 20-30%
Recurrent § Subglottic § Thyroarytenoid Minute ventilation ↑ 50%
laryngeal mucosa membrane Alveolar ventilation ↑ 70%
§ Muscle § Lateral Oxygen consumption ↑ 20%
spindles cricoarytenoid Carbon dioxide production ↑ 35%
membrane Arterial carbon dioxide tension ↓ 10 mmHg
§ Interarytenoid Arterial oxygen tension ↑ 10 mmHg
membrane Minimum alveolar concentration ↓ 32-40%
§ Posterior
cricoarytenoid
membrane
PREOXYGENATION/ DENITROGENATION
ü 8 Vital capacity breaths / deep breaths of 100% oxygen
MEDS & ANESTHETIC IMPLICATIONS PRE-OP over 60 seconds
MEDS ANESTHETIC RECOMMENDATION o 4 vital capacity breaths of 100% oxygen over 30
AMINOGLYCOSIDES Potentiates non- Monitor NMBs carefully seconds = high arterial Pao2 (339mmHg)
depo relaxants ü Tidal volume breathing of 100% oxygen at 10-12 LPM via
CLONIDINE ↓anesthetic Continue on day of sx, tight fitting mask for 5 minutes
requirement; can use dermal periop
HTN crisis o Will give 8 mins apneic time before desaturation
o BOTH replaces 80% of FRC with oxygen
LITHIUM Potentiates Monitor NMBs & s. Na;
NMBs; induces avoid Na-wasting ü Sevoflurane
hypothyroidism diuretics; obtain thyroid o Low pungency
func tests o Rapid onset
MAO INHIBITORS ↑catecholamine Avoid indirect-acting & o High potency permitting delivery of high-inspired
stores; ↓direct-acting oxygen concentration
hepatotoxic sympathomimetics; do ü Priming
LFTs; Avoid Meperidine; o Filling the breathing circuit with 8% sevoflurane by
Discontinue 14-21 days
emptying the reservoir bag
for elective sx
o Open adjustable pressure-limiting valve
WARFARIN Excessive Withdraw in advance;
intraop bleeding substitute Heparin b/c it o Use high fresh gas flow (8L/min) for 1 min before
may stop immediately applying the face mask
preop & restarted o Can produce loss of consciousness for 1 minute

↑ETCO2 ↑ ETCO2 FENTANYL

Change in CO2 production § Continuous infusion IV (off label):
§ Hyperthermia § Hypothermia o Critically ill: 50-700 mcg/hr (based on 70 kg) OR 0.7-
§ Sepsis § Hypometabolism 10 mcg/kg/hour
§ MH muscular activity o When pain is not controlled, may administer
additional small bolus dose (25-50 mcg) prior
Change in CO2 Elimination increasing the infusion rate
§ Hypoventilation § Hyperventilation § Pain in mechanically ventilated patients (off label):
§ Rebreathing § Hypoperfusion o Loading dose: 1.5 mcg/kg
§ Embolism o Maintenance dose: 0.008 to 0.25 mcg/kg/minute OR
0.5-15 mcg/kg/hour
RAPID SEQUENCE INTUBATION § Adult w/ renal impairment
ü Preoxygenation o No dose adjustments required
o <7 to 10% is excreted as unchanged drug and its
ü Propofol
ü Succinylcholine 1-1.5 / Rocuronium 0.6-1.2 metabolites are inactive.
o Remifentanil pharmacokinetics are unchanged in
ü Apply cricoid pressure (Sellick maneuver)
o 30 newtons/ 7 lbs patients with ESRD
o In critically ill w/ renal impairment, Fentanyl or
ü Avoid mask ventilation
o Modified RSI: positive pressure <25 cmH2O Hydromorphone are preferred.
§ Adult w/ hepatic impairment
§ Minimize the risk of gastric insufflation
§ Needed in pts with hypoxemia prior intubation o No dose adjustments required
o Remifentanil pharmacokinetics are unchanged in
ü Tracheal intubation
ü Release of cricoid pressure after confirmation of correct patients with severe hepatic impairment
ETT placement
 DRIPS Theophylline
Nicardipine drip § Aminophylline 250 mcg + 250 cc pNSS to run in 24 hrs
§ 1-2 mg SIVP
§ Nicardipine 10 mg/amp + 90 cc pNSS or D5W to start at 5 Insulin
cc/hr, titrate to maintain BP of ____ (conc 0.1 mg/mL), titrate § Causes potassium shift (extracellular K+ goes intracellular)
±5cc/hr until target BP is achieved (max 15 mg/hr) § 50 mL of D50-50 + 10 ‘U’ RI in 2-5 mins
§ Mix 1 amp D50-50 + 10 ‘U’ Humulin R IV q6h x 4 doses
Nitroglycerine drip § Regular insulin 100 ‘U’ + 100 cc pNSS in soluset to run
§ Organic nitrate causes systemic venodilation, ↓ preload & starting at 0.1 mkd or 0.14 mkd
afterload and ↓ myocardial oxygen demand. Improves
coronary collateral circulation Furosemide
§ 10 mg NTG + 90 cc D5W to start at 5 mcg/min q5mins until § Max at 1.2 mL/kg/hr
pain relief is achieved and BP is controlled, titrate by 3 cc/hr § Furosemide 100mg + 90 cc pNSS in soluset to run in 5cc/hr,
§ 10mg NTG + 90cc pNSS to make 100cc in soluset x 10 cc/hr uptitrate by 5 cc/hr with BP precaution
o May ↑ 2cc/hr to achieve chest pain free § Furosemide 100mg + 90 cc pNSS
o Wt (kg) x 0.2-1.2 = mL/hr titrate hourly with BP
Noradrenaline/Norepinephrine (Levophed) precaution and maintain urine output >0.5 mL/kg/hr
§ 2000/wt (kg) = A/60 = B/0.01 = total volume § Furosemide 200mg + 80 mL pNSS
o (1 cc = 0.01 mkm) o Wt (kg) x 0.2-1.2 = answer / 2 = mL/hr
§ For septic shock: 8 mg + 250 cc D5W to run at 0.1-0.5
mcg/kg/min (0.3) max 3, titrate by 0.02 mcg/kg/min every 15 Pantoprazole/ Omeprazole
mins to maintain SBP >100-110 mmHg § Pantoprazole 80mg + 80cc pNSS to run at 10cc/hr for 8 hrs
§ 4 mg + 46 cc pNSS in soluset to run starting at 0.50 mkd,
uptitrate by 0.3 q30 mins until desired BP (max: 3mkd) Morphine
§ 0.05-0.1 cc/kg/hr (max: 0.1 mg/kg/hr)
Dopamine § 80 mg Morphine in 500 cc D5W, preparation: 0.16 mg/cc
§ Augment BP and cardiac output in cardiogenic shock. § Rescue: 0.2-0.5 mg/kg/day q4h
§ Stimulates α1/β1 receptors
§ 1-2 mkm: renal vasodilation Isoxsuprine
§ 2-4 mkm: increase cardiac output, no change in HR/SVR § 4 amps Isoxsuprine + 500 cc D5W to run at 10 µgtts titrate
§ >5 mkm: vasoconstriction, increase HR q20 mins with 5 µgtts increments until with no uterine
contraction. Downtitrate if with tachycardia or palpitation.
§ Drip factor 13.3: 200 mg Dopamine (1 amp) + 250 cc D5W § Max dose: 60 µgtts
at 2-5 mcg/kg/min (max: 20-50)
§ Drip factor 26.6: 400 mg (2 amps) + 250 cc D5W at 2-5 Lidocaine
mcg/kg/min (max: 20-50) § 4 cc + 96 cc pNSS to run for 24 hrs (for V. Tach)
Dobutamine Heparin
§ Asynthetic sympathomimetic amine with positive inotropic § 5000 ‘U’ (5 vials) in 25 cc pNSS (500 ’U’ per cc) to run at 18
action, ↑HR/contraction. u/kg/hr
§ 2.5 mkm: minimal + chronotropic BP q15-30 mins § Recheck APTT q6h
§ >10 mkm: vasodilatory effect on pt with ↓ SVR
Iron Sucrose
§ Drip factor 16.6: 250 mg Dobutamine + 250 cc D5W at 3 § 2 amps in 100 cc pNSS to run for 4 hrs every other day
mcg/kg/min titrate by 1 mcg/kg/min to maintain SBP >90
§ Drip factor 33.2: 500 mg Dobutamine + 250 cc D5W at 3 Midazolam
mcg/kg/min § 50 mg + 50 cc pNSS to run at 5 cc/hr
§ 200 mg (20cc amp) + 30 cc D5W or pNSS at 5 mkd, uptitrate
at 2.5mkd q30mins or qhourly until desired BP

Hydralazine/Apresoline SPINAL SELECTIVITY OPIOID

§ Apresoline 40mg (20mg/amp) + 250cc D5W at 5-30 High Morphine; Diamorphine
µgtts/min (max: 60)
§ Max daily dose: 3.5 mg/kg per 24 hrs Moderate Fentanyl; Sufentanil
Low Alfentanil
Isoket/ ISDN
§ ISDN 10 mg + D5W/ pNSS 90 cc in soluset to run at 5 cc/hr,
uptitrate by 5 cc/hr until chest pain free DRUG FENTANYL MORPHINE
o 10-50 µgtts/min = 1-5 mg/hr (lipophilic) (hydrophilic)
o If with CHF: double dose with 20 mg Onset Fast (10-20 mins) Slow (60 mins)
o CKD: 20 mg + 80 cc (2.5 cc/hr) Rostral speed Minimal Significant
Duration of Short (4-6 hrs) Long (18-24 hrs)
Clonidine Action
§ 600 mcg + 500 cc pNSS titrate to BP ≤ 140/90 Time of
Respiratory 0-1 hr Up to 24 hrs
Amiodarone Depression
§ 600 mg + 250 cc D5W to run for 24 hrs

Somatostatin
§ 250 mg IV bolus then
o 3 mg in 250cc D5W x 12 hrs
o 3 mg in 500cc D5W x 42 hrs (250 mg/hr)

§ 3 mg in 1 mL in 23 cc pNSS total of 3 mg in 24 cc pNSS

o 0.25 mg IV bolus
o Remaining give D5W 250 cc x 24 hours
 HYPOKALEMIA GENERAL ANESTHESIA CHANGES
ü KCl 750 mg 1-2 tabs TID/QID PO § ↓ FRC 20%
ü KCl 10 mEqs + 100 cc pNSS to run at 5 cc/hr § ↓ Diaphragmatic function – abnormal ventilation/
ü KCl 40 mEqs + 500 cc pNSS x 12 hours perfusion & atelectasis
ü KCl 20-60 mEqs + SS 12 hrs § Inhibit mucociliary clearance
o 0.2-1.4 decrease in K+ if with glucose § ↑ alveolar – capillary permeability
o Kalium durule/ banana: 10 mEqs § Inhibition of surfactant production
o NaHCO3: 45 mEqs § ↑ nitric oxide synthetase
HYPERKALEMIA § ↑ sensitivity of pulmonary vasculature to neurohumoral
§ Normal Crea: STOP K+ drugs mediators
§ Increased Crea:
o MILD <5.5: Restrict K+ drugs
o MOD 5.5-6.5 + Peak T waves: OCULOCARDIAC/ ASCHNER-DAGNINI REFLEX
§ Furosemide 40-80 mg IV § ↓HR by 10% d/t traction to extraocular muscle &
§ Kayexelate 20 gm OR compression of eyeball
§ Kalimate 1 sachet + 100 cc water TID x 3 doses § Trigeminovagal reflex
§ Salbutamol neb o Afferent: Trigeminal nerve
o SEVERE >6.5 + loss of T waves: o Efferent: Vagal nerve
§ Cal gluc 10 mL 1 amp + 10% solution SIVP for § 1.5 hrs after retrobulbar
15-20 mins
o K+ 7-8 + widened QRS complexes: SERUM NA+ CNS CHANGES ECG CHANGES
§ Cal gluc 10 mL/ 1 gm 1 amp + 20 cc pNSS SIVP 120 Confusion, Wide QRS
rpt q10mins restlessness complex
§ 10 ‘U’ Humulin R + D50 50 mL 2-5 mins q6h 115 Nausea, Wide QRS,
§ NaHCO3 1 amp + 100 cc D5W SIVP >10 mins somnolence elevated ST
(fastest) 110 Seizure, coma VT/ V. Fib
HYPONATREMIA
§ Na deficit: Desired – Actual x BW (kg) x 0.6
RELIABLE INDICATORS OF ETT POSITION
o Desired: 125-135 mEq/L
§ Repeated detection of at least 15 mmHg (2%) exhaled
§ Time to infuse: Desired – Actual = answer/0.5
CO2
§ Amount of pNSS needed: Na deficit/ 154
§ Confirming by laryngoscopy the passage of the ET
§ Drip rate: amount of pNSS needed/ time to infuse
between the vocal cords
§ NaCl tab 1-2 tabs TID
§ Seeing tracheal rings through a fiberscope passed
§ Re-check serum Na q6-12h
through the ET
HYPOCALCEMIA
§ Aspiration of 50 mL air abruptly from the tube with a
ü Cal gluc 10% solution of 10 mL/amp, 1 amp SIVP to give suction bulb
for 15-20 mins SD w/ cardiac monitor
ü Calcium gluc 10 amps or 900 mg Calcium in pNSS /D5W
1L x 2 hrs ANATOMIC FEATURES OF UPPER AIRWAY IN INFANTS
o 1 amp (93 mEqs per 10 mL) § Larger occiput naturally positions in sniffing position
ü CaCO3 500 mg/tab, 1 tab BID/TID § Stabilize the head against lateral rotation
ü Vit D 25-10000 IU OD § Obligate nose breathers for the first few months
ü Calcitriol 0.25 mcg/cap OD/BID
o Corrected Ca+ = S. Ca + 0.8 x (4-albumin mg/dL) § Relative large tongue volume in the mouth reduces the
o 0.5-2 mEqs/kg/hr available space for instrumentation
o 93 mEqs/amp § Edentulous
HYPERCALCEMIA
ü Hydration: 1-4L in 24 hours § Larynx is more cephalad in the neck (C3-C4)
ü Furosemide 20-40 mg IV q8h-12 hrs § Epiglottis is omega shaped, longer, narrower, more
HYPOMAGNESEMIA compliant, and at a more acute angle with the glottis.
ü MgSO4 1 gm + pNSS SIVP bolus x 10 mins x 3 doses § Glottis is positioned at a higher cervical level.
o 1 = cut off for cardiac § Aryepiglottic folds are closer to the midline.
§ Vocal cords slant caudally at their insertion in the
arytenoids
PaO2 = 80 – (Age – 60)
§ Narrowest part of the upper airway is the cricoid ring
Desired FiO2 = Current FiO2 x Desired PaO2
covered by pseudostratified columnar epithelium
Current PaO2 in ABG
o Adult: rima glottidis
§ Trachea is short (4-5 cm)

LAYERS TRAVERSING IN MEDIAL SPINAL ANESTHESIA § Acute angle of the right mainstem bronchus at the carina
Skin → subcutaneous fat → supraspinous/interspinous § Turbulent gas flow until the 5th bronchial division
ligament → ligamentum flavum → epidural space → dura (resistance is inversely related to the radius to the 5th
mater → subdural space → arachnoid mater → power)
subarachnoid space
INDICATION IN EPIDURAL SPACE
§ “snap” supraspinous ligament
§ “mushy” intraspinous ligament
§ “gritty” ligamentum flavum = pop