33. PRESSURE SYSTEM
HIGH
ā¢ FROM CYLINDER TO
PRIMARY PRESSURE
REGULATOR
ā¢ cylinder
ā¢ yoke assembly
ā¢ oxygen assembly
ā¢ 1st pressure
reducing valve
INTERMEDIATE
ā¢ 1ST PRESSURE
REDUCING VALVE TO
FLOW CONTROL
VALVE
ā¢ Pipeline source
ā¢ Flow control valve
ā¢ 2nd pressure
reducing valve
LOW
ā¢ DOWNSTREAM TO
FLOW CONTROL
VALVE
ā¢ Rotameter
TONY SCARIA
2010 KMC
34. Fail safe valve in case of
hypoxia shuts off &
decreases supply of
nonoxygen gases ļ
increasing delivery of O2
Oxygen enters downstream
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2010 KMC
35. Hypoxia prevention
ā¢ Oxygen flail valve
ā¢ Low pressure oxygen alarm
ā¢ oxygen is located at downstream position
TONY SCARIA
2010 KMC
42. Gas Pin index Colour of cylinder
Air 1,5
02 2,5 Black body ,white shoulder
Nitrous oxide 3,5 blue
C02 1,6 Grey
Cyclopropane 3,6 Orange
Entonox 7 Blue body with Blue Quartered
Shoulders
Ethylene red
halothane Amber
helium Brown
TONY SCARIA
2010 KMC
45. O2 cylinders
ā¢ Black with white shoulder
ā¢ Pressure -2000 psi
ā¢ As liquid O2
ā¢ Size from AA to H
ā¢ Most commonly used is E
TONY SCARIA
2010 KMC
55. Mapleson D / bain co-axial system
ā¢ Best for controlled ventilation
TONY SCARIA
2010 KMC
56. Mapleson E/ Ayres tube
ā¢ Jackson rees modification of t piece
ā¢ Best circuit for children in spontaneous and assisted ventilation
ā¢ Infants & young children
TONY SCARIA
2010 KMC
58. Circuit type type F (Ja Required fresh gas flow Comments
Spontaneous Controlled
Type A (magill) Equal to minute
volume
Very high &
difficult to
predict
ā¢ Circuit of choice for
spontaneous ventilation
ā¢ Not used for controlled
ventilation
Type B 2*minute
volume
2-2.5 times
minute volume
Type C 2* minute
volume
2-2.5 times
minute volume
ā¢ AMBU bag
ā¢ Co-axial system
Type D (bain circuit) 2-3 times
minute volume
1-2 times
minute volume
ā¢ Circuit used for controlled
ventilation
ā¢ Most commonly used circuit
ā¢ Can also be used for
spontaneous ventilation
Type E (Ayre T piece) 2-3 times
minute volume
3 times minute
volume
ā¢ Circuit of 2nd choice in children
Type F(Jackson rees ) 2-3 times
minute volume
2times minute
volume
ā¢ Circuit of choice in children
TONY SCARIA
2010 KMC
66. Mapleson f
ā¢ Used in infant
ā¢ Jackson rees modification of
Ayres t piece
ā¢ Light weight
ā¢ Fresh gas flow is close to
respiratory tract
ā¢ No valves ļ low resistance
ā¢ High gas flow ļ hence CO2 does
not accumalate
ā¢ Drying of respiratory epithelium
TONY SCARIA
2010 KMC
70. C02 absorbents
ā¢ Circle systems
ā¢ From expired gas CO2 is absorbed by C02 absorbents and then recirculated in
to the patient
ā¢ Soda lime
ā¢ Baralyme
ā¢ Amsorb plus
TONY SCARIA
2010 KMC
72. Soda lime
ā¢ Most commonly used
ā¢ 94% ca hydroxide
ā¢ 5% NaOH
ā¢ 1% KOH
ā¢ Silica ļ to provide hardness & prevent alkaline dust formation
ā¢ Size 4-8 mesh
ā¢ Clayton yellow ļ pH indicator
ā¢ As more CO2 is absorbed colour , pink ļ yellow/white
TONY SCARIA
2010 KMC
73. Drugs contraindicated in circle systems
ā¢ Trichloroethylene
ā¢ Sevoflurane
ā¢ Methoxyflurane
ā¢ chloroform
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2010 KMC
74. Baralyme
ā¢ BaOH (instead of NaOH )5%
ā¢ 80% ca hydroxide
ā¢ 6% KOH
ā¢ Less heat caustic and less heat prdn
ā¢ No silica is necessary to produce hardness
ā¢ Indicator
ā¢ Mimiza Z and ethyl red as indicator
ā¢ Pink ļ red
TONY SCARIA
2010 KMC
75. Amsorb plus
ā¢ Calcium hydroxide
ā¢ Calcium chloride
ā¢ Water
ā¢ Hardness ļ caso4 & polyvinyl pyrrolidine
TONY SCARIA
2010 KMC
77. Guedels staging of anaesthesia for ether
ā¢ Stage 1 (stage of analgesia)
ā¢ Hearing is last sense to be lost
ā¢ Stage 2 stage of delirium
ā¢ Stage 3 stage of surgical anaesthesia
ā¢ Entire relaxation
ā¢ No muscular rigidity
ā¢ Deep regular breathing
ā¢ Satge 4 stage of medullary paralysis (respiratory paralysis)
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2010 KMC
82. Monitoring of depth of anaesthesia
ā¢ Bispectral index : most commonly used
ā¢ Electrode strip placed on forehead ļ electrical activity recorded in the form
of EEG
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2010 KMC
88. 4 PHASE & 2 ANGLES
PHASE 1 ļ INSPIRATORY
BASELINE ļ DEVOID O
CO2
Ī±ANGLE ļ 110*c
TRANSITION FROM
DEAD SPACE TO
ALVEOLI GASES
Ī² ANGLE= 90 *
DEAD SPCE GAS
TONY SCARIA
2010 KMC
89. ETCO2
ā¢ Normal = 35 -45 mmHg
ā¢ 2-5 mmHg LOWER THAN ARTERIAL PaCO2
ā¢ ETCO2 at end expiration
ā¢ Inversely proportional to alveolar CO2
ā¢ Uses
ā¢ Malignant hyperpyrexia (first indicator)
ā¢ Degree and adequacy of alveolar ventilation
ā¢ Correct placement of endotracheal tube (best indicator)
ā¢ In esophageal intubation
ā¢ Absence of CO2 in exhaled air or <10 mm
TONY SCARIA
2010 KMC
90. ETCO2
ā¢ Circuit Disconnection indicator
ā¢ Sudden cessation of CO2 in expiratory phase
ā¢ Indicator of degree of rebreathing (presence of CO2 in inspired air)
ā¢ Massive fall of ETCO2
ā¢ Air embolism
ā¢ Indicator of cardiac output
ā¢ Hypovolemia
ā¢ Pulmonary embolism (following craniotomies major complication)
ā¢ Cardiac arrest
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2010 KMC
101. Deoxy Hbļ red light
oxy Hbļ IR light
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2010 KMC
102. PRINCIPLE OF PULSE OXIMETRY
ā¢ AMOUNT OF LIGHT
ABSORBED Ī±
CONCENTRATION OF
LIGHT ABSORBING
SUBSTANCE
BEERS
LAW
ā¢ LIGHT ABSORBED IS
PROPORTIONAL TO
DISTANCE TRAVELLED
(LENGTH)
LAMBERTS
LAW
TONY SCARIA
2010 KMC
104. Error in SpO2
ā¢ COHb
ā¢ methHb
ā¢ Intravasular dye(methylene blue)
ā¢ Low blood volume (hypovolemia)
ā¢ Nail polish
ā¢ Ambient pressure
ā¢ MOVEMENT OF LIMB
TONY SCARIA
2010 KMC
105. Central venous pressure
ā¢ CVP parallels right atrial P
ā¢ Normal 5-10 cm of H2o(2-7 mmHg)
ā¢ Veins used (seldinger technique)
ā¢ Right internal jugular V***
ā¢ Short straight and valveless
ā¢ Tip of catheter should be at junction of SVC and RA
ā¢ Subclavian
ā¢ Femoral
ā¢ Antecubital TONY SCARIA
2010 KMC
106. MEASUREMENT OF CENTRAL VENOUS
PRESSURE: MANOMETRY
When the stopcock
is turned to direct flow of fluid to the patient, the manometer
is
bypassed.
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2010 KMC
107. To measure central venous pressure, first
turn the stopcock to fill the manometer to
25 cm H2O.
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2010 KMC
108. Next, open the stopcock to the patient and the manometer.
Allow the column of water in the manometer to fall and
stabilize before a reading is taken. Note that the zero mark
must be horizontally aligned with the tricuspid valve (which is
estimated as the
midaxillary line in a supine patient)
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2010 KMC
109. Indications for CVP
ā¢ TPN
ā¢ Open heart surgeries
ā¢ Shock (fluid management)
ā¢ Major surgeries
ā¢ Apirating air embolus
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2010 KMC
111. Hypothermia
ā¢ Temp monitoring in skin rectum nasopharynx
ā¢ Hypothermia causes
ā¢ delayed metabolism of drugs & delayed awakening
ā¢ Shivering
ā¢ Increased o2 consumption
ā¢ Shift of ODC to left
ā¢ Temperature is maintained
TONY SCARIA
2010 KMC
116. Monitoring of neuromuscular blockade
ā¢ Tetany: A sustained stimulation (5 s)
ā¢ Train-of-four (TOF): Four pulses in rapid succession
ā¢ Double-burst stimulation (DBS): A series of 3 pulses followed after a
pause by 2 or 3 pulses.
ā¢ Post-tetanic potentiation: When a pulse is sent after a tetanic
stimulation, it will bring on a stronger twitch than at first.
ā¢ non-depolarizing muscle blockers, there is a fade phenomenon where
twitch amplitude decreases from the first stimulationTONY SCARIA
2010 KMC
119. Train of four
ā¢ Used for neuromuscular monitoring
ā¢ 4 stimuli each of 2 Hz& each for 2second
ā¢ Ratio of T4 to T1 is taken
ā¢ With depolarisers all 4 ampitudes are of same in phase I(T4:T1=1)
ā¢ In phase II & in nondepolarising block
ā¢ Decrease proportionately in response to T1
ā¢ Fading
ā¢ Raito of 0.3 ļ required for most surgeries
ā¢ Ratio of 0.7 ļ for reversal
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2010 KMC
120. ā¢ Adductor pollicis (ulnar nerve)
ā¢ Used for monitoring
ā¢ Paralysis of adductor pollicis ļ adequate blockade of laryngeal & pharyngeal
muscle ļ neuromuscular blockade
ā¢ Absence of activity in orbicularis oculiļ blockade in laryngeal muscle
ā¢ Diaphragm requires 90%of recptor occupation while for Sx only 70 -
75 % is needed
TONY SCARIA
2010 KMC
121. Myasthenia gravis
ā¢ Anaesthesia of choice
ā¢ Isoflurane,propofol
ā¢ Muscle relaxant
ā¢ Atracurium /cisatracurium (1st
choice) ,mivacurium,rapacurium
ā¢ myasthenia is resistant to
depolarising muscle relaxant
ā¢ Myasthenia is sensitive to
nondepolarising
Contra indicated
ā¢ Aminoglycosides
ā¢ Tertacycline
ā¢ Polypeptide Abx
ā¢ Procainamide
ā¢ Pencillamine
ā¢ B blockerTONY SCARIA
2010 KMC
122. Porphyrea
Safe
ā¢ Inhalational
ā¢ N2O,halothane,cyclopropane
ā¢ IV agents
ā¢ Propofol
ā¢ NM blocking agents
ā¢ dTC ,suxmethonium,pancuronium
ā¢ NM reversing agents
ā¢ Atropine,gycopyrrolate ,neostigmine
ā¢ LA safe
ā¢ Lignocaine,bupivacaine,prilocaine,tertrac
ine
Contraindicated
ā¢ IV agents
ā¢ barbiturates.,etomidate
ā¢ LA
ā¢ Ropivacaine
ā¢ Analgesic
ā¢ Pentazocin
TONY SCARIA
2010 KMC
124. Day case surgery
ā¢ DOC for inductionļ propofol
ā¢ Muscle relaxant ļ Sch,mivacurium
TONY SCARIA
2010 KMC
125. Mnemonic day case surgery
ā¢ Manmohan Singh Is A Prime Minister
ā¢ Mivacurium
ā¢ SCh
ā¢ Isoflurane
ā¢ Alfentanyl
ā¢ Propofol
ā¢ Midazolam
TONY SCARIA
2010 KMC
126. Liver failure
Drugs used
ā¢ Isoflurane (hepatic blood flow is
least affected)
ā¢ NM blockerļ cisatracurium
Contraindicated
ā¢ Halothane
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2010 KMC
134. MORPHINE
ā¢ Poisoning
ā¢ Pinpoint pupil
ā¢ Respiratory depression ļ death
ā¢ Rx
ā¢ Naloxone 0.6mg IV repeated every 3 mins till rr peaks up
ā¢ No agonistic action and no resp depression
ā¢ Morphine ļ tolerance except for miosis & constipation
ā¢ Morphine withdrawal
ā¢ Rhinorrhea,hyperhidrosis,sweating,diarrhea,goose flesh
ā¢ Withdrawal of morphine substitute with oral methadone & gradual
withdrawal of methadone
TONY SCARIA
2010 KMC
136. ā¢ Opiods ļ spasm of sphincter of oddi & increase biliary P
TONY SCARIA
2010 KMC
137. ā¢ Opiod with high protein binding
ā¢ Alfentanyl,sufentanyl
ā¢ Very high lipid solubility
ā¢ Sufentanyl,fentanyl
ā¢ With very high ionized fraction
ā¢ Alfentanyl
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2010 KMC
138. Remifentanyl
ā¢ Ultrashort acting opiod
ā¢ Metabolised by RBC and tissue esterases
ā¢ Not influenced by heptic or renal clearance
TONY SCARIA
2010 KMC
142. Modes of ventilation
ā¢ Non invasive ventilation
ā¢ Face mask /nasal cannula
ā¢ Invasive ventilation
ā¢ Mechanical ventilation
ā¢ With endotracheal intubation
TONY SCARIA
2010 KMC
143. Mechanical ventilation
ā¢ Indications
ā¢ Hypoxemic respiratory failure
ā¢ Most common indication
ā¢ ARDS, HF with pulmonary edema ,pneumonia
ā¢ Hypercarbic respiratory failure
ā¢ COPD ,neuromuscular disease
TONY SCARIA
2010 KMC
144. ā¢ Positive pressure ventilation
ā¢ Positive
ā¢ Air pushed in to trachea
ā¢ Most commonly used
ā¢ Negative pressure ventilation
ā¢ Negative pressure is created in alveoli
ā¢ Air is sucked in to lung
ā¢ Not used
TONY SCARIA
2010 KMC
145. Ventilator
ā¢ Volume preset time cycled
ā¢ Delivers fixed tidal volume at regular intervals
ā¢ Most commonly used
ā¢ Pressure preset time cycled
TONY SCARIA
2010 KMC
146. Modes of ventilation
ā¢ Total ventilator support
ā¢ Ventilator provides mechanical breath , patients effort is NIL
ā¢ Patient is passiveā¦ventilator is active
ā¢ Intermittent positive pressure ventilation
ā¢ Volume controlled mechanical ventilation (CMV)
ā¢ Flow delivery is governed by preset flow rate and volume
ā¢ Pressure controlled ventilation
ā¢ Flow delivery is governed by preset inspiratory pressure
ā¢ Partial ventilator support
TONY SCARIA
2010 KMC
147. Partial ventilator support
ā¢ Assisted mechanical ventilation (AMV)
ā¢ Ventilator assists a breath initiated by patient
ā¢ Assist contolled mechanical ventilation
ā¢ Intermittent mandatory ventilation (IMV)
ā¢ Synchronised intermittent mandatory ventilation (SIMV)
ā¢ Pressure support ventilation
TONY SCARIA
2010 KMC
149. Positive airway pressure ventilation
ā¢ PEEP
ā¢ Positive pressure applied at the end of expiration
ā¢ Used during mechanical ventilation
ā¢ CPAP
ā¢ During both expiration and inspiration
ā¢ During spontaneous respiration
TONY SCARIA
2010 KMC
150. Indications for CPAP
ā¢ Abnormal physical examination
ā¢ Increased work of breathing,
ā¢ Substernal & suprasternal retraction,grunting, nasal flaring ,cyanosis , increases RR
ā¢ Inadequate ABG
ā¢ Abnormal CXR
ā¢ Poorly infiltrated/abnormal infiltration
TONY SCARIA
2010 KMC
152. Weaning from ventilator
ā¢ Discontinuing the ventilator support
ā¢ From any mode possible but not from control mode ventilation
ā¢ Because in CMV patient support is nil and Tidal volume is delivered by
ventilator
TONY SCARIA
2010 KMC
153. Weaning from ventilator
ā¢ Modes used are
ā¢ SIMV
ā¢ IMV
ā¢ Assisted controlled ventilation(ACV)
ā¢ Pressure support ventilation (PSV)
ā¢ SIMV+PSV
ā¢ T piece
ā¢ CPAP
TONY SCARIA
2010 KMC