..."VIRGINIA APGAR was an American obstetrical anesthesiologist, best known as the inventor of the Apgar score, a way to quickly assess the health of a newborn child immediately after birth."
P.S. STUDY of Anaesthesia requires knowledge of Physics, Physiology, Pharmacology, Lot of Medicine, Some of Surgery and Many Technical skills!
Anaesthesia also includes ICU (Intensive Care Unit) and is managed by Anaesthesiologists all over the world (unlike yesteryears by Physician) because of knowledge and skills involving Intubation, ventilators, resuscitation, managing critical clinical scenario, advanced life support, inserting various lines like central line, arterial line and many skills! Anaesthesiologist integrates all inputs from various specialists in the ICU for managing the patient!
Anaesthesiologist is the only specialist who is OMNIPRESENT in a hospital: all kinds of operation theatres; A&E (Casualty); ICU (Intensive Care Unit); Wards for Resus and procedures; Out Reach Team; CT, MRI, Radiological intervention suite; Pain Clinic; Intra and inter hospital transfers besides scopes for audit, research, publication and presentation at various forums!
INDUCTION (start) of GA (general anaesthesia - for reversible uncounsciousness) is done by these 4 drugs type after Preoxygenation with 100% oxygen for 3 minutes!
P.S. The 4 drugs (other drugs and gases can also be used) are shown in the pic: the 4 drugs for 4 types of effect or control: 1. Amnesia, 2. Analgesia, 3. Muscle Relaxation and 4. Homeostasis. Even local and regional blocks involve few of these four!
1. Amnesia by 1% Propofol in the dose of 1-2 mg/kg iv in an adult. Generally, 100mg in 10 ml suffices in an Indian adult.
For maintenance of amnesia: Nitrous oxide in Oxygen (2:1 ratio or 1:1 as Entonox) with Isoflurane 1-2% (inhalational volatile anaesthetics - MAC 1.2 - 1 ml vapourises into about 200 ml vapour, which is picked up by oxygen and nitrous oxide gases flowing through the vapouriser)
2. Analgesia by Butorphenol 1 mg iv (agonist-antagonist opioid, which lasts for 1 hour)
For maintenance of analgesia: Nitrous oxide has analgesic property + Fentanyl 1-2 ug/kg in divided doses and/or Morphine 100 ug/kg upto 5-10 mg iv total dose in an adult. NSAID like Diclofenac 75 mg is added to iv fluid like RL (Ringers Lactate). Various nerve blocks can be done with local anaesthetics like Bupivacaine 0.5% or Lignocaine 2% depending on the site of surgery.
3. Muscle relaxation by Suxamethonium 1-2 mg/kg iv (double molecule of acetylcholine mimics acetylcholine at the neuromuscular junction and causes persistent depolarisation leading to fasciculation, which ends into flaccid paralysis) - helpful in laryngoscopy and Intubation.
For maintenance of muscle relaxation, Vecuronium is given in the dose of 100 ug/kg iv initially (total in an adult 3-4 mg) and then topped up with about 20% of initial dose (1 mg in an adult) every half an hour to keep the patient immobile during the surgery.
4. Homeostasis by Glycopyrrolate 200 ug iv for preventing bradycardia and for decreasing salivation. which might be aspirated or blur the field of vision while doing laryngoscopy.
For maintenance fluids like Ringer Lactate to replenish lost fluid during fasting since 10:00 pm the night before (lost through evaporation from skin, in expired gas as vapour, in urine etc). The fasting fluid is 2 ml/kg/hour of fasting. If the heart rate goes down and below 50-60/min, Atropine 20 ug/kg iv or Glycopyrrolate 10 ug/kg iv is given. If blood pressure goes down below 90 mm Hg Systolic, Mephentermine 6 mg iv bolus is given. Likewise, for high blood pressure Nitroglycerin 1-2 ug/kg iv can be given in small incremental doses seeing the response. Further fluid is given according to 4-2-1 rule - first 10 kg of body weight 4ml/kg, second 10 kg of body weight 2ml/kg and the remaining body weight @ 1 ml/kg. Various kinds of fluid like Normal Saline, Hetastarch, Pentastarch, Haemaccel and even blood and blood products might be needed depending on blood loss.
Homeostasis involves lot many things to do to keep the internal environment of the body constant. Surgeons maintain haemostasis. For example in prolonged surgeries, ABG (arterial blood gases) might be needed to see the acid-base status and the adequacy of oxygenation and ventilation. With the advent of computers (monitors), it has been possible to look inside patient while under anaesthesia to optimise the internal environment by using various drugs and techniques.
...BECOME A PART OF THE SOLUTION!
Virginia Apgar:
https://en.m.wikipedia.org/wiki/Virginia_Apgar
A useful mnemonic for pre-anesthetic assessment:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819859/
FAST HUGS BID: Modified Mnemonic for Surgical Patient:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672681/
Anaesthesia: Induction and maintenance of general anaesthesia:
http://student.bmj.com/student/view-article.html?id=sbmj070256
General anaesthesia: Maintenance and Emergence:
https://www.uptodate.com/contents/general-anesthesia-maintenance-and-emergence
Characteristics of anesthetic agents used for induction and maintenance of general anaesthesia:
https://www.ncbi.nlm.nih.gov/m/pubmed/15532143/
INDUCTION AND MAINTENANCE OF GENERAL ANESTHESIA USING KETAMINE-MIDAZOLAM CONTINUOUS INFUSION IN CARDIAC SURGICAL PATIENTS WITH LOW EJECTION FRACTIONS:
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1969186
P.S. STUDY of Anaesthesia requires knowledge of Physics, Physiology, Pharmacology, Lot of Medicine, Some of Surgery and Many Technical skills!
Anaesthesia also includes ICU (Intensive Care Unit) and is managed by Anaesthesiologists all over the world (unlike yesteryears by Physician) because of knowledge and skills involving Intubation, ventilators, resuscitation, managing critical clinical scenario, advanced life support, inserting various lines like central line, arterial line and many skills! Anaesthesiologist integrates all inputs from various specialists in the ICU for managing the patient!
Anaesthesiologist is the only specialist who is OMNIPRESENT in a hospital: all kinds of operation theatres; A&E (Casualty); ICU (Intensive Care Unit); Wards for Resus and procedures; Out Reach Team; CT, MRI, Radiological intervention suite; Pain Clinic; Intra and inter hospital transfers besides scopes for audit, research, publication and presentation at various forums!
INDUCTION (start) of GA (general anaesthesia - for reversible uncounsciousness) is done by these 4 drugs type after Preoxygenation with 100% oxygen for 3 minutes!
P.S. The 4 drugs (other drugs and gases can also be used) are shown in the pic: the 4 drugs for 4 types of effect or control: 1. Amnesia, 2. Analgesia, 3. Muscle Relaxation and 4. Homeostasis. Even local and regional blocks involve few of these four!
1. Amnesia by 1% Propofol in the dose of 1-2 mg/kg iv in an adult. Generally, 100mg in 10 ml suffices in an Indian adult.
For maintenance of amnesia: Nitrous oxide in Oxygen (2:1 ratio or 1:1 as Entonox) with Isoflurane 1-2% (inhalational volatile anaesthetics - MAC 1.2 - 1 ml vapourises into about 200 ml vapour, which is picked up by oxygen and nitrous oxide gases flowing through the vapouriser)
2. Analgesia by Butorphenol 1 mg iv (agonist-antagonist opioid, which lasts for 1 hour)
For maintenance of analgesia: Nitrous oxide has analgesic property + Fentanyl 1-2 ug/kg in divided doses and/or Morphine 100 ug/kg upto 5-10 mg iv total dose in an adult. NSAID like Diclofenac 75 mg is added to iv fluid like RL (Ringers Lactate). Various nerve blocks can be done with local anaesthetics like Bupivacaine 0.5% or Lignocaine 2% depending on the site of surgery.
3. Muscle relaxation by Suxamethonium 1-2 mg/kg iv (double molecule of acetylcholine mimics acetylcholine at the neuromuscular junction and causes persistent depolarisation leading to fasciculation, which ends into flaccid paralysis) - helpful in laryngoscopy and Intubation.
For maintenance of muscle relaxation, Vecuronium is given in the dose of 100 ug/kg iv initially (total in an adult 3-4 mg) and then topped up with about 20% of initial dose (1 mg in an adult) every half an hour to keep the patient immobile during the surgery.
4. Homeostasis by Glycopyrrolate 200 ug iv for preventing bradycardia and for decreasing salivation. which might be aspirated or blur the field of vision while doing laryngoscopy.
For maintenance fluids like Ringer Lactate to replenish lost fluid during fasting since 10:00 pm the night before (lost through evaporation from skin, in expired gas as vapour, in urine etc). The fasting fluid is 2 ml/kg/hour of fasting. If the heart rate goes down and below 50-60/min, Atropine 20 ug/kg iv or Glycopyrrolate 10 ug/kg iv is given. If blood pressure goes down below 90 mm Hg Systolic, Mephentermine 6 mg iv bolus is given. Likewise, for high blood pressure Nitroglycerin 1-2 ug/kg iv can be given in small incremental doses seeing the response. Further fluid is given according to 4-2-1 rule - first 10 kg of body weight 4ml/kg, second 10 kg of body weight 2ml/kg and the remaining body weight @ 1 ml/kg. Various kinds of fluid like Normal Saline, Hetastarch, Pentastarch, Haemaccel and even blood and blood products might be needed depending on blood loss.
Homeostasis involves lot many things to do to keep the internal environment of the body constant. Surgeons maintain haemostasis. For example in prolonged surgeries, ABG (arterial blood gases) might be needed to see the acid-base status and the adequacy of oxygenation and ventilation. With the advent of computers (monitors), it has been possible to look inside patient while under anaesthesia to optimise the internal environment by using various drugs and techniques.
...BECOME A PART OF THE SOLUTION!
Virginia Apgar:
https://en.m.wikipedia.org/wiki/Virginia_Apgar
A useful mnemonic for pre-anesthetic assessment:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819859/
FAST HUGS BID: Modified Mnemonic for Surgical Patient:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672681/
Anaesthesia: Induction and maintenance of general anaesthesia:
http://student.bmj.com/student/view-article.html?id=sbmj070256
General anaesthesia: Maintenance and Emergence:
https://www.uptodate.com/contents/general-anesthesia-maintenance-and-emergence
Characteristics of anesthetic agents used for induction and maintenance of general anaesthesia:
https://www.ncbi.nlm.nih.gov/m/pubmed/15532143/
INDUCTION AND MAINTENANCE OF GENERAL ANESTHESIA USING KETAMINE-MIDAZOLAM CONTINUOUS INFUSION IN CARDIAC SURGICAL PATIENTS WITH LOW EJECTION FRACTIONS:
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1969186
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