Anesthesia rotation

Numbers
Head CRNA 68751. Multi workroom 56645.
Combos 000 and 135
Log onto computer if PCS99 password care02

SET UP:
CDM
- do first one.
- Print list. Surgical list viewer. Room counts. SMH. Retrieve. Select OR#. Details. Print.
- Pull up pt in MICS.
- CDM report in Electronic environment. Select PrePro. Pull MC#. Retrieve list (if not done have to do one).
New. Anesthesiology. Cut and paste from surgical list viewer. Put my pager under provider. ECG pull in.
Allergies pull in. Labs pull in. Get H and W from All screen.
- To Docs Brows get meds etc. Go back until find a ME. Put date of last ME in anesthesia/ plan of care.
- To Chart Plus Anesthesia to see if anesthesia records.
- hit add temp copy. Print 1 for me and 1 for consultant and put in OR slot.
- The consultant signs it.

Supplies
Bucket and fill with:
Miller blade, 2 tubes, airway, drugs

Machine check:
- turn on in 2 places. Put in canisters. Screw in O2 sensor. Put on 2 tube thing. CO2 transducer.
- Check no leaks in the tubing. On bag circuit, occlude tubing hole and flush O2 up to 40 cmH2O and hold.
Should take > 30s to fall to 30 cmH2O. Make sure you can hold it there. O2 flow must be off or it would
mask a leak.
- check that ventilator works (place green bag as a fake lung). Switch to ventilator circuit when green bag
is inflated and pretending to be a lung. Ensure the bellows will move.
- check O2 comes up with N2O. This should be a 3:1 relationship with O2:N2O.
- check O2 in tank, unplug O2, turn on tank and read level at front meter (at least 625cc). Unplug O2 from
wall first.
- check O2 off alarm
- check gases are full. Extra gas in drawer.
- Screen set to adult.
- O2 on
- preset vent
- suction (yankauer + esophageal). Tape on suction hole. Does it work. Under mattress if nasal.
-NG/OG tube (16). NG is 16 french silastic. NG if staying in after case. NG needs water based lube on tip
first. Should be 3rd dot at nares.

Monitoring/Bed:
- muscle stimulator pads
- pulse ox. Not on index finger. Opposite side to BP cuff.
- BP cuff- opposite side to IV. Can be on same side as arterial line, it just won't read when BP cuff is up.
Regular adult 74. Large adult 75.
- EKG with stickers on. R: white>green (white to right and snow on grass), L: black>brown (at mid axial
line)>red (anywhere on right side below others, red clay under the dirt)
- esophageal temp probe/ skin temp probe
- eye tapes
- 2 arm boards on right side
- bed locked

Airway stuff
ET tube: (regular oral, oral rae curves down and out of the way)
- 7.0 is women, 8.0 for men.. 4+ age/4
- make sure plastic end is pushed firmly into the tube.
- put stillete in but not as far as Murphy's eye at tip. Just put a slight bend at tip and keep most of it
straight. Not for nasal.
- Tie on it. Not for nasal.
- check balloon
- black ambu bag

Nasal tube: (nasal rae)

- 7.0 man, 6.0 women. Get an extra of the one you need and one smaller. No stillette. No tie. Lube it up
well.
- Turn connector to be flush with head. Check balloon.
- McGills (taped). Mastasol. Nasal tapes.
- Put in warm water. Lube it up.
- blade (#2 miller) and laryngoscope
- 2 airways. Yellow oral airway (#9).
- mask (98% of people get yellow). X-mas tree on side with mask on it. Remove gray prongs form mask.
- humivent
- intubating stilette
- An LMA (4 for female, 5 for a male).
- hernia blocks, and soft roll. Get from room across from work room. Cart 29, 23, 30.

Fluids/IV
-IV/ art line set up.
- IV: tourniquette, ROH, IVs, Lido, tape, clear covers
- art: chlor, blue roll, tape, pink with Tb syringe, covers, tape, set up
- LR (with tubing)(get air out first). Tubing with 3-way stop cock.
- Blood case get 0.9 NS and blood tubing.

Computer
- Chart plus. Fill out the first info page and sign out. Picker. Height and weight. Health care workers.
Whoever is with me should sign in.

Syringes
- midazolam (3cc)
- fentanyl (6)
- lidocaine - 2%(6) (3) big on is for propofol sting in IV (at least 5 cc in it), and small one to start IV.
- propofol (20)
- succs (12cc)
- vecuronium (12cc)(mix with 10 cc LR to dilute by 10).
- atropine (3)
- [phenylephrine (12) alpha agonist (is 100 mcg/ml, need to dilute by 100 by drawing up 0.1 of drug and 10
of fluid, or 1 of drug and double dilute), made for us]
- [ephedrine (12) alpha + beta ag (is 5mg/ml so dilute by 10 by drawing up 9cc fluid), get from pyxis]
- decadron- check white order sheet for others.

Pyxis (6)
- midazolam (2)
- Fentanyl (1 and 1) (more if jaw case)
- propofol (2)
- oxymorphone (1-3). 0.01-0.05 X kg is the total you want.
- ephedrine (1) already mixed up.
- zofran (1)
- oxymetazoline (1)
- ketorolac (1)
- hit exit

Put drugs in plastic bag along with receipt.

Emergency drugs are: phenylephrine, ephedrine, atropine, succs.

Check drugs in drawer

Labetolol
Esmolol
metoprolol
Atropine
Naloxone
Epi
Flumazenil
Glyco and neostigmine
Hydralazine
Phenylephrine
Vecuronium
decadron

Preop anesthesia questions:

Identify patient, look at arm band. What procedure are they having?
PMH/ ROS
- heart, lungs, liver, kidneys
- GERD - could mean rapid induction. If well controlled on meds its not a problem.
Meds:
All: food allergies.
PE:
- Ensure no contacts.
- Look in mouth. Dentures or loose teeth.
- Neck mobility. Malampati test (should be able to fit three fingers between chin and adams apple).
- Listen to heart and lungs if no anesthesiologist on the case.
4 Special questions:
- When did they last eat. Meds this am. Transfusion question. Which nostril better. Give Afrin.

* Ask consultant before you get the patient.

- Do we need type and cross. If so call blood lab. If antibodies it will take 45 minutes for blood vs 5
minutes.

Am I ready?
M- machine
A- airway
S- suction, scope
T- temp and tube

Patient in room:
Scan ID bracelet
Take off outer robe and loosen knots.
Hook up IV and monitors.
Afrin (oxymetazoline) if nasal tube.
Consultant light on and start to preoxygenate.

Intubate:
Preoxygenate. O2 up to full. Good seal on mask. Try to ventilate to see that you have a good seal and can
ventilate before you give the succs. Look for EtCO2 curve to show air exchanging, bag moving. When bag
don't push pressure above 18-20 cm H2O or will inflate stomach.
Cuff has 5-8cc of air.
Prior to intubation: need to get O2 up to EtO2 above 90%, can go for 8-10 minutes before brain damage.
With normal levels its 3-4 min. EtO2 is not useful for anything else. Pull chin up into mask, don't mash
mask onto face. Consultant gives succs and wait for fasciculations.
- head into sniffing position (neck flexion, head extension)
- use right hand to grab occiput to guide into sniffing position. The right arm should do all the work. The
left hand just finds with minimum liftîng. Stand up straight and the head should rest on the abdomen to
hold it back.
- blade in left hand
- go down right side of tongue
- Find epiglottis. Pick it up. Work your way down to cords. Pull up and away at 45 degrees. Do not cock
wrist into teeth.
- apply pressure to cricoid to visualize cords.
- Tube position: Men 22-24, women 20-22.
- Check: EtCO2 and wave form. Listen.

Nasal tube intubation

- Start by inserting upside down. Twist it at the oropharynx to regular position. Then insert scope.
- Tape nose. Prep with ROH, mastisol, then vertical and horizontal tape across bridge.

After asleep:
-Switch from pressure control to volume control.
- Add PEEP
- Turn on gas.
- esophageal temp probe. Blue wire hooks into it. Or other temp probe.
- print baseline ECG.

- muscle stimulator pads

- giving vecuronium: don't give it until you see that the succs you gave at induction is wearing off. This
ensures they don't have pseudocholine esterase deficiency.
- 0.1 mg/kg for induction (so 70kg person is 7mg) and 0.01mg/kg maintenance.
- start a timer each time you give.

- IVs on big case: - get 18 in and put them to sleep. Then put in 16 on other side. You will use 16 with fluid
warmer. Need to move BP cuff to side opposite running IV. When they tuck make sure your IVs are running.

- Give antibiotics (famotidine, heparin, steroid). Ancef test dose 1cc and wait 5 minutes. To fill piggy back
line hold it below the bag and it will fill.
- og tube- set to low (60-80)
- bair hugger

- At incision give fentanyl.

- If light can give propofol or turn up gas and blow in with bag. Propofol is fastest.

Computer start
- scanning does intro things. Then consultant goes. Start after consultant.
- preoxygentate (induction)
- IV induction (induction)
- eyes taped (pt cares)
- hand ventilated (airway mgt)
- 0 difficulty (oral/nasal ETT)
- tube size
- oral cuffed
- tube distance at teeth
- bilateral breath sounds (airway mgt)
- humid vent
- ET CO2
- mechanical ventilation (vent settings)
- vigilon applied
- ears padded (patient cares)
- esophageal stethoscope/ skin temp probe (monitoring)
- nerve stimulator
- OG tube (generic)
- external warming device (patient cares)
- position and padded (patient cares)
- Iv fluid through warmer ()
- turnover to surgical team (surgical event)
- oral pack inserted
- Pause (icon)
- Incision hit start (icon).
- IVs

Fluids
-
Meds
- put empty meds by computer and throw out after are charted.
- go to med summary and make sure all add up.

Monitoring During Case

a-airway, b-breathing, c- circulation, d- drugs, e- exsanguinate, f- fluid (urine, iv), g- gas, h- heat

Stuf to watch:
- S- Screens. Pressure gauge on ventilator to ensure tube hasn't shifted (rise in pressure could mean tube
shifted too deep).
- T- twitches, muscle relaxation
- U- urine collection hourly. Put in the bottle to measure accurately.
- F- fluids, IV bags.
- and cuff (make sure it is cycling and the computer is recording it.

Temperature
- will fall with GA
- bair hugger, humidvent in airway, can warm fluids in ranger, warm the room.
- Fluid warmer. Put into the warmer. Short tube is hooked to bag. Long one to patient. Must prime tubing
by letting the fluid run through until fill reservoir and comes out long end. Turn on. Canister on tubing gets
totally filled with fluid and stuck in holder on the right.
- less than 34.5 you need to do this
- if person is cold when you wake them up they will shiver= big stress on heart which can cause ischemia
etc. Also cold leads to inability to clot.
- Bair hugger on 32 will cool the patient.

Cardiovascular
- Make sure BP cuff set for every 3 minutes.
- Check a second BP before you react.
- Anes machine has 2 ecg lines. Top is lead II to look at atria for arrhythmias (left leads?). Second line is
lead V to look at LAD distribution for ST elevation and depression (right leads?). Third line at bottom its
arterial line.
- you like the mean no lower than 60.
- Blood pressure keep it no lower than 20% below preop pressure when arrive in room. Do this to keep
everything well perfused. So you keep ppl who are hypertensive at their high BP.
- Print an ECG everytime you play with the leads. Print a baseline EKG.
- MAP should be 60-160. Brain vessels can constrict and contract to accommodate in this range. Gas
caused dilation so vessels can't tolerate high maps under GA. Brain ischemia at maps 18-22. Minimum you
want is 60. Maximum is 100.
Hypotension:
- hypotension and pulse < 70 give ephedrine, > 70 give phenylephrine.
- can increase N20 to allow you to decrease volatile gas.
- Consider Hextend.
- for hypotensive anesthesia you increase gases (usually don't give Beta blockers).
- On jaw case you lose a lot of blood so may need to give fluid. Use fluid warmer.
- can see pulsus paradoxus with systolic pressure variance. Is a sign that they are dry. Shows inadequate
preload to compensate for pressure changes in chest. Can also see this on the Pulse OX wave (or pleth).

hypertension:
- usually give B blocker and then more if no effective. Also give opioid or increase gas. Rarely give
hydralazine or anything else.

Brady
- give glycopyrolate.

Respiratory
Pmax should stay below 40-45.
-tidal volume is 7cc per kg. It can be 10cc/kg in GA bc is positive pressure ventilation.
EtCO2 should be 36. 30-50. You want EtCO2 to run at lower 30's, plasma level is 40 but this is diluted by
the dead space. The normal gradient is 4 (PAO2-PaO2).
During a mac you watch the respiratory rate (AWRR airway respiratory rate- bottom right), you want it
to stay low but not too low 12.
Need 250 cc O2 every minute, but gas analyzer needs 250 cc also to work so must have a minimum of 500
cc O2 per minute.
Should run 2 nitrous : 1 oxygen.
I:E ration- look at rate, this tells you total time of each cycle. Convert to 1:2 into seconds. Don't go below
1:1.5 or get breath stacking.
Peak airway pressure alarm sounds, check they are not breathing over vent. Can turn down peep for short
term solution. Tube could be clogged with secretions.

Paralysis
- Stimulator to 70 mA and give a train of four.
- Want 1 twitch back ideally. Can have 4 back and still be 75% blocked.
- Foot look at anterior tibialis. Leads above and below medial malleolus but slightly posterior to it.

Fluids
- give hourly maintenance, plus deficit, plus blood loss times 3. Replace ½ deficit in 1 hour, and next ½
over next 2-3 hours.

Urine
- Get bottle from trash and decant for accurate measure.
- If low UOP give hextend 500 cc bolus.

Gases
Isoflurane- mac is 1.15% (1.2%). Least cardiac depression. So if low EF use. Need at least 0.3 MAC of iso
for amnesia.
Sevoflurane- 1.9%. Stay above 2.0L total because compound A is nephrotoxic. Filling this need to attach
hose, and pull the black lever forward. Low cough potential so is good for kids and inhalation inductions.
Some say emergence delirium with kids.
Desflurane- mac is 6.6%. Don't use nitrous with desflurane for extended period bc both are stimulants.
Then you can get carrier gases down to low flow. Get it down to 0.8 before remove tube. Needs to be
above 3% to be amnestic. Can check it every 30-45 min if have a good paralysis. Is the drug I use because
people wake up fast. When use desflurane you start at 3.0 and then go up to 6 gradually to avoid possible
tachycardia. Other gases don't have this problem.
Watch the EtDes. This should be equal to the MAC for desflurane. This will tell you how much desflurane
the person is exhaling. EtDes of 5.0 takes 5 minutes to wake up.
halothane: mac is 75%, (can sensitize the myocardium to lidocaine - Dr. Schare)
Nitrous oxide- mac 105%?
Total gas flows should be at least 2.0 L, so 1.0 L 02 and 1.0 L air.
You need 1/3 of MAC for amnesia.
You usually use 2 carrier gases.
Drugs
- Flush lines to ensure drugs get in.
* before give B blocker ask consultant
- any drug in bag you don't use goes back to pharmacy.

Esmolol- 1 cc to start. 10 mg/cc. Dose: 5-100 mg bolus. Brevibloc with purple top. Beta 1 selective.
Labetolol- 1 cc at a time, 5 mg/cc. To induce hypotension use a mixed beta blocker, blocks alpha and beta
(1:7 ratio) so is a beta blocker that also dilates vessels. Labetolol is brief so safe. Labetolol is beta blocker
of choice. Esmolol is shorter acting one.
Hydralazine- 5 mg at a time. Wait 10-15 minutes to see effect. Lasts 4-6 hours.

Phenylephrine- 1 cc at a time, 0.04 or 0.1 mg /cc,

Dose: 0.05-0.2 mg at a time. So 100-200 mcg at a time or 1-2 cc.
double dilute it. Draw up 1cc of drug. Then draw up 9 cc of LR. The dump all but 1 cc. Then draw up 9
more cc of LR. Alpha stimulator only so causes constriction. Drip- 1cc vial (10 mg /cc) into 250 cc bag, so
is 40 mcg/cc, (can get pharmacy to make it), must use 60 drops=1cc tubing ie “mini dripper”.
Ephedrine- 1 cc at a time, 5 mg/cc, Dose: 2.5-5.0 mg. Alpha and beta stimulation so increases heart rate
too.
Atropine- Give 1 cc. 0.4 mg/cc. Dose 0.5-1.0 mg IV q 3-5 minutes. Never give less than 0.4 mg or get
extranpyramidal effects.

oxymorphone- 1-2 cc at a time, 0.1 mg/cc, 0.01-0.03 mg/kg. It is 10 x's stronger than morphine. We dilute
it by 10 from 1 mg/cc. 8-10 times as strong as morphine.
Fentanyl- 1 cc at a time, 50 mcg/cc, 2-50 mcg/kg (sedation 1-2 mcg/kg). Is for pain. 75-100 times as
strong as morphine.
midazolam- 1 cc at a time, 1 mg/cc, 0.05-0.15 mg/kg prn. For anxiety + amnesia.
propofol- 1 cc at a time, 10 mg/cc, 0.1-0.2 mg/kg/min. For sleep. Put lidocaine into the IV before you give it
to numb the vessel. SShelf life is 4-6 hrs
Morphine is diluted by 10 to 1mg/cc.
Dilaudid- 8-10 times as stroing as morphine.
Ketamine- ???cc, 10 mg/cc,????
Ketorolac (toradol) - 0.5-1 cc, 30 mg/cc. Give straight. Put in 1 cc syringe. IM into the deltoid or IV.

Ancef- give test dose of 1cc or 100 mg, wait 5 minutes. Redose every 4 hours.

Vecuronium- 1 cc at a time for maintenance, 1 mg/cc, 0.01 mg/kg. Lasts 5-30 minutes depending on
patient. Intubation dose is 10 times as much or 0.1 mg/kg. It is renally cleared so not for people with renal
problems.
Succinylcholine- 5 cc to intubate?, 20 mg/cc/, 1-2 mg/kg
Neostigmine and Glycopyrolate (robinol) together. Can push it all at once. Rule of thumb is if they are
100kg its 5 and 5, 80kg is 4 and 4.
Neostigmine (0.05 mg/kg, 1 mg/ml, max is 5 mg). Will lower Ach esterase so increase Ach so can out
complete vecuronium for nicotinic rec on muscle. Maximum dose is 5 cc with either one. “Give
Neostigmine Now” ie first.
Glycopyrrolate- 1 cc for every 1cc of neostigmine. (0.2 mg/ml, 0.01mg/kg) to block muscarinic rec so don't
get bradycardic with increased Ach. Maximum dose is 5 cc with either one. If CAD reduce dose of glycol so
avoid tachycardia.

Albuterol- 35 cc syringe. Put canister into syringe and plunger behind it. Attach to mass spec site (remove
mass spec for 10 min or it will ruin the machine). Then press plunger to activate canister into the tubing.
Flumazenil- 0.2 mg repeat q1min up to 1 mg. “point 2 every 1”. Concentration???
Naloxone- Dilute by 10 then give 1 cc or 0.04 mg at a time. Comes 0.4 mg/cc. 0.2-2.0 mg q 2 minutes
“point 2 every 2” is the published dose for emergencies. It's a harsh drug, people wake up screaming in
pain.

Lidocaine- 20 mg/cc, 4.4 mg/kg (7.0 mg/kg with epi)

End of Case
CRAP: computer, reverse, anesthesia gases, pull as much stuff off pt as you can.

Computer end events

- Throat pack out (patient cares)
- reversal with antagonist (end events)
- spontaneous respirations (airway mgt)
- turnover to anesthesia team (surgical event)
- alert and responds to commands (end events)
- oral suction
- extubated
- supplemental oxygen
- portable pulse ox
- xray
- To PACU
- Report given
- vital signs stable

Fluids
- Chart bag levels
- EBL- look at the canister, about 10% will be blood. Soaked salt is 10cc (or 200cc?, 5 per bag), raytec 5cc
(or 20cc?, 10 per bag).

Meds- check med summary that all adds up.

- midazolam, lidocaine, propofol, succs, vec, fentanyl, famotidine, heparin, abx, steroid.
- write on CDM
- Collect meds into bag.

- At closure hit stop.

- Last thing you hit is transfer icon and then transfer
- hit turn over light

Reversal
- Draw up agents.
- Always reverse if paralyzed, even if have all twitches back. Need at least 2 twitches back before try to
reverse. Close abdominal fascia first. Diaphragm is first thing to come back.
- Draw glycopyrolate (robinol) and neostigmine together. Can push it all at once. Rule of thumb is if they
are 100kg its 5 and 5, 80kg is 4 and 4. Glycopyrrolate (0.2 mg/ml, 0.01mg/kg) to block muscarinic rec so
don't get bradycardic with increased Ach. Neostigmine (1mg/ml, 0.05 mg/kg) will lower Ach esterase so
increase Ach so can out complete vecuronium for nicotinic rec on muscle Maximum dose is 5 cc with either
one. Give Glyco first.
- cardiac history- subtract 1cc form usual glycopyrolate dose to avoid tachycardia.

Anesthesia Gases
1. Cut gas in half.
- Can increase N2O when dial down Desflurane to keep them asleep.
- If had N2O need to give 100% O2 for 5 minutes before we extubate.

2. Cut vent settings. Get EtCO2 up to 40 to stimulate patient breathing on their own.

3. Vent off. Can let the patient breath on their own, if the rate is fast its an indication they are in pain, so
will need to give opioid prior to waking up. Watch the Vte (tidal volume), CO2 trace and ETco2 to see
breathing.
- Turn O2 right up. When turn up O2 and patient breathing must decrease pop off valve so pressures don't
get too high.
- When let a person breath on their own and they are not yet, you can support with minimal breaths to
keep O2 sats up. Large breaths will irritate them and make them buck.

4. Gas off and O2 way up

Put in meds/ Pull as much stuff off as you can

- Any meds to give? Torodol. Zofran.

- Esophageal temp probe. OG tube. Eye tape. Humivent. Bear hugger. Nerve monitors after get 4 twitches
back.

- Ready mask and syringe.

- get oxygen tank and check its full by weight.
- have fentanyl on hand for pain.
- Put an oral airway in to act as a bite block as they get light.

Extubate
- Turn gas right off when close. Also empty the green bag of gas.
- Put consultant light on.

- Suction down the oral airway.

- Good tidal volumes. Respiratory rate above 10. Respond to a command.
- Leave tube tied until last moment. Don't pull in stage 2 bc increased risk of laryngospasm. Stage 2 has
excitement and discongugate gaze.
- Breath in and then cough out the tube.
- Ask if they are in pain. Have fentanyl on hand to give. It is the fastest.

Move patient
Unhook all monitors. Disconnect tubing right before move. Grab sheet under head and move as one.
Head up.
Nasal cannula or mask (open valve) with portable O2 on 4L per min.
Portable pulse oximetry.

PACU
Hook it all up when get to the PACU.
PACU report. Name, procedure, anesthesia consultant, IVs, total narcs, events in case.
From PACU get BP cuff, portable pulse ox, portable O2.

Pyxis end
Return unopened drugs. Print off slip, put in bag and put in slot.
Waste any “used” drugs. Print off slip, put in bag and put in slot. Witness ephedrine.
Propofol is just wasted.
Black caps on if too long.
Pick up black ambu bag.

Miscellaneous
Arterial line
Use pink 20 gauge surflow needle catheter. If have atherosclerosis and need to force your way around
plaques use 'arrow' needle.
Cock wrist with towel roll under wrist, tape wrist to roll. Prep it . Local given. Feel for radial artery. Don't
push too hard or you will occlude it and feel nothing.
Loosen catheter first. Hold like a pencil at 45 degrees. No tourniquet. Get flash, lower the angle a bit and
advance a touch then freeze right hand. Use left to twist off the catheter.
Then hook up 1000mg heparin bag. Inflate bag to green pressure. Hook wires to anes machine to monitor
BP.
Need to zero art line by opening it to the air and closed to the patient and hit zero button on screen.
Can put a 1 cc syringe on end of pink needle and wet it with hep saline to make it easy to see the flash.
Drawing form art line
- draw back 10 cc from the patient so you have blood in the line. Turn off to all directions by putting cock
halfway between outside and bag. Then fill sample syringe. Then flush saline through by pulling pig tail.
Flush the port to outside a bit or will get full of clotted blood. Art line can be on same arm as cuff, pulse ox
can not. Sensor must be at same level as heart.
Must say ABP on the monitor for it to chart correctly.
Chart it under forms. There is an icon at the top of the page.
Art line should be at same height as patient's heart.

Blood draw
- Get kit. Fill out card. 1st draw 10 cc off from art line. Close ¾. Then pull up 3cc, get air out. Put label on
from card. Flush line by pulling pig tail. Flush port. Hit lab light. Tape to door. Chart “lab draw” (lab)

Blood volume
- man 70-75 cc/kg, woman 65-70 cc/kg. When down 20% consider transfusion.

- call blood bank to check if are negative for antibodies and to type and screen blood. If are ab negative
you can get blood in 5 minutes, if is positive you will 1hr prep time. Give blood only with 0.9 NS. Through
at least an 18 gauge.
- Blood tubing, you must add a stop cock (in cabinet), 48 inch tubing. To give blood you need the ID# on
the bag.
Call questions
- Last meal. Last meds. Transfusion. Anesthesia in the past. Tell what we are going to do.

DaVinci
- No nitrous allowed. Don't move the bed.

Fiber optic scope

- bring cart in the room. Put battery in.

Hextend 6% hetastarch:
- Maximum dose is two bags.
- hypertonic LR so will pull fluid intravascularly. Get from pyxis.
- Normal LR stays intravascular for 20 minutes only

Humidvent
- should be on all cases to prevent dry secretions blocking the tube. Not on nasal tubes bc pressure sore on
forehead.

Nasal airway:
-30 is standard size.
- stock list. Go through the drawers and ID what is missing and ask for it.

Rapid sequence induction:

- Don't give any breaths after are asleep. Just passively keep O2 on the patient. Give crycoid pressure
while they go to sleep and don't let go until you are sure the tube is in. Is for people with GERD to stop
emesis.

Trandelenberg: pressure increase due to Frank-Starling law, but pulse decrease due to carotid stretch
receptors.
Kids
- large tongue + epiglottis
- narrow part is cricoid ring (in adults its vocal folds)
FiO2
the percent of O2 inhaled in the airl

ICU transport
- Monitored cart. Need a big propofol and pump to keep patient asleep during transport.
- Charting:
- Transfer to ICU care
- VSS stable during transport
- end anesthesia (usually occurs autopmatically when go to PACU)

MAC
- Get tube and scope ready, but don't open.
- Put nasal cannula on O2 with CO2 reader on it (Salter brand).O2 to 10 L on the nasal canula nozzle.
- Skin temp probe.
- Get precordial stethoscope tubing.
- watch the AWRR and Et CO2 to ensure breathing is OK.
-give a bit of fentanyl + midazolam at start, then use midaz + prop, save fent for painful parts.
- Propofol pump. magnetic cover. 60 cc syringe only. Get 3 way stop cock so can refill it. Need low flow
tubing which is smaller than regular tubing. Adapter to plug into regular IV tubing (don't attach until ready
to sedate). Get from the anesthesia work room right side, by the pumps. Charted under fluids at start and
stop. Also chart under meds.
- Start with fentanyl and midazolam and then they rely on prop to keep them down.
- Before go to the PACU you need a normal respiratory rate.
- IV sedation under (induction)

MAC
- Get MAC on computer screen. Hit button on CO2 transduder. Select MAC. 1 MAC 50% don't move. 1.2
MAC 92% don't move. Can add MACs up. So with ½ a nitrous MAC and ½ a des mac you get 1 mac.

If won't wake up:

- narcotized
- brain dead
- paralyzed

soda lime- fresh one on the bottom.

- think about transfusing at 20% blood loss.

Pediatric Case
Peds is less than 12 yo. Get 3 leads, peds pulse ox in white drawers.
- Dosage calculator on anesthesia home page. Print it out and tape to pole. Draw up max dosages of drug.
Draw up atropine to counter possible brady from Sevo induction, on IM needle.
- Draw up succs IM dose with IM (orange) needle.
- induction with good kid is N2O and slowly increase the sevo, if bad kid N2O and sevo way up right away.
- Leave on Pressure control.
Fluid
Watch fluid amounts. Calculate amount with 4:2:1 rule, time NPO plus hours of case. Replace half of defecit
in first hour and next half over next 2-3 hours plus hourly rate. Can use 500 cc bags. IF 1-3yo can use
Buretol dripper to give exact fluids. If <1 use pump.
Induction
- Use Sevo bc is less irritating and fast. If calm give N2O:O2 6:2 then gradually increase Sevo. If not calm
add Sevo at 8L to this.