Anesthesiology Curriculum: Foundations Through Independent Operating Room Practice
Subject: Anesthesiology Curriculum: Foundations Through Independent Operating Room Practice
50 chapters
1. Learning Objectives
[Verse 1]
The alveoli open, gas exchange begins
Partial pressure gradients pulling oxygen in
MAC is the measure — minimal alveolar dose
Where half the patients won't move when you cut them the most
Lipid solubility dictates how fast they go under
Blood-gas partition coefficient splits induction asunder
High solubility means slower equilibration
Low solubility — desflurane hits like a revelation
[Chorus]
Position, ventilation, drugs, and disease
Four forces that reshape the physiology
Predict the MAP, the CO, the SVR
Know the mechanism — you'll read every monitor from afar
Baroreceptors fire, the reflexes cascade
Compensation holds until the pressure starts to fade
Position, ventilation, drugs, and disease
Map the body's logic like a cartographer of breath
[Verse 2]
Trendelenburg tilts the venous return upward
Preload increases but the diaphragm's burdened
FRC drops when you lay the patient supine
Atelectasis blooms along the dependent line
Lateral decubitus shifts perfusion below
V-Q mismatch widens — the hypoxia grows slow
Prone position lifts compliance in the dorsal lung
But venous drainage fights you — monitor every rung
[Chorus]
Position, ventilation, drugs, and disease
Four forces that reshape the physiology
Predict the MAP, the CO, the SVR
Know the mechanism — you'll read every monitor from afar
Baroreceptors fire, the reflexes cascade
Compensation holds until the pressure starts to fade
Position, ventilation, drugs, and disease
Map the body's logic like a cartographer of breath
[Verse 3]
Volatile agents blunt the myocardial wall
Propofol drops the SVR — vasodilation's call
Opioids suppress the ventilatory drive
Ketamine preserves the sympathetic tone alive
Succinylcholine depolarizes fast but watch the potassium climb
Rocuronium competes at the nicotinic site each time
Neostigmine reverses but muscarinic effects flood in
Atropine beside it — anticholinergic discipline
[Bridge]
Here's a rare word woven in — efflorescence
The sudden blooming of symptoms when physiology bends
Like pulmonary edema flowering post-obstruction
Or histamine cascading through a mast cell's grand production
The body effloresces — bursts into pathologic bloom
Know the trigger, trace the mechanism, read the room
Autonomic dysreflexia spikes the pressure high
Spinal cord above T-six — catecholamines reply
[Chorus]
Position, ventilation, drugs, and disease
Four forces that reshape the physiology
Predict the MAP, the CO, the SVR
Know the mechanism — you'll read every monitor from afar
Baroreceptors fire, the reflexes cascade
Compensation holds until the pressure starts to fade
Position, ventilation, drugs, and disease
Map the body's logic like a cartographer of breath
2. 1 Respiratory
[Verse 1]
Tidal breath and residual air,
Four liters resting, FRC sitting there,
Functional reserve — the buffer zone we keep,
But lay supine and watch that margin creep,
Closing capacity climbs above FRC,
Small airways collapse, atelectasis breathes,
Obesity, pregnancy, the aging lung —
All choke the reserve before the case is done
[Chorus]
West zones one, two, three — pressure gradients flow,
PA, Pa, Pv — that's how perfusion goes,
Shunt is blood that never meets the gas,
Dead space is breath that doesn't move the mass,
Hypoxic vasoconstriction pulls away,
Redirecting flow to where the alveoli stay,
V-Q mismatch is the root of hypoxic blame —
Know the gradient, know the game
[Verse 2]
Oxygen falls from atmosphere on down,
One-fifty to alveolar — forty torr unwound,
The A-a gradient widens when the shunt is wide,
Alveolar gas equation — nitrogen can't hide,
PAO2 equals FiO2 times the pressure spent,
Subtract the CO2 divided by the quotient meant,
P50 sits at twenty-seven — hemoglobin's hinge,
Right shift in acidosis, fever, CO2 binge,
Left shift in alkalosis, cold, and HbF terrain,
Delivery equals cardiac output times oxygen contained
[Chorus]
West zones one, two, three — pressure gradients flow,
PA, Pa, Pv — that's how perfusion goes,
Shunt is blood that never meets the gas,
Dead space is breath that doesn't move the mass,
Hypoxic vasoconstriction pulls away,
Redirecting flow to where the alveoli stay,
V-Q mismatch is the root of hypoxic blame —
Know the gradient, know the game
[Verse 3]
Central chemoreceptors taste the CSF,
CO2 dissolves to acid — ventilation's ref,
Peripheral bodies — carotid and the aortic arch,
Respond to hypoxia when the PO2 drops sharp,
Opioids blunt the slope of CO2 response,
Volatiles dampen hypoxic drive at once,
Preoxygenate to fill that FRC tank,
Four minutes tidal or eight deep breaths — full rank,
Apneic oxygenation buys the minutes back,
Diffusion down the trachea keeps SpO2 on track
[Bridge]
Compliance — volume change per unit pressure climb,
Resistance — flow impeded over time,
Time constants couple them — three fills the lung,
Work of breathing spikes when either battle's won,
PEEP recruits the alveoli that fold,
Laparoscopy raises pressures, shifts the diaphragm's hold,
One-lung ventilation — the dependent side breathes,
HPV fights the collapse, but shunt still feeds,
Prone positioning — dorsal zones now perfuse,
Lateral: the down lung works, the up lung tends to lose
[Chorus]
West zones one, two, three — pressure gradients flow,
PA, Pa, Pv — that's how perfusion goes,
Shunt is blood that never meets the gas,
Dead space is breath that doesn't move the mass,
Hypoxic vasoconstriction pulls away,
Redirecting flow to where the alveoli stay,
V-Q mismatch is the root of hypoxic blame —
Know the gradient, know the game
3. 2 Cardiovascular
[Verse 1]
The cardiac cycle opens like a door —
diastole fills the chamber, preload builds the store,
end-diastolic volume stretches every fiber wide,
Frank-Starling says the harder that you stretch, the stronger is the stride.
Isovolumetric contraction, pressure climbing steep,
aortic valve cracks open when the ventricle won't sleep,
ejection, then relaxation, pressures fall again —
trace the pressure-volume loop and watch it close and then begin.
[Chorus]
Preload, afterload, contractility —
the three levers of cardiac ability.
Stroke volume times the rate gives output clean,
SVR times CO equals pressure in between.
Baroreceptors in the carotid sinus sing,
Bainbridge fires when the venous pressures ring —
autonomic arms race, vagal versus SNS,
anesthetics blunt it all — expect hemodynamic stress.
[Verse 2]
Coronary flow occurs mostly in diastole,
when diastole gets shortened, the myocardium pays the toll.
Oxygen supply is flow times oxygen content,
demand is wall stress, rate, and contractile extent.
The subendocardium sits most vulnerable there,
perfusion pressure — diastolic minus LVEDP — beware.
ST depression creeping on your monitor screen —
intraoperative ischemia, the silent guillotine.
[Chorus]
Preload, afterload, contractility —
the three levers of cardiac ability.
Stroke volume times the rate gives output clean,
SVR times CO equals pressure in between.
Baroreceptors in the carotid sinus sing,
Bainbridge fires when the venous pressures ring —
autonomic arms race, vagal versus SNS,
anesthetics blunt it all — expect hemodynamic stress.
[Bridge]
Positive pressure ventilation — venous return collapses,
the right ventricle struggles when the pulmonary vascular bed expands and lapses.
Hypoxic vasoconstriction guards the pulmonary gate,
RV is thin-walled, hates resistance, preload-sensitive fate.
Cerebral flow tracks CO₂ with exquisite fidelity,
the kidney guards its GFR through autoregulatory agility —
that word, agility, means self-correcting grace,
hepatic and splanchnic flows surrender last when shunting takes their place.
Uteroplacental — no autoregulation there,
maternal pressure drops, the fetal circuit lays bare.
[Verse 3]
Shock is the organ-level debt you cannot quickly pay —
distributive, cardiogenic, obstructive, hypovolemic array.
Distributive drops the SVR while output climbs up warm,
cardiogenic chokes the CO, pressors weather every norm.
Obstructive — tamponade, pneumothorax, embolus impedes —
fix the cause before the vasopressor briefly supersedes.
The ECG reads rhythm, axis, intervals, and ischemia's art —
Q-waves mark the necrosis written deep in scarred myocardial chart.
4. 3 Central Nervous System
[Verse 1]
Fifty milliliters per hundred grams per minute —
cerebral blood flow keeps the cortex in it
Pressure drops below sixty, autoregulation bends,
a myogenic, metabolic vessel that defends
Carbon dioxide — the master vasodilator,
hypercapnia floods the flow like a tidal renovator
Hyperventilate, you constrict, PaCO2 descends,
but ischemia lurks when the vasoconstriction never ends
Oxygen plays a subtler game — below fifty torr
the vessels finally dilate, screaming out for more
Cerebral metabolic rate drives the coupling tight —
when neurons fire, blood follows, synaptic appetite
[Chorus]
Авторегуляция — hold the pressure steady
Monroe-Kellie — drei Komponenten, always ready
Blood and brain and CSF inside the vault,
one volume rises, something else must halt
Авторегуляция — sixty up to one-sixty
the plateau keeps the perfusion nifty
Монро-Келли — the doctrine never lies —
fixed box, no mercy, pressure always rise
[Verse 2]
The Monro-Kellie doctrine: skull's a rigid dome,
blood, brain, and cerebrospinal fluid share this home
Compensatory compliance — first the CSF retreats,
then venous blood evacuates — but elastance defeats
When all buffering's exhausted, each milliliter more
sends ICP exponential, crashing through the floor
Anesthetic agents split their loyalties here —
volatiles uncouple flow from metabolism, hear —
They vasodilate cerebral vessels, raise ICP,
propofol reduces CMRO2, keeps intracranial free
Ketamine — contested, likely safe with sedation —
yet historically maligned, a tarnished reputation
[Chorus]
Авторегуляция — hold the pressure steady
Monroe-Kellie — drei Komponenten, always ready
Blood and brain and CSF inside the vault,
one volume rises, something else must halt
Авторегуляция — sixty up to one-sixty
the plateau keeps the perfusion nifty
Монро-Келли — the doctrine never lies —
fixed box, no mercy, pressure always rise
[Verse 3]
The choroid plexus weaves its ultrafiltrate slow,
five hundred mils of CSF per day in flow
The blood-brain barrier — tight junctions, astrocyte feet,
lipophilic molecules get a first-class seat
Charged and large? Rejected at the gate —
selective permeability determines drug fate
Anterior spinal artery — a single threadbare seam,
feeds the cord from aortic branches, fragile as a dream
The artery of Adamkiewicz, T8 through L1 zone —
clip it in aortic surgery, the cord is left alone
Anterior cord syndrome — motor, pain, and heat are lost —
posterior columns spared; proprioception bears no cost
5. 4 Autonomic and Neuromuscular
[Verse 1]
Thoracolumbar fibers, T1 through L2
Preganglionic short, postganglionic shoots through
Paravertebral chains where the synapses form
Norepinephrine flooding like an electrical storm
Alpha one constricts the vessels, beta one speeds the heart
Beta two dilates the bronchi, let's take it apart
Adrenal medulla skips a step — chromaffin cells release
Epinephrine straight to blood, no ganglion in between
[Chorus]
SLUD for parasympathetic — Salivation, Lacrimation
Urination, Defecation — craniosacral origination
Fight or flight is sympathetic, acetylcholine preganglionic
Postganglionic norepinephrine — alpha, beta, supersonic
Muscarinic, nicotinic — remember where each one sits
Nicotinic at the ganglion, muscarinic after it
[Verse 2]
Cranial nerves three, seven, nine, and ten
Vagus nerve is wandering the viscera again
Short preganglionic, long postganglionic fiber
Sacral roots S2 through S4 — the pelvic plexus provider
ACh binds the muscarinic, M2 slows the SA node
M3 contracts the gut wall, opens up the glandular road
Atropine blocks the muscarinic — heart rate climbing, pupils wide
Glycopyrrolate can't cross the blood-brain barrier — keep that centralized
[Chorus]
SLUD for parasympathetic — Salivation, Lacrimation
Urination, Defecation — craniosacral origination
Fight or flight is sympathetic, acetylcholine preganglionic
Postganglionic norepinephrine — alpha, beta, supersonic
Muscarinic, nicotinic — remember where each one sits
Nicotinic at the ganglion, muscarinic after it
[Verse 3]
At the neuromuscular junction, motor nerve terminal dips
Voltage-gated calcium channels open, acetylcholine ships
Quanta released into the cleft, diffuses to the fold
Nicotinic alpha subunits bind — the end-plate threshold's crossed and bold
Sodium rushes, potassium exits, action potential ignites
Acetylcholinesterase hydrolyzes fast, resets the synaptic sites
Choline gets recycled back, choline acetyltransferase
Loads the vesicle again — a beautifully efficient chase
[Bridge]
Burns and denervation spread the receptors out
Extrajunctional nicotinic receptors, gamma subunit throughout
Succinylcholine hyperkalemia — potassium pours from every pore
Immobility creates the same — resistance to non-depolarizers, plus more
Fade on tetanus — train-of-four ratio reveals the depth
Post-tetanic potentiation — calcium mobilized, a transient breath
Phase two block with succinylcholine overdose starts to look like non-depol
Monitoring your twitches tells you where you are in the protocol
[Chorus]
SLUD for parasympathetic — Salivation, Lacrimation
Urination, Defecation — craniosacral origination
Fight or flight is sympathetic, acetylcholine preganglionic
Postganglionic norepinephrine — alpha, beta, supersonic
Muscarinic, nicotinic — remember where each one sits
Nicotinic at the ganglion, muscarinic after it
6. 5 Renal, Hepatic, and Endocrine
[Verse 1]
Renal blood flow, a quarter of cardiac output
Autoregulation holds the pressure, keeps the nephrons stout
Between sixty and one-sixty millimeters, the flow stays true
But drop below that window and the glomeruli are through
Anesthesia cuts the sympathetic tone, vasodilates the bed
Volatile agents trim the GFR, watch the creatinine instead
Surgery triggers neurohormonal storms, vasopressin floods the gate
Perioperative AKI — catch it early, don't wait
[Chorus]
Le rein, le foie, les glandes — tout est connecté
Cortisol, catecholamines, glucose dysrégulé
Buffer, clear, and filter through the operative haze
Les organes parlent ensemble — learn to read their ways
[Verse 2]
Hepatic blood flow splits between two tributaries, elegant design
Portal vein brings seventy-five percent, hepatic artery fills the line
When portal flow decreases, the artery dilates to compensate
That hepatic arterial buffer response — adenosine mediates the gate
Volatile agents slash total hepatic flow, halothane hits it hard
Propofol, ketamine, regionals — they guard the liver yard
Cytochrome P450 enzymes slow when perfusion falls away
Drug clearance stumbles, half-lives lengthen through the operative day
[Chorus]
Le rein, le foie, les glandes — tout est connecté
Cortisol, catecholamines, glucose dysrégulé
Buffer, clear, and filter through the operative haze
Les organes parlent ensemble — learn to read their ways
[Verse 3]
Surgical incision triggers the stress cascade, hypothalamus fires first
CRH to ACTH to cortisol — a hormonal thirst
Catecholamines spike the SVR, glucagon breaks the glycogen chain
Cytokines — IL-6, TNF-alpha — amplify the inflammatory refrain
Neuraxial anesthesia blunts this axis at the afferent arc
Epidural blocks the nociceptive signal, mutes the cortisol mark
Glucose climbs despite no carbohydrates — insulin resistance reigns
Tight glycemic control between one-forty and one-eighty still contains
[Bridge]
Adrenal insufficiency — the perioperative specter, quiet and sly
Exogenous steroids suppress the axis, stress doses or the patient will run dry
The thyroid slows under surgery, euthyroid sick syndrome fools the test
Free T3 drops, reverse T3 climbs — the pituitary still thinks it's best
Diabetes insipidus after pituitary surgery — ADH goes mute
Prolixity of fluid, sodium spikes — recognize this cardinal route
That rare word "prolixity" — an overflow, an excess that runs long
When AVP abandons post, the urine pours torrential and strong
[Chorus]
Le rein, le foie, les glandes — tout est connecté
Cortisol, catecholamines, glucose dysrégulé
Buffer, clear, and filter through the operative haze
Les organes parlent ensemble — learn to read their ways
[Outro]
Autoregulation, buffer response, the axis of cortisol and kin
Renal, hepatic, endocrine — three systems beneath the skin
Périopératoire — where physiology meets the blade
Know the mechanisms, read the signals, master the trade
7. 6 Thermoregulation
[Verse 1]
The moment that you push the propofol through,
Vasodilation opens up — heat scatters to the periphery too,
Core-to-shell redistribution, first hour steep decline,
One to two degrees of core temp lost before the patient's even mine.
That first phase hits the hardest, peripheral vessels wide,
The warm blood at the center hemorrhages to the outside.
Then linear cooling follows, radiation, conduction slow,
Until the plateau finds its floor — the thermostat below.
[Chorus]
Hipotermia — it creeps without a sound,
Three phases pulling body temp to ground.
Coagulopathy, infecção, shivering through the bone —
Mantenha o calor, don't let the patient go cold alone.
Redistributed, radiated, plateaued in a row —
Mantenha o calor — protect the heat you know.
[Verse 2]
Neuraxial blocks the sympathetic chain along the spine,
Peripheral vasodilation wide — the patient can't confine
That metabolic furnace heat to where it needs to stay,
Spinal or epidural, thermal defense is stripped away.
And patients lose the shiver reflex when the local spreads,
The thermoregulatory threshold plummets — cool the tissue beds.
Obese patients, pediatric, elderly at the extremes,
Surface-area to mass ratio ruptures all the seams.
[Chorus]
Hipotermia — it creeps without a sound,
Three phases pulling body temp to ground.
Coagulopathy, infecção, shivering through the bone —
Mantenha o calor, don't let the patient go cold alone.
Redistributed, radiated, plateaued in a row —
Mantenha o calor — protect the heat you know.
[Bridge]
Below thirty-six — the clotting factors stutter,
Platelet aggregation falters, wound edges mutter.
Surgical site infection doubles, triples in the cold,
Myocardial ischemia lurks when perfusion isn't bold.
Opioids linger longer, neuromuscular blockade stays,
Fentanyl accumulates inside the hypothermic haze.
And shivering — that frigoric spasm — spikes the oxygen demand,
Four-hundred percent above baseline — more than most hearts withstand.
Frigoric: born of cold and trembling, the body's last command.
[Verse 3]
Forced-air warming blankets, prewarming thirty minutes prior,
Fluid warmers on the IV line, raise the patient higher — wait —
Warm the ambient temperature, especially for the small,
Active warming strategies deployed before induction's call.
Resistive polymer blankets, circulating water too,
Heat-moisture exchangers on the circuit, every breath anew.
Monitor the core — esophageal, nasopharyngeal,
Bladder, rectal, tympanic — temperature is real.
[Chorus]
Hipotermia — it creeps without a sound,
Three phases pulling body temp to ground.
Coagulopathy, infecção, shivering through the bone —
Mantenha o calor, don't let the patient go cold alone.
Redistributed, radiated, plateaued in a row —
Mantenha o calor — protect the heat you know.
[Outro]
Três fases — redistribute, radiate, plateau.
Consequences stack like dominoes below.
Warm before, warm during, monitor with care —
Normothermia isn't optional — it's oxygen, it's there.
8. 7 Acid–Base, Fluids, and Electrolytes
[Verse 1]
Henderson-Hasselbalch, pH is the ledger
Bicarbonate over carbonic acid, measured with precision
Six-point-one plus the log of the ratio
Respiratory shifts the CO2, kidneys hold the base slow
Stewart says it differently — strong ion difference, the driver
Chloride heavy, acidosis; albumin drops, alkaline survivor
Both frameworks tell the truth, just different dialects spoken
Anion gap: sodium minus chloride minus bicarb, never broken
[Chorus]
Gap, base excess, pH in range
MUDPILES creeping, osmol acting strange
Bicarbonate drifting, CO2 in play
Stewart's strong ions won't let you look away
Remember the gap, remember the base
Acid-base balance is the perioperative case
[Verse 2]
Sixty percent of body weight is water, distributed in thirds
Two-thirds intracellular, one-third outside where the action occurs
Plasma's only eight percent, protected by the glycocalyx layer
Starling said hydrostatic pushes out, oncotic pulls back inward
But the glycocalyx is the gatekeeper — degrade it and you drown
Crystalloid floods the interstitium when the scaffold is torn down
Edema isn't volume, context rewrites the story
Hydroxyethyl starch disrupts the coat, synthetic without glory
[Chorus]
Gap, base excess, pH in range
MUDPILES creeping, osmol acting strange
Bicarbonate drifting, CO2 in play
Stewart's strong ions won't let you look away
Remember the gap, remember the base
Acid-base balance is the perioperative case
[Verse 3]
Sodium commands osmolarity, hyponatremia seizes
Correct too fast, central pontine myelinolysis
Hypernatremia pulls the neurons tight, free water is the answer
Potassium: peaked T-waves, sine wave — cardiac disaster
Calcium ionized matters most, not the total in the albumin haze
Hypocalcemia after transfusion, citrate binding through the malaise
Magnesium quiets the myocyte, blocks NMDA in preeclampsia
Low magnesium lets potassium bleed out — repletion comes first, not later
[Bridge]
Base excess minus three or less, metabolic compensation pending
Lactic acid, ketones, salicylate — anion gap ascending
Non-gap acidosis: bicarbonate wasting, hyperchloremic terrain
Alkalosis: vomiting chloride, NG suction down the drain
The electrolyte cascade connects across each organ system
Perioperative imbalance amplifies every surgical problem
[Chorus]
Gap, base excess, pH in range
MUDPILES creeping, osmol acting strange
Bicarbonate drifting, CO2 in play
Stewart's strong ions won't let you look away
Remember the gap, remember the base
Acid-base balance is the perioperative case
[Outro]
Glycocalyx intact, compartments respected
Electrolytes corrected, pH redirected
From Henderson to Stewart, from sodium to mag
Every number in the chart is a clinical flag
9. 8 Physiology of Pregnancy, Neonates, Infants, the Elderly, and Obesity
[Verse 1]
Gravida carries a hidden sea inside,
Cardiac output climbs, MAC values slide,
Forty percent more blood, the plasma leads the cells,
Dilutional anemia — the body overspells,
Gastric emptying slows, aspiration looms,
Progesterone relaxes the esophageal rooms,
Functional residual capacity drops fast,
Oxygen reserves won't let the apnea last
[Chorus]
Corpi diversi, fisiologia cambia —
The gravid, the newborn, the ancient, the ample,
Each body rewrites the pharmacokinetic script,
Corpi diversi — know the difference or slip,
MAC goes down in pregnancy, up in infancy,
La conoscenza — that's what sets the clinician free
[Verse 2]
Neonates breathe with obligate nasal grace,
Fetal hemoglobin holds oxygen in place,
Higher affinity — the curve shifts left with pride,
But oxygen offloads slow to the tissue tide,
Myelin is thin, the blocks spread wide and far,
Hepatic enzymes immature — dose by the gram, not jar,
Hypothermia stalks the small and surface-wide,
High body-to-surface ratio, nowhere left to hide
[Chorus]
Corpi diversi, fisiologia cambia —
The gravid, the newborn, the ancient, the ample,
Each body rewrites the pharmacokinetic script,
Corpi diversi — know the difference or slip,
MAC goes down in pregnancy, up in infancy,
La conoscenza — that's what sets the clinician free
[Verse 3]
The senescent frame — a word for what time sculpts —
Organ reserves hollowed like forgotten vaults,
Glomerular filtration fades across the years,
Hepatic blood flow thins, drug clearance disappears,
Decreased albumin means the free drug roams unchecked,
Volatile requirements fall — their nervous systems flecked,
Atrophy of muscle, fat percentage climbs instead,
Volume of distribution shifts — recalibrate your head
[Bridge]
Obesity tilts the axis of the assumed —
Airway redundant, FRC entombed,
Obstructive apnea primes the hypoxic knife,
Increased cardiac output, a paradox of life,
Dose to ideal or lean? The choice is not a guess,
Adipose as depot — prolonged drug egress,
Pulmonary hypertension waits offstage,
Every body writes a pharmacologic page
[Chorus]
Corpi diversi, fisiologia cambia —
The gravid, the newborn, the ancient, the ample,
Each body rewrites the pharmacokinetic script,
Corpi diversi — know the difference or slip,
MAC goes down in pregnancy, up in infancy,
La conoscenza — that's what sets the clinician free
[Outro]
Senescent, gravid, neonatal, obese —
No universal dose can grant you peace,
Read the body like a manuscript, each chapter rare,
Fisiologia — the only constant is that bodies dare to vary,
Corpi diversi — sempre
10. Self-Assessment
[Verse 1]
An obese patient on the table, oxygen debt comes fast
Reduced FRC means the reservoir just cannot last
Fat compresses diaphragm, compliance starts to fall
Less gas stored in the alveoli — apnea takes it all
A lean body holds a buffer, minutes till the dip
But extra mass cuts margin thin, watch the saturation slip
Pre-oxygenate with diligence, buy every second earned
Denitrogenate the lungs — that's the first lesson learned
[Chorus]
FRC is the fortress, autoregulation holds the gate
Pressure-volume loops will tell you everything about the state
Obesity compresses, aortic lesions narrow down the lane
Propofol preserves the curve, volatiles shift the terrain
FRC — the fortress, loops — the map, cerebral flow — the refrain
[Verse 2]
Now draw the loop for normal hearts — an elegant ellipse
Wide stroke volume, low end-diastolic, nothing amiss
But aortic stenosis warps the geometry entire
The outflow tract is throttled so the pressure climbs up higher
The loop grows tall and narrow, like a column under stress
Concentric hypertrophy compensates — the ventricle's distress
Steeper slope on isovolumic contraction, slower to relax
The stenotic loop is viscid — thickened walls, restricted tracts
[Chorus]
FRC is the fortress, autoregulation holds the gate
Pressure-volume loops will tell you everything about the state
Obesity compresses, aortic lesions narrow down the lane
Propofol preserves the curve, volatiles shift the terrain
FRC — the fortress, loops — the map, cerebral flow — the refrain
[Verse 3]
Cerebral autoregulation — MAP from fifty up to one-fifty
Constant flow through that plateau, the vasculature is thrifty
Volatile agents blunt the curve, dose-dependent vasodilation
They uncouple flow from metabolism — pressure drives perfusion
Propofol keeps autoregulation largely still intact
Cerebrovascular resistance bends but doesn't fully crack
When ICP is elevated, choose your agent with precision
Volatile or intravenous — that's a consequential decision
[Bridge]
Here's a word for your lexicon — lambent, meaning softly bright
The way autoregulation glows when everything runs right
A lambent homeostasis, smooth and barely visible
Until the anesthetic breaks it, then the pressure's indivisible
Stenotic loops go tall, obese patients drop in seconds flat
Propofol protects the plateau — commit that to your format
[Chorus]
FRC is the fortress, autoregulation holds the gate
Pressure-volume loops will tell you everything about the state
Obesity compresses, aortic lesions narrow down the lane
Propofol preserves the curve, volatiles shift the terrain
FRC — the fortress, loops — the map, cerebral flow — the refrain
[Outro]
Reduced reserve, a narrow valve, a curve that starts to bend
Three concepts woven into practice — know them end to end
The obese airway, the stenotic squeeze, the cerebral plateau's span
Assess yourself against the physiology — that's how you build your plan
11. Learning Objectives
[Verse 1]
Propofol drips into the vein, a white emulsion smooth,
Lipid soluble, high clearance — watch it redistribute and move,
Context-sensitive half-time climbs when infusions run too long,
GABA-A receptor agonist, hypnosis short and strong,
Apnea, hypotension, pain on injection — know the cost,
Without a titrated hand, the patient's airway can be lost
[Chorus]
Pharmacokinetics: absorption, distribution, metabolism, elimination
Pharmacodynamics: the receptor interaction, the clinical sensation
Volume of distribution tells you where the molecule goes to hide,
Clearance drives the half-life — let those four letters be your guide
Absorption, distribution, metabolism, elimination — A-D-M-E
Protein binding, hepatic extraction, renal filtration — that's the key
[Verse 2]
Opioids bind mu receptors, analgesia is the aim,
Fentanyl's lipophilic — rapid onset, potent frame,
Morphine glucuronidation yields active metabolites,
Remifentanil is ester-cleaved — context half-time never bites,
Respiratory depression, pruritis, delayed gastric drain,
Tolerance shifts the dose-response — you're titrating against pain
[Chorus]
Pharmacokinetics: absorption, distribution, metabolism, elimination
Pharmacodynamics: the receptor interaction, the clinical sensation
Volume of distribution tells you where the molecule goes to hide,
Clearance drives the half-life — let those four letters be your guide
Absorption, distribution, metabolism, elimination — A-D-M-E
Protein binding, hepatic extraction, renal filtration — that's the key
[Verse 3]
Neuromuscular blockers — depolarizing versus non,
Succinylcholine mimics ACh, then the fasciculations come,
Pseudocholinesterase deficiency prolongs the block for hours,
Rocuronium, vecuronium — aminosteroids with competitive powers,
Sugammadex chelates and wraps them, reversal quick and clean,
Monitoring train-of-four — don't extubate on residual curaremia
[Bridge]
Drug interactions thread through every case,
CYP enzymes induct or inhibit — metabolic race,
Volatile agents potentiate the block, MAC reduction too,
Polypharmacy demands you calculate the pharmacologic queue,
Therapeutic index narrow — ketamine dissociates the mind,
Dexmedetomidine at alpha-two: sedation, no respiratory bind,
Vasopressors, reversal agents, local anesthetics — each one a pharmacologic art,
Sodium channel blockade, bupivacaine cardiotoxic — lipid emulsion, restart
[Verse 4]
Benzodiazepines potentiate GABA chloride flow,
Midazolam water-soluble, becomes lipid once it hits below,
Neostigmine inhibits acetylcholinesterase — muscarinic side effects rise,
Pair it with glycopyrrolate — anticholinergic counters, that's the wise,
Adjuncts layer depth: ketamine, dexamethasone, regional nerve block,
Multimodal analgesia — you're building pharmacology around the clock
12. 1 Principles
[Verse 1]
Three compartments talking — central, fast, and slow
Propofol floods the plasma, then it starts to go
Redistribution pulls it from the brain to fat
Effect-site lags behind, remember that
Context-sensitive half-time isn't simple math —
Longer infusion, longer is the aftermath
Target-controlled infusion chases concentration
Pharmacokinetics: precision, not approximation
[Chorus]
Фармакологія — знай свої дози
Kompartiment, Verteilung, know how the drug goes
MAC is the anchor, fifty percent suppressed
Synergy cuts it — opioid does the rest
Терапевтичний індекс — narrow is the line
Знай свій препарат — every time
[Verse 2]
MAC modifiers — age and temperature bend it low
Nitrous adds its fraction, volatile agents flow
Opioids shift the curve — dose-response compressed
Hypnotic-opioid synergy outperforms the rest
Therapeutic index: margin slim as a blade
One click too far on the pump — the debt gets paid
Isobologram shows where the curves collide —
Synergy isn't addition, it's a steeper slide
[Chorus]
Фармакологія — знай свої дози
Kompartiment, Verteilung, know how the drug goes
MAC is the anchor, fifty percent suppressed
Synergy cuts it — opioid does the rest
Терапевтичний індекс — narrow is the line
Знай свій препарат — every time
[Verse 3]
Pseudocholinesterase — the variant delays the block
Succinylcholine lingers when the enzyme's off the clock
RYR1 mutation, CACNA1S too —
Trigger the volatile, and malignant hyperthermia breaks through
CYP2D6 — poor metabolizer in the chair
Codeine accumulates when the enzyme isn't there
Pharmacogenomics isn't footnotes in a text —
It's the reason one dose saves and one dose wrecks
[Verse 4]
Protein binding shifts when albumin runs low
Free fraction rises — more drug on the go
The elderly patient needs a gentler hand
Reduced clearance, altered Vd — understand
Hepatic flow determines what survives first pass
Renal function clears what the liver lets bypass
Titrate to effect, but know the physiology —
The patient's state rewrites the pharmacology
[Bridge]
Und dann — the syringe swap, the look-alike vial
Vecuronium beside the midazolam — wrong profile
High-alert medications demand a second eye
Labeling fades under pressure — patients shouldn't die
Sticker every syringe, confirm before you push
Дивись двічі, перевір — no room for a rush
Drug errors haunt the OR like a silent audit trail —
Systemic vigilance, not individual blame to scale
[Chorus]
Фармакологія — знай свої дози
Kompartiment, Verteilung, know how the drug goes
MAC is the anchor, fifty percent suppressed
Synergy cuts it — opioid does the rest
Терапевтичний індекс — narrow is the line
Знай свій препарат — every time
[Outro]
Compartments, context, MAC, and gene
The pharmacology machine runs clean
Перевір — label, dose, and interaction
Sichere Praxis — precision is protection
13. 2 Inhaled Anesthetics
[Verse 1]
Vapor pressure drives the molecules up high,
Desflurane boils at twenty-three — volatile supply,
Partition coefficients split between the blood and gas,
Low blood-solubility means induction goes fast,
Desflurane, sevoflurane — wash in quick and clean,
Isoflurane lingers longer, 0.45 between,
The concentration effect fills alveoli first,
Second gas effect tags along — nitrous quenches thirst
[Chorus]
Anestesia, os agentes no ar —
MAC é a dose, não pode errar,
Konzentration, Blut und Gas,
Partition coefficients, first in class,
Sevoflurane, desflurane, breathe them in slow,
MAC one-point-eight, let the numbers flow,
Anestesia — merke dir das gut,
Every modifier shifts the cut
[Verse 2]
MAC values anchor what we know —
Age brings it down, hyperthermia makes it grow,
Pregnancy drops MAC by forty percent,
Opioids, ketamine — the value gets bent,
Hyponatremia lowers CNS demand,
Neonates peak higher — cerebral bandwidth, unplanned,
Volatile agents hit the myocardium hard,
Isofl'rane dilates vessels, coronary on guard,
Respiratory drive blunted, CO2 climbs the chart,
Cerebral vasodilation — ICP plays its part
[Chorus]
Anestesia, os agentes no ar —
MAC é a dose, não pode errar,
Konzentration, Blut und Gas,
Partition coefficients, first in class,
Sevoflurane, desflurane, breathe them in slow,
MAC one-point-eight, let the numbers flow,
Anestesia — merke dir das gut,
Every modifier shifts the cut
[Verse 3]
Compound A forms in the soda lime with sevo heat,
Nephrotoxic threshold — two parts per million, keep it neat,
Carbon monoxide blooms from desiccated baralyme,
Desflurane and isoflurane — the usual pantomime,
Halothane hepatitis, immune-mediated cascade,
Enflurane — the seizure ghost from decades past, unmade,
Xenon: blood-gas coefficient near one-point-one-four,
Hemodynamic ghost — no pressor, no floor
[Bridge]
Lachgas — Raumexpansion, sei vorsichtig jetzt,
Nitrous doubles pneumothorax where no margin's left,
Diffusion hypoxia crashes oxygen on wake,
B-twelve and methionine synthase — irreversible mistake,
PONV climbs, the ozone pays the toll,
Low-flow anesthesia — recirculate the whole,
O meio ambiente sofre — feche o fluxo, sim,
Environmental debt compounds from begin to fim
[Chorus]
Anestesia, os agentes no ar —
MAC é a dose, não pode errar,
Konzentration, Blut und Gas,
Partition coefficients, first in class,
Sevoflurane, desflurane, breathe them in slow,
MAC one-point-eight, let the numbers flow,
Anestesia — merke dir das gut,
Every modifier shifts the cut
[Outro]
Malignant hyperthermia — ryanodine receptor springs,
Volatile triggers plus succinylcholine — calcium floods and sings,
Dantrolene, cooling, bicarb, the protocol unfolds,
Xenon leaves no carbon trace — that's the future story told,
Sevoflurane, desflurane, isoflurane in low-flow,
MAC, partition, organ effects — now you know
14. 3 Intravenous Induction and Sedative Agents
[Verse 1]
Milky white emulsion in the syringe,
Propofol hits fast — it's the lipid hinge,
Cytochrome P450 barely gets a say,
Hepatic and extrahepatic — clears away,
Drop in SVR, cardiac output falls,
Respiratory drive just hits the walls,
Apnea on induction, don't walk away,
Lidocaine in the line to dull the sting today,
And if you drip it days on end, watch the pH,
Metabolic acidosis — PRIS won't delay
[Chorus]
Propofol drops the pressure, ketamine climbs,
Etomidate holds steady — read the signs,
NMDA blocked, dissociation's near,
BIS is falling, burst suppression's clear,
Every agent carves a different trace —
Know your drugs before you take the case
[Verse 2]
Etomidate — the hemodynamic friend,
Steroid synthesis blocked around the bend,
11-beta-hydroxylase takes the hit,
Single dose cortisol suppression — just a bit,
Myoclonus fires without a seizure there,
Pretreat with benzo if you want to spare,
Septic shock or cardiac compromise in view,
Etomidate's the bridge to get you through
[Chorus]
Propofol drops the pressure, ketamine climbs,
Etomidate holds steady — read the signs,
NMDA blocked, dissociation's clear,
BIS is falling, burst suppression's near,
Every agent carves a different trace —
Know your drugs before you take the case
[Verse 3]
Ketamine speaks a dissociative tongue,
Phencyclidine cousin — thalamo-limbic rung,
Sympathomimetic surge, catecholamines flood,
Bronchodilation — useful if you could,
Sub-dissociative dosing, point-three per kilo,
Analgesic ceiling without the vertigo,
Emergence phenomena — vivid, strange, and bright,
Benzo coadministration smooths the night,
Awake fiberoptic? Ketamine keeps tone,
Airway intact — you're never left alone
[Bridge]
Thiopental's legacy lives in ECT's hall,
Methohexital still answers seizure's call,
Midazolam preops the anxious mind,
Remimazolam — organ-sparing by design,
Flumazenil reverses but don't trust the clock,
Resedation lurks when the antagonist stops,
Dexmedetomidine — alpha-two's quiet hand,
Bradycardia's the tax on this sedation plan,
Locus coeruleus quieted, cooperative airway won,
Awake intubation done without a benzodone
[Chorus]
Propofol drops the pressure, ketamine climbs,
Etomidate holds steady — read the signs,
NMDA blocked, dissociation's clear,
BIS is falling, burst suppression's near,
Every agent carves a different trace —
Know your drugs before you take the case
[Outro]
BIS below forty — deep suppression zone,
Burst suppression patterns etched in raw EEG bone,
Entropy measures order in the cortical hum,
Processed EEG guides the depth — don't fly numb,
Each molecule a lever on the conscious state,
Pharmacology sharp — that's how you operate
15. 4 Opioids in Anesthesia
[Verse 1]
Fentanyl drips into the line, a hundred times past morphine's climb
Lipophilic, fast to cross the brain, binds mu receptors, dulls the pain
Sufentanil — ten times stronger still, the ICU's familiar chill
Short procedures call for alfentanil's speed, context-sensitive kinetics plant the seed
Remifentanil, ester-cleaved by blood and tissue, metabolized before you blink
No organ needed, plasma esterases do the work, gone faster than you'd think
But pull that infusion, watch the patient wake to agony — hyperalgesia's sting
Pre-emptive multimodal cover or you'll hear the postop suffering
[Chorus]
Fent, sufent, remi, alfent — mu receptor melody
Context-sensitive half-times shift with infusion history
Morphine, hydromorphone, meperidine, methadone in the mix
Know your opioid, know your patient, know your fix
[Verse 2]
Context-sensitive half-time — not elimination, don't confuse the two
The longer that you run the drug, redistribution changes what it'll do
Remifentanil stays flat across the clock, fentanyl curves steep with time
Morphine's active metabolite accumulates in renal decline
Chest wall rigidity — the wooden chest, it comes with bolus, comes with speed
Fentanyl and sufentanil, high-dose induction, watch the patient freeze
Succinylcholine breaks the lock, or naloxone if you dare reverse
Ventilate them manually first, then troubleshoot the universe
[Chorus]
Fent, sufent, remi, alfent — mu receptor melody
Context-sensitive half-times shift with infusion history
Morphine, hydromorphone, meperidine, methadone in the mix
Know your opioid, know your patient, know your fix
[Verse 3]
Neuraxial opioids — intrathecal morphine's the gold standard post-op tool
Rostral spread to respiratory centers, apnea monitoring's the rule
Lipophilic remi and fentanyl stay segmental, hydrophilic morphine roams
Pruritus, nausea, urinary retention — the neuraxial side-effect homes
Naloxone titration — twenty-five to forty micrograms at a time
Too much reversal crashes analgesia, triggers withdrawal, dysrhythmia rhyme
Drip it slow, redose with caution, half-life's shorter than the opioid's hold
Renarcotization will come back and bite — the textbooks told you so
[Bridge]
Opioid-free, opioid-sparing — not a trend, it's mechanism
Ketamine blocks NMDA, dexmedetomidine quiets the system
Lidocaine infusions, NSAIDs, dexamethasone, regional nerve block
Tap the multimodal toolkit, reduce receptor overlock
Because every opioid given seeds a postoperative cost —
PONV, ileus, tolerance, the recovery days lost
[Chorus]
Fent, sufent, remi, alfent — mu receptor melody
Context-sensitive half-times shift with infusion history
Morphine, hydromorphone, meperidine, methadone in the mix
Know your opioid, know your patient, know your fix
16. 5 Neuromuscular Blocking Drugs and Reversal
[Verse 1]
Succinylcholine walks in fast, depolarizing every end plate
Fasciculations ripple through, the potassium can't wait
Burns and denervation, myopathies on the floor
Prolonged immobility — don't open that door
Pseudocholinesterase deficient? Paralysis extends
Malignant hyperthermia lurks around the bends
Raises intraocular, raises intracranial too
Bradycardia in children — black box warning, hear it through
[Chorus]
TOF, TOF, train-of-four tells you where you stand
Quantitative monitoring — never guess, demand
Neostigmine needs glycopyrrolate beside
Sugammadex encapsulates, reversal deep and wide
Rocuronium, vecuronium, cis-atracurium's Hofmann fade
Pancuronium, atracurium — know the choices that were made
Phase II block, residual harm, potentiation all around
Magnesium, volatiles, aminoglycosides compound
[Verse 2]
Non-depolarizing agents, competitive at the receptor
Rocuronium hits in sixty seconds — rapid intubator
Vecuronium runs on liver, intermediate in stay
Pancuronium vagolytic, slow and long to fade away
Cisatracurium degrades through Hofmann elimination
No organ dependence — kidneys, liver — no hesitation
Atracurium releases histamine, watch the pressure dip
Choose your agent for the patient, don't let safety slip
[Chorus]
TOF, TOF, train-of-four tells you where you stand
Quantitative monitoring — never guess, demand
Neostigmine needs glycopyrrolate beside
Sugammadex encapsulates, reversal deep and wide
Rocuronium, vecuronium, cis-atracurium's Hofmann fade
Pancuronium, atracurium — know the choices that were made
Phase II block, residual harm, potentiation all around
Magnesium, volatiles, aminoglycosides compound
[Bridge]
Neostigmine hits a ceiling — acetylcholinesterase inhibition
Time it right or muscarinic chaos joins the mission
Sugammadex doses deeper for profound rocuronium block
Sixteen milligrams per kilogram to reverse the total lock
Hormonal contraceptives — interaction, seven-day gap
Anaphylaxis rare but real — keep epinephrine on the map
Renal failure? Accumulation — clearance starts to crawl
Acidosis, hypothermia, volatiles potentiate them all
[Verse 3]
Residual block post-extubation — hypoxia on the ward
TOF ratio under ninety percent — an outcome you can't afford
Quantitative monitoring isn't optional, it's standard of care
Subjective tactile feeling of four twitches leaves you bare
Phase two block from succinylcholine — repeated dosing leads
Infusion without monitoring plants complications like seeds
Know your depth before reversing — sugammadex by block level
Shallow, moderate, profound — dose accordingly, be level
17. 6 Local Anesthetics
[Verse 1]
Sodium channels sitting in the membrane wall
A local anesthetic comes to block the hall
Uncharged form diffuses through the lipid gate
Then ionized inside — that's how we seal your fate
Potency tied to lipid solubility high
Protein binding holds the duration, watch it climb
Onset governed by pKa — the lower wins the race
More un-ionized at body pH, faster to the place
[Chorus]
Chloro, lido, mepivacaine
Ropi, levo, bupivacaine
Esters cleave in plasma, amides through the liver chain
Max dose, LAST response, lipid emulsion on the brain
Three percent chloroprocaine — fastest one to call
Bupivacaine — longest acting, heaviest baricity of all
[Verse 2]
Esters carry para-amino, allergic risk is real
Amides got that second "i" in name — the trick to seal
Add epinephrine, vasoconstrict, prolong and contain
But never on a digit, never near a ring-shaped vein
Bicarbonate accelerates onset, raises pH fast
Clonidine extends the sensory block designed to last
Liposomal bupivacaine — slow release, extended window wide
Seventy-two hours of post-op cover wrapped inside
[Chorus]
Chloro, lido, mepivacaine
Ropi, levo, bupivacaine
Esters cleave in plasma, amides through the liver chain
Max dose, LAST response, lipid emulsion on the brain
Three percent chloroprocaine — fastest one to call
Bupivacaine — longest acting, heaviest baricity of all
[Verse 3]
LAST comes in stages — metallic tongue and ringing ears
Circumoral numbness, then the CNS appears
Seizures first, then cardiovascular collapse descends
Bupivacaine the worst — it wedges deep where sodium ends
Call for help and stop the drug, secure that airway fast
Twenty percent lipid emulsion — fifteen mils per kilo mass
One point five per kilo bolus, then the infusion runs
ASRA checklist in your pocket, prop-o-fol is shunned
[Bridge]
Intrathecal baricity — hypo, iso, hyper three
Heavy bupivacaine sinks down with gravity
Position the patient, tilt the table, watch where it goes
Lidocaine spinal — transient neurologic symptoms show
Burning down the buttocks, shooting bilateral thighs
TNS resolves, but cauda equina never fully dies
High concentration, pooling drug, the roots begin to scar
Keep your doses calibrated — know exactly where you are
[Chorus]
Chloro, lido, mepivacaine
Ropi, levo, bupivacaine
Esters cleave in plasma, amides through the liver chain
Max dose, LAST response, lipid emulsion on the brain
Three percent chloroprocaine — fastest one to call
Bupivacaine — longest acting, heaviest baricity of all
[Outro]
Ropivacaine — less cardiotoxic, S-enantiomer pure
Levobupivacaine follows close behind that door
Mepivacaine — medium duration, vasoconstricts alone
Six agents mapped across your practice, carved in bone
Block the channel, read the signs, and keep that lipid near
Anesthesiology foundations — crystal clear
18. 7 Cardiovascular Drugs
[Verse 1]
Phenylephrine squeezes the vessels down pure alpha tone
Ephedrine kicks both alpha-beta, dopamine stored and grown
Norepinephrine dominates the alpha with some beta weight
Epinephrine opens everything — low dose dilates, high dose constricts the gate
Vasopressin locks the V1 receptor, holds the line
Metaraminol — the quiet cousin, steady by design
[Chorus]
Сосуды, сердце, ритм — мы держим баланс
Vasopressors hold the pressure, give the organs one more chance
Alpha, beta, dopamine — выбирай с умом
Pick your drug, read the hemodynamics, never run on autopilot home
[Verse 2]
Dobutamine feeds the failing heart with beta-one devotion
Dopamine dose-dependent — renal, cardiac, pressor ocean
Milrinone — the phosphodiesterase blocker, inotropy without the rate
Levosimendan sensitizes calcium — it's the troponin binding trait
For vasodilation: nitro gives the veins, nitroprusside both sides steals
Hydralazine arterial drop, tachycardia in your heels
[Chorus]
Сосуды, сердце, ритм — мы держим баланс
Vasopressors hold the pressure, give the organs one more chance
Alpha, beta, dopamine — выбирай с умом
Pick your drug, read the hemodynamics, never run on autopilot home
[Verse 3]
Labetalol alpha-beta blocked, nicardipine calcium gated slow
Clevidipine metabolized by esterase — the shortest half-life you'll know
Esmolol — beta-one selective, cardioselective brevity
Now antiarrhythmics: Vaughan-Williams sorts them by propensity
Class one blocks sodium fast, class two beta-blocks the node
Class three prolongs repolarization — amiodarone carries that load
Class four calcium channel blocks, verapamil slows conduction cold
Lidocaine one-B, adenosine snaps SVT — two seconds bold
Magnesium calms the torsades, the electrolyte that mends the storm
[Bridge]
Atropine — muscarinic block, the vagolytic norm
Glycopyrrolate won't cross the blood-brain, choose it when you want no fog
POISE trial warned us: perioperative beta-blockade cuts the infarct rate
But stroke risk climbed — так что осторожно — titrate, don't sedate
Statins: pleiotropic — a rare word meaning "many-targeted" action wide
Anti-inflammatory, plaque-stabilizing — continue perioperative inside
ACE inhibitors, ARBs — hold the morning dose before your case
Refractory hypotension intraoperative — vasopressin fills that space
[Chorus]
Сосуды, сердце, ритм — мы держим баланс
Vasopressors hold the pressure, give the organs one more chance
Alpha, beta, dopamine — выбирай с умом
Pick your drug, read the hemodynamics, never run on autopilot home
[Outro]
Chronotropy, inotropy, afterload, preload — map the physiology
Vasopressor, inotrope, antiarrhythmic — cardiovascular pharmacology
Запомни каждый класс — remember every class
The hemodynamics shift, your knowledge holds the pass
19. 8 Other Perioperative Drugs
[Verse 1]
Apfel score tallied — female, nonsmoker, history of motion sickness too
Opioids in the plan, so the risk is climbing through
Ondansetron blocks the serotonin tide at five-HT-three
Dex four milligrams, droperidol low-dose, multimodal is the key
Scopolamine patch behind the ear the night before the blade
Aprepitant for NK-one, metoclopramide to aid
Aspiration prophylaxis — sodium citrate, ranitidine, a PPI
Rapid sequence induction, full stomach, keep that acid dry
[Chorus]
Другие препараты, запомни их все —
Antiemetics, steroids, коагуляция везде
Dantrolene is waiting, антибиотик в срок
Perioperative pharmacology — это наш урок
[Verse 2]
Heparin bridging, warfarin held five days pre-op
INR normalized before you let the bleeding stop
DOACs — hold two to four half-lives, renally dosed and cleared
Protamine reverses heparin, vitamin K when warfarin's feared
PCC four-factor for the urgent bleed that won't delay
Idarucizumab for dabigatran, andexanet for factor Xa
P2Y12 inhibitors — clopidogrel, hold it five to seven days
Aspirin context-dependent, regional timing always weighs
[Chorus]
Другие препараты, запомни их все —
Antiemetics, steroids, коагуляция везде
Dantrolene is waiting, антибиотик в срок
Perioperative pharmacology — это наш урок
[Verse 3]
Tranexamic acid — CRASH-2 showed it cuts traumatic death
WOMAN trial, obstetric hemorrhage, buying precious breath
POISE-3 added perioperative surgical data to the case
Aminocaproic acid, lysine analog, holding fibrin in its place
Stress dosing steroids — cortisol axis suppressed below
Hydrocortisone one hundred milligrams, let the physiologic rivers flow
Dexamethasone wears two hats — antiemetic and anti-inflammatory frame
Insulin infusion targets glucose tight — hyperglycemia takes the blame
[Bridge]
Cefazolin one gram, sixty minutes before the skin
Redose every four hours if the operation pulls you in
Penicillin allergy — ninety percent are mislabeled, skin-test and delabel them
Oxytocin slow infusion post-delivery, carboprost for the refractory phlegm
Misoprostol sublingual, ergometrine raises pressure, know the contraindication
Dantrolene two point five per kilo — malignant hyperthermia obliteration
Magnesium sulfate tocolysis and seizure, bronchodilators open the constricted gate
Mannitol osmotic, furosemide for volume, hypertonic saline for ICP — calculate
[Chorus]
Другие препараты, запомни их все —
Antiemetics, steroids, коагуляция везде
Dantrolene is waiting, антибиотик в срок
Perioperative pharmacology — это наш урок
[Outro]
Every drug a role, every timing deliberate and precise
Reversal agents stocked, the prophylaxis balanced on a knife
Pharmacology не спит — it runs beneath the drape and blade
Know your drugs by mechanism, know the evidence that was made
20. Self-Assessment
[Verse 1]
Context-sensitive half-time — not a constant, not a lie,
It's how the drug accumulates the longer that you try,
Fentanyl will linger, hours pooled in fat and bone,
Sufentanil redistributes slower on its own,
But remifentanil — ester bonds cleaved fast and clean,
Plasma half-time ninety seconds, shortest ever seen,
Infusion runs for hours, cut it off and patients wake,
No accumulation — that's the pharmacist's daybreak
[Chorus]
Полчаса — не твій час, контекст вирішує,
Context-sensitive — the lipid store accrues,
Remi cuts through, fentanyl settles in the fat,
Знай свій препарат — know exactly where you're at,
Час — це все, time is everything,
Half-time shifts with every hour the drip is running
[Verse 2]
Succinylcholine — elegant but dangerous to some,
Contraindications etched before you give the drug and run,
Denervation burns — upregulated receptors bloom,
Hyperkalemia strikes, potassium fills the room,
Burns beyond twenty-four hours, crush and cord disease,
Myopathies lurk quiet — rhabdomyolysis with ease,
Malignant hyperthermia — ryanodine receptor flaw,
Pseudocholinesterase deficient, prolonged by natural law,
Raised intragastric pressure — relative, weigh the cost,
Glaucoma and open globe, the vitreous could be lost
[Chorus]
Полчаса — не твій час, контекст вирішує,
Context-sensitive — the lipid store accrues,
Remi cuts through, fentanyl settles in the fat,
Знай свій препарат — know exactly where you're at,
Час — це все, time is everything,
Half-time shifts with every hour the drip is running
[Verse 3]
MAC is one-point-zero — fifty percent won't move,
Modifiers bend that number out of every textbook groove,
Age decreases MAC — elderly need less sevoflurane,
Hypothermia, opioids, pull the number down again,
Hyperthyroid, fever, alcohol acute — they push it higher,
Nitrous oxide adds its fraction — additive, no synapse wire,
Sevo at point-six-five MAC, nitrous brings point-five,
One-point-one-five combined — surgical depth, patient's alive,
It's the concept of veridical addition — truthful math,
Stack the agents carefully and calculate the path
[Bridge]
Sugammadex encapsulates rocuronium complete,
But renal failure traps that complex — excretion won't delete,
The drug returns, the block returns — vecuronium wakes,
Рекурарізація — watch the diaphragm as it breaks,
Monitor with train-of-four, anticipate recurarization,
Redose sugammadex sixteen milligrams per kilogram — precision,
Ventilate until the fade resolves and TOF ratio's sound,
Веди пацієнта — hold the airway, don't stand down
[Chorus]
Полчаса — не твій час, контекст вирішує,
Context-sensitive — the lipid store accrues,
Remi cuts through, fentanyl settles in the fat,
Знай свій препарат — know exactly where you're at,
Час — це все, time is everything,
Half-time shifts with every hour the drip is running
21. Learning Objectives
[Verse 1]
Before the patient breathes, before the needle threads,
You audit every circuit, every valve, every med.
The machine wakes up cold — you warm it with your hands,
Pressure gauges, flow controls, vaporizer stands.
Check the oxygen supply, the pipeline and the tank,
Central pressure holding? Note the level and the rank.
Flush the fresh gas outlet, listen for the hiss,
Miss a cracked connection and you'll remember this.
[Chorus]
Проверь всё до конца — не торопись,
каждый клапан, каждый газ — убедись.
Check it high, check it low, check the breathing loop,
Всё в порядке — только тогда в операционную войди.
Leaks and blocks and hypoxic mix, know them one by one,
Проверь всё — твой пациент зависит от тебя одного.
[Verse 2]
The CO2 absorber — granules pale or purple?
Exhausted soda lime makes rebreathing a hurdle.
Fresh granules sit violet, spent granules fade to white,
Color shift mid-case means your circuit's out of fight.
Pop the APL valve open, test your reservoir bag,
Squeeze it, watch it rise and fall — no resistance lag.
Occlude the patient port, dial the pop-off down,
Pressure holds at thirty? Then your system's solid ground.
[Chorus]
Проверь всё до конца — не торопись,
каждый клапан, каждый газ — убедись.
Check it high, check it low, check the breathing loop,
Всё в порядке — только тогда в операционную войди.
Leaks and blocks and hypoxic mix, know them one by one,
Проверь всё — твой пациент зависит от тебя одного.
[Verse 3]
Vaporizer seated firm, dial calibrated clean,
Agent-specific keyed fillers stop the wrong gas scene.
Oxygen analyzer reading twenty-one percent?
Calibrate before induction — that's the baseline meant.
Ventilator bellows cycling, tidal volumes set,
Alarms armed for pressure, volume, rate — cover every bet.
Suction catheter tested, laryngoscope blades lit,
Backup Ambu bag in reach — never skip a bit.
[Bridge]
When the capnograph goes flat mid-case and monitors scream,
It's not the time to study — it's the time to trust the scheme.
Disconnect and ventilate by hand while you trace the fault,
Check the circuit junction to junction, bring the chaos to a halt.
Систематичность — это не рутина,
это спасённая жизнь за одну минуту.
Methodical is faster when the pressure's absolute.
[Chorus]
Проверь всё до конца — не торопись,
каждый клапан, каждый газ — убедись.
Check it high, check it low, check the breathing loop,
Всё в порядке — только тогда в операционную войди.
Leaks and blocks and hypoxic mix, know them one by one,
Проверь всё — твой пациент зависит от тебя одного.
[Outro]
Machine intelligence fails — your eyes and hands don't lie,
Know the mechanism behind each number, each reply.
Audit, troubleshoot, rebuild the mental map,
Anesthesia's architecture lives inside that gap.
Before induction — check it.
Mid-case alarm — trace it.
Unexpected reading — question it.
Всё под контролем.
22. 1 Gas Supply and the Anesthesia Machine
[Verse 1]
Pipeline at fifty PSI comes through the wall,
Cylinders backup when the pressure drops to fall,
Pin index safety keeps the gases in their place,
Oxygen is white, nitrous oxide gets blue face,
Two-thousand PSI inside the E-tank stored,
Oxygen failure trips the alarm, cuts hypoxic cord,
Second source kicks in, the failsafe holds the gate,
No hypoxic mixture makes it past the interlock's weight
[Chorus]
Pipeline, cylinder, flowmeter, vape,
Pin index stops the lethal swap escape,
Oxygen flush at fifty, bypass the flow,
Soda lime absorbing CO2 below,
Check the machine before the patient's under,
Miss a step and you'll be torn asunder
[Verse 2]
Flowmeters read from bottom, bobbin spins and floats,
Variable bypass vaporizer, agent concentration notes,
Desflurane needs a heated pressurized design,
Twenty-three degrees boiling point keeps it out of line,
Tec six vaporizer, electronically controlled,
Injection-type for total vapor, newer stories told,
Interlocks prevent two vaporizers running hot,
One agent at a time is all the circuit's got
[Chorus]
Pipeline, cylinder, flowmeter, vape,
Pin index stops the lethal swap escape,
Oxygen flush at fifty, bypass the flow,
Soda lime absorbing CO2 below,
Check the machine before the patient's under,
Miss a step and you'll be torn asunder
[Verse 3]
Mapleson A is Magill, efficient for the awake,
D and E for pediatric, F for Jackson-Rees sake,
Circle system rebreather, unidirectional valves,
Inspiratory, expiratory, soda lime resolves,
Granules turn from white to violet when they're spent,
Desiccated absorbent brews compound A, COvent,
High flow flushes channel heat, reaction gone compound,
Sevoflurane plus dry soda lime, toxic ground
[Bridge]
Bellows rise on exhalation, piston drives without a bag,
VCV targets volume, PCV rides the pressure tag,
PSV for spontaneous, SIMV bridges both the states,
APL valve limits circuit pressure, sixty centimeters gates,
Scavenging pulls the waste gas out before it fills the air,
Occupational limits, chronic exposure — handle with care
[Chorus]
Pipeline, cylinder, flowmeter, vape,
Pin index stops the lethal swap escape,
Oxygen flush at fifty, bypass the flow,
Soda lime absorbing CO2 below,
Check the machine before the patient's under,
Miss a step and you'll be torn asunder
[Verse 4]
ASA checklist, AAGBI morning ritual,
High pressure, low pressure, leak test habitual,
Flush with oxygen, occlude the Y-piece tight,
Pressure holds or circuit compromise comes to light,
Disconnect alarm triggers when the capnograph flatlines,
Stuck expiratory valve traps breath in dangerous confines,
Wrong agent filled, tipped vaporizer, cross-contamination,
Systematic checkout is your strongest foundation
[Outro]
So trace the gas from wall to lung and back again,
Know your pressures, colors, volumes, valves, and when,
Every bobbin, granule, bellows has a role to play,
The machine that breathes for others needs your full survey
23. 2 Physics
[Verse 1]
Boyle says pressure times volume stays the same
Charles adds temperature to the gas law game
Dalton's law — each partial pressure stands alone
Henry's law — dissolved gas follows tension home
Poiseuille says flow goes with radius to the fourth
Double the tube, sixteen times the worth
Viscosity drags it, length takes its toll
Resistance governs every molecule's role
[Chorus]
Las leyes del gas, they never bend
Flujo laminar or turbulent end
Reynolds number tells you which way it breaks
Critical velocity, everything's at stake
Bernoulli speeds the flow, pressure drops below
Venturi pulls the oxygen, watch the entrainment go
La física no miente — physics doesn't lie
Learn the laws or watch your patient's numbers fly
[Verse 2]
Laminar flow is orderly, parabolic and clean
Turbulent flow is chaotic, loud, and mean
Reynolds number under two thousand, smooth and steady
Climb past four thousand — turbulence is ready
Between them sits the critical velocity zone
Kinematic viscosity, density, diameter — never alone
Ohm's law: voltage over resistance equals current through
Electrical safety — what you don't know can hurt you
[Chorus]
Las leyes del gas, they never bend
Flujo laminar or turbulent end
Reynolds number tells you which way it breaks
Critical velocity, everything's at stake
Bernoulli speeds the flow, pressure drops below
Venturi pulls the oxygen, watch the entrainment go
La física no miente — physics doesn't lie
Learn the laws or watch your patient's numbers fly
[Verse 3]
Laplace says tension equals pressure times the radius
Small alveoli collapse — that's the hazard
Surfactant cuts the tension, keeps the small ones round
Without it, atelectasis drags the patient down
Macroshock needs milliamps to stop a heart cold
Microshock through a catheter — microamps is all it takes to fold
Isolated power systems break the earth connection
Line isolation monitors — your electrical protection
[Bridge]
El fuego en el quirófano — three things ignite
Fuel and oxidizer, an ignition source takes flight
Laser strikes the ETT, oxygen-rich and bare
Saline-filled cuffs and foil-wrapped tubes — take care
MRI pulls ferromagnetic objects without warning
Zone four means implants screened every single morning
Pacemakers feel EMI, diathermy scrambles their beat
Bipolar cautery near the generator — keep it discreet
[Verse 4]
Pressure transducers — level them at the phlebostatic point
Zero them to atmosphere or your readings will disappoint
Resonance inflates the waveform, damping flattens it out
Optimal damping coefficient — point six four, without a doubt
Heat and humidity — the airway needs both to survive
Hygroscopic heat exchangers keep inspired gas alive
Active humidifiers add water vapor, temperature-controlled
The nose is a heat exchanger — bypass it, and the story's cold
24. 3 Airway and Ventilation Equipment
[Verse 1]
Macintosh curves into the vallecula, blade tip lifts the epiglottis indirectly
Miller runs straight, flips the epiglottis over, Miller loves the infant airway perfectly
Videolaryngoscopy bends around the corner, channeled blade guides the tube right through the port
Hyperangulated angles past ninety degrees, non-channeled needs a stylet for support
Bougies slip through cords when the view is grade three, feel the tracheal rings beneath your fingers click
Stylets shape the tube but pull before the cuff, malleable memory, withdraw it quick
[Chorus]
Mac in the vallecula, Miller lifts the flap
Video bends around what direct cannot unwrap
Bougie, stylet, cuff and tube, supraglottic sealed
Every airway tool has its own battlefield
Grade your view, choose your blade, know what's in the kit
LEMONS tells you when the difficult airway fits
[Verse 2]
Cuffed tubes seal the airway, high-volume low-pressure rides against aspiration
Double-lumen left or right, bronchial blocker too, surgical lung isolation
RAE curves nasal or oral, keeps the circuit away from the surgical drape
Armored tubes resist kinking when the head is flexed, flexometallic won't reshape
Laser-resistant wrapping guards against ignition, Merocel and foil, the triad of fire
Tube size, cuff position, check the bilateral breath sounds a little higher
[Chorus]
Mac in the vallecula, Miller lifts the flap
Video bends around what direct cannot unwrap
Bougie, stylet, cuff and tube, supraglottic sealed
Every airway tool has its own battlefield
Grade your view, choose your blade, know what's in the kit
LEMONS tells you when the difficult airway fits
[Verse 3]
First-generation LMA seals around the glottis, no gastric port, no drain tube at the back
Second-generation ProSeal, i-gel, Supreme, gastric channel lets the stomach decompress slack
Supraglottic bridges cannot to can-intubate, Aintree catheter threads the fiberscope inside
Fiberoptic nasal or oral awake approach, topicalize and sedate, let the scope glide
Rigid bronchoscopes for foreign body, massive bleed, jet ventilation through the Sander's injector
Cricothyrotomy kits, surgical or Seldinger-wire, scalpel-finger-bougie the preferred vector
[Bridge]
Bag-valve-mask seals with a CE grip, two hands better than one thumbs down
Oral airway follows the curve of the palate, nasal airway bevel toward the septum crown
High-flow nasal oxygen, sixty liters apneic, buys you minutes when saturation dips
HFNO warms and humidifies the column, continuous positive pressure through the nares and the lips
[Chorus]
Mac in the vallecula, Miller lifts the flap
Video bends around what direct cannot unwrap
Bougie, stylet, cuff and tube, supraglottic sealed
Every airway tool has its own battlefield
Grade your view, choose your blade, know what's in the kit
LEMONS tells you when the difficult airway fits
[Outro]
Mask to cric, every rung on the ladder matters
Know your tools before the oxygen scatters
25. 4 Monitoring Equipment (physics and interpretation detailed in Module 4)
[Verse 1]
Infrared absorption, two wavelengths dancing through,
Oxyhemoglobin reads red, deoxy reads blue,
The Beer-Lambert law behind every SpO2,
Pleth waveform tells you perfusion, not just the number too,
Capnography upstream or sidestream from the airway flow,
Mainstream clips the circuit, sidestream pulls it slow,
The waveform's four phases, plateau tells you alveolar CO2,
A shark fin means obstruction, steep alpha angle breaking through
[Chorus]
Pulse ox, capno, gas and pressure line,
Oscillometry finds the mean, then works the math to nine,
ECG for axis, arrhythmia, ischemia defined,
Monitors are the dialect that the patient speaks in signs,
Read the waveform, trust the physics, keep the signal clean,
Every artifact has a reason if you know what numbers mean
[Verse 2]
Volatile agents measured by infrared spectra split,
Gas analyzer cross-checks your vaporizer fit,
NIBP oscillometry finds the mean arterial first,
Algorithmic extrapolation, systolic and diastolic parsed,
Arterial lines transmit hydraulic pulse through fluid column long,
Overdamped or underdamped — your natural frequency's wrong,
Fast-flush test the square wave, count the oscillations back,
Resonance above ten hertz keeps the waveform on track
[Chorus]
Pulse ox, capno, gas and pressure line,
Oscillometry finds the mean, then works the math to nine,
ECG for axis, arrhythmia, ischemia defined,
Monitors are the dialect that the patient speaks in signs,
Read the waveform, trust the physics, keep the signal clean,
Every artifact has a reason if you know what numbers mean
[Verse 3]
Four electrodes trace depolarization's sweep,
ST segments climbing, V leads never sleep,
Neuromuscular monitoring — train of four, the count,
Tetanic fade and post-tetanic measuring the amount,
TOF ratio above ninety says reversal is complete,
BIS and entropy sample EEG frequency discrete,
Burst suppression means too deep, forty-to-sixty is the zone,
Cerebral oximetry — near-infrared, reading cortex tone
[Bridge]
TEE rotates through twenty standard views,
Midesophageal, transgastric, picking up the clues,
Cardiac output: thermodilution, Fick, or pulse contour derived,
Point-of-care ultrasound confirms what your exam contrived,
TEG and ROTEM trace the clot from initiation through lysis spread,
Amplitude at thirty minutes, MA tells you what the platelets did,
Kaolin versus tissue factor — know which cup you've spun,
Coagulation is a river, not a single number won
[Chorus]
Pulse ox, capno, gas and pressure line,
Oscillometry finds the mean, then works the math to nine,
ECG for axis, arrhythmia, ischemia defined,
Monitors are the dialect that the patient speaks in signs,
Read the waveform, trust the physics, keep the signal clean,
Every artifact has a reason if you know what numbers mean
26. 5 Vascular Access Devices and Infusion Systems
[Verse 1]
Eighteen gauge in the antecubital, taped and secured with care,
Short peripheral cannula, the workhorse always there,
Gauge determines flow rate, Poiseuille taught us that much,
Fourteen for the trauma bay, rapid bolus at a touch,
Check for flashback, aspirate, confirm before you flush,
Phlebitis creeps in quietly, so rotate — never rush
[Chorus]
Central, arterial, peripheral, intraosseous,
Rapid infuser, cell salvage — run the calculus,
TCI pumps model plasma, warming keeps you whole,
Access is the architecture, infusion is the soul,
Access is the architecture, infusion is the soul
[Verse 2]
Triple lumen central line, subclavian or internal jugular placed,
Confirm with chest X-ray, tip at the cavo-atrial traced,
CVP waveform reading, a through to x descent,
Peripherally inserted for the patient long-term meant,
Sterile technique mandatory, ultrasound guides the needle true,
Pneumothorax, arterial puncture — complications you walk through
[Chorus]
Central, arterial, peripheral, intraosseous,
Rapid infuser, cell salvage — run the calculus,
TCI pumps model plasma, warming keeps you whole,
Access is the architecture, infusion is the soul,
Access is the architecture, infusion is the soul
[Verse 3]
Radial artery cannulated, twenty gauge, non-dominant wrist,
Allen test before insertion, ischemia on the risk list,
Continuous waveform pressure, beat-by-beat displayed,
Dampened trace means air or clot, flush and re-appraise,
Femoral when radial fails, brachial if you must,
Never sample from the drip arm — accuracy or bust
[Bridge]
When the vein collapses, marrow answers the call,
Proximal tibia or humeral head absorbs it all,
IO access in sixty seconds, pressure bag to drive,
Fluids, drugs, and blood products — keep the patient alive,
Belmont or Level One rapid, four to six hundred per minute,
Cell salvage washes surgical blood, reinfuse what's in it,
Bair Hugger blankets, fluid warmers, Ranger inline heat —
Hypothermia is the enemy bleeding makes complete
[Chorus]
Central, arterial, peripheral, intraosseous,
Rapid infuser, cell salvage — run the calculus,
TCI pumps model plasma, warming keeps you whole,
Access is the architecture, infusion is the soul,
Access is the architecture, infusion is the soul
[Outro]
TCI Marsh or Schnider, target-controlled propofol,
Effect-site versus plasma — pick the right protocol,
Syringe pump, volumetric, gravity drip — each has its place,
Every access point a decision, every drop a careful trace,
Cannulate with purpose, monitor what you've placed,
Vascular access isn't plumbing — it's precision, not haste
27. Self-Assessment
[Verse 1]
Before the patient breathes a molecule of gas,
I walk the machine like a cartographer of glass —
High-pressure sources, cylinders, the pipeline check,
Low-pressure circuit, vaporizers, nothing wrecked.
I open the oxygen tank, watch the needle hold,
Confirm the backup's full before the room grows cold.
The flowmeters move, the APL valve I spin,
The bellows rise — that's when I know to begin.
Every step's a reason, not a ritual done blind:
The checkout is the covenant I keep with every mind.
[Chorus]
Vérifier, vérifier — check the whole machine,
Перевір кожен крок — nothing in between.
From high-pressure down to low, the circuit sealed and clean,
Oximetry reads the blood, troubleshoot what you've seen.
Vérifier — the rationale is the discipline,
Перевір — know the physics under every reading's sheen.
[Verse 2]
Airway pressure's climbing — now where do you go?
Start at the patient, work out slow.
Bronchospasm, mucus plug, the tube against the carina wall,
Endobronchial slip, the cuff's too small.
Move outward — check the circuit, the expiratory valve,
An obstructed limb, a kinked corrugated half.
Then reach the machine — the vaporizer, the absorber spent,
A fresh gas flow too low, a pressure sensor bent.
Stepwise and deliberate, no scatter-shot approach —
The algorithm is the scaffold, panic is the hoax.
[Chorus]
Vérifier, vérifier — check the whole machine,
Перевір кожен крок — nothing in between.
From high-pressure down to low, the circuit sealed and clean,
Oximetry reads the blood, troubleshoot what you've seen.
Vérifier — the rationale is the discipline,
Перевір — know the physics under every reading's sheen.
[Verse 3]
Two wavelengths pierce the fingertip — six-sixty, nine-forty,
Red and infrared parsing oxyhemoglobin's party.
Oxygenated absorbs the infrared and fades,
Deoxygenated drinks the red — that's how the number's made.
But carboxyhemoglobin mimics oxy, reads as high,
Methemoglobin pulls both channels, splits toward eighty-five.
Methylene blue and indocyanine dyes — they fake a drop,
Motion artifacts and low perfusion make the signal stop.
The pulse ox is a window, not an oracle of truth —
Interpret through the context, interrogate the proof.
[Bridge]
Here's a word the clinic rarely speaks aloud —
The pulse ox signal is lambent — softly glowing through a cloud,
Wavering with each heartbeat, phosphorescent, slight,
A lambent flicker, not a searchlight — handle it with rigor, not delight.
And the checkout? It's a catechism — question and reply,
Each valve and seal confessing what it holds before you try.
Catechism: a structured recitation of the known —
So when the pressure spikes at three a.m., you're not alone.
28. 1 Standards
[Verse 1]
Before the needle drops, before the mask descends,
We lay the groundwork down — this is where safety bends
Around a scaffold built from decades, consensus, care,
The ASA, the AAGBI, WHO — they all declare:
No anesthetic starts without the vigil in place,
Five pillars standing guard across the operating space —
Oxygenation, ventilation, circulation's beat,
Temperature, and consciousness — the pentad is complete
[Chorus]
Wach bleiben, wach bleiben — keep the monitors alive
Pulse ox on the finger, capnograph to survive
Alarms sind nicht optional — they sing the patient's truth
Ohne diese Standards — there's no anesthetic proof
Wach bleiben, wach bleiben — every case, every time
Vigilance ist Wissenschaft — precision is the line
[Verse 2]
Pulse oximetry continuous — saturation read,
Capnography the carbon dioxide that we need,
End-tidal CO2 confirms the airway's clear,
A waveform on the screen — intubation's souvenir
Non-invasive blood pressure, cycling every few,
The ECG tracing every heartbeat threading through —
These aren't luxuries, not options, not a preference's whim,
They're the minimum — the floor, the hull, the vessel's rim
[Chorus]
Wach bleiben, wach bleiben — keep the monitors alive
Pulse ox on the finger, capnograph to survive
Alarms sind nicht optional — they sing the patient's truth
Ohne diese Standards — there's no anesthetic proof
Wach bleiben, wachbleiben — every case, every time
Vigilance ist Wissenschaft — precision is the line
[Bridge]
And here's the word they rarely teach in textbooks on the shelf —
Noctilucent — luminous in darkness, by itself —
Like a monitor glowing in a dimmed theater hall,
Each alarm a phosphorescent whisper down the wall
The alarms must be audible, must never be silenced cold,
Oxygen supply failure screams the story to be told —
Disconnect, apnea, hypoxia incoming fast —
The sentinel machine is why the patient's life holds fast
Temperature probes the hypothermic drift below,
Core warmth is a standard too, though quieter in its glow
[Verse 3]
A dedicated, qualified provider — in the room,
Not charting in the corridor, not stepping through the gloom —
Present, trained, their eyes upon the field and on the screen,
The human element inside the monitoring machine
And when you document, you capture what you saw —
Continuous surveillance isn't custom, it is law —
WHO checklist signed, equipment checked before induction's call,
Vaporizer calibrated, circuits checked through all
[Chorus]
Wach bleiben, wachbleiben — keep the monitors alive
Pulse ox on the finger, capnograph to survive
Alarms sind nicht optional — they sing the patient's truth
Ohne diese Standards — there's no anesthetic proof
Wach bleiben, wach bleiben — every case, every time
Vigilance ist Wissenschaft — precision is the line
29. 2 Individual Monitors
[Verse 1]
Red light, infrared, two wavelengths chasing oxygen
Pulse ox reads the ratio, ninety-four to a hundred ten
But nail varnish, cold peripheries, methemoglobin in the vein
Can fool the probe — the plethysmograph waveform tells the strain
Capnography draws the rectangle, plateau, baseline, upstroke clean
Obstruction clips the plateau's edge, rebreathing lifts the baseline scene
Curare cleft splits the plateau when the patient breathes against the vent
Esophageal intubation? Flat line — no alveolar content
[Chorus]
Pulse ox, capnography, ECG, arterial trace
TOF and processed EEG to monitor time and space
EtCO2 minus PaCO2, gradient growing wide
Means dead space is expanding — perfusion falling on the slide
Every waveform tells a story, every number has a cost
Read the signal, trust the pattern, count what can't be lost
[Verse 2]
Lead two for arrhythmias, V5 for ischemia's door
ST depression, elevation — myocardium keeping score
Artifact mimics every rhythm, loose electrode, shivering hand
NIBP underestimates atrial fibrillation — understand
Arterial waveform: systolic upstroke, dicrotic notch descending
Pulse pressure variation over thirteen percent — fluids worth sending
Central venous pressure: a-wave atrial contraction, v-wave filling back
CVP alone can't tell you preload — Starling's off the track
[Chorus]
Pulse ox, capnography, ECG, arterial trace
TOF and processed EEG to monitor time and space
EtCO2 minus PaCO2, gradient growing wide
Means dead space is expanding — perfusion falling on the slide
Every waveform tells a story, every number has a cost
Read the signal, trust the pattern, count what can't be lost
[Bridge]
Train of four: four twitches, ratio ninety to declare reversal safe
Quantitative over qualitative — don't eyeball, don't conflate
Processed EEG gives you index numbers, raw shows burst suppression glow
B-Aware, B-Unaware, BAG-RECALL — awareness must be low
NIRS watches cerebral saturation, SSEP guards the cord
MEP checks the motor tracts while BAEP monitors the auditory chord
Thermodilution, pulse contour, esophageal Doppler's beam
TEE short-axis, transgastric view — the ventricle fills the screen
[Verse 3]
Malignant hyperthermia spikes EtCO2 before the fever shows
Embolism drops end-tidal, hypoperfusion ebbs and flows
Jugular bulb oximetry below fifty — brain is starved of flow
ICP waveforms: P1 percussion, P2 rising means compliance low
Lactate, glucose, hemoglobin — point-of-care beside the field
Viscoelastic TEG and ROTEM show clot forming, strength, and yield
Temperature varies: tympanic, nasopharyngeal, bladder deep
Esophageal sits closest to the core — the one worth choosing to keep
[Chorus]
Pulse ox, capnography, ECG, arterial trace
TOF and processed EEG to monitor time and space
EtCO2 minus PaCO2, gradient growing wide
Means dead space is expanding — perfusion falling on the slide
Every waveform tells a story, every number has a cost
Read the signal, trust the pattern, count what can't be lost
30. 3 Point-of-Care Ultrasound
[Verse 1]
Probe in hand before the needle drops,
Compress the vein and watch the vessel flop,
Transverse plane first, confirm the lumen's round,
Tilt to long-axis, thread your wire down,
Dynamic guidance, real-time needle tip,
Infiltrate the artery — you'll catch that slip,
Doppler tells the difference, pulsatile flow,
Vein compresses, artery says no
[Pre-Chorus]
Six zones on the lung, B-lines cascade,
Sliding pleura means pneumothorax stayed away,
Comet tails in pulmonary edema pour,
Absent sliding — barcode sign, open that door
[Chorus]
Vascular, gastric, lung and heart,
Bladder, airway — scan before you start,
FAST and FoCUS, sliding, stripes and shred,
Point-of-care ultrasound inside your head,
Antrum in the right decubitus view,
Full stomach graded, aspiration's cue,
BLUE protocol, parasternal, subcostal spread —
Scan it, know it, keep the patient safe instead
[Verse 2]
Gastric antrum, right lateral decubitus,
Graded zero, one, or two — the status is discussed,
Grade two means content solid or mixed beyond,
Delay elective, modified RSI respond,
Qualitative volume, cross-sectional area reads,
Greater than 1.5 mils per kilo — heed,
The antrum swells with fluid in its bay,
Nil by mouth compliance? Ultrasound will say
[Verse 3]
Four FoCUS windows — parasternal long,
Apical four-chamber, subcostal strong,
PLAX shows LV function, septal wall,
Global squeeze or pericardial effusion call,
Tamponade: the right atrium collapses inward,
IVC plethoric, equalization — absurd,
Hypovolemia reads a flat collapsed cave,
Hypervolemic IVC barely waves
[Bridge]
Airway now — probe transverse on the neck,
Cricothyroid membrane — TACA check,
Tracheal rings like pearls below the chin,
Esophageal intubation — donut sign within,
Bladder dome above the pubic arch appears,
Volume estimated cubed before the Foley clears,
Lung point confirms the pneumothorax border zone,
Seashore sign returns — the lung's reclaimed its home
[Chorus]
Vascular, gastric, lung and heart,
Bladder, airway — scan before you start,
FAST and FoCUS, sliding, stripes and shred,
Point-of-care ultrasound inside your head,
Antrum in the right decubitus view,
Full stomach graded, aspiration's cue,
BLUE protocol, parasternal, subcostal spread —
Scan it, know it, keep the patient safe instead
[Outro]
Six findings, six windows, six reasons to probe,
Effusion, edema, the consolidation globe,
Needle tip confirmed, the airway verified,
Gastric risk quantified before you slide inside,
Every anesthetic starts with what you see —
The transducer whispers what the history can't be
31. Self-Assessment
[Verse 1]
The capnograph is printing out its story on the screen,
A rectangular plateau, sharp upstroke, color it clean,
But when the plateau tilts into a shark-fin slope,
That's bronchospasm talking — time to reach for hope in your scope,
Curare cleft cuts a notch mid-plateau, patient's breathing through,
Double-humped and bifid means the circuit's fighting you,
Absent waveform, esophageal, the tube is in the wrong,
Slow upstroke means COPD — that gas is holding on too long
[Chorus]
Cap-no-graph, read the wave, ten shapes to know by name,
Train-of-four, one-point-oh, the ratio ends the game,
SPV climbing tells you — preload's running thin,
Read the line, check the trace, this is where we begin,
Capnograph, neuromuscular, arterial sine,
Three pillars of assessment keeping patients fine
[Verse 2]
Now the renal nerves are quiet and the patient's lying still,
Vecuronium lingered through the case against your will,
Qualitative twitch monitoring — that subjective squeeze —
Can't tell you ninety percent block from a residual wheeze,
You need the acceleromyograph, the quantitative read,
A TOF ratio under point-nine means your patient cannot breathe,
Point-nine or higher at the vocal cords, the trachea clears,
Quantitative proof, not clinical feel, is what extubation hears
[Chorus]
Cap-no-graph, read the wave, ten shapes to know by name,
Train-of-four, one-point-oh, the ratio ends the game,
SPV climbing tells you — preload's running thin,
Read the line, check the trace, this is where we begin,
Capnograph, neuromuscular, arterial sine,
Three pillars of assessment keeping patients fine
[Verse 3]
Now the arterial line is drawing out its signature in red,
Controlled ventilation cycling, watch the systolic thread,
Systolic pressure variation — SPV above thirteen,
Means the Starling curve still climbs, the tank needs gasoline,
Pulse pressure variation riding over twelve or more,
Predict a fluid responder through a hemodynamic door,
But if the numbers barely move through every ventilated sweep,
The ventricle is filled enough — let the vasopressors keep
[Bridge]
Here's a word the textbooks rarely prize — vellichor —
That strange nostalgia reading waveforms from the floor,
Knowing every pattern holds a story of decay or mend,
And another: aubade — the dawn-watch vigil at the end,
When the extubation comes and monitoring aligns,
These aren't merely numbers — they are clinical divines,
So read the capnograph with ten shapes catalogued tight,
Check the train-of-four ratio until it crests to right
[Chorus]
Cap-no-graph, read the wave, ten shapes to know by name,
Train-of-four, one-point-oh, the ratio ends the game,
SPV climbing tells you — preload's running thin,
Read the line, check the trace, this is where we begin,
Capnograph, neuromuscular, arterial sine,
Three pillars of assessment keeping patients fine
32. 1 Anatomy and Assessment
[Verse 1]
Tongue base to trachea, map it before you cut
Glossopharyngeal guards the pharynx, vagus runs the gut
Superior laryngeal splits — internal feels the supraglottic zone
Recurrent laryngeal hugs the groove, moves the cords you own
Epiglottis, arytenoids, the vocal folds in between
Vallecula, piriform sinus — structures you must've seen
Kids have a higher larynx, omega epiglottis, narrower ring
Cricoid's the tightest point in peds — that changes everything
[Chorus]
Mallampati, boca abierta, distancia al mentón
Thyromental distance, neck mobility, upper lip bite — toma nota
Predicting the difficult airway, it's never just one sign
Ningún predictor solo — combine the whole design
Mask ventilation, laryngoscopy, SGA, front-of-neck
Evalúa todo — or you'll land a wreck
[Verse 2]
History first: the snorer, the bleeder, the radiation neck
Prior intubations — was it smooth or was it checked?
Mallampati one through four, pillars visible or gone
Class three and four correlate, but sensitivity's not strong
Thyromental under six centimeters, hyomental matters too
Mouth opening less than three — that's a Verburg signal coming through
Upper lip bite test, can the lower incisors reach the skin?
Limited neck extension — add it to the picture you're building in
[Chorus]
Mallampati, boca abierta, distancia al mentón
Thyromental distance, neck mobility, upper lip bite — toma nota
Predicting the difficult airway, it's never just one sign
Ningún predictor solo — combine the whole design
Mask ventilation, laryngoscopy, SGA, front-of-neck
Evalúa todo — or you'll land a wreck
[Bridge]
MOANS for the mask: Mask seal, Obese, Age, No teeth, Stiff
RODS for the rigid scope — Restricted, Obstructed, Distorted, Short stiff neck to sniff
Ultrasound quantifies the tongue, the pre-epiglottic space
Nasendoscopy scopes the anatomy face to face
But every tool has limits — no test predicts with perfect grace
Plan A through D before you ever touch the face
[Verse 3]
Aspiration risk — the stomach isn't always what you assume
Solids: eight-hour fast, breast milk is four, clear fluids just two
GLP-one agonists delay gastric emptying, slow the pour
Even fasted patients may pool — so probe before you score
Gastric ultrasound: antrum in right lateral decubitus view
Empty antrum, grade zero; grade two is full — that shifts what you do
High-risk features: symptomatic reflux, trauma, bowel obstruction too
Modified RSI or awake — el riesgo dicta la ruta
[Chorus]
Mallampati, boca abierta, distancia al mentón
Thyromental distance, neck mobility, upper lip bite — toma nota
Predicting the difficult airway, it's never just one sign
Ningún predictor solo — combine the whole design
Mask ventilation, laryngoscopy, SGA, front-of-neck
Evalúa todo — or you'll land a wreck
33. 2 Techniques
[Verse 1]
Tight mask seal, head elevated forty-five,
CPAP primes the nitrogen washout, keeps the margin wide,
High-flow nasal oxygen threading through the nose,
Apneic diffusion buys the seconds no one knows,
Two hands grip the mask, EC-clamp, thumbs compress,
Jaw thrust forward, chin up, tidal volumes coalesce,
Oropharyngeal, nasopharyngeal in your kit,
Size it nostril to earlobe — wrong adjunct, wrong fit
[Chorus]
Atemweg — secure it, read the signs,
Wähle die Klinge, check the capnography lines,
BURP and ramping, optimization in the frame,
Bougie first when angles aren't the same,
Atemweg — jetzt handeln, hold the view,
Capnography is gold — six waveforms prove it true
[Verse 2]
Supraglottic airways: size by weight, second-gen preferred,
Gastric drainage port confirms placement, drain what's deferred,
Deflate the cuff before you pull, rotate slightly out,
Used as conduits for fiber scopes threading without doubt,
Direct laryngoscopy: Macintosh tip sits the vallecula,
Miller lifts the epiglottis straight — anatomy's vernacular,
Video blade widens angles, externalizes the grade,
BURP displaces larynx backward, upward, rightward — don't be swayed
[Chorus]
Atemweg — secure it, read the signs,
Wähle die Klinge, check the capnography lines,
BURP and ramping, optimization in the frame,
Bougie first when angles aren't the same,
Atemweg — jetzt handeln, hold the view,
Capnography is gold — six waveforms prove it true
[Verse 3]
Rapid sequence: cricoid pressure — still contested ground,
Succinylcholine sixty seconds, rocuronium one-point-two around,
Sellick's force can fold the tube, distort the posterior wall,
Modified RSI allows gentle breaths before the fall,
Awake intubation when anatomy predicts defeat,
Topicalize the airway, lidocaine atomized, complete,
Dexmedetomidine keeps them breathing, calm, and cooperative still,
DAS guideline maps the nasal-oral fiberoptic drill
[Bridge]
Wenn die Lage kritisch wird — front of neck, scalpel out,
Bougie through the cricothyroid, tube it without doubt,
Needle and cannula for jet vent, pressure-driven flow,
Transtracheal oxygen threading low,
Extubation criteria: reverse, protect, obey,
High-risk airways get an exchanger staged to stay,
Laryngospasm breaks with CPAP, propofol, or sux,
Shared airways — laser protocols and THRIVE flux
[Chorus]
Atemweg — secure it, read the signs,
Wähle die Klinge, check the capnography lines,
BURP and ramping, optimization in the frame,
Bougie first when angles aren't the same,
Atemweg — jetzt handeln, hold the view,
Capnography is gold — six waveforms prove it true
[Outro]
Double-lumen tubes for lung isolation, bronchial blocker too,
Left-sided DLT default — confirm fiberoptically through,
Percutaneous tracheostomy, Seldinger wire technique,
ENT shares the glottis — tubeless THRIVE at its peak,
Jede Technik zählt — every method earns its place,
Secure the airway first, then let the surgeon have their space
34. 3 Difficult Airway Algorithms
[Verse 1]
You walk into the room with a Mallampati score,
Thyromental distance measured, mouth opening four,
But history whispers — prior intubation failed,
So you map the contingencies before the patient's veiled.
ASA and DAS lay the architecture down,
Plan A through D — a scaffold, not a crown.
Awake fiberoptic first when the anatomy's a threat,
Document the difficulty — don't let anyone forget.
[Chorus]
A, B, C, D — four plans before the cut,
Declare the difficulty, never keep it shut,
The Vortex pulls you: mask, supraglottic, blade,
Three lifelines cycling — before the surgical cascade.
Cannot intubate, cannot oxygenate — call it loud,
Cricothyrotomy cuts right through the shroud,
Wake the patient when the margins start to fray,
The algorithm is the anchor, not the getaway.
[Verse 2]
Human factors creep in — fixation, ego, time,
Tunnel vision on the laryngoscope is the silent crime.
Declare it early — "This airway is difficult" —
A spoken word to teammates breaks the occult cult.
The Vortex isn't spiral — it's a three-rung lattice frame,
Face mask, supraglottic, tracheal — cycling through the same.
When all three fail, you've reached the CICO shore,
Scalpel, bougie, tube — the front-of-neck restore.
[Chorus]
A, B, C, D — four plans before the cut,
Declare the difficulty, never keep it shut,
The Vortex pulls you: mask, supraglottic, blade,
Three lifelines cycling — before the surgical cascade.
Cannot intubate, cannot oxygenate — call it loud,
Cricothyrotomy cuts right through the shroud,
Wake the patient when the margins start to fray,
The algorithm is the anchor, not the getaway.
[Verse 3]
Obesity shifts the axes — ramping positions matter,
Obstetrics adds a timeline where the margins shatter.
Pediatric cords sit anterior, epiglottis floppy,
Cervical collar narrows every angle, makes it choppy.
Angioedema swells the supraglottis like a tide,
Thyroidectomy hematoma — decompress or step inside.
Anterior mediastinal mass collapses when supine —
Keep them breathing spontaneously along that precipice line.
Burns and trauma, abscesses, the foreign body lodge —
Each scenario a palimpsest, old dangers underscored.
[Bridge]
There's a word — tmesis — for the split inside a phrase,
We split our plans apart the same, inserting saving grace.
After every difficult encounter, write the letter, file the form,
Register the airway — let the next clinician be forewarned.
A MedicAlert, a registry entry, a discharge note that's clear,
The documentation is the covenant with whoever's next, right here.
[Chorus]
A, B, C, D — four plans before the cut,
Declare the difficulty, never keep it shut,
The Vortex pulls you: mask, supraglottic, blade,
Three lifelines cycling — before the surgical cascade.
Cannot intubate, cannot oxygenate — call it loud,
Cricothyrotomy cuts right through the shroud,
Wake the patient when the margins start to fray,
The algorithm is the anchor, not the getaway.
35. Self-Assessment
[Verse 1]
The patient's neck is frozen in a crooked angle down
Flexed and fixed, no extension — conventional grounds won't hold
You planned this from the waiting room, awake scope is the call
Topicalize the airway, spray the cords before you go all in
Glycopyrrolate to dry the field, sedation light and thin
Nasal route or oral, but the patient's still in charge
Cooperative and breathing while you navigate the large
Vocal shadow on the scope — you thread and then you pass
Confirm position with the capnograph before you gas
[Chorus]
A, B, C, D — the plan is on the wall
Attempt, Best blade, Camera, then the scalpel's final call
Spray the cords, thread the scope, keep the patient wide awake
Know the sequence cold before you ever get to take
A, B, C, D — don't skip a single rung
DAS algorithm carved into your tongue
[Verse 2]
Plan A — direct or video, optimize the head
Best external laryngeal pressure, don't declare them dead
Two attempts, no more, then pivot — stubborn pride costs air
Plan B brings the supraglottic, SAD goes in right there
iGEL or classic LMA, oxygenate the gap
Can you pass the tube through it? Try — but read the map
Plan C, if ventilation fails, you call the room to hush
One last mask attempt before the final push
[Chorus]
A, B, C, D — the plan is on the wall
Attempt, Best blade, Camera, then the scalpel's final call
Spray the cords, thread the scope, keep the patient wide awake
Know the sequence cold before you ever get to take
A, B, C, D — don't skip a single rung
DAS algorithm carved into your tongue
[Bridge]
And then the child comes out of the sevoflurane mist
Laryngospasm clamps the cords — a reflex you can't dismiss
Jaw thrust forward, CPAP pressure, call it Larson's point
Notch behind the ear, the mastoid, press it to the joint
Ten seconds of firm pressure — cords may break their grip
If hypoxia deepens — sux, one milligram per kilo, quick
Never freeze in silence when the small airway defies
The physics of a pediatric glottis the size of your eyes
[Verse 3]
Self-assessment lives between the action and the debrief chair
Did you recognize the moment when Plan A was no longer fair?
Did you call for help before the saturation scrolled toward grey
Or tunnel down alone because your ego owned the day?
The simulation room forgives — the actual OR does not
So index every hesitation, every thing you almost forgot
Rate your own decision tree, not just the outcome's grade
The airway saved by luck and the airway saved by trade —
Only one of those will replicate when pressure hits the blade
[Chorus]
A, B, C, D — the plan is on the wall
Attempt, Best blade, Camera, then the scalpel's final call
Spray the cords, thread the scope, keep the patient wide awake
Know the sequence cold before you ever get to take
A, B, C, D — don't skip a single rung
DAS algorithm carved into your tongue
36. 1 General Approach
[Verse 1]
Pull the chart before the patient takes a breath,
Read the history like you're mapping out a quest —
Surgeries, allergies, the medications penned,
Functional capacity from DASI or METs assessed
Can they climb two flights without stopping at the top?
Four METs or better means the workup doesn't stop there
ASA one through six, we stratify the risk,
Examine every system, don't let details slip the disc
[Chorus]
RCRI counts the cardiac flags — diabetes, failure, creatinine high,
Gupta and NSQIP MICA calculate MACE before the knife,
Apfel scores the nausea, STOP-BANG screens the airway tight,
History, exam, then risk indices — sequence it precise
Don't order bloods for ritual — order them with purpose and rationale,
Preop is the prologue to the anesthetic tale
[Verse 2]
ECG for known or suspected cardiac disease,
ACC slash AHA algorithm, follow the cascade please —
Stress testing only if results will change the plan,
Echo when you're hunting for the murmur contraband
PFTs when lung resection's on the surgical docket,
Pulmonary hypertension hiding — better fish it from the pocket
Routine testing is a vestigial act, an artifact of habit old,
Evidence-based selection is the standard we uphold
[Chorus]
RCRI counts the cardiac flags — diabetes, failure, creatinine high,
Gupta and NSQIP MICA calculate MACE before the knife,
Apfel scores the nausea, STOP-BANG screens the airway tight,
History, exam, then risk indices — sequence it precise
Don't order bloods for ritual — order them with purpose and rationale,
Preop is the prologue to the anesthetic tale
[Bridge]
Consent is not a signature, it's a conversation slow —
Disclose the risks proportional to what the patient ought to know,
Capacity means reasoning, not just saying yes or no,
In emergencies implied consent lets the anesthesiologist go
Advance directives, DNR — do they stand inside the OR?
Discuss it with the surgeon, with the patient at the door
Suspend or honor — document the rationale in full,
Autonomy is sacrosanct, never something you can dull
Premedicate with intention — anxiolytics, aspiration guard,
Ranitidine or sodium citrate if the stomach history's scarred
[Verse 3]
Prehabilitation — a proleptic word, anticipating strain,
Optimizing patients weeks before the operative campaign —
Smoking cessation six to eight weeks trims the pulmonary toll,
Anemia treated preop saves the transfusion toll
Nutritional status, albumin low, a healing wound impaired,
Iron, folate, B-twelve — replenish what's been spared
The preop clinic catches what the rushed consult might miss,
Frailty scores revealing who needs more than just this
[Outro]
History and exam, the fundament of every case,
Risk indices as lenses bringing hazard into place,
Informed consent the contract, premedication the grace,
Optimize before the drape — preparation is the base
Preop is the prologue to the anesthetic tale
37. 2 Cardiovascular Disease
[Verse 1]
Ischemic heart disease, the plaque narrows down the pipe
A stent was placed last Tuesday — wrong timing for the knife
Bare metal needs four weeks, drug-eluting needs a year
DAPT disruption mid-elution, thrombosis is the fear
CABG patients carry grafts like detoured arterial maps
The left internal mammary bridging coronary gaps
Before you touch the chest wall, know the anatomy cold
Stress test findings, ejection fraction, vessels manifold
[Chorus]
Keep the rate down in stenosis, keep the preload full
Regurgitant valves want afterload pulled
MINS hides in silence, troponin tells the tale
Check the VISION protocol — don't let surveillance fail
Rate, load, rhythm, pressure — four pillars holding the hall
Know the magnet behavior before you make the call
[Verse 2]
Heart failure splits in two — preserved and then reduced
HFrEF pumps weakly out, HFpEF is stiff and bruised
Cardiomyopathy dilated wants offload and rate control
Hypertrophic obstructive — vasopressors take a toll
Phenylephrine holds the gradient closed, avoid vasodilation
Inotropes in HOCM fan the obstruction like inflation
Hold the ACE inhibitor the morning of the case
ARBs too — refractory hypotension is the price you'll face
[Chorus]
Keep the rate down in stenosis, keep the preload full
Regurgitant valves want afterload pulled
MINS hides in silence, troponin tells the tale
Check the VISION protocol — don't let surveillance fail
Rate, load, rhythm, pressure — four pillars holding the hall
Know the magnet behavior before you make the call
[Verse 3]
Aortic stenosis — maintain sinus, keep the rate around sixty
Vasodilation drops perfusion pressure, outcomes aren't pretty
Mitral stenosis mirrors it — slow the rate, fill the left
Regurgitant lesions flip the script, unload to manage stress
Prosthetic valves and anticoagulation, bridging is the question
Mechanical mitral carries highest risk — don't skip the consultation
Pulmonary hypertension spikes with hypoxia and pain
Nitric oxide standing by, avoid what raised it in the first place again
[Bridge]
Pacemaker in the field — place the magnet, asynchronous mode
ICD gets silenced so the shock won't interfere with your load
HRS and ASA consensus — program before elective cases start
Congenital adults with Fontan circulations need a careful heart
Single ventricle physiology — preload is everything here
Systemic RV function, fenestrations, shunt direction unclear
[Chorus]
Keep the rate down in stenosis, keep the preload full
Regurgitant valves want afterload pulled
MINS hides in silence, troponin tells the tale
Check the VISION protocol — don't let surveillance fail
Rate, load, rhythm, pressure — four pillars holding the hall
Know the magnet behavior before you make the call
38. 3 Respiratory Disease
[Verse 1]
The airways tell a story written long before the blade,
Asthma coils like bronchospasm waiting in the shade,
Reactive, hyperactive, mast cells primed to fire,
We pre-treat with albuterol and raise the baseline higher,
COPD's a different beast — emphysema, chronic wheeze,
Air trapping, barrel chest, FEV1 on its knees,
Obstruction on the flow loop, auto-PEEP's the hidden trap,
Slow your rate, extend expiration, give the lungs a gap
[Chorus]
A-R-I-S-C-A-T, count the score before the day,
Saturation, surgical site, anemia in the way,
Preop stay beyond two days, respiratory infection near,
Seven factors, seven chances — pulmonary risk is clear,
Obstruct, restrict, hypertense, the lungs demand respect,
Optimize before the knife, then monitor and protect
[Verse 2]
Restrictive lungs are stiffened — fibrosis, scoliosis, obesity's weight,
Low compliance, small tidal volumes, pressures that inflate,
The pulmonary hypertensive — RV perched upon a cliff,
Avoid hypoxia, hypercarbia, any vasoconstrictive riff,
Nitric oxide on the ready, phosphodiesterase in check,
One acute RV failure and you're catching a full wreck,
These patients need invasive monitoring, ICU planned tight,
And regional beats general when the physiology's not right
[Chorus]
A-R-I-S-C-A-T, count the score before the day,
Saturation, surgical site, anemia in the way,
Preop stay beyond two days, respiratory infection near,
Seven factors, seven chances — pulmonary risk is clear,
Obstruct, restrict, hypertense, the lungs demand respect,
Optimize before the knife, then monitor and protect
[Verse 3]
The snoring child with adenoids, the adult with the STOP-BANG,
OSA carries collapsing pharynx, opioid sensitivity pang,
Screen them early — CPAP at home means bring that device in,
Postop prone to obstruction, so you watch them close again,
Continuous monitoring, oximetry the sentinel,
And regional anesthesia keeps the opioid dose gentle,
Recent URTI in the pediatric case — elective? Postpone six weeks,
Secretions, bronchospasm risk, a volatile airway leaks
[Bridge]
Here's your rare word — call it borborygmus? No, today we learn: inspissate,
When mucus thickens, desiccates, grows viscous — inspissated sputum blocks the gate,
Humidify your circuits, chest physiotherapy, mucolytics advocated,
Smoking cessation eight weeks prior keeps the secretions less coagulated,
And another gift of language — the word is nidus, meaning breeding ground,
The inflamed, infected airway is a nidus where complications compound,
Know your nidus, treat your nidus, optimize the terrain,
Before you press that induction drug and enter their domain
[Chorus]
A-R-I-S-C-A-T, count the score before the day,
Saturation, surgical site, anemia in the way,
Preop stay beyond two days, respiratory infection near,
Seven factors, seven chances — pulmonary risk is clear,
Obstruct, restrict, hypertense, the lungs demand respect,
Optimize before the knife, then monitor and protect
39. 4 Endocrine and Metabolic
[Verse 1]
Glucose creeping in the perioperative dawn,
Target one-forty to one-eighty, keep the range drawn,
Hold the SGLT2 — three days before the cut,
Euglycemic ketoacidosis hides the rut,
GLP-1 agonists slow the stomach's churn,
Aspiration lurks when gastric emptying won't turn,
Insulin drips and subcutaneous sliding scales,
Check the ketones when the clinical picture fails
[Chorus]
Alpha before beta, block the pheo first,
Cortisol at stress dose quenches adrenal thirst,
T3 and T4, thyroid storm will rage,
Electrolytes in balance, metabolic sage,
Phenoxybenzamine, then the propranolol,
Steroid supplementation, never let it fall —
Endocrine and metabolic, learn them one by one,
The hormones run the OR before the case is done
[Verse 2]
Hypothyroid slows conduction, blunts the vascular tone,
Hyperthyroid spikes the cardiac rate down to the bone,
Cushing's rounds the face and thins the capillary wall,
Acromegaly distorts the airway — video laryngoscope call,
Pituitary tumors crowd the sella's narrow hall,
Diabetes insipidus follows if the stalk should fall,
Adrenal cortex stripped by illness, surgery, or steroid years —
Supplement with hydrocortisone to quiet perioperative fears
[Chorus]
Alpha before beta, block the pheo first,
Cortisol at stress dose quenches adrenal thirst,
T3 and T4, thyroid storm will rage,
Electrolytes in balance, metabolic sage,
Phenoxybenzamine, then the propranolol,
Steroid supplementation, never let it fall —
Endocrine and metabolic, learn them one by one,
The hormones run the OR before the case is done
[Verse 3]
Obesity reshapes the physics of the lung,
Functional residual capacity wrung,
Preoxygenate with ramping — head above the chest,
Lean body weight for propofol, IBW for the rest,
OSA lurks in every crowded Mallampati throat,
VTE stockings, heparin prophylaxis — always note,
Positioning pressure ulcers haunt the longer case,
Rhabdomyolysis smolders when the padding's out of place
[Bridge]
Malnutrition, a cachexia of cellular will —
Albumin cratered, wound healing standing still,
Hyponatremia corrects no faster than a crawl,
Hyperkalemia peaks the T-wave like a wall,
Hypocalcemia tingles in the Chvostek sign,
Hypomagnesemia makes the arrhythmias intertwine,
Every ion has a kinesis — ordered, tidal, slow —
The body's sempiternal ledger balancing below
[Chorus]
Alpha before beta, block the pheo first,
Cortisol at stress dose quenches adrenal thirst,
T3 and T4, thyroid storm will rage,
Electrolytes in balance, metabolic sage,
Phenoxybenzamine, then the propranolol,
Steroid supplementation, never let it fall —
Endocrine and metabolic, learn them one by one,
The hormones run the OR before the case is done
[Outro]
Sempiternal — ever-present, always cycling through,
Kinesis — motion in the ions shifting in you,
Check the glucose, check the cortisol, ask about the pheo,
Every gland a quiet architect of everything we know
40. 5 Renal, Hepatic, and Hematologic
[Verse 1]
Creatinine climbing, the nephrons slow their trade
GFR below sixty, a CKD cascade
Dialysis timing — potassium seals the fate
Hyperkalemia at five-five, don't hesitate
Renally-cleared medications need a dose reduction
Morphine metabolites accumulate — neurotoxic intrusion
Hold the NSAIDs, watch the contrast load
The failing kidney writes its own strict code
[Chorus]
Rein it in, les reins qui souffrent — watch the potassium
Child-Pugh, MELD score — le foie dit "attention"
Coagulopathy bleeds through every hesitation
Sang et sel, blood and salt — organ constellation
Check the levels, check the function, feel the pulsation
C'est l'équilibre fragile — critical foundation
[Verse 2]
Cirrhotic patient, ascites pooling low
Child-Pugh adds the bilirubin, albumin, INR in tow
Encephalopathy staged from one to four
MELD predicts mortality — the higher, the less in store
Hepatorenal syndrome, the kidneys starve in sympathy
Pseudo-cholinesterase drops — succinylcholine lasts lavishly
Highly protein-bound drugs lose their anchor in the plasma
Avoid hepatotoxins — don't compound the miasma
[Chorus]
Rein it in, les reins qui souffrent — watch the potassium
Child-Pugh, MELD score — le foie dit "attention"
Coagulopathy bleeds through every hesitation
Sang et sel, blood and salt — organ constellation
Check the levels, check the function, feel the pulsation
C'est l'équilibre fragile — critical foundation
[Verse 3]
Anemia — optimize the iron before the knife
Patient blood management, transfusion sparing life
Sickle cell demands hydration, warmth, and oxygen pressure
Vasoocclusive spiral — no cold, no tourniquet measure
Thalassemia shifts the curve of hemoglobin affinity
Factor eight for hemophilia A, nine for B's infinity
Von Willebrand — DDAVP releases what's withheld
Thrombocytopenia — count below fifty, the surgeon felled
[Bridge]
Antiphospholipid — the clot that masquerades as lupus kin
Warfarin bridges, heparin holds, then taper back again
DOAC half-lives — rivaroxaban out in twenty-four
Neuraxial block demands a window, nothing less, nothing more
VTE prophylaxis — sequential compression while you wait
Pharmacologic anticoagulation calibrates the rate
Phospholipid antibodies — sanguinolent, a word for blood-soaked fate
Meaning: saturated, drenched in the hemorrhagic state
[Chorus]
Rein it in, les reins qui souffrent — watch the potassium
Child-Pugh, MELD score — le foie dit "attention"
Coagulopathy bleeds through every hesitation
Sang et sel, blood and salt — organ constellation
Check the levels, check the function, feel the pulsation
C'est l'équilibre fragile — critical foundation
[Outro]
Miasma — a rare word carried through the hepatic haze
Meaning: toxic vapors, corruption of the organ's days
Sanguinolent and miasma — wear them in your clinical gaze
Renal, hepatic, hematologic — balance through the maze
41. 6 Neurologic and Neuromuscular
[Verse 1]
Carotid plaques and stenosed walls, embolic risk before the call
CEA or stent in place, anesthesia must keep the pace
Maintain the pressure, keep perfusion fed
A watershed infarct leaves neurons dead
Seizure history, note the drugs they take
Phenytoin induces enzymes — half-lives break
[Chorus]
Know your neuro, know the risk
Parkinson's meds — never miss a dose
Myasthenia's sensitive to the block
Lambert-Eaton flips the clock
Autonomic dysreflexia spikes the cuff
Raised ICP — PEEP and cough are rough
Map it out before you cut
Neuro first — no ifs, no buts
[Verse 2]
Parkinson's patient, dopamine's thin
Skip the levodopa and the tremors win
Droperidol — contraindicated here
Metoclopramide will make the rigors severe
Multiple sclerosis, heat is the enemy
Neuraxial's debated, document carefully
Succinylcholine in muscular dystrophy
Triggers rhabdo, hyperkalemia — catastrophe
[Chorus]
Know your neuro, know the risk
Parkinson's meds — never miss a dose
Myasthenia's sensitive to the block
Lambert-Eaton flips the clock
Autonomic dysreflexia spikes the cuff
Raised ICP — PEEP and cough are rough
Map it out before you cut
Neuro first — no ifs, no buts
[Verse 3]
Myasthenia gravis, acetylcholine's thin
NMBDs hit harder — titrate, begin
Pyridostigmine aboard — cholinergic swell
Neostigmine reversal can work too well
Lambert-Eaton — calcium channel's the fault
Presynaptic gap with a vesicle halt
Sensitive to both depolarizing and non
Volatile agents — potentiate, gone wrong
Myotonic dystrophy won't relax with the block
Contracture from succinyl — don't turn that lock
Volatiles dangerous, cardiomyopathy lurks
Screen the ECG before the surgeon works
[Bridge]
Spinal cord injury, T-six and above
Autonomic dysreflexia — nothing gentle here, no glove
Noxious input fires the sympathetic gun
Hypertension, bradycardia — reflex that won't run
Remove the stimulus, deepen the plane
Nitroprusside ready, control that gain
Raised intracranial pressure — hyperventilate with care
Mannitol draws the edema, hypertonic saline there
Head up thirty degrees, avoid jugular compression
CO2 in the thirties — controlled, deliberate session
[Chorus]
Know your neuro, know the risk
Parkinson's meds — never miss a dose
Myasthenia's sensitive to the block
Lambert-Eaton flips the clock
Autonomic dysreflexia spikes the cuff
Raised ICP — PEEP and cough are rough
Map it out before you cut
Neuro first — no ifs, no buts
[Outro]
Delirium post-op — the old, the frail
Minimize benzos, keep the anticholinergics stale
Orientation anchors, daylight through the glass
Every neuro detail — nothing gets to pass
Map the lesion, time the med, assess the baseline score
Anesthesia shaped around the deficit — that's the core
42. 7 Other
[Verse 1]
Rheumatoid joints, the neck won't flex right
Ankylosing spine fused stiff by night
Scleroderma mouth too small to blade
Lupus patient, airway plans get made
C-spine instability, atlantoaxial threat
Video laryngoscope before you sweat
Every autoimmune case demands a scout
Map the anatomy before you're in doubt
[Chorus]
Avant de commencer, évalue tout
Check the list, there's no shortcut through
Latex, lithium, malignant heat
Psychiatric meds and the pregnant beat
Avant de couper, connais ton patient
Seven categories, sois vigilant
[Verse 2]
MAOIs and serotonin, dangerous blend
Lithium narrows where the therapeutic ends
SSRIs shift platelet aggregation low
ECT needs succinylcholine, careful though
Antipsychotics prolong the QT wave
Cannabis daily, MAC reduction craved
Cocaine blocks the catecholamine reuptake gates
Add a beta-blocker, coronary spasm waits
Alcohol withdrawal, the Ciwa scale your guide
Opioid tolerance — underdose and they'll slide
[Chorus]
Avant de commencer, évalue tout
Check the list, there's no shortcut through
Latex, lithium, malignant heat
Psychiatric meds and the pregnant beat
Avant de couper, connais ton patient
Seven categories, sois vigilant
[Verse 3]
Latex allergy — go synthetic, every line
Chlorhexidine reactions, subtle, read the signs
NMBD cross-reactivity, one drug triggers two
Anaphylaxis workup: tryptase, skin test, review
Malignant hyperthermia, ryanodine receptor flaw
Trigger-free machine, dantrolene on the floor
Family history counts, don't skip the kin
Total intravenous anesthesia, close the volatile in
[Bridge]
La femme enceinte needs two patients covered
Fetal monitoring, teratogen risk discovered
First trimester fragile, elective surgery waits
Non-obstetric cases — smallest dose, elective dates
Jehovah's Witness, refusal signed and clear
Cell salvage, erythropoietin, autologous here
Document the conversation, respect autonomy's ground
Legal minors — courts can override, if life is found
[Verse 4]
The elderly patient, frailty index scored
Cognitive screening catches what the chart ignored
Geriatric co-management, delirium prevention planned
Smaller doses, longer half-lives, steady hand
Pediatric preop — NPO windows narrowed down
Clear fluids two hours, solids six, don't drown
Parental presence, distraction kits deployed
Anxiety undertreated leaves recovery destroyed
[Chorus]
Avant de commencer, évalue tout
Check the list, there's no shortcut through
Latex, lithium, malignant heat
Psychiatric meds and the pregnant beat
Avant de couper, connais ton patient
Seven categories, sois vigilant
[Outro]
Sept catégories — spine, psych, and substance drawn
Allergy, MH, pregnancy, and age upon
The Witness at the table, the infant in the bay
Assess them all before the blade sees day
43. Self-Assessment
[Verse 1]
A vascular patient walks through the door,
Can't climb a flight, can barely do more,
Functional capacity under four METs,
The ACC/AHA algorithm resets,
We ask: is this surgery truly urgent care?
If not, we test — stress echo strips it bare,
Non-invasive workup, weigh the coronary risk,
RCRI score tallied, nothing hit or missed,
Elevated risk with poor capacity means
We dig for answers underneath the surface seams
[Chorus]
ACC slash AHA, step by step we go,
Urgent or elective, risk is what we know,
METs below four, the algorithm speaks,
Test if it changes management, not just for weeks,
Stent plus surgery — timing is the key,
Aortic stenosis — pressure gradients decree,
Self-assess your plan, question what you see,
Perioperative thinking, sharp and free
[Verse 2]
Four months out from a drug-eluting stent,
The antiplatelet therapy hasn't been spent,
Twelve months is the target before you stop,
But urgent surgery means the clock won't drop,
Clopidogrel pulled too soon invites catastrophe,
Stent thrombosis, MI, acute pathology,
Coordinate the surgeon, hematology in tow,
Continue aspirin through the case if you can go,
Discuss the bleeding risk against occlusion's toll,
Shared decision-making pulls the patient whole
[Chorus]
ACC slash AHA, step by step we go,
Urgent or elective, risk is what we know,
METs below four, the algorithm speaks,
Test if it changes management, not just for weeks,
Stent plus surgery — timing is the key,
Aortic stenosis — pressure gradients decree,
Self-assess your plan, question what you see,
Perioperative thinking, sharp and free
[Verse 3]
Severe aortic stenosis, valve area tight,
Hip fracture bleeding won't politely wait the night,
Mean gradient over forty, AVA below one,
The stenotic valve means cardiac output's nearly done,
Preload is the lifeline — don't let systemic drop,
Phenylephrine primed and ready at the stop,
Avoid tachycardia, keep the sinus rate,
Neuraxial caution — slow titration at the gate,
General or careful spinal, weigh it close,
Invasive arterial monitoring is the dose
[Bridge]
Ask yourself before the case:
What's the risk, what's the pace?
Did I calculate the RCRI?
Did I check the stent and timeline twice?
Is the preload safe, the gradient known?
Would I hand this plan to the attending — my own?
Self-assessment isn't doubt, it's calibration,
The sharpest tool inside the operating station
[Chorus]
ACC slash AHA, step by step we go,
Urgent or elective, risk is what we know,
METs below four, the algorithm speaks,
Test if it changes management, not just for weeks,
Stent plus surgery — timing is the key,
Aortic stenosis — pressure gradients decree,
Self-assess your plan, question what you see,
Perioperative thinking, sharp and free
[Outro]
Vascular risk, stent timing, stenotic valve,
Three scenarios — one standard, no shortcuts to halve,
The algorithm grounds you, the physiology leads,
Self-assessment seeds the practice that the patient needs
44. 1 Planning and Preparation
[Verse 1]
Before the patient crosses through the threshold of the bay,
You're already three moves ahead, mapping out the play,
General, regional, or sedation — weigh the risk and gain,
Comorbidities, the surgical site, anticipated pain,
Airway assessment first — Mallampati, neck, and jaw,
Thyromental distance, mouth opening, any flaw,
IV access, arterial lines, central if the case demands,
The plan is built before you ever scrub your hands
[Chorus]
T-A-M-P-A-S is how we start the scheme —
Technique, Airway, Monitoring, Positioning, Analgesia supreme,
Add temperature management, PONV, and antibiotics in time,
VTE prophylaxis, blood availability — every piece aligned,
Check the WHO list, call the time-out, name and procedure clear,
Equipment primed, drugs drawn and labeled — no ambiguity here
[Verse 2]
Monitoring choices logged before induction's first breath,
Standard ASA — the baseline set against arrest and death,
Five-lead ECG for cardiac cases, arterial for the tight,
BIS for depth of anesthesia, neuromonitoring for the spine,
Position matters more than surgeons sometimes like to say,
Lateral, prone, or lithotomy — nerves can fray,
Padding pressure points, protecting eyes, securing every limb,
A sloppy setup at the start means trouble at the trim
[Chorus]
T-A-M-P-A-S is how we start the scheme —
Technique, Airway, Monitoring, Positioning, Analgesia supreme,
Add temperature management, PONV, and antibiotics in time,
VTE prophylaxis, blood availability — every piece aligned,
Check the WHO list, call the time-out, name and procedure clear,
Equipment primed, drugs drawn and labeled — no ambiguity here
[Bridge]
Your emergency drugs are a vellichor of readiness —
That bittersweet catalogue of crises you prepare for but dread,
Epinephrine, atropine, suxamethonium close at hand,
Lipid emulsion for the local toxic reprimand,
Draw your induction agents, label every syringe in line,
Machine checked, circuit pressured, capnograph assigned,
Suction primed, difficult airway trolley stocked and near,
Preparation is the antidote to operative fear
[Verse 3]
The WHO checklist is no bureaucratic rite of passage dull —
Three pauses, three intentions, every gap designed to cull,
Sign-in before induction: allergies, airway risk confirmed,
Time-out before incision: team and plan reaffirmed,
Sign-out before the patient leaves: counts and specimens logged,
Every deviation from the plan gets catalogued,
Surgical safety culture built on speaking up aloud —
The quietest voice in the room should still be heard above the crowd
[Outro]
So greet each case with rigor, treat each variable with care,
The anesthetic plan is crafted long before you're there,
From technique down to temperature, from access to the vein,
Meticulous preparation is the discipline of the brain,
T-A-M-P-A-S — say it once more, let it stay,
The work you do before the knife is what keeps harm away
45. 2 Induction
[Verse 1]
Two paths to unconscious — needle or the mask,
Propofol drops the pressure, so you have to ask:
Is the ventricle compensating, preload holding on?
Bolus plus ketamine when the gradient's gone.
Co-induction blends the agents, cuts the doses down,
Midazolam with fentanyl before the propofol crown.
Volatile induction when the vein won't show,
Sevoflurane smooth and steady — watch the capnograph glow.
[Chorus]
Préparez-vous, the airway plan is set,
RSI for the full stomach — don't forget.
Succinylcholine sixty seconds to the floor,
Sellick's hand on the cricoid, bimanual pressure more.
Préparez-vous — the shock patient waits,
Ketamine holds the sympathetics at the gates.
Difficult airway mapped before you start,
Videolaryngoscope in hand, bougie close to the heart.
[Verse 2]
Raised ICP demands a calculated mind,
Blunt the pressor surge or leave herniation behind.
Lidocaine, fentanyl, propofol controlled,
Avoid the succinylcholine fasciculation bold.
Rocuronium works just as fast with sugammadex near,
Modified RSI in the ICP sphere.
Ventilate with purpose — eucapnia the aim,
Hyperventilation's rescue-only, not a routine game.
[Verse 3]
Septic shock — the vasodilated, tachycardic mess,
Fluid-load before induction under duress.
Ketamine or etomidate, spare the cortisol debate,
Push-dose epinephrine ready at the gate.
Cardiac disease demands you know the lesion first —
Aortic stenosis needs a slower, gentle burst.
Tamponade needs rate and preload, vasodilators kill,
Phenylephrine on the syringe — steady hand, steady will.
[Bridge]
L'obstétrique — deux vies sur la table,
RSI obligatoire, aspiration capable.
Thiopental fades but propofol's here,
Cricoid, left uterine tilt, the fetal Dopplers clear.
The pediatric patient — inhalational first,
Sevoflurane on the mask until the vein's rehearsed.
Calculate the weight, the tube uncuffed below eight,
Atropine for bradycardia — vagal reflex won't wait.
[Chorus]
Préparez-vous, the airway plan is set,
RSI for the full stomach — don't forget.
Succinylcholine sixty seconds to the floor,
Sellick's hand on the cricoid, bimanual pressure more.
Préparez-vous — the shock patient waits,
Ketamine holds the sympathetics at the gates.
Difficult airway mapped before you start,
Videolaryngoscope in hand, bougie close to the heart.
[Outro]
Plan A, Plan B, the surgical airway last,
Declare the difficult early — the moment passes fast.
Every induction scripted like a calibrated score,
Hémodynamique stable — then you open up the door.
46. 3 Maintenance
[Verse 1]
Volatile or TIVA, weigh the case before you start
Malignant hyperthermia — propofol wins that part
High PONV risk, neuromonitoring on the line
Environmental burden tilts toward intravenous design
Marsh and Schnider model your effect-site concentration
Eleveld spans the ages, Minto handles opioid titration
TCI keeps the plasma target steady in the stream
Balanced anesthesia — more than gas and a dream
[Chorus]
Maintain the depth, protect the lung
Watch the block, keep the pressure from the wrong
IBW for tidal volume, PEEP to hold alveoli wide
Hemodynamics, glucose, temperature — nothing slips aside
Six to eight mils per kilo, recruitment when you need
Document every shift — precision is the creed
[Verse 2]
Lung-protective ventilation, PROVHILO showed us how
IMPROVE confirmed the benefit — low tidal volumes now
Spontaneous breathing through an SGA — monitor the seal
Awareness lurks below MAC oh-point-seven, make it real
Bispectral index, entropy — depth has many faces
Underdose the volatile and awareness leaves its traces
Neuromuscular blockade — TOF before you say reversal's done
Residual curarization caught by quantitative monitoring, one by one
[Chorus]
Maintain the depth, protect the lung
Watch the block, keep the pressure from the wrong
IBW for tidal volume, PEEP to hold alveoli wide
Hemodynamics, glucose, temperature — nothing slips aside
Six to eight mils per kilo, recruitment when you need
Document every shift — precision is the creed
[Verse 3]
INPRESS taught us MAP below sixty injures kidney and brain
POISE revealed that beta-blockade cuts MI but strokes remain
Fluids guided by stroke volume variation, dynamic response
Avoid the temperature drift — hypothermia confounds
Glucose above ten is toxic, below four you're blind
Tight control without hypoglycemia — walk that narrow line
Multimodal analgesia maps the postoperative terrain
Ketamine blunts opioid tolerance, lidocaine dulls visceral pain
[Bridge]
Dexmedetomidine quiets the sympathetic surge
Magnesium steadies voltage-gated channels at the verge
Now position every patient like a lawsuit's watching close
Ulnar nerve at the medial epicondyle — padding matters most
Brachial plexus stretched in beach chair, common peroneal at the knee
Prone eyes checked every thirty minutes — cornea and retina
Compartment syndrome, venous air embolism, lithotomy time limits too
ASA positioning guidance isn't optional review
[Chorus]
Maintain the depth, protect the lung
Watch the block, keep the pressure from the wrong
IBW for tidal volume, PEEP to hold alveoli wide
Hemodynamics, glucose, temperature — nothing slips aside
Six to eight mils per kilo, recruitment when you need
Document every shift — precision is the creed
[Outro]
Handover carries every number, every drug, every event
Intraoperative record — the story of intent
Maintenance isn't passive, it's a hundred small decisions
Anesthesia written in precision
47. 4 Emergence and Extubation
[Verse 1]
The volatile's dialed down, the surgery is closing,
Nitrous off, the patient's slowly surfacing and showing,
Reversal timing matters — don't jump the gun too fast,
Neostigmine needs a twitch count, four-of-four to last,
Sugammadex wraps the rocuronium tight,
Cyclodextrin chemistry, it pulls it from the site,
Check the TOF ratio, point-nine or above,
Residual block will steal the airway that you love
[Chorus]
Wake up smooth, not bucking on the tube,
Deep or awake — you've got to choose,
Reflexes back, tidal volume in range,
Laryngospasm's the ghost that haunts the stage,
D-R-U-G-S, M-E-T, N-E-U-R-O — delayed emergence, you need to know,
Hypothermia, residual block, check the whole row
[Verse 2]
Awake extubation — you want the patient biting,
Following commands, eyes open, cough igniting,
Sustained head lift, five seconds minimum cleared,
Oxygen saturation, end-tidal CO2 reared,
Deep extubation works for the laryngospasm-prone,
Asthmatic airways, pediatric patients on their own,
But you need a patent airway and a steady hand,
Guaranteed mask ventilation — that's the contraband plan
[Chorus]
Wake up smooth, not bucking on the tube,
Deep or awake — you've got to choose,
Reflexes back, tidal volume in range,
Laryngospasm's the ghost that haunts the stage,
D-R-U-G-S, M-E-T, N-E-U-R-O — delayed emergence, you need to know,
Hypothermia, residual block, check the whole row
[Verse 3]
Laryngospasm hits — the cords slam shut like vault doors,
Positive pressure first, jaw thrust the mandible toward yours,
Succinylcholine point-one to point-two per kilo,
Breaks the spasm open, gives the oxygen somewhere to go,
Negative pressure pulmonary edema follows in the wake,
Frothy pink sputum flooding alveoli in its earthquake,
Treat it with CPAP, diuresis if severe,
Watch the oxygen, it clears within a day or near
[Bridge]
Delayed emergence — the differential's wide,
Benzodiazepines linger, opioids hide,
Flumazenil, naloxone, but use them with care,
Rebound sedation sneaking back when you're not there,
Hypothermia steals the metabolism slow,
Warm the patient, watch the temperature before you go,
Hyponatremia, hypoglycemia, stroke —
Neurologic causes aren't just anesthetic smoke,
Emergence delirium — the pediatric wild card,
Sevoflurane inhalation hits the hardest and the hardest scarred,
Dexmedetomidine soothes it, fentanyl trims the edge,
Propofol in small doses walks you back from off the ledge
[Chorus]
Wake up smooth, not bucking on the tube,
Deep or awake — you've got to choose,
Reflexes back, tidal volume in range,
Laryngospasm's the ghost that haunts the stage,
D-R-U-G-S, M-E-T, N-E-U-R-O — delayed emergence, you need to know,
Hypothermia, residual block, check the whole row
[Outro]
Lidocaine on the tube before the volatile clears,
Dexmedetomidine infusion quiets emergence fears,
Timing the reversal, watching every single sign,
Smooth extubation — that's the clinical bottom line
48. 5 Sedation and Monitored Anesthesia Care
[Verse 1]
Picture a dial, not a switch, not a cliff —
Sedation's a spectrum, a graduated drift
Minimal, moderate, deep, then general's door
Each rung on the ladder demands something more
Minimal — anxiolysis, you respond to my call
Moderate — purposeful, airway stands tall
Deep sedation, repeated stimulation required
General — unconscious, all reflexes retired
The ASA carved these definitions in stone
So every practitioner speaks in the same tone
Because the patient who slips past your target zone
Can obstruct or apnea when left alone
[Chorus]
P-M-D-K-R — five drugs in your hand
Propofol, Midazolam, Dex, Ketamine, Remimazolam
Monitor the capnograph, the pulse ox, the pressure
Oversedation's a thief that steals at leisure
Know the continuum, know where you stand
Sedation is science, not sleight of hand
[Verse 2]
Propofol moves fast — context-sensitive, clean
Titrate by the syringe, watch the apnea convene
Midazolam's the prelude, anxiolytic and mild
Flumazenil reverses if the dosing ran wild
Dexmedetomidine — an alpha-two agonist, precise
Cooperative sedation, keeps the airway in service
Arousable, analgesic, hemodynamically priced
Bradycardia's the toll — know the balance sufficed
Ketamine dissociates — a phencyclidine kin
Preserves the airway, keeps the drive breathing in
Bronchodilation, analgesia, sympathomimetic surge
Emergence phenomena lurk at the procedure's verge
Remimazolam — benzodiazepine by ester design
Metabolized by tissue esterases, bypassing the renal line
Flumazenil reverses it, short-acting and defined
A newer card dealt from the sedation hand
[Chorus]
P-M-D-K-R — five drugs in your hand
Propofol, Midazolam, Dex, Ketamine, Remimazolam
Monitor the capnograph, the pulse ox, the pressure
Oversedation's a thief that steals at leisure
Know the continuum, know where you stand
Sedation is science, not sleight of hand
[Bridge]
Here's where the anesthesiologist earns their place —
Non-anesthesiologists sedate in endoscopy's space
Gastroenterology, radiology, the cardiac suite
They need oversight protocols, rescue skills complete
Capnography catches the apnea before desaturation blooms
A minute of warning before hypoxia consumes the room
The mordant truth of monitored anesthesia care:
The deepest risk is the sedation nobody labeled as there
MAC isn't minimal — it can touch the general plane
Assign an anesthesia provider, document the chain
Airway assessment first: Mallampati, neck, the jaw
Because the patient who deteriorates deserves no pause
[Verse 3]
Monitor the standard: ECG, the non-invasive cuff
Pulse oximetry, temperature when the procedure's rough
Capnography — end-tidal carbon dioxide's the voice
That tells you breathing's failing before cyanosis makes the noise
Supplemental oxygen — a double-edged reprieve
It masks the desaturation that the capnograph perceives
So trust the waveform, trust the number on the screen
Titrate to effect, and watch the whole machine
49. 6 Ambulatory and Office-Based Anesthesia
[Verse 1]
Patient walks in, no overnight bed reserved,
Ambulatory stage — every margin must be observed,
ASA one or two, maybe three if stable ground,
No obstructive apnea that's uncontrolled and profound,
Escort at home, a working phone nearby,
Procedure under four hours — those are the qualifying lines,
Screen for anxiety, screen for prior PONV,
Build the selection matrix before the patient breathes with me
[Chorus]
Seleziona con cura, ogni paziente conta,
Aldrete or PADSS — la scala che affronta,
Score eight or above before they walk out the door,
Attività, respiro, keep watching for more,
Fast-track the recovery, bypass phase one,
Dimissione sicura when the criteria's done
[Verse 2]
LMA and propofol, desflurane fades clean,
Dexamethasone early — keeps the nausea lean,
Multimodal analgesia, skip the opioid rope,
Ketamine low-dose, acetaminophen, and regional scope,
TIVA protocol minimizes hangover fog,
Sugammadex reversal — no neostigmine slog,
Ondansetron at closing, scopolamine patch behind the ear,
Risk factors stacked above two — triple therapy's clear
[Chorus]
Seleziona con cura, ogni paziente conta,
Aldrete or PADSS — la scala che affronta,
Score eight or above before they walk out the door,
Attività, respiro, keep watching for more,
Fast-track the recovery, bypass phase one,
Dimissione sicura when the criteria's done
[Bridge]
Aldrete checks five domains — activity, respiration,
Circulation, consciousness, oxygen saturation,
PADSS goes further — adds pain tolerance and surgical bleeding,
Ambulation, voiding, whether the discharge is proceeding,
Phase one skipped when vitals stay pristine from the OR,
Modified Aldrete guides who walks directly out the door,
Unplanned admission haunts the metrics, audit every case,
Airway trouble, bleeding, cardiac — document with grace
[Verse 3]
PONV risk: female, nonsmoker, motion history,
Opioid-dependent planning — that's no mystery,
Apfel score drives your prophylaxis ladder up,
One risk factor, one drug — four risks, fill the cup,
For pain: nerve block outlasts the case by several hours clean,
Liposomal bupivacaine stretching the analgesic seam,
Discharge scripts written preoperative, clear instruction given,
Responsible adult confirmed — no solo patient-driven
[Chorus]
Seleziona con cura, ogni paziente conta,
Aldrete or PADSS — la scala che affronta,
Score eight or above before they walk out the door,
Attività, respiro, keep watching for more,
Fast-track the recovery, bypass phase one,
Dimissione sicura when the criteria's done
[Outro]
Ambulatory care — it's precise, no margin thin,
Select the right candidate, then let the work begin,
Criteri chiari, the score decides the gate,
Safe passage, clean discharge — that's the ambulatory fate
50. Self-Assessment
[Verse 1]
Obese patient on the table, OSA in the chart,
Mask ventilation risky from the very start,
Ramped position, pre-ox five minutes full,
TIVA induction, prop and remi pull,
Laparoscopic pressures pushing on the diaphragm,
Ventilate with PEEP, protect the parenchyma,
ETCO2 climbing with the pneumoperitoneum,
Adjust your minute ventilation, track it on the screen
Sugammadex reversal, wait for T4 over T1,
Extubate awake and upright, watch the SpO2 run,
Handover to PACU, OSA protocol in place,
Document your reasoning, every step and every space
[Chorus]
P-O-S-T — assess before you pass,
Plan, Optimize, Systematize, Then transfer at last,
Know your Why before your What, justify the choice,
Self-assess at every turn, precision is your voice,
PONV, MEP, delayed wake — three tests of what you know,
Audit your own reasoning, that's how experts grow
[Verse 2]
Delayed emergence, don't just wait and hope,
Work through it methodically — it's not a slippery slope,
Check the volatile concentration, check the reversal done,
Hypoglycemia, hypoxia, hypothermia — run
Through hypotension, opioid excess, CO2 retained,
Benzodiazepines lingering, residual drug restrained,
Flumazenil and naloxone if the story fits the clue,
Physostigmine if anticholinergic toxidrome broke through
Rule out stroke and intracranial catastrophe last,
Self-assess your differential — how complete, how fast,
Could you name twelve causes without looking at a list?
That's the gap between competent and nothing that was missed
[Chorus]
P-O-S-T — assess before you pass,
Plan, Optimize, Systematize, Then transfer at last,
Know your Why before your What, justify the choice,
Self-assess at every turn, precision is your voice,
PONV, MEP, delayed wake — three tests of what you know,
Audit your own reasoning, that's how experts grow
[Bridge]
Spine surgery, MEP monitoring, history of wretched nausea,
Volatile agents suppress the signal, that's the data,
Nitrous amplifies the emesis cascade,
TIVA with propofol — the cleaner choice is made,
Remifentanil infusion keeps the analgesia tight,
Motor evoked potentials read crisp and bright,
You didn't guess — you cross-referenced the evidence,
Then documented why, with clinical deference
Ask yourself: could I defend this to a skeptic in review?
If the answer hesitates, there's more work left to do
[Verse 3]
Self-assessment isn't ego, isn't checking off a box,
It's interrogating comfort zones, dismantling the blocks,
Did the induction go exactly as I planned it?
Where did I improvise — and do I understand it?
Write the case debrief while the memory runs hot,
Identify the three things that worked, the two that did not,
Calibrated confidence — not too tight, not too loose,
Knowing where your ceiling is cuts medical misuse
The attending watched you manage every pivot, every turn,
But the sharper judge is inward — what did you actually learn?
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