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\author{lkmaceac}
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  /Title (induction-sequence.pdf)
  /Creator (Cheatography)
  /Author (lkmaceac)
  /Subject (Induction Sequence Cheat Sheet)
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    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Induction Sequence Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{lkmaceac} via \textcolor{DarkBackground}{\uline{cheatography.com/188320/cs/39271/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}lkmaceac \\
  \uline{cheatography.com/lkmaceac} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 20th June, 2023.\\
   Updated 20th June, 2023.\\
   Page {\thepage} of \pageref{LastPage}.
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  Measure your website readability!\\
  www.readability-score.com
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\begin{multicols*}{2}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Preadmit Holding Area}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Talk to patient} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Check name band (identifier)} \tn 
% Row Count 2 (+ 1)
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\mymulticolumn{1}{x{8.4cm}}{{\bf{Check consents - ALWAYS}} - before sedation} \tn 
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% Row 3
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\mymulticolumn{1}{x{8.4cm}}{Check if patient is marked} \tn 
% Row Count 4 (+ 1)
% Row 4
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\mymulticolumn{1}{x{8.4cm}}{Check with holding are RN if patient is ready to go} \tn 
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% Row 5
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\mymulticolumn{1}{x{8.4cm}}{Running IV?} \tn 
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% Row 6
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\mymulticolumn{1}{x{8.4cm}}{Give pre-op sedation} \tn 
% Row Count 8 (+ 1)
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\begin{tabularx}{8.4cm}{x{1.064 cm} x{3.268 cm} x{3.268 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Pre-op Sedation}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{3}{x{8.4cm}}{{\bf{Only give once consent is confirmed to have been signed}}} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
{\bf{Midazolam}} & Administered by TBW because of an increased central volume of distribution. Just about all books seem to agree with this. Dosing in this way will prolong the elimination half-life and its duration of effect. In practice, it may cause over sedation in the obese pts who is sensitive to respiratory depressant drugs &  \tn 
% Row Count 21 (+ 19)
% Row 2
\SetRowColor{LightBackground}
 & TBW = total body weight (obese patients could overdose due to larger body weight and thus larger dose) &  \tn 
% Row Count 27 (+ 6)
% Row 3
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 & {\bf{MOA}} & GABA-A Agonist \tn 
% Row Count 28 (+ 1)
% Row 4
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 &  & change frequency of channel opening - neuronal \seqsplit{hyperpolarization} \tn 
% Row Count 32 (+ 4)
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\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Pre-op Sedation (cont)}}  \tn
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 &  & {\emph{most GABA-A agonists increase channel open time, benzos increase open frequency}} \tn 
% Row Count 5 (+ 5)
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 & {\bf{Onset}} & 30-60 seconds \tn 
% Row Count 6 (+ 1)
% Row 7
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 & {\bf{Duration}} & 20-60 min \tn 
% Row Count 7 (+ 1)
% Row 8
\SetRowColor{white}
 & {\bf{Clearance}} & Liver \tn 
% Row Count 8 (+ 1)
% Row 9
\SetRowColor{LightBackground}
 & {\bf{Active Metabolite}} & \seqsplit{1-hydroxymidazolam} \tn 
% Row Count 10 (+ 2)
% Row 10
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 & {\bf{Sedation dose}} & IV 0.01-0.1 mg/kg \tn 
% Row Count 11 (+ 1)
% Row 11
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 & {\bf{Respiratory Effects}} & minimal but synergistic respiratory depression when combined with other sedatives \tn 
% Row Count 16 (+ 5)
% Row 12
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 & {\bf{CV Effects}} & minimal \tn 
% Row Count 17 (+ 1)
% Row 13
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 & {\bf{CNS Effects}} & anterograde amnesia, anticonvulsant properties, anxiolysis, antispasmodic effects {\emph{No analgesia}} \tn 
% Row Count 23 (+ 6)
% Row 14
\SetRowColor{white}
 &  & \textasciitilde{}anti spasmodic effects good for spinally mediated skeletal muscle relaxation (useful in CP patients) \tn 
% Row Count 29 (+ 6)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Proceed to Operating Room}}  \tn
% Row 0
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\mymulticolumn{2}{x{8.4cm}}{Transport patient to OR via stretcher or amulation} \tn 
% Row Count 1 (+ 1)
% Row 1
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Move patient to OR table and {\bf{ensure safety strap is secured}} & usually placed across thighs 2 inches above the knees over the cover \tn 
% Row Count 5 (+ 4)
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 & arms secured on padded arm boards or tucked \tn 
% Row Count 8 (+ 3)
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Apply Monitors & record vital signs {\emph{at least}} every 5 minutes \tn 
% Row Count 11 (+ 3)
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 & -EKG \tn 
% Row Count 12 (+ 1)
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 & -BP \tn 
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 & -Pulse Ox \tn 
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 & -Capnography \tn 
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 & -Temperature \tn 
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Preoxygenation aka Denitrogenation}}  \tn
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\mymulticolumn{2}{x{8.4cm}}{o	1948: Fowler and Comroe demonstrated that inhalation of 100\% oxygen (O2) resulted in a very rapid increase of arterial oxyhemoglobin saturation (Sao2) to between 98\% and 99\%, but that attainment of the last 1\% to 2\% was a much slower process \{\{nl\}\}o	1950s: Rapid Sequence Induction (RSI) began being utilized in patients at risk for aspiration of gastric contents, preoxygenation became a component of the technique} \tn 
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\mymulticolumn{2}{x{8.4cm}}{{\emph{Preoxygenation}} extends periods of {\bf{safe apnea}}} \tn 
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 & •	defined as the time until a patient reaches a saturation level of 88\% - 90\%, to allow for the placement of a definitive airway. \tn 
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 & 	  Below this level, oxygen saturation can decrease to critical levels \textless{}70\% within moments. \tn 
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{\bf{Goals of preoxygenation}} & 	Achieve 100\% oxygenation saturation prior to procedure \tn 
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 & 	Denitrogenate the residual capacity of the lungs, maximizing oxygen storage \tn 
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 & 	Denitrogenate and maximally oxygenate the bloodstream. \tn 
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Preoxygenation aka Denitrogenation (cont)}}  \tn
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{\bf{Preoxygenation techniques}} & o	Tidal volume breathing with 100\% O2 for 3-5 minutes \tn 
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 & o	8 deep breaths of 100\% O2 for 60 seconds \tn 
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 & o	Sit up or reverse Trendelenburg to increase FRC \tn 
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{\bf{Nasal oxygen @ 15L during intubation}} & 	Preoxygenation and apneic oxygenation are particularly beneficial if manual ventilation after induction of anesthesia is undesirable (eg during rapid sequence induction and intubation RSI), if difficulty with airway management is anticipated and for pts who are expected to desat rapidly \tn 
% Row Count 24 (+ 15)
% Row 11
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 & •	Obese \{\{nl\}\}•	Pregnant \{\{nl\}\}•	Pediatric  \{\{nl\}\}•	Hypermetabolic pts \tn 
% Row Count 28 (+ 4)
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\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{FRC Measurement}}  \tn
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\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687191851_Screenshot 2023-06-19 122347.png}}} \tn 
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Functional Residual Capacity}}  \tn
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{\bf{FRC}} & Volume of air in lungs at end of expiration \tn 
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 & o	FRC is the reservoir of oxygen that prevents hypoxemia during apnea \tn 
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 & o	Diaphragmatic tone and position {\emph{also}} effect FRC \tn 
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 & o	FRC cannot be measured with spirometry because the residual volume cannot be exhaled and RV is a component of FRC \tn 
% Row Count 16 (+ 6)
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\SetRowColor{LightBackground}
{\bf{Static equilibrium}} & {\emph{At FRC}} the inward elastic recoil of the lungs is balanced by the outward elastic recoil of the chest wall \tn 
% Row Count 22 (+ 6)
% Row 5
\SetRowColor{white}
{\bf{Normal FRC}} & 35 ml/kg \tn 
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% Row 6
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{\bf{Indirect FRC measurement}} & Nitrogen washout \tn 
% Row Count 25 (+ 2)
% Row 7
\SetRowColor{white}
 & Helium wash in \tn 
% Row Count 26 (+ 1)
% Row 8
\SetRowColor{LightBackground}
 & Body plethysmography \tn 
% Row Count 27 (+ 1)
% Row 9
\SetRowColor{white}
{\bf{How will FRC last during apnea?}} & o	We can estimate how long a pt can remain apneic before desaturation if we know the patients FRC and oxygen consumption (VO2) \tn 
% Row Count 33 (+ 6)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Functional Residual Capacity (cont)}}  \tn
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 & {\bf{o	Healthy adult breathing 100\% O2 takes 6.9 minutes to desaturate to 90\%  on pulse oximetry}}\{\{nl\}\}{\bf{	1 minute if the patient was breathing room air}} \tn 
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\SetRowColor{white}
{\bf{Desat formula}} & time until patient desats = FRC/VO2 \tn 
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% Row 12
\SetRowColor{LightBackground}
{\bf{Conditions that decrease FRC}} & {\emph{Obesity}} \{\{nl\}\} •	Decreased chest wall compliance\{\{nl\}\}•	Increased airway collapsibility \tn 
% Row Count 15 (+ 5)
% Row 13
\SetRowColor{white}
 & {\emph{Pregnancy }}\{\{nl\}\}•	Diaphragm shifts cephalad due to gravid uterus \{\{nl\}\}•	First give O2!!! \{\{nl\}\}•	Decreased chest wall compliance \tn 
% Row Count 22 (+ 7)
% Row 14
\SetRowColor{LightBackground}
 & {\emph{Neonates}}\{\{nl\}\}•	Less alveoli  \{\{nl\}\}•	Decreased lung compliance \{\{nl\}\}•	Cartilaginous ribcage prone to collapse during inspiration \tn 
% Row Count 29 (+ 7)
% Row 15
\SetRowColor{white}
{\bf{Postions that affect FRC}} & {\emph{Decrease}}\{\{nl\}\}•	Supine \{\{nl\}\}•	Trendelenburg \{\{nl\}\}•	Lithotomy \tn 
% Row Count 33 (+ 4)
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\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Functional Residual Capacity (cont)}}  \tn
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 & {\emph{Increase}}\{\{nl\}\}•	Prone \{\{nl\}\}•	Sitting \{\{nl\}\}•	Lateral- unchanged or increase \tn 
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\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Opioid Potency}}  \tn
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\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\mymulticolumn{1}{x{8.4cm}}{Opioid Potency Least potent (left) Most Potent (Right) \newline Meperidine 100mg / 0.1 RP \newline Morphine 10mg / 1 \newline Hydromorphone 1.4m / 7 \newline Alfentanil 1000mcg / 10 \newline Remifentanil 100mg / 100 \newline Fentanyl 100mcg / 100 \newline Sufentanil 10mcg / 1000}  \tn 
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\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia}}  \tn
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{\bf{Opioids - Fentanyl}} & {\bf{MOA}} & mu receptor agonist \tn 
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 & {\bf{Onset}} & 5 min \tn 
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 & {\bf{Duration}} & 20-30 min \tn 
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\SetRowColor{white}
 & {\bf{Active Metabolite}} & CYP3A4 (P450) \tn 
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\SetRowColor{LightBackground}
 & {\bf{Clearance}} & Liver \tn 
% Row Count 11 (+ 2)
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 & {\bf{Dosing}} & {\emph{IV}} 1-2 mcg/kg \{\{nl\}\}{\emph{induction}} 10 mcg/kg (watch for chest wall or glottis rigidity) \tn 
% Row Count 17 (+ 6)
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\SetRowColor{LightBackground}
 & {\bf{Resp Effects}} & respiratory depression \tn 
% Row Count 19 (+ 2)
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 & {\bf{CV Effects}} & bradycardia, vasodilation \tn 
% Row Count 21 (+ 2)
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 & {\bf{CNS Effects}} & analgesia, N/V \tn 
% Row Count 23 (+ 2)
% Row 9
\SetRowColor{white}
{\bf{Amine - Lidocaine}} & {\bf{MOA}} & {\bf{o	Local anesthetics bind to alpha-subunit on inside of sodium channel}}\{\{nl\}\}o	When critical number of sodium channels are blocked cell can't be depolarized and action potential cant be propagated \tn 
% Row Count 37 (+ 14)
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\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia (cont)}}  \tn
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 & {\bf{Adverse Effects}} & {\emph{	Mild CNS-related symptoms}} \{\{nl\}\}•	Drowsiness \{\{nl\}\}•	dizziness \{\{nl\}\}•	metallic taste \{\{nl\}\}•	Headache \{\{nl\}\}•	 blurred vision \{\{nl\}\}•	paresthesia dysarthria \{\{nl\}\}•	 euphoria  \{\{nl\}\}•	 Nausea {\emph{\{\{nl\}\}	Larger doses or if given rapidly }}\{\{nl\}\}•	Tinnitus \{\{nl\}\}•	 Tremor \{\{nl\}\}•	Agitation \{\{nl\}\}•	Cardiovascular changes are usually minimal with the usual doses \tn 
% Row Count 26 (+ 26)
% Row 11
\SetRowColor{white}
 & {\bf{Uses}} & o	5\% of patients have pain at propofol injection and of these, 1\% of them have severe or excruciating pain \{\{nl\}\}	40 mg Lidocaine prevents this\{\{nl\}\} 	Also can mix Lidocaine and Propofol \{\{nl\}\}•	Propofol and lidocaine= Magic \{\{nl\}\}o	Add 1 ml of 1 \% or 2\% lidocaine to a 10 ml syringe of propofol \{\{nl\}\}	Place the IV in an antecubital vein (vs the hand).\{\{nl\}\} 	Pretreat with IV opioids. \{\{nl\}\}	If the IV is in the hand, place a tourniquet proximally and pretreat with lidocaine \tn 
% Row Count 59 (+ 33)
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\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia (cont)}}  \tn
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{\bf{Propofol}}\{\{nl\}\}most common induction agent & {\bf{MOA}} & GABA-A agonist (how long the channel stays open)\{\{nl\}\}	GABA-A receptor stimulation hyperplarizes neurons by increasing Cl- conductance. More Cl- inside the cell makes the cell more negative. This reduces resting membrane potential (RMP moves further away from TP) \tn 
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 & {\bf{Onset}} & 30-60 seconds \tn 
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 & {\bf{Duration}} & 5-10 min \tn 
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 & {\bf{Clearance}} & Liver and extra hepatic metabolism \tn 
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 & {\bf{Active Metabolite}} & None \tn 
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 & {\bf{Induction dose}} & 1.5-2.5 mg/kg IV \tn 
% Row Count 31 (+ 3)
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 & {\bf{Maintenance dose}} & 25-200 mcg/kg/min \tn 
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% Row 19
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 & {\bf{Resp Effects}} & decreased resp drive \tn 
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% Row 20
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 & {\bf{CV Effects}} & decreased BP, SVR, preload, contractility \tn 
% Row Count 8 (+ 3)
% Row 21
\SetRowColor{white}
 & {\bf{CNS Effects}} & decreased ICP and IOP, no analgesia, +/- seizure activity \tn 
% Row Count 12 (+ 4)
% Row 22
\SetRowColor{LightBackground}
{\bf{Etomidate}} & {\bf{MOA}} & GABA-A agonist \tn 
% Row Count 13 (+ 1)
% Row 23
\SetRowColor{white}
 & {\bf{Onset}} & 30-60 seconds \tn 
% Row Count 15 (+ 2)
% Row 24
\SetRowColor{LightBackground}
 & {\bf{Duration}} & 5-15 min \tn 
% Row Count 17 (+ 2)
% Row 25
\SetRowColor{white}
 & {\bf{Clearance}} & Liver \& plasma esterases \tn 
% Row Count 19 (+ 2)
% Row 26
\SetRowColor{LightBackground}
 & {\bf{Active Metabolite}} & None \tn 
% Row Count 22 (+ 3)
% Row 27
\SetRowColor{white}
 & {\bf{Induction dose}} & 0.2-0.4 mg/kg IV \tn 
% Row Count 25 (+ 3)
% Row 28
\SetRowColor{LightBackground}
 & {\bf{Resp Effects}} & Mild Resp Depression \tn 
% Row Count 27 (+ 2)
% Row 29
\SetRowColor{white}
 & {\bf{CV Effects}} & Minimal \tn 
% Row Count 29 (+ 2)
% Row 30
\SetRowColor{LightBackground}
 & {\bf{CNS Effects}} & Decreased ICP, no analgesia \tn 
% Row Count 31 (+ 2)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.964 cm} x{1.672 cm} x{2.964 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia (cont)}}  \tn
% Row 31
\SetRowColor{LightBackground}
 & {\bf{Side Effects}} & o	Myoclonus (not a seizure) \{\{nl\}\}o	Does not cause seizures if the patient does not have a history of seizures  \{\{nl\}\}o	Suppression of adrenocortical function for up to 24 hrs. It should be avoided in sepsis and acute adrenal failure \{\{nl\}\}o	N\&V (greater than any other induction agent) \{\{nl\}\}o	Acute intermittent porphyria \tn 
% Row Count 22 (+ 22)
% Row 32
\SetRowColor{white}
{\bf{Ketamine}} & {\bf{MOA}} & NMDA antagonist (creates dissociated state) \tn 
% Row Count 25 (+ 3)
% Row 33
\SetRowColor{LightBackground}
 & {\bf{MOA secondary}} & Many 2nd receptor targets including opioid, MAO, serotonin, NE, muscarinic, and NA channels \tn 
% Row Count 32 (+ 7)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.964 cm} x{1.672 cm} x{2.964 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia (cont)}}  \tn
% Row 34
\SetRowColor{LightBackground}
 & {\bf{Onset IV}} & 30-60 seconds \tn 
% Row Count 2 (+ 2)
% Row 35
\SetRowColor{white}
 & {\bf{Onset IM}} & 2-4 minutes \tn 
% Row Count 4 (+ 2)
% Row 36
\SetRowColor{LightBackground}
 & {\bf{Onset PO}} & variable \tn 
% Row Count 6 (+ 2)
% Row 37
\SetRowColor{white}
 & {\bf{Duration}} & 10-20 minutes (can last 60-90 min to return to full orientation) \tn 
% Row Count 11 (+ 5)
% Row 38
\SetRowColor{LightBackground}
 & {\bf{Clearance}} & Liver \tn 
% Row Count 13 (+ 2)
% Row 39
\SetRowColor{white}
 & {\bf{Active Metabolite}} & Norketamine \tn 
% Row Count 16 (+ 3)
% Row 40
\SetRowColor{LightBackground}
 & {\bf{Induction Doses}} & IV 1-2 mg/kg \{\{nl\}\} IM 4-8 mg/kg \{\{nl\}\}PO 10mg/kg \tn 
% Row Count 20 (+ 4)
% Row 41
\SetRowColor{white}
 & {\bf{Opioid Sparing Dose}} & 0.1-0.5 mg/kg or 1-3 mcg/kg/min \tn 
% Row Count 23 (+ 3)
% Row 42
\SetRowColor{LightBackground}
 & {\bf{Resp Effects}} & maintains resp drive, increased oral secretions (DROOL EVERYWHERE, GIVE GLYCO) \tn 
% Row Count 29 (+ 6)
% Row 43
\SetRowColor{white}
 & {\bf{CV Effects}} & Increased SNS tone, SVR, HR, and CO \tn 
% Row Count 32 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.964 cm} x{1.672 cm} x{2.964 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{IV Induction Agents - General Anesthesia (cont)}}  \tn
% Row 44
\SetRowColor{LightBackground}
 & {\bf{CNS Effects}} & Increased ICP, IOP, nystagmus and analgesia\{\{nl\}\}causes emergence delirium and lowers seizure threshold, can also treat severe depression \tn 
% Row Count 10 (+ 10)
\hhline{>{\arrayrulecolor{DarkBackground}}---}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Food Allergies \& Propofol}}  \tn
% Row 0
\SetRowColor{LightBackground}
Overseen by the American Academy of Allergy, Asthma and Immunology. They state: & o	Propofol can cause anaphylactic reactions, the cause of these reactions is unclear and appears not to be related to soy or egg allergy. \tn 
% Row Count 7 (+ 7)
% Row 1
\SetRowColor{white}
o	Egg allergy & 	Patients with soy, peanut allergy or egg allergy can receive propofol without any special precautions. – Probably safe \{\{nl\}\}	Most people with egg allergies are allergic to the albumin egg whites. Egg lecithin found in propofol is derived from the YOLK \tn 
% Row Count 21 (+ 14)
% Row 2
\SetRowColor{LightBackground}
o	Soy & 	Any soy proteins that are capable of producing an immune response are removed during the refining process \{\{nl\}\}	Prop is safe to use in pts with soy allergy \tn 
% Row Count 30 (+ 9)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Food Allergies \& Propofol (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
o	Peanut & 	Like soy peanuts are a type of legume. Some have speculated the potential of cross sensitivity between peanuts and soy (and thus propofol) although there is no evidence to support this  \{\{nl\}\}	Prop is safe to use in pts with a peanut allergy \tn 
% Row Count 13 (+ 13)
% Row 4
\SetRowColor{white}
o	Increased Risk of Bacterial Contamination & 	Propofol syringes must be discarded within 6 hrs \{\{nl\}\}	Infusions (and the tubing) must be discarded within 12 hrs \tn 
% Row Count 20 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.584 cm} x{3.496 cm} x{1.52 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{LBW vs TBW}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{TBW}} & Total body weight {\bf{Maintenence}} &  \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
 & •	Weight when individual steps on scale &  \tn 
% Row Count 5 (+ 3)
% Row 2
\SetRowColor{LightBackground}
{\bf{IBW}} & Describes the BMI associated with the lowest risk of body weight related comorbidities. We can estimate the ideal body weight with the following formulas: &  \tn 
% Row Count 14 (+ 9)
% Row 3
\SetRowColor{white}
 & o	Men (kg)= height (cm) – 100 \{\{nl\}\}o	Women (Kg)= Height (cm) - 105 &  \tn 
% Row Count 18 (+ 4)
% Row 4
\SetRowColor{LightBackground}
{\bf{LBW}} & Lean body weight &  \tn 
% Row Count 19 (+ 1)
% Row 5
\SetRowColor{white}
 & 	LBW = 1.3 X IBW &  \tn 
% Row Count 21 (+ 2)
% Row 6
\SetRowColor{LightBackground}
{\bf{Drug}} & {\bf{Dose}} & {\bf{Recommendation}} \tn 
% Row Count 24 (+ 3)
% Row 7
\SetRowColor{white}
Propofol & Induction \{\{nl\}\} Maintenance & LBW\{\{nl\}\}TBW \tn 
% Row Count 26 (+ 2)
% Row 8
\SetRowColor{LightBackground}
\seqsplit{Succinylcholine} & Intubation & TBW \tn 
% Row Count 28 (+ 2)
% Row 9
\SetRowColor{white}
Rocuronium \{\{nl\}\}Vecuronium & Intubation \{\{nl\}\} Maintenance & LBW\{\{nl\}\}LBW \tn 
% Row Count 31 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.584 cm} x{3.496 cm} x{1.52 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{LBW vs TBW (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
\seqsplit{Cisatracurium} \{\{nl\}\}Atracurium & Intubation \{\{nl\}\}Maintenance & TBW\{\{nl\}\}TBWvsLBW \tn 
% Row Count 3 (+ 3)
% Row 11
\SetRowColor{white}
Fentanyl \seqsplit{((nl))Sufentanil} & Loading\{\{nl\}\}Maintenance & TBW\{\{nl\}\}LBW \tn 
% Row Count 5 (+ 2)
% Row 12
\SetRowColor{LightBackground}
Remifentanil & Loading\{\{nl\}\}Maintenance & LBW\{\{nl\}\}LBW \tn 
% Row Count 7 (+ 2)
% Row 13
\SetRowColor{white}
Midazolam & Loading (not preop)\{\{nl\}\}Maintenance & TBW\{\{nl\}\}TBW \tn 
% Row Count 9 (+ 2)
% Row 14
\SetRowColor{LightBackground}
Epidural Local &  & 75\% of normal dose \tn 
% Row Count 12 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}---}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Guedel's Stages of Anesthesia}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Stage 1 - Analgesia or Disorientation}} & o	Can be initiated in a preoperative holding area \{\{nl\}\}o	Patient is given medication and may begin to feel its effects but has not yet become unconscious \tn 
% Row Count 8 (+ 8)
% Row 1
\SetRowColor{white}
{\emph{o	Induction stage }} & 	Patients are sedated but conversational \{\{nl\}\}	Breathing is slow and regular \{\{nl\}\}	Patient progresses from analgesia free of amnesia to analgesia with concurrent amnesia \{\{nl\}\}	This stage comes to an end with the loss of consciousness. \tn 
% Row Count 21 (+ 13)
% Row 2
\SetRowColor{LightBackground}
{\emph{o	Loss of Consciousness}} & 	Count backwards from 100, the patient typically loses consciousness between 80 to 90, i.e. stops counting – the old way \{\{nl\}\} 	 Blinking increases, and nystagmus may appear \{\{nl\}\}	Eyes eventually fix in the midline as the lids close •	GENTLE \{\{nl\}\}	Patient becomes unresponsive, atonic, apneic, and the oculocephalic (or more precisely \seqsplit{vestibular-oculocephalic)} and corneal reflexes are lost\{\{nl\}\} 	Call patients name \{\{nl\}\}	Eyelash reflex \{\{nl\}\}	Tape eyes- as soon as you lose consciousness  \{\{nl\}\}•	If you struggle to ventilate they you could hurt their eyes \{\{nl\}\}•	Not on sedation cases \{\{nl\}\}•	Don't tape in endo watch the L eye \tn 
% Row Count 55 (+ 34)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Guedel's Stages of Anesthesia (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
{\emph{o	Eye Protection after Loss of Consciousness}} & 	Tape eyes horizontally after loss of consciousness \{\{nl\}\}	Eyes should be  protected before instrumenting the air way \tn 
% Row Count 7 (+ 7)
% Row 4
\SetRowColor{white}
{\bf{Stage 2 - Excitement}} & o	There is a higher risk of laryngospasm (involuntary tonic closure of vocal cords) at this stage, which may be aggravated by any airway manipulation \{\{nl\}\}o	The combination of spastic movements, vomiting, and rapid, irregular respirations can compromise the patient's airway.{]} \{\{nl\}\}o	Fast-acting agents help reduce the time spent in stage 2 as much as possible and facilitate entry to stage 3. \{\{nl\}\}o	NEVER EXTUBATE AT THIS TIME \tn 
% Row Count 29 (+ 22)
% Row 5
\SetRowColor{LightBackground}
 & o	If you are using gas induction no muscle relaxation- you can really see this \{\{nl\}\} 	Its really short with IV induction  \{\{nl\}\}	FOR KIDS \{\{nl\}\}•	Laryngospasm\{\{nl\}\} •	Don't touch them too soon \tn 
% Row Count 40 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Guedel's Stages of Anesthesia (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
{\bf{Stage 3 - Deep}} & o {\emph{Surgical Anesthesia targeted anesthetic level for procedures requiring general anesthesia}}\{\{nl\}\}o	Ceased eye movements and respiratory depression are the hallmarks of this stage. \{\{nl\}\}o	Airway manipulation is safe at this level \tn 
% Row Count 12 (+ 12)
% Row 7
\SetRowColor{white}
 & {\bf{4 planes in stage}} \tn 
% Row Count 14 (+ 2)
% Row 8
\SetRowColor{LightBackground}
 & 	{\bf{Plane 1}}, there is still regular spontaneous breathing, constricted pupils, and central gaze \{\{nl\}\}•	 eyelid, conjunctival, and swallow reflexes usually disappear in this plane \{\{nl\}\}•	Just gazing \tn 
% Row Count 25 (+ 11)
% Row 9
\SetRowColor{white}
 & 	{\bf{Plane 2}}, there are intermittent cessations of respiration along with the loss of corneal and laryngeal reflexes. Halted ocular movements and increased lacrimation may also occur. \tn 
% Row Count 35 (+ 10)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Guedel's Stages of Anesthesia (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
 & 	{\bf{Plane 3}} is marked by complete relaxation of the intercostal and abdominal muscles and loss of the pupillary light reflex. This plane is referred to as "true surgical anesthesia" because it is ideal for most surgeries. \tn 
% Row Count 12 (+ 12)
% Row 11
\SetRowColor{white}
 & 	 {\bf{Plane 4}} is marked by irregular respiration, paradoxical rib cage movement, and full diaphragm paralysis resulting in apnea. \tn 
% Row Count 19 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Mask Ventilation}}  \tn
% Row 0
\SetRowColor{LightBackground}
One hand & o	C \{\{nl\}\}o	E \{\{nl\}\}o	If you are struggling put in oral airway \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
Two hands & o	Get it less than 20  \{\{nl\}\}o	Two people approach \tn 
% Row Count 7 (+ 3)
% Row 2
\SetRowColor{LightBackground}
Non- Invasive Airway Maneuvers & •	Chin lift \{\{nl\}\}•	 Not usually in induction  \{\{nl\}\}•	Jaw Thrust \tn 
% Row Count 11 (+ 4)
% Row 3
\SetRowColor{white}
Placement of LMA if unable to ventilate & •	LMA \{\{nl\}\}•	Difficult supraglottic airway placement \{\{nl\}\}o	Restricted mouth opening \{\{nl\}\}o	Obstruction  \{\{nl\}\}o	Distorted airway \{\{nl\}\}o	Stiff lungs or C spine \tn 
% Row Count 20 (+ 9)
% Row 4
\SetRowColor{LightBackground}
Upper Airway Patency & •	Pharynx \{\{nl\}\}•	Collapsible tube inside box \{\{nl\}\}•	Box is formed: \{\{nl\}\}o	Tongue \{\{nl\}\}o	Soft palate \{\{nl\}\}o	Pharyngeal tissue \{\{nl\}\}o	Cervical spine \tn 
% Row Count 28 (+ 8)
% Row 5
\SetRowColor{white}
During inspiration a negative gradient draws air into lungs & •	Tendency to make airway collapse \{\{nl\}\}•	In awake state \{\{nl\}\}o	Counteracted by three sets of dilator muscle \tn 
% Row Count 34 (+ 6)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Mask Ventilation (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
If able to ventilate give muscle Relaxant & •	Upper airway consists of the cartilaginous and bony structures of the nose and mouth, followed by the soft tissue of the oropharynx and laryngopharynx, and ending in the rigid trachea \{\{nl\}\}•	Soft tissue of the pharynx is prone to collapse in the unconscious, or anesthetized, patient and may be further compromised by obesity, a large tongue, airway edema, large neck circumference, external compression, and many other factors \tn 
% Row Count 22 (+ 22)
% Row 7
\SetRowColor{white}
Controversy & •	When placing an endotracheal tube after induction  o	Historically been instructed to refrain from administering muscle relaxation until adequate mask ventilation in the anesthetized patient was confirmed in order to both avoid \{\{nl\}\}	Critical hypoxemic event \{\{nl\}\}	Ensure an attempt at an escape wake up. \{\{nl\}\} o	There is little published evidence to support this practice, and the administration of muscle relaxation before ensuring adequate BVM ventilation remains controversial \{\{nl\}\}o	Neuromuscular Blockade and the Airway \{\{nl\}\}	Regarding Mask Ventilate- There is evidence that paralysis of the upper airway musculature improves ability to ventilate  \{\{nl\}\}	 A recent study published data indicating that NMB using rocuronium facilitated bag-mask ventilation in anesthetized patients \tn 
% Row Count 63 (+ 41)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Oral Airways}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211166_Screenshot 2023-06-19 174253.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Airway Obstruction}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211200_Screenshot 2023-06-19 174305.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Difficult Ventilation Mnemonic}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687210306_Screenshot 2023-06-19 172848.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Ventilate Patient with mask after loss of consciousness}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Upper Airway Patency}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211135_Screenshot 2023-06-19 174325.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Mneumonic for Difficult LMA Placement}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211093_Screenshot 2023-06-19 174442.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{4 cm} x{4 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Why Neuromuscular Blockades (NMB)?}}  \tn
% Row 0
\SetRowColor{LightBackground}
•	They allow for easy airway and operative field manipulation & o	Good for specific types of surgery\{\{nl\}\} o	 No single agent is ideal for every situation \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
•	What is the Neuromuscular Junction? (NMJ) & o	The neuromuscular junction is a synapse that develops between a motor neuron and a muscle fiber  o	Made up of several components: the presynaptic nerve terminal, the postsynaptic muscle membrane, and the intervening cleft (or gap) \{\{nl\}\} o	End Plate \{\{nl\}\}	Acetylcholine is hydrolyzed rapidly by the enzyme \seqsplit{acetylcholinesterase} in the synaptic cleft \{\{nl\}\} 	Not all acetylcholine that is released reaches the endplate, some is hydrolyzed en route. \tn 
% Row Count 28 (+ 23)
% Row 2
\SetRowColor{LightBackground}
•	Muscle Relaxants & o	Disrupts the physiological sequence of neuromuscular transmission.  \{\{nl\}\}o	Provides NO ANALGESIA or AMNESIA  \{\{nl\}\}o	Used to optimize surgical condition and facilitate intubations. \{\{nl\}\} o	Mechanism of action occurs at the neuromuscular junction (NMJ) \{\{nl\}\} o	Post junction nicotinic receptors are composed of five subunits \{\{nl\}\}o	Lined up circumferentially around ion conducting core \{\{nl\}\}o	Two alpha subunits \tn 
% Row Count 49 (+ 21)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Neuromuscular junction}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211740_Screenshot 2023-06-19 175423.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Muscle Relaxants}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211797_Screenshot 2023-06-19 175439.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{End Plate}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211768_Screenshot 2023-06-19 175432.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Post Junction Nicotinic Receptors}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/lkmaceac_1687211850_Screenshot 2023-06-19 175458.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{o	Post junction nicotinic receptors are composed of five subunits \newline o	Lined up circumferentially around ion conducting core \newline o	Two alpha subunits}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.584 cm} x{2.508 cm} x{2.508 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Depolarizing NMB}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Succinylcholine chloride (Anectine, Quelicin)}} & \seqsplit{o	Depolarizing} \seqsplit{neuromuscular} blockers act as {\bf{agonists}} at postsynaptic nicotinic \seqsplit{acetylcholine} receptors and cause prolonged membrane \seqsplit{depolarization} resulting in \seqsplit{neuromuscular} blockade. \{\{nl\}\} &  \tn 
% Row Count 15 (+ 15)
% Row 1
\SetRowColor{white}
 & • Resemble ACH bind to ACH receptors  \{\{nl\}\}• generating an action potential ....{\bf{depolarization}}.  \{\{nl\}\}• Sodium channels are {\bf{open}} as a result of \seqsplit{depolarization},  then {\bf{close}} in a resting state and muscle relaxation occurs. &  \tn 
% Row Count 34 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.584 cm} x{2.508 cm} x{2.508 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Depolarizing NMB (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
 & • Ach binds to \seqsplit{subunit-allows} channel to open -{\emph{depolarization occurs}} \{\{nl\}\}• Depolarizing neuro muscular blockers \{\{nl\}\}– Bind to alpha subunits \{\{nl\}\}– Cause Channel to remain open- mimics Ach \{\{nl\}\}– Prolonged \seqsplit{depolarization} occurs &  \tn 
% Row Count 19 (+ 19)
% Row 3
\SetRowColor{white}
 & {\emph{Chemical formula}}: C14H30N2O4 &  \tn 
% Row Count 22 (+ 3)
% Row 4
\SetRowColor{LightBackground}
 & {\bf{MOA}} & agonists at postsynaptic nicotinic \seqsplit{acetylcholine} receptors and cause prolonged membrane \seqsplit{depolarization} resulting in \seqsplit{neuromuscular} blockade \tn 
% Row Count 33 (+ 11)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{2.584 cm} x{2.508 cm} x{2.508 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Depolarizing NMB (cont)}}  \tn
% Row 5
\SetRowColor{LightBackground}
 & {\bf{Onset}} & IV 60-90 sec \{\{nl\}\}IM 2-3 min \tn 
% Row Count 3 (+ 3)
% Row 6
\SetRowColor{white}
 & {\bf{Duration}} & 5 min \tn 
% Row Count 4 (+ 1)
% Row 7
\SetRowColor{LightBackground}
 & {\bf{Reversal}} & None \tn 
% Row Count 5 (+ 1)
% Row 8
\SetRowColor{white}
 & {\bf{Dose}} & {\bf{IV 0.5-1.5 mg/kg }}\{\{nl\}\}Ped IV 4-5 mg/kg \{\{nl\}\}Laryngospasm: 1-.5 mg/kg/IV or 4-6mg/kg IM \tn 
% Row Count 13 (+ 8)
% Row 9
\SetRowColor{LightBackground}
 & {\bf{Metabolism}} & \seqsplit{Psuedocholinesterase} \tn 
% Row Count 15 (+ 2)
% Row 10
\SetRowColor{white}
 & {\bf{Adverse Effects}} & \seqsplit{	Hyperkalemia}  \{\{nl\}\}	Malignant Hyperthermia \{\{nl\}\}	 Apnea \tn 
% Row Count 21 (+ 6)
\hhline{>{\arrayrulecolor{DarkBackground}}---}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{1.748 cm} x{2.964 cm} x{2.888 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Non-Depolarizing NMB}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{3}{x{8.4cm}}{o	NDMR compete with acetylcholine for the active binding sites at the postsynaptic nicotinic acetylcholine receptor  \{\{nl\}\}o	Resemble ACH enough to {\bf{bind to the ACH receptor}}, but {\bf{fail to activate}} the receptor, thus blocking its action (paralyzing the muscle transmission)  \{\{nl\}\}o	{\emph{"The key fits but won't open the door." }}\{\{nl\}\}{\bf{o	Competitive Antagonist – compete with ACH  \{\{nl\}\} 	     SO THEY CAN BE REVERSED}} \{\{nl\}\}o	The bond is very tight depending upon the drug, it will last from 20 to 90 minutes.} \tn 
% Row Count 11 (+ 11)
% Row 1
\SetRowColor{white}
\seqsplit{o	Competitive} \seqsplit{Antagonist} & 	Two alpha subunits are binding sites for Ach\{\{nl\}\} 	Sites occupied by \seqsplit{nondepolarizing} neuro muscular blockers\{\{nl\}\} 	Cause channel to remain closed \{\{nl\}\}	Ion flow to produce depolarization can't occur &  \tn 
% Row Count 26 (+ 15)
% Row 2
\SetRowColor{LightBackground}
{\bf{Rocuronium}} & 	Rocuronium is the most widely used \seqsplit{nondepolarizing} relaxant in the United States. \{\{nl\}\} 	Can be used for rapid sequence induction (RSI) when \seqsplit{succinylcholine} is \seqsplit{contraindicated}. &  \tn 
% Row Count 39 (+ 13)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{1.748 cm} x{2.964 cm} x{2.888 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Non-Depolarizing NMB (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
 & {\bf{MOA}} & o	Resemble ACH enough to bind to the ACH receptor, but fail to activate the receptor, thus blocking its action (paralyzing the muscle transmission)\{\{nl\}\}o	Competitive Antagonist – compete with ACH \tn 
% Row Count 14 (+ 14)
% Row 4
\SetRowColor{white}
 & {\bf{Onset}} & 1-2 min \tn 
% Row Count 15 (+ 1)
% Row 5
\SetRowColor{LightBackground}
 & {\bf{Duration}} & 20-35 min \tn 
% Row Count 16 (+ 1)
% Row 6
\SetRowColor{white}
 & {\bf{Dose}} & {\bf{IV 0.6 - 1.2 mg/kg}} \{\{nl\}\}Infusion 5-12 mcg/kg/min\{\{nl\}\}Pretreatment 5mg\{\{nl\}\} {\emph{no reconstitution}} \tn 
% Row Count 23 (+ 7)
% Row 7
\SetRowColor{LightBackground}
 & {\bf{Reversal}} & Sugammadex\{\{nl\}\}Neostigmine (less effective) \tn 
% Row Count 26 (+ 3)
% Row 8
\SetRowColor{white}
 & {\bf{Metabolism}} & some de-acetylation \tn 
% Row Count 28 (+ 2)
% Row 9
\SetRowColor{LightBackground}
{\bf{Vecuronium}} & {\bf{MOA}} &  \tn 
% Row Count 30 (+ 2)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{1.748 cm} x{2.964 cm} x{2.888 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{3}{x{8.4cm}}{\bf\textcolor{white}{Non-Depolarizing NMB (cont)}}  \tn
% Row 10
\SetRowColor{LightBackground}
 & {\bf{Onset}} & 3-5 min \tn 
% Row Count 1 (+ 1)
% Row 11
\SetRowColor{white}
 & {\bf{Duration}} & 20-35 min \tn 
% Row Count 2 (+ 1)
% Row 12
\SetRowColor{LightBackground}
 & {\bf{Metabolism}} & Liver \tn 
% Row Count 3 (+ 1)
% Row 13
\SetRowColor{white}
 & {\bf{Dose}} & {\bf{IV: .08 - .12 mg/kg }}\{\{nl\}\} Infusion: 1-2 mcg/kg/min \tn 
% Row Count 7 (+ 4)
% Row 14
\SetRowColor{LightBackground}
 &  & •	To shorten the onset time, the priming principle involves the administration of a small dose of rocuronium usually 3 minutes prior to induction  \{\{nl\}\}•	The optimal priming dose which is the largest dose that it is given that will not produce weakness in an awake patient is very small  \{\{nl\}\}•	Priming dose is given prior to \seqsplit{succinylcholine} rapid sequence induction to decrease the myalgias (5 mg) \tn 
% Row Count 35 (+ 28)
\hhline{>{\arrayrulecolor{DarkBackground}}---}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Rapid Sequence Induction}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Indicators}} & o	Patient at risk for regurgitation and aspiration who require GA History of \{\{nl\}\}o	Recent vomiting or recent meal\{\{nl\}\} o	Pregnancy  \{\{nl\}\}	Over 18 weeks \{\{nl\}\}	Full stomach \{\{nl\}\} 	Loose spincter  \{\{nl\}\}o	Increased intra-abdominal pressure \{\{nl\}\}o	Abdominal distension  \{\{nl\}\}o	Poorly controlled GE reflux \{\{nl\}\}o	Decreased level of consciousness \{\{nl\}\}o	Gastroparesis \{\{nl\}\}o	Bowel Obstruction \{\{nl\}\}	GOP1 \tn 
% Row Count 21 (+ 21)
% Row 1
\SetRowColor{white}
{\bf{Rapid Sequence Induction Method}} & o	Preoxygenation is critical\{\{nl\}\} o	 Suction and airway alternatives available \{\{nl\}\} o	Use adjuvant drugs to control BP, HR response: midazolam, narcotics, lidocaine, ketamine, etc \{\{nl\}\} o	Explain and rehearse use of cricoid pressure with the patient. \{\{nl\}\} o	Optimize position of upper airway.  \{\{nl\}\}o	Identify person to do cricoid pressure \{\{nl\}\}o	Apply Cricoid while patient is awake\{\{nl\}\} 	 Conscious 20N (2 kg)\{\{nl\}\} 	If you cant see they are pushing too hard \{\{nl\}\}	Tell them to keep holding pressure until you them to let go \{\{nl\}\}o	Propofol 1.5-2.5 mg/kg  \{\{nl\}\}o	asleep 40N (4 kg) of pressure \{\{nl\}\}o	{\bf{Succinylcholine 0.5 to 1.5 mg/kg}} or {\bf{Rocuronium 1.2 mg/kg}} \{\{nl\}\}o	Loss of consciousness-fasciculations\{\{nl\}\} o	Eye Protection \{\{nl\}\}o	Intubate \{\{nl\}\}o	Hold cricoid until endotracheal tube cuff is inflated and placement is confirmed \tn 
% Row Count 63 (+ 42)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.76 cm} x{4.24 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{Rapid Sequence Induction (cont)}}  \tn
% Row 2
\SetRowColor{LightBackground}
{\bf{Modified Rapid Sequence}} & o	Same steps but with ventilation  \{\{nl\}\}o	Gentle IPPV (Paw 10-15 cm H2O) with 100\% O2 until relaxant has peak effect. \{\{nl\}\}o	If you cant see vent until glide scope \tn 
% Row Count 8 (+ 8)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{3.84 cm} x{4.16 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{General Anesthesia - Inhalation Induction}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Indications}} & 	Difficult IV access\{\{nl\}\} 	Developmentally delayed adult \{\{nl\}\}	Pediatrics\{\{nl\}\} 	Potential airway obstruction e.g. epiglottitis  \{\{nl\}\}	Kids or special need,  \{\{nl\}\}	Sevo dilates vein- if you cant get IV \tn 
% Row Count 12 (+ 12)
% Row 1
\SetRowColor{white}
{\bf{Contraindications}} & 	Aspiration risk \{\{nl\}\} 	Active bleeding in airway (risk of cough, laryngospasm) \tn 
% Row Count 17 (+ 5)
% Row 2
\SetRowColor{LightBackground}
{\bf{Inhalation Induction Technique}} & 	Prime circuit with anesthesia agent from vaporizer at maximum setting\{\{nl\}\} 	Oxygen at 8L/min \{\{nl\}\}	 Pop off valve open and patient end of circuit occluded.\{\{nl\}\} 	Have patient exhale maximally, then apply face mask to patient and inhale maximally from primed circuit. \{\{nl\}\}	Expect prompt onset of sleep (60 seconds) followed by transient apnea, then pattern of rapid shallow respirations. \{\{nl\}\}	They are crying then go dominate \{\{nl\}\} 	Then you put the IV in and tube them  \{\{nl\}\}	Need the pop up valve OPEN \tn 
% Row Count 44 (+ 27)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{x{3.84 cm} x{4.16 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{General Anesthesia - Inhalation Induction (cont)}}  \tn
% Row 3
\SetRowColor{LightBackground}
{\bf{Inhalation Induction Technique \#2}} & 	Prime circuit with N2O 70\%, \{\{nl\}\}	FGF at 8L/min \{\{nl\}\}	Pop off valve open and patient end of circuit occluded. \{\{nl\}\}	When patient is comfortable with situation, begin volatile agent increasing vaporizer setting by 0.5\% every 3 or 4 breaths\{\{nl\}\} 	 Reassure patient with calm voice encouraging a regular smooth breathing pattern. \{\{nl\}\}	Use of a deep breathing pattern here may lead to premature onset of apnea with prolonged phase. \{\{nl\}\}	Expect several minutes to fall asleep. Assist ventilation \{\{nl\}\}	Don't use N2O if you are trying to get pregnant- spont miscarriage  \{\{nl\}\}	For adults or special needs \tn 
% Row Count 32 (+ 32)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{x{2.32 cm} x{5.68 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{8.4cm}}{\bf\textcolor{white}{General Anesthesia - LMA Induction Sequence}}  \tn
% Row 0
\SetRowColor{LightBackground}
{\bf{Induction}} & 	Pre-Oxygenate \{\{nl\}\}	Lidocaine \{\{nl\}\}	Propofol \{\{nl\}\}	Loss of consciousness \{\{nl\}\}	Eye protection \{\{nl\}\}{\bf{	Usually don't ventilate}} \{\{nl\}\}	Open mouth insert LMA \{\{nl\}\}	When you take it out don't deflate cough- all the secretions go right in the airway \tn 
% Row Count 11 (+ 11)
% Row 1
\SetRowColor{white}
{\bf{Fentanyl LMA}} & 	Many anesthesia providers do not give fentanyl on induction \{\{nl\}\}	Wait for return of spontaneous respiration \{\{nl\}\}	Others give small dose \tn 
% Row Count 17 (+ 6)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
\par\addvspace{1.3em}


% That's all folks
\end{multicols*}

\end{document}