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Anesthesia Residents' Vital Information Navigator

Anesthesia Residents' Vital Information Navigator

A collection of some of the most common calculations; and some uncommonly done procedures in Anesthesiology

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ABG Interpreter ACLS Algorithm Difficult Airway Eleveld TCI Calculator Glasgow Coma Score LAST Protocol Malignant Hyperthermia O2% Calculator

Eleveld TCI Model

BIS 60: 1.80 mcg/ml
BIS 56: 2.30 mcg/ml
BIS 46: 2.80 mcg/ml
BIS 37: 3.45 mcg/ml
BIS 33: 3.85 mcg/ml
StateBIS Range
Awake98 - 100
Minimal sedation78 - 85
Moderate sedation70 - 78
Deep sedation60 - 70
General anesthesia45 - 60
Over medicated< 45
Vellinga R, et al. Prospective clinical validation of the Eleveld propofol PK-PD model. Br J Anaesth 2021;126(2):386-394.

Glasgow Coma Score

Glasgow Coma Score: 15
13-15: Minor brain injury

ACLS Cardiac Arrest Algorithm

Call for Help. Start CPR. Attach monitor/defibrillator.

Shockable Rhythm (VF / pVT)

  1. Defibrillate: Biphasic 120-200J (or manufacturer recommendation)
  2. CPR 2 minutes. IV/IO access
  3. Defibrillate again if still shockable
  4. Epinephrine 1 mg IV/IO every 3-5 minutes
  5. Defibrillate
  6. Amiodarone 300 mg IV/IO bolus (2nd dose: 150 mg)
  7. Continue CPR cycles. Consider reversible causes

Non-Shockable (Asystole / PEA)

  1. CPR 2 minutes. IV/IO access
  2. Epinephrine 1 mg IV/IO every 3-5 minutes
  3. CPR 2 minutes. Check rhythm every 2 min
  4. Identify and treat reversible causes (H's and T's)

H's

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion (acidosis)
  • Hypo/Hyperkalemia
  • Hypothermia

T's

  • Tension pneumothorax
  • Tamponade (cardiac)
  • Toxins
  • Thrombosis (PE)
  • Thrombosis (coronary)
Post-ROSC: Optimize ventilation (SpO2 92-98%), targeted temperature management, 12-lead ECG, treat cause.

CPR / Epinephrine Timer

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Difficult Airway Algorithm

Based on ASA Practice Guidelines for Management of the Difficult Airway

1. Assess the Airway
Mallampati, thyromental distance, neck mobility, mouth opening, obesity, history
▼
2. Formulate Primary Plan
Awake intubation vs. intubation after induction of general anesthesia
▼
Awake Intubation
Topicalize airway. Flexible bronchoscopy or video laryngoscopy. Confirm with ETCO2.
▼ If awake intubation fails or not chosen
3. After Induction
Attempt direct/video laryngoscopy. Use bougie, different blade, external laryngeal manipulation.
▼ If intubation fails
4. Supraglottic Airway (SGA)
Place LMA/iGel. If ventilation adequate, consider: wake patient, intubate via SGA, or proceed with SGA.
▼ If SGA fails
5. CICO Emergency
Cannot Intubate, Cannot Oxygenate
Front-of-neck access (cricothyrotomy)
Scalpel-bougie-tube technique
Call for help early. Maximum 3 intubation attempts + 1 by an expert before declaring failed intubation.

LAST - Local Anesthetic Systemic Toxicity

Recognition

StageSymptoms
CNS (early)Tinnitus, metallic taste, perioral numbness, agitation, dizziness
CNS (late)Seizures, loss of consciousness
CardiovascularHypotension, bradycardia, arrhythmias, cardiac arrest

Management

  1. Stop injection of local anesthetic immediately
  2. Call for help. Get Intralipid 20%
  3. Airway management - 100% O2, avoid hyperventilation
  4. Seizure suppression: Midazolam (preferred) or small dose Propofol. Avoid large doses of propofol
  5. If cardiac arrest: Start CPR. Avoid vasopressin, calcium channel blockers, beta blockers, local anesthetics (lidocaine)

Intralipid 20% Protocol

  • Bolus: 1.5 mL/kg over 1 minute
  • Infusion: 0.25 mL/kg/min
  • Repeat bolus 1-2 times if cardiovascular instability persists
  • Increase infusion to 0.5 mL/kg/min if needed
  • Maximum total dose: 12 mL/kg

For 70 kg patient: Bolus = 105 mL, Infusion = 17.5 mL/min (1050 mL/hr)

Malignant Hyperthermia

EMERGENCY: Call for help immediately. Get the MH cart. Call the MH Hotline: 1-800-644-9737 (USA)

Recognition - Early Signs

SignDetails
Unexplained rise in ETCO2Most sensitive and earliest sign. Unresponsive to increased ventilation
Masseter muscle rigidityAfter succinylcholine administration
TachycardiaUnexplained, often sinus tachycardia or ventricular arrhythmias
TachypneaIn spontaneously breathing patients
HyperthermiaLate sign - temperature rises 1-2°C every 5 min. May exceed 43°C
Metabolic acidosisMixed respiratory and metabolic acidosis
Muscle rigidityGeneralized (not always present)
RhabdomyolysisElevated CK, myoglobinuria (dark/cola-colored urine)

Triggering Agents

Triggers (AVOID)

  • Succinylcholine
  • All volatile anesthetics:
    • Sevoflurane
    • Desflurane
    • Isoflurane
    • Halothane

Safe Agents

  • Propofol
  • Opioids (all)
  • Benzodiazepines
  • Ketamine
  • Etomidate
  • Nitrous oxide
  • Non-depolarizing NMBAs
  • Local anesthetics
  • Dexmedetomidine

Immediate Management

  1. STOP all triggering agents immediately. Turn off vaporizer. Do NOT delay for machine change.
  2. Hyperventilate with 100% O2 at high fresh gas flows (≥ 10 L/min)
  3. Dantrolene 2.5 mg/kg IV bolus. Repeat every 5 min as needed. No max dose in acute crisis.
  4. Call for help. Assign roles. Get MH cart.
  5. Notify surgeon - conclude surgery ASAP if possible

Dantrolene Dosing

Initial Bolus175 mg (2.5 mg/kg)
Repeat q5min PRNUp to 10 mg/kg total
Max initial700 mg (10 mg/kg)

Preparation: Each vial = 20 mg lyophilized powder. Reconstitute with 60 mL sterile water. For 175 mg = 9 vials.

Ryanodex: 250 mg/vial, reconstitute with 5 mL sterile water. Much faster to prepare.

Supportive Measures

ProblemTreatment
HyperthermiaActive cooling: cold IV NS, ice packs (axillae, groin, neck), cooling blanket, cold lavage. Target <38.5°C then stop active cooling.
HyperkalemiaCalcium chloride 10 mg/kg or calcium gluconate 30 mg/kg. Insulin 0.1 U/kg + glucose 0.5 g/kg. Sodium bicarbonate 1-2 mEq/kg. Hyperventilate.
Metabolic acidosisNaHCO3 1-2 mEq/kg IV guided by ABG
ArrhythmiasTreat hyperkalemia first. Amiodarone for persistent arrhythmias. AVOID calcium channel blockers with dantrolene (cardiac arrest risk)
MyoglobinuriaIV fluids to maintain UO >2 mL/kg/hr. Consider mannitol (within dantrolene) or furosemide.
DICCheck coagulation studies. Treat with FFP, cryoprecipitate, platelets as needed.

Monitoring / Labs

  • ABG, electrolytes (K+, Ca2+), lactate q15-30 min
  • CK (peaks at 12-24 hrs, may exceed 20,000)
  • Urine output, myoglobin
  • Coagulation studies (PT, PTT, fibrinogen, D-dimer)
  • Core temperature (esophageal or bladder preferred)

Post-Crisis Management

  1. Dantrolene 1 mg/kg IV q4-6h for at least 24 hours (recrudescence occurs in ~25%)
  2. ICU admission for at least 24-72 hours
  3. Monitor CK, renal function, potassium, coagulation q6h
  4. Maintain UO >2 mL/kg/hr
  5. Refer patient and family for caffeine-halothane contracture testing (CHCT) and genetic testing (RYR1 mutation)
  6. Report to MHAUS (Malignant Hyperthermia Association of the United States)
MH Hotline (USA): 1-800-644-9737 (available 24/7). Genetics: Autosomal dominant, RYR1 gene (most common) or CACNA1S. Incidence: ~1:10,000-15,000 anesthetics.

Dexmedetomidine IV Drip

Stock Preparation: 200 mcg/1 mL

Concentration4.00 mcg/mL
Loading Dose50.0 mcg over 10-15 min
Loading Volume12.5 mL over 10-15 min
Dose (mcg/kg/hr)Regulation (mL/hr)Dose (mcg/kg/hr)Regulation (mL/hr)
Source: jscimedcentral.com/Anesthesiology

Ketamine IV Drip

Stock Preparation: 500 mg/10 mL (50 mg/mL)

Concentration2 mg/mL
Dose (mg/kg/hr)Regulation (mL/hr)

Propofol

Stock: 10 mg/mL (200 mg/20 mL). No dilution needed.

Induction105-175 mg (1.5-2.5 mg/kg)
Maintenance100-200 mcg/kg/min
Sedation25-75 mcg/kg/min
Dose (mcg/kg/min)mL/hr
Monitor for propofol infusion syndrome with prolonged use (>48h) or high doses (>5 mg/kg/hr).

Remifentanil IV Drip

Stock: 1 mg vial

Concentration50 mcg/mL
Dose (mcg/kg/min)Regulation (mL/hr)

Dopamine IV Drip

Stock: 250 mg/5 mL. Max Dose: 40 mcg/kg/min

Concentration800 mcg/mL
Dose (mcg/kg/min)mL/hrDose (mcg/kg/min)mL/hr
Dose ranges: Low (1-5): renal/mesenteric; Medium (5-10): beta-1; High (10-20): alpha-1

Dobutamine IV Drip

Stock: 250 mg/20 mL. Dose range: 2-20 mcg/kg/min

Concentration1000 mcg/mL
Dose (mcg/kg/min)mL/hr

Epinephrine IV Drip

Stock: 1 mg/mL (1:1000)

Concentration4 mcg/mL
Dose Range0.01-0.5 mcg/kg/min
Dose (mcg/kg/min)mL/hr
Low dose (0.01-0.03): Beta effect (inotropy). High dose (>0.1): Alpha effect (vasoconstriction).

Amiodarone

Mix: 900 mg in 500 mL D5W (1.8 mg/mL)

Loading

PhaseDoseRateDuration
Rapid Loading150 mg15 mg/min10 min
Slow Loading360 mg1 mg/min6 hours
Maintenance540 mg0.5 mg/min18 hours
Cardiac arrest dose: 300 mg IV push (first), then 150 mg IV push (second). Use D5W only, not NS.

Lidocaine 2% Drip for Arrhythmia

Stock: Lidocaine 2% (20 mg/mL). Mix: 2 g in 500 mL (4 mg/mL). Loading: 1-1.5 mg/kg bolus

Loading Bolus70-105 mg
Concentration4 mg/mL
Rate (mg/min)mL/hr
115
230
345
460
Reduce dose in elderly, heart failure, hepatic impairment. Monitor for CNS toxicity.

Labetalol

IV Bolus

MethodDoseDetails
Initial bolus10-20 mgOver 2 minutes
Repeat20-80 mgEvery 10 min
Max total300 mg--

IV Infusion

Mix: 200 mg in 200 mL (1 mg/mL). Rate: 0.5-2 mg/min

Rate (mg/min)mL/hr
0.530
1.060
1.590
2.0120
Contraindicated in: severe bradycardia, heart block, decompensated HF, asthma.

Nicardipine

Mix: 25 mg in 250 mL NS (0.1 mg/mL)

Rate (mg/hr)mL/hr
5 (start)50
7.575
10100
12.5125
15 (max)150
Increase by 2.5 mg/hr every 5-15 minutes until target BP. Max: 15 mg/hr.

Nitroglycerine

Mix: 50 mg in 250 mL D5W (200 mcg/mL)

Dose (mcg/min)mL/hr
5 (start)1.5
103
206
4012
6018
8024
10030
200 (max)60
Titrate by 5 mcg/min every 3-5 minutes. Use non-PVC tubing. Tolerance may develop after 24-48 hours.

Norepinephrine IV Drip

Stock: 4 mg/4 mL

Concentration16 mcg/mL
Dose Range0.01-0.5 mcg/kg/min
Dose (mcg/kg/min)mL/hr

Ketamine for Analgesia

Bolus7-35 mg (0.1-0.5 mg/kg)
Infusion7-21 mg/hr (0.1-0.3 mg/kg/hr)
Sub-anesthetic dose for opioid-sparing analgesia. Avoid in patients with psychotic disorders, elevated ICP, or severe cardiovascular disease.

Morphine IV

IV Dose7-10.5 mg q4h PRN (0.1-0.15 mg/kg)

PCA Settings

ParameterSetting
Demand dose1-2 mg
Lockout interval6-10 min
Basal rate (optional)0-1 mg/hr
4-hour limit10-30 mg

Lidocaine 2% IV for Analgesia

Stock: Lidocaine 2% (20 mg/mL). Mix: 2 g in 250 mL NS (8 mg/mL)

Loading105 mg over 10 min (1.5 mg/kg)
Infusion70-140 mg/hr (1-2 mg/kg/hr)
Infusion Rate8.75-17.5 mL/hr
Monitor for toxicity: tinnitus, perioral numbness, dizziness. Reduce in hepatic impairment.

Local Anesthetic Concentration Calculator

Concentration: 2.5 mg/mL

Common Concentrations

Drug%mg/mLUse
Bupivacaine0.0625%0.625Epidural infusion
Bupivacaine0.125%1.25Epidural infusion
Bupivacaine0.25%2.5Nerve block / Epidural
Bupivacaine0.5%5Nerve block / Spinal
Lidocaine1%10Infiltration
Lidocaine2%20Nerve block
Ropivacaine0.2%2Epidural infusion
Ropivacaine0.5%5Nerve block

Bupivacaine Epidural

ParameterValue
Concentration0.0625% - 0.25%
Rate6-14 mL/hr
Max dose (plain)140 mg (2 mg/kg)
Max dose (with epi)210 mg (3 mg/kg)
Onset15-20 min
Duration2-4 hours
Bupivacaine has high cardiotoxicity. Use ropivacaine if concerned. Monitor for motor block.

Morphine Epidural

ParameterValue
Dose2-5 mg preservative-free
Onset30-60 minutes
Duration12-24 hours
Concentration0.5 mg/mL or 1 mg/mL (Duramorph)
Monitor for delayed respiratory depression for at least 24 hours. Biphasic respiratory depression (early at 1-2h, late at 6-12h).
Keep naloxone at bedside. Monitoring: respiratory rate, sedation score, SpO2.

Ropivacaine Epidural

ParameterValue
Concentration0.1% - 0.2%
Rate6-14 mL/hr
Max dose210 mg (3 mg/kg)
Onset15-20 min
Duration2-6 hours
Less motor block than bupivacaine at equivalent concentrations. Preferred for labor epidurals.

Atracurium

Stock: 10 mg/mL

Concentration5 mg/mL
ParameterDoseCalculated
Intubating dose0.4-0.5 mg/kg28-35 mg
Maintenance bolus0.08-0.1 mg/kg q15-25min5.6-7 mg
Infusion5-9 mcg/kg/min350-630 mcg/min

Drip Regulation

Dose (mcg/kg/min)mL/hr
Duration: 20-35 min. Organ-independent elimination (Hofmann degradation).

Cisatracurium

Concentration2 mg/mL
ParameterDoseCalculated
Intubating dose0.15-0.2 mg/kg10.5-14 mg
Maintenance bolus0.03 mg/kg q20min2.1 mg
Infusion1-3 mcg/kg/min70-210 mcg/min

Drip Regulation

Dose (mcg/kg/min)mL/hr
4x potency of atracurium. Duration: 40-60 min. Hofmann degradation (organ-independent).

Rocuronium

Concentration5 mg/mL
ParameterDoseCalculated
Intubating dose0.6 mg/kg42 mg
RSI dose1.2 mg/kg84 mg
Maintenance0.1-0.2 mg/kg7-14 mg
Infusion10-12 mcg/kg/min700-840 mcg/min

Drip Regulation

Dose (mcg/kg/min)mL/hr
Duration: 30-40 min (intubating dose), 60-70 min (RSI dose). Hepatic elimination.

Sugammadex

IndicationDoseCalculated
Routine reversal (T2 reappearance)2 mg/kg140 mg
Deep block (PTC 1-2)4 mg/kg280 mg
Immediate reversal (RSI rescue)16 mg/kg1120 mg
Wait 24 hours before re-administering rocuronium/vecuronium. May reduce efficacy of hormonal contraceptives.

Pediatrics

Age group: Child (>1 year)

Airway

ETT Uncuffed--
ETT Cuffed--
ETT Depth (oral)-- cm
LMA Size--
iGel Size--

Induction & Drugs

DrugDose/kgCalculated

Fluids

Maint. Fluids (4-2-1)-- mL/hr
Deficit (NPO 8h)-- mL
EBL Allowable (Hct 40→25)-- mL

Emergency Drugs

Epinephrine (10 mcg/kg)-- mL of 1:10,000
Atropine (0.02 mg/kg)-- mg
Defibrillation (2 J/kg)-- J

Weight Estimation Reference

AgeEst. WeightETTETT Depth
Premature1-2.5 kg2.5-3.07-9 cm
Term neonate3-4 kg3.0-3.59-10.5 cm
3 months5-6 kg3.510.5 cm
6 months7-8 kg3.5-4.010.5-12 cm
1 year9-10 kg4.012 cm
2 years12 kg4.513.5 cm
4 years16 kg5.015 cm
6 years20 kg5.516.5 cm
8 years24 kg6.018 cm
10 years28 kg6.519.5 cm
12 years36 kg7.021 cm
Weight formulas: <1yr: (age in months × 0.5) + 4. 1-5yr: (age × 2) + 8. 6-12yr: (age × 3) + 7.

Body Mass Index Calculator

BMI: 24.2 kg/m² — Normal weight
CategoryBMI Range
Underweight< 18.5
Normal weight18.5 - 24.9
Overweight25 - 29.9
Obese Class I30 - 34.9
Obese Class II35 - 39.9
Obese Class III≥ 40

ABG Interpreter

Normal Values Reference

ParameterNormal
pH7.35 - 7.45
PaCO235 - 45 mmHg
HCO322 - 26 mEq/L
PaO280 - 100 mmHg
Base Excess-2 to +2
Anion Gap8 - 12

Supraglottic Airway (SGA) Sizes

iGel Sizes

SizeColorPatient Weight
1Pink2 - 5 kg
1.5Blue5 - 12 kg
2Green10 - 25 kg
2.5Orange25 - 35 kg
3Yellow30 - 60 kg
4Red50 - 90 kg
5Purple90+ kg
No cuff inflation required. Single-use, non-inflatable cuff. Gastric channel available on sizes ≥ 2.

LMA Sizes

SizePatient WeightMax Cuff Volume (mL)
1< 5 kg4
1.55 - 10 kg7
210 - 20 kg10
2.520 - 30 kg14
330 - 50 kg20
450 - 70 kg30
570 - 100 kg40

Bicarbonate Replacement

NaHCO3 8.4% = 1 mEq/mL

HCO3 Deficit: 210 mEq
Give 50%: 105 mEq (105 mL of 8.4%)
Formula: 0.3 × weight(kg) × base deficit. Give 50% of calculated deficit initially, then recheck ABG.

Expected Body Weight

Expected Body Weight: 72.6 kg
Males: 50 + 2.3 × (height in inches - 60). Females: 45.5 + 2.3 × (height in inches - 60).

Ideal Body Weight

Ideal Body Weight: 72.6 kg
Tidal Volume (6 mL/kg)436 mL
Tidal Volume (8 mL/kg)581 mL
Used for ventilator tidal volume calculations (6-8 mL/kg IBW for lung-protective ventilation).

Single Shot Nerve Blocks (Ultrasound-Guided)

Max Dose (plain)-- mg
Max Dose (with epi)-- mg
Max Volume (plain)-- mL
BlockVolumeDose (mg)Duration

Ultrasound Guidance by Block

Interscalene Block

SCM Ant. Scalene Mid. Scalene C5-C7 roots Probe CA IJV

Probe: Linear, transverse on lateral neck at C6 level (cricoid)

Target: C5-C7 nerve roots between anterior and middle scalene muscles

Needle: In-plane, lateral to medial

Volume: 15-20 mL

Watch for: Phrenic nerve palsy, vertebral artery, epidural/intrathecal spread

Supraclavicular Block

1st Rib Pleura SCA BP Probe

Probe: Linear, coronal oblique in supraclavicular fossa

Target: Brachial plexus (divisions) — "cluster of grapes" lateral and posterior to subclavian artery, above 1st rib

Needle: In-plane, lateral to medial

Volume: 20-30 mL

Watch for: Pneumothorax (pleura), subclavian artery

Infraclavicular Block

Probe: Linear or curvilinear, parasagittal below clavicle midpoint

Target: Lateral, posterior, and medial cords around axillary artery (posterior cord at 6 o'clock)

Needle: In-plane, cephalad to caudad. Target posterior to axillary artery

Volume: 20-30 mL | Duration: 12-24 hr

Watch for: Pneumothorax, axillary vessels

Axillary Block

Probe: Linear, transverse on proximal medial arm (axilla), arm abducted 90°

Target: Median (superficial to artery), ulnar (medial), radial (posterior to artery), musculocutaneous (within coracobrachialis)

Needle: In-plane. Deposit LA around each nerve

Volume: 20-30 mL (5-8 mL per nerve) | Duration: 10-16 hr

Watch for: Axillary artery puncture, intravascular injection

Femoral Nerve Block

Fascia lata Fascia iliaca FA FV FN Iliopsoas Probe N - A - V - L (lateral to medial)

Probe: Linear, transverse at inguinal crease

Target: Femoral nerve — lateral to femoral artery, deep to fascia iliaca, on iliopsoas

Needle: In-plane, lateral to medial

Volume: 15-20 mL

Remember: N-A-V-L (Nerve, Artery, Vein, Lymphatics) lateral to medial

Watch for: Femoral artery/vein puncture, quadriceps weakness (fall risk)

Adductor Canal Block

Probe: Linear, transverse at mid-thigh (deep to sartorius muscle)

Target: Saphenous nerve adjacent to superficial femoral artery, deep to sartorius, between vastus medialis and adductor longus

Needle: In-plane, lateral to medial through sartorius

Volume: 15-20 mL | Duration: 12-18 hr

Advantage: Motor-sparing (preserves quadriceps strength) vs femoral block

TAP Block (Transversus Abdominis Plane)

Probe: Linear, transverse between costal margin and iliac crest at mid-axillary line

Target: Fascial plane between internal oblique and transversus abdominis muscles

Needle: In-plane, anterior to posterior. Hydrodissection of plane

Volume: 20 mL per side | Duration: 12-24 hr

Coverage: T10-L1 dermatomes (abdominal wall)

Popliteal Sciatic Block

Probe: Linear or curvilinear, transverse in popliteal fossa (patient prone or lateral)

Target: Sciatic nerve before bifurcation (~5-8 cm above popliteal crease), or tibial + common peroneal individually

Needle: In-plane, lateral to medial. Inject where nerves are still in common sheath

Volume: 20-30 mL | Duration: 18-24 hr

Watch for: Popliteal artery/vein (anterior to nerve), intraneural injection

Max doses: Bupivacaine 2 mg/kg (plain), 3 mg/kg (with epi). Ropivacaine 3 mg/kg. Lidocaine 4.5 mg/kg (plain), 7 mg/kg (with epi).
General US tips: Use linear probe (6-13 MHz) for superficial blocks, curvilinear (2-5 MHz) for deep structures. Always aspirate before injecting. Visualize needle tip at all times. Look for LA spread around nerve (donut sign).

Continuous Nerve Block Infusions

BlockDrugRateBolus
InterscaleneRopivacaine 0.2%5-8 mL/hr5 mL q60min PRN
SupraclavicularRopivacaine 0.2%5-8 mL/hr5 mL q60min PRN
InfraclavicularRopivacaine 0.2%5-8 mL/hr5 mL q60min PRN
FemoralRopivacaine 0.2%5-8 mL/hr5 mL q60min PRN
Adductor CanalRopivacaine 0.2%6-8 mL/hr5 mL q60min PRN
Popliteal SciaticRopivacaine 0.2%5-8 mL/hr5 mL q60min PRN
Daily assessment for catheter site infection, sensory/motor function, and adequacy of analgesia.

Arterial Line Insertion

Indications

  • Continuous BP monitoring
  • Frequent ABG sampling
  • Hemodynamically unstable patients
  • Major surgical procedures

Technique (Radial Artery - Modified Seldinger)

  1. Position: Wrist dorsiflexion 30-45°, tape hand to arm board
  2. Prep and drape. Infiltrate with 1% lidocaine
  3. Palpate radial pulse (or use ultrasound)
  4. Puncture at 30-45° angle. Advance until flash of blood
  5. Lower angle, thread guidewire. Remove needle
  6. Thread catheter (20G) over wire. Remove wire
  7. Connect to transducer, confirm waveform, secure
Allen Test: Compress radial and ulnar arteries. Release ulnar. Normal: hand reperfuses in <7 seconds.

Basic Echocardiography

Standard Views

ViewProbe PositionKey Assessments
Parasternal Long AxisLeft sternal border, 3-4th ICSLV size/function, MV, AV, pericardium
Parasternal Short AxisRotate 90° from PLAXLV wall motion, RV, septal motion
Apical 4-ChamberApex, left lateral decubitusAll 4 chambers, valves, RV/LV comparison
SubcostalSubxiphoid, flat anglePericardial effusion, IVC, global function
IVC ViewSubcostal, rotate longitudinalVolume status (IVC diameter/collapse)
IVC assessment: <2.1 cm with >50% collapse = low CVP (~3 mmHg). >2.1 cm with <50% collapse = high CVP (~15 mmHg).

Internal Jugular Catheter Insertion

Technique (Ultrasound-Guided Seldinger)

  1. Position: Trendelenburg, head turned slightly contralateral
  2. Identify IJ with ultrasound (compressible, lateral to carotid)
  3. Prep, drape, local anesthetic
  4. Needle at 45° under real-time ultrasound guidance
  5. Aspirate venous blood (dark, non-pulsatile)
  6. Thread J-tip guidewire. Confirm with ultrasound
  7. Nick skin, dilate, thread catheter. Remove wire
  8. Aspirate all ports, flush. Secure and dress
  9. Confirm placement with chest X-ray (tip at SVC-RA junction)
Complications: Pneumothorax, carotid puncture, hematoma, air embolism, arrhythmia, infection.

Intraosseous Access

Indications

Emergency vascular access when IV access cannot be obtained within 90 seconds or after 2 failed attempts.

Sites (in order of preference)

SiteLandmark
Proximal tibia1-2 cm below tibial tuberosity, medial flat surface
Distal tibia1-2 cm above medial malleolus
Proximal humerusGreater tubercle (adults preferred with EZ-IO)
Distal femur2 cm above patella, midline (pediatric)

Insertion Site Diagrams

Patella TT IO site 1-2 cm
Proximal Tibia
1-2 cm below tibial tuberosity
Medial flat surface
MM IO site 1-2 cm
Distal Tibia
1-2 cm above medial malleolus
Flat medial surface
Humeral head GT IO site Deltoid
Proximal Humerus
Greater tubercle
Adults preferred (EZ-IO)
Patella IO site 2 cm
Distal Femur
2 cm above patella, midline
Pediatric patients

Technique

  1. Identify landmark. Clean and prep the site.
  2. Stabilize the limb. Do NOT place hand behind insertion site.
  3. Insert IO needle perpendicular (90°) to bone with gentle rotating/drilling motion.
  4. Feel a "pop" or loss of resistance when entering the marrow cavity.
  5. Remove stylet. Aspirate marrow (not always possible).
  6. Flush with 5-10 mL NS. Observe for extravasation.
  7. Connect IV tubing. Use pressure bag for fluids.
All IV medications and fluids can be given IO. Flush with 5-10 mL NS after each medication. Flow rates up to 125 mL/min under pressure.
Contraindications: Fracture at or proximal to site, previous IO in same bone within 24h, infection at site, inability to identify landmarks, bone disease (osteogenesis imperfecta).

PICC Line Insertion

Peripherally Inserted Central Catheter

  1. Measure: insertion site to right sternal border, down to 3rd ICS
  2. Select vein with ultrasound (basilic preferred > brachial > cephalic)
  3. Prep, drape, local anesthetic
  4. Access vein under ultrasound, advance guidewire
  5. Introduce peel-away sheath, advance catheter to measured length
  6. Confirm tip position: chest X-ray (lower SVC / cavo-atrial junction)
Tip position: Lower third of SVC or cavo-atrial junction. Complications: thrombosis, infection, malposition, PICC fracture.

Point of Care Ultrasound (POCUS)

FAST Exam (Focused Assessment with Sonography for Trauma)

ViewLocationLooking For
RUQ (Morrison's pouch)Right mid-axillary, 8-11th ribFree fluid between liver/kidney
LUQ (Splenorenal)Left posterior axillary, 6-9th ribFree fluid around spleen
SuprapubicMidline above symphysisFree fluid in pelvis
SubxiphoidBelow xiphoid processPericardial effusion

Lung Ultrasound

FindingInterpretation
Lung sliding + A-linesNormal aerated lung
B-lines (>3 per zone)Pulmonary edema / interstitial fluid
Absent lung slidingPneumothorax (confirm with M-mode)
Lung pointConfirms pneumothorax border

O2% (FiO2) Calculator

FiO2: 47.0%
FiO2 = (O2 × 100% + Air × 21%) / Total Fresh Gas Flow. Minimum safe FiO2 for N2O use: 30% (always ensure O2 ≥ 30%).

Contact

For suggestions, improvements, or bug reports:

📞 +63 920 913 7831

This project is maintained for anesthesiology resident for educational purposes. Feedback is welcome to improve accuracy and usability.

Disclaimer

This tool is for educational purposes only.

The information provided is not a substitute for professional clinical judgment. Drug doses and protocols should always be verified independently before clinical use. The authors assume no liability for any errors or outcomes related to the use of this tool.

Always consult current institutional guidelines, pharmacopeias, and package inserts for the most up-to-date dosing information.