The document defines and describes breathing systems used in anesthesia. It discusses the purpose of breathing systems to deliver anesthetic gases and oxygen safely. The key components and requirements of breathing systems are explained, including minimizing resistance to gas flow. Different types of breathing systems are classified and their mechanisms and advantages/disadvantages are summarized.
Humidifiers in anaesthesia and critical careTuhin Mistry
Humidification of inhaled gases has been standard of care during mechanical ventilation in anaesthesia and intensive care. Active & Passive humidification devices have rapidly evolved. basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for anaesthesiologists and intensivists.
Humidifiers in anaesthesia and critical careTuhin Mistry
Humidification of inhaled gases has been standard of care during mechanical ventilation in anaesthesia and intensive care. Active & Passive humidification devices have rapidly evolved. basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for anaesthesiologists and intensivists.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
A breathing system is a device that conducts gases such as oxygen and anesthetic agents to the patient and conducts waste gases such as CO2 away.
Breathing systems are classified as
Open,
Semi-open,
Semi-closed
Closed.
Semi-closed systems are further divided into
Rebreathing Systems With CO2 Absorption,
Rebreathing Systems Without CO2 Absorption
Non-rebreathing Systems.
More simply, systems can be classified in two groups:
systems with CO2 washout (includes open and semi-open systems)
systems with CO2 absorption (includes closed and semi-closed systems).
The questions asked in the Anaesthesiology viva examination are presented in this presentation which will be useful for the post-graduates appearing for the M.D-Anaesthesia examination.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
A breathing system is a device that conducts gases such as oxygen and anesthetic agents to the patient and conducts waste gases such as CO2 away.
Breathing systems are classified as
Open,
Semi-open,
Semi-closed
Closed.
Semi-closed systems are further divided into
Rebreathing Systems With CO2 Absorption,
Rebreathing Systems Without CO2 Absorption
Non-rebreathing Systems.
More simply, systems can be classified in two groups:
systems with CO2 washout (includes open and semi-open systems)
systems with CO2 absorption (includes closed and semi-closed systems).
The questions asked in the Anaesthesiology viva examination are presented in this presentation which will be useful for the post-graduates appearing for the M.D-Anaesthesia examination.
Simple,inexpensive and rugged,parts are easy to dismentle and sterilize, safe to use.
Delivers the right gas mixture
Allows all methods of ventilation in all age groups
Resistence low at flows in practice
Compression and compliance loss is less.
Sturdy, small and light
Allows easy removal of waste gases
Easy to maintain with low running costs
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
REQUIREMENTS OF A BREATHING SYSTEM: The components when assembled should satisfy certain requirements, some essential and others desirable. Essential: The breathing system must a) deliver the gases from the machine to the alveoli in the same concentration as set and in the shortest possible time; b) effectively eliminate carbon-dioxide; c) have minimal apparatus dead space; and d) have low resistance. Desirable: The desirable requirements are a) economy of fresh gas; b) conservation of heat; c) adequate humidification of inspired gas; d) Light weight; e) convenience during use; f) efficiency during spontaneous as well as controlled ventilation (Efficiency is determined in terms of CO2 elimination and fresh gas utilization); g) adaptability for adults, children and mechanical ventilators; h) provision to reduce theatre pollution.
CLASSIFICATION OF BREATHING SYSTEMS: One will realise the reason for the failure of the attempts at classification in the 50's to 60's, if this definition and requirements are taken into account. There are numerous classifications of breathing systems according to the whims and fancy of the person classifying. Many of them are irrelevant as they do not define a breathing system. Different authors classified the same system under different headings, adding to confusion1. McMohan in 1951 classified them as open, semiclosed and closed taking the level of rebreathing into account. It as follows: Open no rebreathing Semiclosed partial rebreathing Closed total rebreathing Dripps et al have classified them as Insufflation, Open, Semiopen, Semiclosed and Closed taking into account the presence or absence of Reservoir, Rebreathing, CO2 absorption and Directional valves1. The ambiguity of the terminology used as open, semi open, semi closed and closed allowed inclusion of apparatus that are not breathing systems at all into the classification. To overcome this problem Conway2 suggested that a functional classification be used and classified according to the method used for CO2 elimination as: 1. Breathing systems with CO2 absorber and 2. Breathing systems without CO2 absorber. Miller.D.M.3 in 1988 widened the scope of this classification so as to include the enclosed afferent reservoir system. A new breathing system called 'The Maxima'4 has been designed by Miller in 1995 and to include it in the classification5, the enclosed afferent reservoir systems have been grouped under 'displacement afferent reservoir' systems. This classification also has a personal bias as the Humphrey ADE system is not included in the classification, even though he preferred to compare his system with that of Humphrey's6. The classification suggested in table.1. is a partial modification of Miller's3 classification.
Bi-Directional Flow: Systems with bi-directional flow are extensively used. These systems depend on the FGF for effective elimination of CO2. Understanding these systems is most important as their functioning can be manipulated by changing parameters like Fresh gas flow, alveolar ventilation, apparatus dead space, etc. We will analyze these in detail.
Fresh Gas Supply; Fresh gas flow (FGF) forms one of the essential requirements of a breathing system. If there is no FGF into the system, the patient will get suffocated. If the FGF is low, most systems do not eliminate carbon-dioxide effectively, and if there is an excess flow there is wastage of gas. So, it becomes imperative to specify optimum FGF for a breathing system for efficient functioning. If the system has to deliver a set concentration in the shortest possible time to the alveoli, the FGF should be delivered as near the patient's airway as possible.
Elimination Of Carbon-Dioxide: The following may be taken as an example for better understanding of CO2 elimination by the bi-directional flow systems. Normal production of carbon-dioxide in a 70 kg adult is 200 ml per minute and it is eliminated through the lungs. Normal end-tidal concentration of carbon-dioxide is 5%. Hence, for eliminating 200 ml of carbon-dioxide as a 5% gas mixture, the alveolar ventilation has to be: 200 x 100 = 4,000 ml. 5 This 4000 ml or 4 litres is the normal alveolar ventilation. Any breathing system connected to an adult's airway should provide a minimum of 4 litres per minute of carbon-dioxide free gas to the alveoli for eliminating carbon-dioxide. If the alveolar ventilation becomes less than 4 litres per minute, it would lead to hypercarbia. If the alveoli are ventilated with 5 litres/minute of a gas containing 1% carbon-dioxide, or 8 litres/minute of a gas containing 2.5% carbon-dioxide, it could still eliminate 200 ml of carbon-dioxide per minute from the alveoli. It may be construed as 4 litres of CO2 free gas and 1 litre of gas with 5% CO2 in the first instant and as 4 litres of CO2 free gas and 4 litres of gas with 5% CO2 in the second instant. In effect, 4 litres of alveolar ventilation with CO2 free gas is provided in both cases.
If the alveolar ventilation becomes less than 4 litres per minute, it would lead to hypercarbia. If the alveoli are ventilated with 5 litres/minute of a gas containing 1% carbon-dioxide, or 8 litres/minute of a gas containing 2.5% carbon-dioxide, it could still eliminate 200 ml of carbon-dioxide per minute from the alveoli. It may be construed as 4 litres of CO2 free gas and 1 litre of gas with 5% CO2 in the first instant and as 4 litres of CO2 free gas and 4 litres of gas with 5% CO2 in the second instant. In effect, 4 litres of alveolar ventilation with CO2 free gas is provided in both cases.
Apparatus Dead Space: It is the volume of the breathing system from the patient-end to the point up to which, to and fro movement of expired gas takes place. The dynamic dead space will depend on the FGF and the alveolar ventilation. The dead space is minimal with optimal FGF. If the FGF is reduced below the optimal level, the dead space increases and the whole system will act as dead space if there is no FGF. Increasing the FGF above the optimum level will only lead to wastage of FG
The afferent limb is that part of the breathing system which delivers the fresh gas from the machine to the patient. If the reservoir is placed in this limb as in Mapleson A, B, C and Lack's systems, they are called afferent reservoir systems (ARS).
The afferent limb is that part of the breathing system which delivers the fresh gas from the machine to the patient. If the reservoir is placed in this limb as in Mapleson A, B, C and Lack's systems, they are called afferent reservoir systems (ARS). The efferent limb is that part of the breathing system which carries expired gas from the patient and vents it to the atmosphere through the expiratory valve/port. If the reservoir is placed in this limb as in Mapleson D, E, F and Bain systems, they are called efferent reservoir systems (ERS). Enclosed afferent reservoir system has been described by Miller and Miler.
The Mapleson D, E, F and Bain systems have a 6 mm tube as the afferent limb that supplies the FG from the machine. The efferent limb is a wide-bore corrugated tube to which the reservoir bag is attached and the expiratory valve is positioned near the bag. In Mapleson E system, the corrugated tube itself acts as the reservoir (Fig.8). In Bain system, the afferent and efferent limbs are coaxially placed (Fig.9).
All these ER systems are modifications of Ayre's T-piece. This consists of a light metal tube 1 cm in diameter, 5 cm in length with a side arm (Fig.10). Used as such, it functions as a non-rebreathing system. Fresh gas enters the system through the side arm and the expired gas is vented into the atmosphere and there is no rebreathing. The dead space is minimal as it is only up to the point of FG entry and elimination of CO2 is achieved by breathing into the atmosphere. FGF equal to peak inspiratory flow rate of the patient has to be used to prevent air dilution.
In an attempt to reduce FGF requirements, ER systems are constructed with reservoirs in the efferent limb. The functioning of all these systems are similar. These systems work efficiently and economically for controlled ventilation as long as the FG entry and the expiratory valve are separated by a volume equivalent to atleast one tidal volume of the patient. They are not economical during spontaneous breathing.
Factors that influence the composition of gas mixture in the corrugated tube with which the patient gets ventilated are the same as for spontaneous respiration namely FGF, respiratory rate, tidal volume and pattern of ventilation. The only difference is that these parameters can be totally controlled by the anaesthesiologist and do not depend on the patient. Using a low respiratory rate with a long expiratory pause and a high tidal volume, most of the FG could be utilized for alveolar ventilation without wastage.
Analyzing the performance of these systems during controlled ventilation, two relationships have become evident. 1) When FGF is very high the PaCO2 becomes ventilation dependent (as during spontaneous respiration). 2) When the minute volume exceeds the FGF substantially, the PaCO2 is dependent on the FGF17. Combining these influences a graph can be constructed as shown in Fig.13. An infinite number of combinations of FGF and minute ventilation can be chosen to achieve a desired PaCO2. One can use a high FGF and a normal minute volume of 70 ml/kg to achieve a normal PaCO2 of 40 mm Hg. This is uneconomical and leads to low humidity and heat loss. Alternately, a FGF equivalent to the predicted minute volume i.e., 70 ml/kg can be chosen and the patient ventilated with at least twice the predicted minute volume i.e. 140 ml/kg. Here a deliberate controlled rebreathing is allowed in order to maintain normal PaCO2 along with high humidity, less heat loss and greater economy of fresh gas. Combinations between these two extremes can also be used. It is important to remember that using a low FGF with normal minute ventilation, can lead to hypercarbia; a moderate FGF and hyperventilation, can lead to hypocarbia.
a sodalime canister, (2) Two unidirectional valves, (3) Fresh gas entry, (4) Y-piece to connect to the patient, (5) Reservoir bag (6) a relief valve and (7) low resistance interconnecting tubing. (1) There should be two unidirectional valves on either side of the reservoir bag, (2) Relief valve should be positioned in the expiratory limb only, (3) The FGF should enter the system proximal to the inspiratory unidirectional valve.
A) Economy: The FGF could be reduced to as low as 250 - 500 ml of oxygen. The consumption of Halothane/Isoflurane has been found to be around 3.5 ml/hour19. b) Humidification: In the completely closed system, once the equilibrium has been established, the inspired gas will be fully saturated with water vapour20. C) Reduction of heat loss: In addition to conserving water the totally closed system will also conserve heat. The CO2 absorption is an exothermic reaction and the system may actively assist in maintaining body temperature. D) Reduction in atmospheric pollution: Once the expiratory valve has been closed, no anaesthetic escapes, except for the small percutaneous loss from the patient.
E) Control of anaesthesia: It is possible to compute the time course of uptake of anaesthetic in a patient of known size and add the appropriate quantity of the anaesthetic to the circuit at a rate decreasing in a manner calculated to maintain a constant alveolar concentration21. In practice an alveolar concentration of about 1.3 x MAC is found to be suitable. The technique has several potential disadvantages. i) A greater knowledge of uptake and distribution is required to master closed circuit anaesthesia. ii) Inability to alter any concentration quickly. iii) Real danger of hypercapnia may result from, a) an inactive absorber, B) incompetent unidirectional valves and c) incorrect use of absorber bypass.