text:
Home Books Improvised Medicine: Providing Care in Extreme Environments
Chapter 15. Sedation and General Anesthesia
Example: John Doe
Error: Please enter a valid sender email address. Example: jdoe@example.com
CC Me
Recipient Email Address(es) (required - use a semicolon to separate multiple addresses)
Separate multiple email address with semi-colons (up to 5).
One or more of your email addresses are invalid. Please review before submitting.
Subject for your email.
(Maximum characters: 1,000)
Thank you! Your email has been sent to:
The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe.
Send Another Email
An error has occurred sending your email(s). Please try again later or contact an administrator at OnlineCustomer_Service@email.mheducation.com.
Chapter 15. Sedation and General Anesthesia. In: Iserson KV. Iserson K.V.(Ed.),Ed. Kenneth V. Iserson.eds. Improvised Medicine: Providing Care in Extreme Environments . McGraw Hill; 2012. Accessed February 09, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=666&sectionid=43485127
Chapter 15. sedation and general anesthesia. Iserson KV. Iserson K.V.(Ed.),Ed. Kenneth V. Iserson. (2012). Improvised Medicine: Providing Care in Extreme Environments . McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=666&sectionid=43485127
"Chapter 15. Sedation and General Anesthesia." Improvised Medicine: Providing Care in Extreme Environments Iserson KV. Iserson K.V.(Ed.),Ed. Kenneth V. Iserson. McGraw Hill, 2012, https://accessmedicine.mhmedical.com/content.aspx?bookid=666&sectionid=43485127.
General Anesthesia Guidelines
Anesthesia in Special Circumstances
Procedural Sedation
Intravenous General Anesthesia
General Inhalation Anesthetics
Rectal Anesthesia
Anesthesia for Cesarean Sections
Anesthesia Delivery Systems
Postoperative Recovery
Download Section PDF
The following vignette provides an excellent picture of typical operating room (OR) anesthesia in a resource-poor venue1:
John, an anaesthetic clinical officer, is administering a general anaesthetic [and] performs a rapid sequence induction with thiopental and suxamethonium and intubates using his own laryngoscope and a tracheal tube that has been used dozens of times before … John carries all his own equipment with him, along with a supply of drugs for the day—anything left in theatre will disappear by tomorrow. Normal saline is running in through an 18G cannula that the patient's family were asked to buy from the local pharmacy.
John administers 50 mg of pethidine—this may be the last analgesic the patient receives until the unpredictable visit of the night matron to the ward in 9 h time—and turns up the OMV [Oxford Miniature Vaporizer] to deliver 2% halothane. The inspired concentration must be estimated clinically because the halothane "expired" 8 months ago and the clinical effect is unpredictable. The EMO [Epstein-Macintosh-Oxford] vaporiser and a bottle of ether are on stand-by behind the anaesthetic machine, as we are down to our last bottle of halothane…. The modern anaesthesia monitor, looking out of place in these surroundings, was purchased, along with eight others, by the European project. The screen has a psychedelic tinge to it and I suspect it is on its last legs. The capnograph trace is flat, as the last remaining moisture trap has been "borrowed" for use in ICU, where it will be circulated around the four beds. The ECG trace is true, but periodically interrupted as the long out-of-date electrodes require a small drop of thiopental to improve their conductivity. The oximetry probe is a paediatric one and roughly taped with grubby Elastoplast around the man's little finger.
John ventilates the patient using the Oxford Inflating Bellows as part of a draw-over system, aiming to keep him deeply anaesthetised and apnoeic using a high concentration of halothane. There are no muscle relaxants apart from suxamethonium. Emergency drugs, atropine and adrenaline, are drawn up on a redundant Boyle's machine, which acts as a trolley and equipment store. A lone size H oxygen cylinder is deep in dust in the corner and has been empty for several years.
John requests a nasogastric tube, so I head to the locked anaesthetic store room where 10 or so years of unsorted donations to the department have piled up. After 15 min, I find one at the bottom of a box of out-of-date NG feed. I can tell by the look on his face that John is torn between using this valued commodity for this patient or saving it for the next.
Anesthesia in Austere Circumstances
Anesthesia's three principal functions are to keep the patient alive through surgery, to make surgery painless, and to provide the best possible surgical conditions.
The purpose of this chapter and, in fact, this entire book is illustrated by two questions that Drs. Boulton and Cole posed in their series entitled, "Anaesthesia in Difficult Situations"2:
What would I do if had to give an anesthetic and operate on a patient in an isolated hospital 100 miles from the nearest outpost of civilization?
What would I take on an expedition to the Arctic … or in the Himalayas … or on a ship … or to an area of devastation following an earthquake or nuclear holocaust?
This chapter and the next are for clinicians who may need to administer anesthesia in austere situations with limited supplies and equipment. These chapters highlight medications that can safely be used by non-anesthesiologists (e.g., ketamine), little-used anesthetics that are generally available in austere situations (e.g., IV ethanol), and anesthetics available in austere settings that are not familiar to younger anesthesiologists from industrialized nations (e.g., ether, halothane), as well as classic basic methods of delivering anesthesia (e.g., open-drop). Those trained in anesthesia obviously are more familiar with these medications and techniques than are other clinicians. The key to providing safe and effective anesthesia is to use equipment and techniques that employ the skills you already possess.
Standards and Shortages
Although international standards for anesthesia administration exist, the norm is that shortages of trained anesthesiologists, equipment, and medications limit how these standards can be implemented.
Scarcity of Trained Anesthetists/Anesthesiologists
A worldwide shortage of trained anesthetists means that in developing countries, other practitioners, including physicians, dentists, nurse practitioners, physician assistants, and paramedics, may need to provide general anesthesia with limited additional training and with minimal supervision.
The basic rule of thumb is that "a practitioner faced with the necessity of giving an emergency anesthetic, perhaps for the first time since his student days, is well advised to stick to a technique which he has at least seen used at one time or another." If an experienced anesthetist must supervise or manage multiple inexperienced practitioners giving anesthesia, which may be the case in many situations, "the technique employed would have to be as simple as possible so that it could be quickly taught."2
Commonly, the clinician must be both the surgeon and the anesthetist. In these cases, the rule is "use local and regional methods where you can. If you have to give a general anesthetic, secure the patient's airway and make sure that there is [an IV] running before you start. With a clear airway and [an IV line], most of your problems will be over. Induce and intubate the patient yourself, and don't operate until anesthesia is stable."3 During the procedure, have an assistant monitor the patient by continually checking the blood pressure (BP) and the pulse using an esophageal or precordial stethoscope.3,4 (See Chapter 5, Basic Equipment, for how to improvise these devices.)
Medication Standards and Scarcity
The World Health Organization (WHO) lists what they consider to be the essential medications for anesthetic care, although cost and supply problems may limit the anesthetics and associated medications (Table 15-1) that are available for local, regional, and general anesthesia.
Table Graphic Jump Location
Table 15-1 Availability of Anesthetic and Related Medications in the Developing World
View Table||Download (.pdf)
Percentage of Anesthetists With Medications Available
Always (%)
Sometimes (%)
Never (%)
Neuromuscular blocking agent
Neostigmine
Blood for transfusion
Labetalol
Halothane
Spinal local anesthetic
Narcotic (IV/IM)
Vasopressor
Succinylcholine
Thiopental
Intravenous fluid
Local block anesthetic
Ergometrine
Abbreviations: IM, intramuscular; IV, intravenous.
Data from Hodges et al.5
Goals of General Anesthesia
Administering general anesthesia provides three benefits: (a) hypnosis, putting the patient to sleep; (b) analgesia, relieving pain; and (c) relaxation, easing the muscles sufficiently to perform the procedure, primarily in abdominal and some orthopedic cases.6
An anesthetist's primary goal is to anesthetize patients and have them recover without ill effects from the anesthesia. Whether this happens depends a great deal on the anesthetist's abilities and how carefully he follows the rules for safely anesthetizing patients (Table 15-2).
Table 15-2 Ten Rules for Safely Anesthetizing Patients
Assess the patient carefully to be aware of any underlying medical condition or medication that might interfere with the anesthesia or surgery.
If possible, keep the patient NPO for ≥6 hours before the procedure. (Modify for infants and small children.) Small sips of water taken with a preanesthetic medication are acceptable. Also consider this course for procedures done under local or regional blocks, since you may have to switch to using general anesthesia during the procedure.
Use a tilting OR table, so that you can put the patient in a head-down position if there is a risk of emesis. During surgery, turning the patient on his side may not be an option.
Check available drugs and equipment before you start. The truism is that, whatever you don't have available or that doesn't function properly will be what you need in a crisis.
Have suction instantly available. This is the most-often-neglected piece of equipment. Check that the parts are assembled, the equipment is turned on or ready to be quickly turned on, and the vacuum works. When you don't have suction available, it is almost certain that you will need it—quickly.
Keep the patient's airway clear. Use a nasal or an oral airway, as needed. If the patient doesn't need it, he will spit out an oral airway.
Be ready to control ventilation. No matter what anesthetic you use (including ketamine), you may need to assist ventilations with a BVM, with or without a controlled airway device such as an LMA or ET tube.
Have an IV running. This is not only therapeutic, but also an excellent precaution if something goes awry. In a crisis, it is far easier to begin administering medications or fluids through an established IV than to struggle to insert one.
Continually monitor the pulse, BP, and skin color (and the color of any blood from the surgical site). A precordial or esophageal stethoscope, a BP cuff that is used on a regular basis (q5min), and good observation are all that is required for basic monitoring.
Have an assistant in the room who can help in an emergency.
Abbreviations: BP, blood pressure; BVM, bag-valve-mask; ET, endotracheal; LMA, laryngeal mask airway; NPO, nothing by mouth; OR, operating room.
Data from King.7
Four of the five essential elements for general anesthesia may need to be improvised or omitted in austere situations: premedication, monitoring, induction medications, and oxygen. Additionally, alternative maintenance drugs (anesthetics) or delivery methods may need to be used.
Premedication
Premedication provides mild sedation for the patient and counteracts some side effects, primarily excess salivation and increased vagal tone.
A wide variety of narcotics, benzodiazepines, phenothiazines, and other medications may be used for premedication. Try to use sedating anticholinergics (e.g., those with antihistamine activity) if the normal medication cannot be used. Premedications are usually administered parenterally, but many may be given orally.
Promethazine 50 mg (1 mg/kg) tablets (which also have anticholinergic activity) can be used in adults for nausea and very mild sedation. Give promethazine about 2 hours before anesthesia. This medication is particularly good if ketamine is used as a general anesthetic. Diazepam tablets, 10 to 20 mg (0.15 to 0.25 mg/kg), can be used as a tranquilizer before either regional or general anesthesia. Oral diazepam has a more rapid and reliable onset than does intramuscular (IM) diazepam.8 Diphenhydramine (Benadryl) is cheap, and almost always available. It can be given parenterally or orally, and is both sedating and anticholinergic.
Considered by many anesthesiologists to be the only essential preoperative medication, atropine 0.4 to 0.6 mg dries secretions and diminishes vagal tone on the heart. Atropine may be administered IM 30 to 40 minutes before induction or diluted and given IV immediately before anesthesia.6 Atropine can also be administered orally in tablet form (0.5 mg in an adult) at least 20 minutes before the general anesthetic is administered. There is no harm if the patient takes it with a small amount (~20 mL) of water.8
Basic Monitoring
In austere situations, anesthesia with only the most basic monitoring (even more basic than what you're thinking) is the norm. Often the only monitoring is checking the pulse: either constantly with an esophageal or precordial stethoscope (improvised models of both instruments are described in Chapter 5, Basic Equipment) or at least every 5 minutes while taking a BP. You can also monitor the pulse by laying a finger just anterior to the tragus of the ear to feel the superficial temporal artery pulsate. Also, monitor the patient's skin color, capillary refill, and the color of any blood from the surgical site, since this requires little or no apparatus. A wisp of cotton taped near the nostril is a useful indicator that the patient is still breathing.6
Esophageal stethoscopes are particularly important during thoracic procedures. Only one earpiece is needed, although a modified stethoscope can also be used. Precordial stethoscopes (that can also be placed over the back) are particularly important to use during procedures on babies. Likewise, only one earpiece is needed, but the bell should be securely taped to the patient before the procedure begins.
Both IV and inhalation agents are often used for induction. Ketamine needs no induction agent.
Benzodiazepines, although not often used for induction, can be used for this purpose. Diazepam, often the most readily available benzodiazepine, can be used as an IV induction agent, although it has a longer onset and longer duration (i.e., longer "hangover") than most other agents.9 The newer benzodiazepines generally work faster and have shorter half-lives.
The most feared complication during induction is laryngospasm. Since a neuromuscular blocking agent may or may not be available, provide constant positive pressure with an anesthesia bag or a bag-valve-mask (BVM). This normally breaks the spasm. If not, spray the cords with lidocaine, and be prepared to do a cricothyrotomy (rarely needed).
In austere situations, oxygen is frequently unavailable, and so is considered a luxury. If oxygen is scarce, use it only to preoxygenate patients who will undergo brief apneic procedures, to induce and intubate small children10, and to supplement anesthesia at altitudes >9000 feet (2743 meters). Also provide it for patients with laryngospasm, acute desaturation, significant anemia (Hgb <9 g/dL), or heart or lung disease, and to those in shock.9
Also consider using oxygen when (a) inducing anesthesia in a patient using ether and air; (b) giving anesthesia with more than 8% ether; (c) doing a Cesarean section (C-section), but use only until the baby is delivered; (d) patients have any respiratory disease or considerable airway secretions; and (e) the preoperative BP has fallen by >30%.
Stages of Anesthesia
Theoretically, all patients may go through four stages (plus substages, or planes) of anesthesia, no matter which agent is used (Table 15-3). Ether is the anesthetic that shows all the classic stages, so the pattern with ether is described more fully under "Ether" in Chapter 16, Anesthesia: Ketamine, Ether, and Halothane.
Table 15-3 Signs of General Anesthesia Stages and Planes (Levels of Stages)
Response to surgical stimulus
Eye signs
I. Analgesia
Voluntary control
Voluntary movement
Adequate output
Consciousness Lost
II. Excitement (Delirium)
1. Early
Coughing*
Actively purposeful*
Lash reflex goes*
Variable movement
Possibly arrhythmias
2. Late
Breath holding*
Weakly purposeful*
Disconjugate gaze
III. Surgical Anesthesia
Regular*
Lid reflex gone*
Adequate output†
2. Moderate
Eyes fixed*
3. Deep
Tracheal tug†
Pupil dilated*
Hypotension†
IV. Medullary Paralysis
Absent*
Pupil of anoxia*
Good contraction†
*Applicable to all anesthetics.
†Applicable only to ether.
†Paradoxical respiration.
Adapted with permission from Boulton.6
When anesthesia is given with basic equipment and few medications, tracking anesthetic stages can be a useful safeguard against over-medication.
Anesthetics vary widely in their effects, so staging must be used with the particular drug's effects in mind. The general pattern follows the oversimplified, but useful, concept that anesthetics suppress the central nervous system from above downward, as blood concentration increases. This progression (stages) is based upon the patient's body movements, respiratory rhythm, oculomotor reflexes, and muscle tone. The classic anesthetic stages are detailed in the following paragraphs.
Stage 1: Analgesia
There is suppression of the highest cerebral centers, with the patient gradually losing the sensation of pain. Patients remain conscious and rational, and have decreased pain perception. Muscle tone, breathing, and pulse are normal. Stage 1 anesthesia is indicated for obstetric analgesia, and as a supplement to local anesthesia for minor procedures.
Stage 2: Excitement (Delirium)
This stage begins when patients lose consciousness and become excited, struggle, and (possibly) become difficult to control. Patients retain their gag reflex and can protect their airway, although they breathe irregularly and may hold their breath. Their pupils generally become dilated. Their abdominal muscles contract during expiration. They lose their eyelash reflex and have roving eye movements and dilated but reactive pupils. They retain reflex responses to any painful or irritating stimuli, including noxious anesthetic vapors.
Stage 3: Surgical Anesthesia
In this stage, patients no longer respond to painful stimuli. Muscular relaxation progressively increases, spontaneous respiration diminishes, and patients lose their protective gag reflex. Non-anesthesiologists need only recognize two planes: acceptable ("Light") and too deep.11
Plane: Light Surgical Anesthesia
This is the optimal anesthetic level for most patients during surgery. Patients' breathing becomes regular again, although they will inspire deeply every 2 to 3 minutes. The eyes no longer move and, as the anesthesia level deepens, the pupils gradually dilate. The patient no longer moves and muscular tone decreases. The abdomen and chest move synchronously. An artificial airway or endotracheal (ET) tube may be inserted in this plane—but not earlier.
Plane: Deep Surgical Anesthesia (Too Deep)
In this plane of anesthesia, patients' intercostal muscles become progressively paralyzed, eventually having paradoxical movement (moving in with inspiration). Sudden inspirations pull on the mediastinum and trachea, drawing it downward (the "tracheal tug"). Patients' pupils become progressively less reactive to light. Abdominal surgery is actually very difficult at this anesthesia level if the patient is not pharmacologically paralyzed.
Stage 4: Medullary Depression (Way Too Deep)
During stage 4, the brainstem's respiratory center becomes depressed, which causes patients to stop breathing and lose all muscle tone. Their pupils are fixed and dilated. The heart may (as with chloroform) or may not (as with ether) be dangerously depressed.6 If a patient stays in this stage too long, his heart stops and he dies.11
Trauma Patients
Assume that all trauma patients have full stomachs; the elective anesthesia standard of "nothing-by-mouth (NPO) for six hours" is a pure fantasy. Airway control, preventing aspiration, and being prepared to provide anesthesia immediately to hypovolemic, unstable patients optimize trauma anesthesia.
Altitude and General Anesthesia
High altitude (arbitrarily considered to be above 3000 meters or 10,000 feet) and extreme cold may affect anesthesia delivery. Three types of individuals may present for anesthesia at high altitude: the unacclimatized newcomer, the acclimatized newcomer, and the resident native.
The unacclimatized newcomer, who has been at altitudes above 3000 meters for less than 4 months, is in an extremely unstable physiological state, and initially may suffer from acute mountain sickness (e.g., high-altitude pulmonary edema, high-altitude cerebral edema).12 This makes sedation and general anesthesia precarious, at best.
Acclimatized newcomers may also be in danger of pulmonary edema. They have probably acquired similar physiological characteristics to the natives, including polycythemia, hypervolemia, increased pulmonary blood volume, pulmonary hypertension, right ventricular hypertrophy, and increased diffusion capacity. Nevertheless, give oxygen to these patients during any emergency surgery and, if at all possible, return them to sea level for surgical treatment.12
Resident natives, who were born and live at altitude, are capable of exhaustive physical exercise despite their often plethoric, cyanotic, and barrel-chested appearance. After visiting lower altitudes for a few days, however, they too may get acute pulmonary edema on returning to altitude.12
Anesthetic Agents
The conduct and choice of anesthesia and analgesia at high altitudes depends on three factors: (a) the patient's pathophysiological state, (b) the decreased oxygen tension due to low barometric pressure, and (c) the peculiarities of inhalational agents. With some modifications, particularly the addition of oxygen, general inhalation anesthesia may be administered.13
When preparing to deliver general anesthesia above 3000 meters (approx. 10,000 feet), try not to use any drug that depresses the respiratory center. If you must use such a drug, reduce the dose of premedication. The increase in respiratory tract secretions at high altitudes, especially when using ether, suggests using higher doses of atropine even though that risks increasing preexisting tachycardia. Provide careful fluid replacement because of the increased risk of pulmonary edema.
During surgery, use oxygen supplementation, if available, on all anesthetized patients. To achieve an oxygen tension equivalent to that at sea level (150 mm Hg), 32% supplementation is required at 3000 meters (approx. 10,000 feet) and 42% at 5000 meters (16,500 feet). However, unsupplemented ether–air anesthesia has been successfully used at altitudes of 2500 to 3000 meters.12 On the other hand, nerve blocks and anesthetic infiltration may be limited by the vasoconstriction accompanying hypothermia.13
Consider using IV ketamine, since at doses of 2.0 mg/kg, it produces a dissociative anesthesia while not depressing the hypoxic drive or interfering with the pharyngeal or laryngeal reflexes. Use supplemental oxygen when available, especially during recovery, for less-acclimatized individuals.14,15 Avoid using N2O.
Both anesthetics and the associated equipment work progressively less well as the altitude increases. The practical limits for general inhalation anesthesia are not precisely known, but, whenever possible, surgery should not be performed at altitudes higher than 4000 meters (~13,000 feet).16
Extreme Cold and General Anesthesia
Use caution when giving general anesthesia—or doing surgery—in extremely cold environments. Aside from the obvious problem of IV fluids freezing if not properly insulated, vasoconstriction reduces the size of veins, which makes IV placement difficult and reduces the absorption of drugs injected subcutaneously. Increased static electricity and open-flame heating units may augment the explosive hazard of the inhalational agents. To humidify the extra-dry air, use an IV infusion set to deliver normal (0.9%) saline (NS) at 2 to 4 drops/minute through a very fine hypodermic needle inserted into the connector between a BVM and the patient's ET tube.13
What Is Sedation?
While sedation implies that patients have a depressed consciousness rather than being asleep, there is often little difference between procedural sedation and short-term general anesthesia, except that the former usually does not include the use of neuromuscular blockade or invasive airways (e.g., ET tube or laryngeal mask airway [LMA]). The similarity between the two is highlighted in the ASA's description of sedation levels (Table 15-4).
Table 15-4 American Society of Anesthesiologists' Sedation Levels
Moderate Sedation
Deep Sedation
Normal response to verbal stimulation
Purposeful response to verbal or tactile stimulation
Purposeful response following repeated or painful stimulation
Unarousable even with painful stimulation
No intervention required
Intervention may be required
Intervention often required
Spontaneous ventilation
May be inadequate
Frequently inadequate
Cardiovascular function
Usually maintained
May be impaired
Data from Godwin.17
In the acute, outpatient setting, the most common reasons to sedate patients are for fracture reductions/treatments, joint relocations, laceration repairs, and lumbar punctures. The fewest complications occur with ketamine (0.7% of cases), propofol (0.8%), or morphine (2.9%). The most complications occur when the sedative is hydromorphone (9.7%), fentanyl (9.5%), midazolam (6.4%), or etomidate (6.2%).18
Sedation is often used for pediatric procedures. However, if a practitioner does not have the skills or the appropriate medications and equipment to sedate the child safely, "tie and cry" (see Fig. 14-4) with liberal use of local or regional anesthesia is a more prudent way to proceed.19
Various medications can be used for sedation, depending upon their availability and the clinician's comfort level and experience using them. These include ketamine, narcotics, ethanol, benzodiazepines, and propofol (Table 15-5).
Table 15-5 Agents Commonly Used for Conscious Sedation
Total Dose*
Methohexital†
Respiratory depression, Hypotension
0.75-1.00 mg/kg
20-30 mg/kg
Pentobarbital†
2.5 mg/kg
PO/PR
2-6 mg/kg
1-4 hr
Thiopental†
25 mg/kg
Midazolam
Respiratory depression
IV (<5yr)
0.05-0.1 mg/kg; then titrate to 0.6 mg/kg
IV (6-12yr)
0.025-0.05 mg/kg; then titrate to 0.4 mg/kg
0.1-0.15 mg/kg
0.25-1 mg/kg
0.2-0.5 mg/kg
0.15-0.2 mg/kg
2 mcg/kg
Respiratory depression, Hypotension, Nausea, and Vomiting
IM/SQ
Other sedative agents
Chloral hydrate†
Prolonged sedation
25-100 mg/kg; may repeat 25-50 mg/kg after 30 min
Post-emergence delirium
0.5-1 mg/kg
4 mg/kg
5-10 mg/kg
IV over 20-30 sec;
<5 min
then repeat boluses, or
0.5 mg/kg prn
IV Drip
0.05-0.1 mg/kg/min
Myoclonus, Nausea, Respiratory depression, Adrenocortical suppression
Abbreviations: IM, intramuscular; IV, intravenous; NA, not available; PO, by mouth; PR, per rectum; SQ, subcutaneous.
*Doses should be administered in fractional boluses (e.g., one-quarter to one-half) and titrated to effect.
†Particularly useful for sedation during diagnostic imaging.
Data from Spitalnic et al20, Green et al21, and other sources.
Ketamine is often used for sedation, especially in children, and is discussed in Chapter 16, Anesthesia: Ketamine, Ether, and Halothane.
Using IV narcotics to a point short of anesthesia is a valuable technique to know when "extreme emergency" conditions are physically dangerous to both the patient and clinician.2,6 An initial dose of l0 mg of diluted morphine or 50 mg of meperidine will give you an idea of the patient's reaction, but at least 30 mg of morphine or 200 to 300 mg of meperidine may be required before adequate sedation is achieved if local anesthesia is not used simultaneously.6 Maintaining an adequate airway may become a problem when using this method.
Since ancient times, ethanol (ETOH) has been a known soporific.22–24 Intravenous alcohol has been used successfully as an anesthetic induction agent for nearly a century.25 In the 1960s, Dundee used an 8% (weight/volume) solution prepared by adding 110 mL of 95% ethanol to a 1-L bag of Hartmann's solution (similar to lactated Ringer's solution). Its pH was about 6.4. Each otherwise healthy adult patient received just over 500 mL of the solution. Of those receiving a strong opiate (meperidine) and often pentobarbital as a premedication, 70% could be induced with ethanol–nitrous oxide and 60% had the surgery completed with only these medications. He found that the onset of sleep with ethanol induction was accompanied by a progressive fall in oxygenation (PaO2) and that any post-ethanol delirium could be rapidly controlled by small IV doses of benzodiazepines.26
Benzodiazepines can induce relaxation and cooperation, and often provide an amnestic response. Titrate doses (Table 15-5) to patient tolerance depending upon the patient's age, the patient's other illnesses, the use of additional medications, and the procedure's complexity. Significant respiratory depression can occur, but is more common if these medications are combined with opiates. The two most commonly used medications in this class are midazolam (best) and diazepam (most readily available worldwide).
Midazolam is short-acting, with a short recovery period. A dose of 0.02 mg/kg to 0.1 mg/kg IV typically produces sedation in 2 to 3 minutes, with the clinical effects lasting from 10 to 30 minutes. In elderly or debilitated patients, use lower doses, since these patients may be more sedated and have longer recovery periods at lower doses. Repeat doses until the desired effect is achieved. Side effects include dose-related respiratory depression, especially in elderly patients, patients with chronic obstructive pulmonary disease (COPD), or patients who have taken alcohol, barbiturates, opioids, or other central nervous system depressants. Hypotension can be significant in hypovolemic and elderly patients. Midazolam has no analgesic activity. It crosses the placenta and enters breast milk.27
Diazepam is also used for conscious sedation. However, because of its long half-life, it may be difficult to titrate and may provide a duration of action that is longer than desired. Compared to midazolam, diazepam poses greater risk for phlebitis, has less associated amnesia, and has erratic absorption if given IM. If no other sedative agent is available, it may be useful, especially if given orally about 30 minutes prior to a procedure.
Propofol, due to its high cost, will often be unavailable in austere settings. If it is available, use it in increments of 0.5 mg/kg every 60 seconds IV until the desired effect is achieved and to maintain that level of sedation. Because of its pharmacokinetics, oral administration will not sedate the patient. (Angela M. Plewa, PharmD, personal communication, April 8, 2008.) Similarly scarce will be the popular ketamine-propofol combination (ketofol), which is a 1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL titrated in 1- to 3-mL aliquots to attain deep or dissociative sedation.
One method of administering IV agents is to use a syringe attached to an in-line three-way stopcock. This allows frequent administration of anesthetic boluses; a reservoir of additional anesthetic is in the IV bag/bottle. If supplies are limited and there has been no backward gross contamination from the patient (which is probably more common than realized), only the IV needle and the extension tubing flowing from the three-way stopcock to the patient need be changed between patients.6
Narcotics, ketamine, and short-acting barbiturates can be used in this fashion.
How much to give? In resource-scarce situations in which patients do not receive neuromuscular blockade, slight movements of the fingers or toes indicate a need for supplementary anesthetic injections. 28
Neuromuscular Blockade
Do not even consider using a neuromuscular blocking agent unless you are highly proficient at obtaining (and have the equipment to control) an airway using several means (e.g., BVM, intubation, LMA, and cricothyrotomy).
If a neuromuscular blockade (NMB) is to be used, it may be important, especially for those not experienced in giving general anesthesia, to know whether the patient is awake. During surgery, paralyzing a patient who is awake is not, to say the least, good medical practice. The "isolated arm test" can help to determine whether a patient is awake. Just before administering the NMB, inflate a BP cuff on one arm to about 30 mm Hg above the systolic pressure, effectively isolating that arm from blood flow. Ten minutes after giving the NMB, ask the patient to signal to you by squeezing your hand or moving his thumb. If he does it, he is not asleep. Then, of course, deflate the BP cuff and either put the patient to sleep or stop the procedure—or both.29,30
This section is designed only for clinicians who are highly experienced in airway and critical care monitoring and management. Optimally, general anesthesia will be administered only by clinicians experienced in delivering anesthetics, although that may not be possible in resource-poor situations. The most common inhalation anesthetics used in resource-poor settings are discussed in Chapter 16, Anesthesia: Ketamine, Ether, and Halothane.
Basic Pharmacology
Inhaled anesthetics pass through the lungs, enter the circulation, and produce anesthesia in the brain. Anesthetics that are more soluble in blood, such as ether, take longer to act (induction) and to wear off (emergence; recovery). Those, such as N2O, that are relatively insoluble in blood have much faster induction and emergence.
Shortages
Ether (most portable) and halothane (inexpensive) are the inhalation agents commonly used in Africa and other places where resources are limited. Other inhaled anesthetics commonly used by anesthesiologists in developed countries, including N2O, are generally not available. As Boulton noted, "In all isolated situations, the most likely commodities to be in short supply are composed medical gases. Not only are cylinders heavy and bulky and difficult to transport in regions where communications are limited, but they provide relatively few 'anesthesia-hours' in proportion to their bulk in comparison with volatile agents vaporized in ambient air."2
Both logistics and cost affect the availability of anesthetic agents. The following are approximate costs for common anesthetics, which vary greatly by region; some are also available from chemical supply companies.31,32
Chloroform—$27.00 (100 mL)
Halothane—$50.00 (200 mL)
Ether—$5.00 (500 mL)
Procaine—(for injection) $1.66 (20 mg/2 mL)
Ketamine—$7.69 (500 mg/10 mL)
In austere circumstances, improvising even the most basic methods of delivering anesthetic gases is vital, since more modern anesthesia machines may not be available. So-called "portable" anesthesia machines may not really be so portable in rough terrain. As Boulton and Cole pointed out, "If the only available transport is the flat-footed anesthetist himself, even such apparatus as the EMO [Epstein-Macintosh-Oxford] air-ether outfit, which weighs 25 lb (11 Kg), or the 'Haloxair' halothane-air-oxygen apparatus [at] 13 lb (6 Kg) may prove to be intolerably heavy. In such a circumstance, the anesthetist might well prefer [a very] simple apparatus or even a resuscitator bag and intravenous drugs alone."2 A can of ether and a mask, of course, weigh much less than any of these, and they don't even take much backpack space.
Using Volatile Agents
Anesthetic gases can be used for both the induction and the maintenance phases of anesthesia. Alternatively, an IV induction agent or a faster-acting volatile agent (e.g., chloroform to induce ether) can be used, followed by an anesthetic gas for maintenance.33 Intravenous inductions are done with the agents discussed previously in "General Anesthesia Guidelines: Essential Elements." Take great care not to cause respiratory depression from the synergistic action of the induction agent and the inhaled anesthetic.
Inhalational induction requires a seal between the face and the mask for the gas to be drawn through the vaporizer. If there is no seal, the patient will breathe room air around the mask and remain conscious. In adult anesthesia it is relatively easy to coax a mask on the face and still keep the patient calm and cooperative."34 Premedicating patients, especially anxious ones, assists the process.
Use in Closed Spaces
Using anesthetic gases is problematic in closed spaces, such as on a ship or in "closed down" conditions such as might occur after a nuclear, chemical, or biological attack or contamination. This situation becomes more dangerous when using open methods, such as open-drop ether. Try to eliminate as much of the ambient anesthetic as possible.35
Nitrous oxide (laughing gas; N2O), in combination with oxygen, is a commonly used anesthetic gas in developed countries. It has a sweet, pleasant aroma (although to a patient, it appears odorless in the presence of the smell from the anesthesia mask) and, when inhaled, it is absorbed by the body and has a calming effect. Normal breathing eliminates N2O from the body. Nitrous oxide has a rapid onset and recovery. It is a good analgesic supplement for halothane and reduces the incidence of awareness. It produces minimal cardiovascular and respiratory effects.
A World War I physician described the benefits of nitrous oxide: "Nitrous oxide is particularly useful for multiple short procedures in mass casualty situations. Induction and emergence take a matter of seconds rather than minutes and most of the patients can walk out of the OR alone or with minimal assistance."36
The main problem with N2O is that it will usually be unavailable in situations of scarcity, since it is expensive to produce and transport. Anesthesiologists familiar with disaster and austere environments believe that N2O should not be used due to the logistical nightmare of supplying it, the possibility of errors when using it, the high cost, and its tendency to diffuse into air-containing spaces, such as pneumothoraces, the gut, middle ear, and ET tube cuff.33,35
At least 50% N2O must be delivered to be effective. It is delivered to the patient through a rotameter (a clear tapered tube with a float inside that is pushed up by flow and pulled down by gravity) and is mixed with oxygen to produce an inspired mixture of not less than 30% O2. A hypoxic gas mixture may result from using it with an oxygen concentrator. Nitrous oxide should not be used in draw-over circuits and should never be given to a patient with an untreated pneumothorax or who has been scuba diving within the previous 24 hours due to the potential for decompression sickness.33 Some places may have cylinders of a 50% mixture of nitrous oxide in oxygen, primarily used for self-administered outpatient analgesia.
Rectal anesthesia, sedation, or analgesia (see also Chapter 13, Analgesics) is relatively uncommon, although it has been shown to be effective in children for "preinduction" sedation. This method requires less technical skill and equipment than IV or IM drug administration.
A major limitation of this method is the poor predictability of the clinical effects. These are determined by the anatomical properties of the patient's rectum and, owing to individual variance, the result is inconsistent anesthetic absorption and elimination.37 Using hydrophilic solutions and larger volumes with lower concentrations results in improved absorption by enlarging the mucosal surface in contact with the drug.
In clinical practice, rectally administering anesthetic medications is more common for procedural sedation or as an anesthetic premedication, where a lighter stage is needed and the exact timing of medication onset is not as vital. The medication can be delivered to children via a lubricated tip of a small (14-Fr) suction catheter or nasogastric tube. A similar-sized urethral catheter also works, as does simply using a syringe and holding it there for 2 or 3 minutes. Medications for sedation and anesthesia that can be used rectally include the benzodiazepines, barbiturates, and ketamine. Ether, although not commonly administered by this method, is also an option.
Doses and Method
Midazolam 1.0 mg/kg (preinduction): Administer at least 30 minutes, but no longer than 90 minutes, prior to anesthetic induction.38
Methohexitone (Methohexital): Administer 15 mg/kg of 10% methohexitone for anesthetic induction or for short procedures.39
Ketamine 10 mg/kg: This medication has a delayed onset. Ketamine occasionally causes respiratory distress and, at the recommended 10 mg/kg rectal dose, may result in prolonged postoperative sedation if used for brief procedures.37,40
A common, but somewhat dangerous situation is for the surgeon doing the Cesarean section (C-section) also to administer the anesthetic. If this is the only option, employ one of the methods (described in the following paragraphs) using ketamine. Other methods include local infiltration (described in the subsequent text), spinal anesthesia (discussed here and also in Chapter 14, Anesthesia—Local and Regional), or epidural anesthesia for those having experience with the technique. In these cases, having a trained assistant to monitor and care for the patient throughout the operation is vital.
Local Infiltration
The main advantages of using local anesthesia infiltration in austere situations are that it is safe, inexpensive, and uses few resources. Especially for mothers in poor condition and those who are hypotensive, local anesthesia may provide the best safety margin, especially if adjunctive sedatives are not used. Epinephrine added to the anesthetic reduces local bleeding. However, using local infiltration requires significant operator experience, and even then, it may not be completely effective. It also takes time to administer.41
Determine the maximum safe anesthetic dose and, if not premixed, add 0.1 mL epinephrine 1:1000 to each 20 mL of anesthetic to make a 1:200,000 solution. If available, give oxygen to the mother until delivery. Using a 10-cm (4-inch) needle, infiltrate two long bands of skin on either side of the proposed incision line. Keep the needle parallel to the skin; remember that the abdominal wall is very thin at term—do not stick the needle into the uterus. Infiltrate the rectus sheath after incising the skin. To anesthetize the parietal peritoneum, inject 10-mL anesthetic under the linea alba. Then inject 5 mL more into the loose visceral peritoneum of the uterus where the incision will be made.
Collins provided some additional advice: "Reassure the patient and explain that after the local anesthetic has been given, she will still feel certain sensations of touch. She may experience discomfort if the head is well engaged in the pelvis. However, the anesthetic will prevent her feeling significant pain."41 Giving additional sedatives or analgesics, while desirable from an anesthetic standpoint, may adversely affect the baby. It is optimal to give nothing until the cord is clamped, after which small doses of narcotic or sedative may be used.
Ketamine is contraindicated in pregnancy before term, since it is oxytocic and is a US FDA fetal-risk category C drug. It is also relatively contraindicated in patients with eclampsia or preeclampsia. When the woman goes into labor, ketamine 10 mg to 20 mg IV can be used to provide analgesia. It can be repeated every 2 to 5 minutes, but do not administer >1 mg/kg in 30 minutes; the total dose should not exceed 100 mg.14
While ketamine may be used for vaginal delivery, only an experienced anesthetist who can adjust the dose according to the circumstances should use it.42
Ketamine is often used for C-sections because it has some unique advantages: (a) There is less discomfort than with spinal or epidural anesthesia for patients in advanced labor. (b) Although ketamine crosses the placenta easily and concentrations in the fetus are the same or higher than those in the mother, its use results in less fetal and neonatal depression than with other anesthetics.14–16 (c) Babies have good APGAR scores, even after periods of neonatal asphyxia—an important consideration when limited neonatal resuscitation equipment is available. This depends in part on the skill and speed of the surgeon.43 However, be careful with the dose, since a dose above 2 mg/kg may cause both respiratory depression and chest wall rigidity in the newborn.44 (d) Uterine contractility is unimpaired, so there is less danger of postpartum hemorrhage. (e) Ketamine supports maternal blood pressure, which may be important in the face of significant hypotension.14 This blood pressure increase can be ameliorated for those with eclampsia by using hydralazine or similar medications.45
If the mother experiences an emergence reaction to the ketamine, do not administer sedatives (benzodiazepines) to block the reaction until the baby is delivered, since these also can cause respiratory depression in the newborn. In cases of fetal distress, avoid ketamine, since it causes the uterus to contract.44
Methods for Cesarean Section
The following two methods describe how ketamine can be used successfully for C-sections.
In a remote Kenyan hospital, Dr. Veeken describes the successful use of a combination of local infiltration and a ketamine drip:
No premedication is given. An intravenous line is set up; local anesthesia (lidocaine 0.5%) is injected in the midline from symphysis up to the umbilicus. The doctor then scrubs. Opening is performed under this local anesthesia only. It's impressive how well the women tolerate this. If necessary, more local anesthetic could be administered for the deeper layers, but we never do. Atropine 0.6 mg is given IV. Just before the opening of the uterus, a bolus of 75 mg ketamine is given IV. The child is quickly delivered. The uterus is closed during the effect of the ketamine; a bilateral tubal ligation can be performed. Usually the women start waking up while closing the abdomen, the local anesthesia still enables us to close the fascia and the skin. If necessary, diazepam is given IV during the closure. This method is very safe for both mother and child.… Although not very elegant, it is satisfactorily cheap, very easy to administer, and extremely safe. It is highly recommended for working under primitive circumstances.46
Dr. Zimmermann described the method used in Bangladesh for 8000 C-sections (with one avoidable anesthetic death): "Routine premedication is omitted.… If necessary, oxygen is administered via mask or nasal tube. For induction, 0.6 mg atropine plus 100 mg ketamine diluted to 5 cc is administered IV over about 60 seconds."45 While ketamine is normally given as an mg/kg dose, a standard dose is used to avoid errors. It results in <2 mg/kg in virtually all these patients. This injection achieves an adequate surgical stage of anesthesia, and the patient continues to breathe spontaneously. For C-sections, administer oxygen if there is fetal distress. Maintenance anesthesia is achieved using a ketamine drip of 200 mg ketamine diluted in 200-mL NS or dextrose solution, resulting in 1 mg ketamine/1 mL fluid. This is run at 20 to 30 drops/min, which is 1 to 1.5 mg/min. A benzodiazepine (diazepam 10 to 20 mg has been used successfully) can be added once the baby is delivered. It provides a sound sleep and decreases possible psychomimetic reactions. The ketamine drip is discontinued once the surgical incision is closed.45
Improvised Vaporizers
Vaporizers deliver safe concentrations of volatile anesthetic vapor into the anesthetic system going to the patient. The volatile agent enters the vaporizer in liquid form, and comes out as a vapor. Vaporizers can be improvised.
The ideal vaporizer has a clear chamber so the amount of anesthetic is visible. Keeping the anesthetic temperature relatively constant is also important, since the liquid's temperature falls as it passes into vapor. This, in turn, lowers the output of the vaporizer. In improvised vaporizers, the equipment sits in a water bath, which transfers heat to the anesthetic to minimize any fall in temperature.34
The Coffee Jar Vaporizer
Boulton devised a very workable vaporizer for a draw-over system using two sizes of jars. To make the large vaporizer suitable for ether administration, he used a 135-g (118-mL; 4-oz) Maxwell House coffee jar (7.5-cm [3-inch] diameter, 13-cm [5-inch] tall). Other containers of THIS SIZE can be used instead. The jar's size partially determines the anesthetic concentration. The smaller jar, which can be used for ether, halothane, or trichloroethane, has a 5-cm diameter and is 19-cm (7.5-inch) tall.
Put a piece of plastic tubing with a 1.25-cm (0.5-inch) diameter through one of two holes of that size that you have punched into the lid; the tube should just fit. Cut the end of this obliquely, so that fluid is less likely to be sucked through it. Cut a wide hole in the tube, in such a position that you can lift it above the lid to reduce the vapor concentration, if necessary (Fig. 15-1). Fix a piece of cotton at one edge of the other open hole in the lid. Each time the patient breathes, it will move, allowing you to monitor his ventilation. If available, add oxygen through a tube that fits loosely in the open hole.6
Fig. 15-1.
Coffee jar vaporizer. (Redrawn from Boulton.6)
Fill the large jar by adding 150 mL—about 4-cm deep—of ether. Once the patient is induced, the vaporizer is ready to put in-line with whatever system you are using (a non-rebreathing valve and an Oxford bellows or a self-inflating bag, or attached directly to a tracheal tube). The initial 11% ether concentration falls to 8% in 5 minutes and remains relatively constant thereafter. Gently shaking the bottle for 1 minute doubles the concentration. The concentration can be halved by opening a T-piece closed by the finger cot (the cut finger from a surgical glove) and still further reduced by tightening the screw clamp. Using trichloroethane, a constant 1% concentration is obtained, which is halved by opening the T-piece. Halothane gives too high a concentration for use with the larger vaporizer.
The apparatus is converted to a "semi-one-way" system by snipping off the end of the finger cot, thus creating a simple valve that closes on inspiration and opens on expiration. As it vaporizes, the ether will get cold and the concentration will diminish. At that point, gently agitate the bottle for about a minute, or put it in a bath of warm water. When using trichloroethylene, no water bath is needed.
If using the smaller bottle, prepare it the same way, but with 50 mL of halothane. A constant 1% vapor concentration is obtained, which is halved by opening the T-piece or doubled by shaking the jar for 1 minute. Secure this bottle firmly to the table or another fixed structure—the vaporizer is dangerous if knocked over.6,47
Anesthesia (Plenum) Machines
Under normal circumstances, anesthesiologists in developed countries use plenum machines to deliver inhalational anesthetics. Boulton described the "frustrating experience of administering anesthesia with the 'rag and bottle' in a well-equipped OR while a typical modern anesthesia machine stood idle because of the lack of cylinders."2
In situations with limited resources and few trained personnel, the safest place for an anesthetized patient to recover is in the operating room. The key is ensuring that the patient is awake when he leaves the OR. Boulton notes that "if vigilance is relaxed when the drama of the operating room is over, death can still strike if the patient is left unsupervised."48 To prevent this, leave the patient intubated until pharyngeal reflexes return.49
Postoperatively, place patients in the "recovery" position, lying on their side (see Fig. 8-1). As often as possible, check their airway, vital signs, blood loss, and temperature. The latter is important because, while many operating rooms in hot climates are now air-conditioned or cooled, patients run the risk of hyperpyrexia when they are transferred to a hot ward.48
1. McCormick BA, Eltringham RJ. Anaesthesia equipment for resource-poor environments. Anaesthesia. 2007;62(suppl 1):54-60.
2. Boulton TB, Cole PV. Anaesthesia in difficult situations. (1) What would I do if …? Anaesthesia. 1966;21(2):268-276. [PubMed: 5956580]
3. King MH (ed.). Primary Anaesthesia. Oxford, UK: Oxford University Press, 1986:4.
4. Husum H, Ang SC, Fosse E. War Surgery: Field Manual. Penang, Malaysia: Third World Network, 1995:66.
5. Hodges SC, Mijumbi C, Okello M, et al. Anesthesia services in the developing world: defining the problems. Anaesthesia. 2007;62:4-11. [PubMed: 17156220]
6. Boulton TB. Anaesthesia in difficult situations. (3) General anaesthesia technique. Anaesthesia. 1966;21(4):513-545. [PubMed: 5331993]
7. King MH (ed.). Primary Anaesthesia. Oxford, UK: Oxford University Press, 1986:11.
9. King MH (ed.). Primary Anaesthesia. Oxford, UK: Oxford University Press, 1986:70-71.
10. Hodges SC, Walker IA, Bosenberg AT. Pediatric anaesthesia in developing countries. Anaesthesia. 2007;62(suppl 1):26-31.
11. King MH (ed.). Primary Anesthesia. Oxford, UK: Oxford University Press, 1986:85-89.
12. Safar P. Anesthesia at high altitude. Ann Surg. 1956;144(5):835-840. [PubMed: 13373267]
13. Boulton TB, Cole PV. Anaesthesia in difficult situations. (9) Some solutions, new drugs and a conclusion. Anaesthesia. 1968;23(4):597-630.
14. Stevenson C. Ketamine: a review. Update Anaesth. 2005;20:25-29.
15. Tomlinson A. Ketamine. Update Anaesth. 1994;4(5):1-2. www.nda.ox.ac.uk/wfsa/htmL/u04/u04_010.htm. Accessed September 13, 2006. [PubMed: 7767273]
16. Nunn JF. Anaesthesia at altitude. In: Ward MP, Milledge JS, West JB (eds.). High Altitude Medicine and Physiology, 2nd ed. London, UK: Chapman & Hall Medical, 1995:523-526.
17. Godwin A. Tough cases of sedation and analgesia in the critically ill (adapted from handout). ACEP Scientific Assembly, Seattle, WA, October 8, 2007.
18. Sacchetti A, Senula G, Strickland J, et al. Procedural sedation in the community ED: initial results of the ProSCED registry. Acad Emerg Med. 2007;14:41-46. [PubMed: 16946280]
19. King MH (ed.). Primary Anesthesia. Oxford, UK: Oxford University Press, 1986:137.
20. Spitalnic S, Blazes C, Anderson AC. Conscious sedation: a primer for outpatient procedures. Hosp Phys. 2000;36(5):22-32.
21. Green SM, Krauss B. Procedural sedation and analgesia. In: Baren JM, Rothrock SG, Breenan JA, et al. (eds.). Pediatric Emergency Medicine. Philadelphia, PA: W.B. Saunders, 2008:1119-1137.
22. Wong SME, Fong E, Tauck DL, et al. Ethanol as a general anesthetic: actions in spinal cord. Eur J Pharmacol. 1997;329(2-3):121-127.
23. Armstrong-Davison MH. The Evolution of Anaesthesia. Altrincham, UK: John Sherratt, 1965.
24. Anon. Civil War Anesthesia. http://home.nc.rr.com/fieldhospcsa/Anesthesia.htmL. Accessed April 6, 2008.
25. Constantin JD. General anaesthesia by the intravenous injection of ethyl alcohol. Lancet. 1929;1:1247.
26. Dundee JW, Isaac M, Clarke RSJ. Use of alcohol in anesthesia. Anesth Analg. 1969;48:665-669. [PubMed: 4893568]
27. Waring JP, Baron TH, Hirota WK, et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc. 2003;58(3):317-322. [PubMed: 14528201]
28. Ruben H, Knudsen EJ, Winkel E, et al. Anaesthesia in mass emergencies. Lancet. 1958;1(7018):460-461. [PubMed: 13515252]
29. King MH (ed.). Primary Anaesthesia. Oxford, UK: Oxford University Press, 1986:18.
30. Motamed C, Kirov K, Lieutaud T, et al. The mechanism of pancuronium potentiation of mivacurium block: use of the isolated-arm technique. Anesth Analg. 2000;91:732-735. [PubMed: 10960409]
31. Sid Patanwala, Pharm.D., BCPS, Clinical Assistant Professor, The University of Arizona College of Pharmacy, Tucson, AZ. Personal communication received April 9, 2008.
32. Other sources, including Epocrates (www.epocrates.com), PEPID (www.pepid.com), and on-line pharmacies.
33. Fenton P. Using volatile anaesthetic agents. Update Anaesth. 1995;5(5):1-3. www.nda.ox.ac.uk/wfsa/htmL/u05/u05_009.htm. Accessed September 13, 2006.
34. Simpson S, Wilson IH. Draw-over anaesthesia review. Update Anaesth. 2002;15(6):1-10. www.nda.ox.ac.uk/wfsa/htmL/u15/u1506_01.htm. Accessed September 14, 2006.
35. Grande CM, Baskett PJF, Donchin Y, et al. Trauma anesthesia for disasters: anything, anytime, anywhere. Crit Care Clin. 1991;7(2):339-361. [PubMed: 2049643]
36. Flagg PJ. Anaesthesia in Europe on the Western battlefront. Int Clinics. 1918;3:210-228.
37. Jantzen JP, Diehl P. Die rektale medikamentenverabreichung: grundlagen und anwendung in der anaesthesie. [Rectal administration of drugs: fundamentals and applications in anaesthesia.] Anaesthesist. 1991;40(5):251-261. [PubMed: 1678254]
38. Spear RM, Yaster M, Berkowitz ID, et al. Pre-induction of anesthesia in children with rectally administered midazolam. Anesthesiology. 1991;74(4):670-674. [PubMed: 2008948]
39. Kotiniemi LH, Ryhanen PT. Behavioural changes and children's memories after intravenous, inhalation and rectal induction of anaesthesia. Paediatr Anaesth. 1996;6(3):201-207. [PubMed: 8732611]
40. Tanaka M, Sato M, Saito A, et al. Reevaluation of rectal ketamine premedication in children: comparison with rectal midazolam. Anesthesiology. 2000;93(5):1217-1224. [PubMed: 11046209]
41. Collins C, Gurung A. Anaesthesia for Caesarian section. Update Anaesth. 1998;9(3):1-6. www.nda.ox.ac.uk/wfsa/htmL/u09/u09_006.htm. Accessed September 13, 2006.
42. World Health Organization. Model Prescribing Information: Drugs Used in Anesthesia. Geneva, Switzerland: WHO, 1989:18-20. www.who.int/medicinedocs/en/d/Jh2929e.4.5.
43. Ketcham DW. Where there is no anaesthesiologist: the many uses of ketamine. Trop Doct. 1990;20:163-166. [PubMed: 2284669]
44. Craven R. Ketamine. Anaesthesia. 2007;62(suppl 1):48-53.
45. Zimmermann H. Ketamine drip anaesthesia for Caesarean section: report on 200 cases from a rural hospital in Zimbabwe. Trop Doct. 1988;18:60-61. [PubMed: 3368951]
46. Veeken H. Ketamine drip anaesthesia for Caesarean section. Trop Doct. 1989;19(1):47. [PubMed: 2922822]
47. King MH (ed.). Primary Anaesthesia. Oxford, UK: Oxford University Press, 1986:83-84.
48. Boulton TB, Cole P. Anaesthesia in difficult situations. (5) General and local complications. Anaesthesia. 1967;22(3):435-464. [PubMed: 4952782]


text:
New York City School Library System Homepage
New York City School Library System
Read with PRIDE
Lambda Literary: Read with PRIDE
Lambda Literary Writers in Schools
LGBTQ CurriculaToggle Dropdown
LGBTQ Publications
LGBTQ Booklists
LGBTQ Organizations
Digital LGBTQ History Collections
LGBTQ CCD Collection
2022-2023 Lambda Books
Fiction Titles
George (FY 2017)
George feels even more out of place than other kids in class. Desperate to be seen for who she is, George longs to play the lead in Charlotte's Web. However, her classmates only see an awkward, quiet boy. With the encouragement of her best friend, George steals the show as the best Charlotte the school has seen. This compassion filled book gives you a glimpse into the life of a transgender teen.
Julián Is a Mermaid
A young boy sees three ravishing ladies in the subway, dressed in colorful gowns that end in fishtails. He gets home and sets to work creating his own glorious mermaid garb. But what will his Abuela think?
The GayBCs
A joyous, timely alphabet book of LGBTQ+ vocabulary, celebrating the beauty of embracing one's true self. In this inclusive book of ABCs, four friends play and exploreduring a playdate extravaganza. As they sashay out of closetsand discover a wardrobe fit for a king or queen, they realize that manyproblems can be solved with a little makeup, imagination, and,of course, your best friends! Featuring bright illustrations and upbeat, accessible poems,The GayBCsis perfect for fans ofA Is for ActivistandFeminist Baby-showing kids and adults alikethat every identity is worthy of being celebrated.
Gracefully Grayson (FY 2016)
Have you ever felt like you didn't belong? Like you didn't fit into your own skin? As long as Grayson can remember he's felt like he was in the wrong body. On a whim, Grayson tries out for the lead female role in the school play and he gets it. But will he be able to put up with the derision from his classmates, cousin, and even his aunt? Will Grayson have the courage to follow through?
Simon vs. the Homo Sapiens Agenda
Sixteen-year-old and not-so-openly gay Simon Spier prefers to save his drama for the school musical. But when an email falls into the wrong hands, his secret is at risk of being thrust into the spotlight. Now change-averse Simon has to find a way to step out of his comfort zone before he's pushed out; without alienating his friends, compromising himself, or fumbling a shot at happiness with the most confusing, adorable guy he's never met.
I'll Give You the Sun
Available in Spanish. Twins Jude and Noah used to be close. They used to have a complete family. They used to be happy. They used to understand how life was supposed to work. But now Noah is just a regular guy, and Jude is an artist who can't make anything that doesn't break. This psychological, complex, romantic, challenging book will pull you in and keep you reading to the end.
Aristotle and Dante Discover the Secrets of the Universe
A lyrical novel about family and friendship from critically acclaimed author Benjamin Alire Senz. Aristotle is an angry teen with a brother in prison. Dante is a know-it-all who has an unusual way of looking at the world. When the two meet at the swimming pool, they seem to have nothing in common. But as the loners start spending time together, they discover that they share a special friendship--the kind that changes lives and lasts a lifetime. And it is through this friendship that Ari and Dante will learn the most important truths about themselves and the kind of people they want to be.
In this character-driven world of magic and monsters, Simon Snow may be the chosen one sent to save the magical world from the Humdrum, but all he can think about is how this is his last year at Watford School for Magicks and how his nemisis and roommate, Baz, a vampire, is missing. Reminiscent of Hogwarts, this love letter to fanfic is an engrossing story with just the right amount of kissing.
One Man Guy
Alek Khederian should have guessed something was wrong when his parents took him to a restaurant. Everyone knows that Armenians never eat out. Between bouts of interrogating the waitress and criticising the menu, Alek's parents announce that he'll be attending summer school to bring up his grades. Alek is sure this experience will be the perfect hellish end to his hellish freshman year of high school. He never could've predicted that he'd meet someone like Ethan. Ethan is everything Alek wishes he were: confident, free-spirited, and irreverent. He can't believe a guy this cool wants to be his friend. And before long, it seems like Ethan wants to be more than friends. Alek has never thought about having a boyfriend - he's barely ever had a girlfriend - but maybe it's time to think again.
Putting Makeup on the Fat Boy
In this spirited exploration of strength and personality, a fabulous New YorkCity teen knows he's destined for greatness--if only he can survive his firstjob as a makeup artist in Macy's.
Non Fiction Titles
Gay and Lesbian History for Kids
Who transformed George Washington's demoralized troops at Valley Forge into a fighting force that defeated an empire? Who cracked Germany's Enigma code and shortened World War II? Who successfully lobbied the US Congress to outlaw child labor? And who organized the 1963 March on Washington? Ls, Gs, Bs, and Ts, that's who. Given today's news, it would be easy to get the impression that the campaign for lesbian, gay, bisexual, and transgender (LGBT) equality is a recent development, but it is only the final act in a struggle that started more than a century ago.
This Book Is Gay (FY 2017)
Get all the facts you need to know about LGBTQ and beyond. This frank, funny and uncensored work is an upbeat exploration of what it means to be a gay teen today. This should be required reading.
Gay Power!
In this riveting story, we'll explore the decades of discrimination and abuse that gay people endured in the United States. We'll also learn how gay people continue to fight for equal rights and recognition.
Gay Lives
In this book, Robert Aldrich presents a fascinating portrait of gay men and women throughout history that reveals the full diversity of gay lives as lived in their times.
What Was Stonewall?
In the early-morning hours of June 28, 1969, police arrived at the Stonewall Inn's doors and yelled, "Police! We're taking the place!" But the people in this New York City neighborhood bar, members of the LGBTQ community, were tired of being harassed. They rebelled in the streets, turning one moment into a civil rights movement and launching the fight for equality among LGBTQ people in the United States.
A riveting exploration of the Stonewall Riots and the national Gay Rights movement that followed is eye-opening, unflinching, and inspiring.
Trans Bodies, Trans Selves
Trans Bodies, Trans Selves is a revolutionary resource - a comprehensive, reader-friendly guide for transgender people, with each chapter written by transgender or genderqueer authors. Inspired by Our Bodies, Ourselves, the classic and powerful compendium written for and by women, Trans Bodies,Trans Selves is widely accessible to the transgender population, providing authoritative information in an inclusive and respectful way and representing the collective knowledge base of dozens of influential experts.
Transgender Lives: Complex Stories, Complex Voice
Alternating biographies of trans* people with information about trans* issues, this book will change your perspective. The stories are filled with bravery, challenge and success—a real inspiration. This brief introduction to a complex world will open your eyes and make you want to learn more.
Transgender 101
Written by a social worker, popular educator, and member of the transgender community, this well-rounded resource combines an accessible portrait of transgenderism with a rich history of transgender life and its unique experiences of discrimination.
Gay America
Milestones of gay and lesbian life in the United States are brought together in the first-ever nonfiction book published specifically for teens. Profusely illustrated with archival images, the groundbreaking Gay America reveals how gay men and women have lived, worked, and loved for the past 125 years. The book includes a bibliography and an index.
The Gay Agenda
A joyful celebration of the LGBTQ+ community's dvelopment, history, and culture, packed with facts, trivia, timelines, and charts, and featuring 100 full-color illustrations. Compiled and designed by queer power couple and illustrators extraordinaire, Ashley Molesso and Chessie Needham, founders of the popular Brooklyn stationery company Ash + Chess, The Gay Agenda is an inviting and entertaining guide that pays tribute to the LGBTQ+ community. Filled with engaging descriptions, interesting facts, helpful features--such as historical queer icons and events and LGBTQ+ acronym definitions--this fabulous compendium illuminates the transformation of the community, highlighting its struggles, achievements, landmarks, and contributions. It also salutes iconic members of the LGBTQ+ community--the celebrities, politicians, entrepreneurs and ordinary citizens who have made a notable impact on gay life and society itself. The Gay Agenda is a nostalgic look back for older generations, an archive for younger people, and a helpful introduction for those interested in learning more about the community and its contributions. From James Baldwin and Emma Goldman to Marsha P. Johnson and Jodie Foster; the Pink Triangle and the Rainbow Flag to Stonewall and the AIDS crisis; Matthew Shepard and Pulse Nightclub to Sodomy Laws and Obergefell; Drag and Transitioning to The L Word and The Kinsey Scale, Freddie Mercury and Ellen Degeneres to Laverne Cox and David Bowie, this magnificent digest is a keepsake honoring all LGBTQ+, and the ongoing fight to gain--and maintain--equality for all.
<< Previous: LGBTQ CCD Collection
Next: 2022-2023 Lambda Books >>
Last Updated: Dec 6, 2022 10:34 AM
URL: https://nycdoe.libguides.com/lambdaliterary
The DOE is committed to creating and supporting learning environments that reflect the diversity of New York City. To ensure that our website serves the needs of everyone, it follows the Web Content Accessibility Guidelines 2.0, Level AA. That means the sites work for people with disabilities, including those who are blind and partially sighted. We are committed to creating accessible digital experiences for all website visitors. If you require assistance with any documents on our site, please please call 917-521-3654, email mdodes2@schools.nyc.gov, or mail to: Michael Dodes, 4360 Broadway, 4th Floor, New York, NY, 10033 for assistance.

redpajama_set_name: RedPajamaCommonCrawl


text:
Lego 71043 Harry Potter Hogwarts Castle Stores
In the course of the Hogwarts School of Witchcraft and Wizardry, the characters of Harry Potter and his friends are enrolled in the school. The Wizarding World universe has the Hogwarts School of Witchcraft & Wizardry as its primary setting. It is a fictional British boarding school for children aged 11 to 18.
The Hufflepuffs are the least well-known of all the houses, yet they have left a lasting impression in Harry Potter's world. The Hufflepuffs are known for its generosity, loyalty, and willingness to assist. They are also committed and hardworking. They are also known as the house of the best wizards and witches.
One of the most significant characters in the Harry Potter franchise is Newt Scamander, a Hufflepuff. He was a remarkable magizoologist and was loved by everyone. He never reacted with anger when he was detained and handed the death penalty. He remained cool and focused and fought to get out of the situation.
The first year at Hogwarts, each student is assigned one of the houses based on the student's characteristics. The Sorting Hat does the heavy lifting, putting students in the best House to challenge them. It's a great way for students to test their strengths and weaknesses.
The Sorting Hat is imaginative and magical. It was created by J.K. Rowling and pays tribute to the magician's hat which was the property of Godric Gryffindor. It is also used to determine which students will be placed in the Hogwarts Houses , as decided by the Founders of Hogwarts.
The Sorting Hat can also be used to determine the house a student should live in. It can read the wearer's thoughts and respond to their thoughts. It can even speak to them. It is also used to determine the House a student belongs to and to present the Sword of Gryffindor to those who are worthy of it.
During Harry's time at Hogwarts The Room of Requirement played a crucial role in the story. Apart from the fact that it provided Harry with his first (and final) horcrux, it was also the place where Voldemort's diadem, which was lost, was hidden. In actuality, the Room of Requirement was so mysterious that it took the most enigmatic part of a year for Dumbledore to uncover its sinister past.
The room also contains a number of odd artifacts, including the Sorting Hat, which is an ancient artifact. The hat also contains the legilimen, a device that uses legitmization to read minds. This is a challenging task, but it has been accomplished by a handful.
The organization was founded by Salazar Slytherin, Slytherin was known for its self-preservation and ambition. Slytherin also gained a bad reputation for being self-centred and a vicious. Slytherin actually produced the most Death Eaters.
The Slytherin common area was located beneath the Black Lake, and had rough stone walls and silver lamps that hung from the ceiling. It is famous for its beautiful views of the surrounding mountains.
Slytherin was a noble House, while Gryffindor was famous for its rivalry with Slytherin. Hufflepuff, the least noble of the four houses, was known for its values of loyalty, patience, and perseverance.
Hogwarts is the home of all students during the academic school year. Students live in dormitories and sleep in four-poster beds. Students are taught by professors. Students can gather at the tables of the House. There are also notice boards located in strategically placed locations around the school.
Whether you're a Harry Potter fan or simply curious about the world of Harry Potter that Harry Potter is a part of, the Library at Hogwarts has a lot to offer. It is home to thousands of books. However, it also has a section only accessible to students who have granted written permission. This section is located on the lower level of the library.
The library is divided into five stories and has shelves for books. The first story is the main room which is lit by natural light from stained glass and stained-glass windows. The ceiling is 65 feet high.
The second story houses the headmaster's office. It also contains the Charms classroom. The Reading Room is located on the third floor. This is the only room in the library that is entirely silent. It features rows of study tables upholstered in red-carpeted rooms. Under the study tables are outlets.
The Deathly Hallows, despite its reputation as a fantasy novel , is an actual story of three former Hogwarts students who are trying to escape Voldemort at Godric's Hollow. The plot involves the final battle between Harry Potter and Voldemort.
This book is the seventh in the Harry Potter series and the final chapter in the story of the wizard's boy. It was published July 21 July, 2007 by the Bloombury Publishing Company and translated into 120 languages. It is the most popular fantasy ever with over 500 million copies sold around the world.
Five short stories are included in the book. Several of them are tied to the Deathly Hallows story.
Hogwarts, a magical school for young wizards, is located in the Scottish Highlands. Founded in the 10th century it was established to protect wizards from Muggle persecution. Hogwarts is one of the most sought-after private boarding schools in Britain. The school is surrounded by the Forbidden Forest, which is sometimes called the Dark Forest.
There are many secrets in Hogwarts. Some of these secrets are hidden from the public like the Chamber of Secrets. Others are well-known and often used, like the Leaky Cauldron Restaurant and Gringotts Money Exchange.
Salazar Slytherin erected the Chamber of Secrets before he left Hogwarts. It was intended to purge the school of students who were born in the wizarding world. Voldemort believed he had won the last battle and planned to make all Hogwarts students into Slytherin. He passed away before he could complete his plan.
The Chamber of Secrets lies deep beneath Hogwarts school. It is also the home to the ancient Basilisk. The Chamber is left open when Dumbledore's army gets betrayed. It is home to floor cushions for defensive spells as well as Dark Detectors. The Chamber also houses an embodied memory of Tom Riddle, who was murdered by Harry Potter.
The Chamber of Secrets is also home to two serpents, carved into the solid wall of the Room. They have emerald eyes. They are believed to have been summoned by Tom Riddle. They are also able to create the Devil's Snare, a large snake that can attack anyone who is in the Chamber. The Chamber also has a snake-scratching faucet. It also houses the huge black boarhound Fang. He is more friendly than Mrs. Norris.
The Slytherin dormitory is located inside the dungeon. The room is green and has carved armchairs. It is also home to the statue of Salazar Slytherin. The room is decorated with green lamps and a greenish glow.
The Hufflepuff dormitory has low ceilings and is a relaxing bright and sunny place. It has plants hanging from its ceiling. It also has a huge communal room. The badger is the House animal. It is believed that the badger is a symbol of gathering family. Nearly Headless Nick is also a ghost that haunts the House.
There are several shortcuts to take you from the castle to the school. They aren't always readily accessible however. These are often hidden by tapestry or with an entry that is hidden. These shortcuts are only accessible to House members. The secret entrance to Hufflepuff is behind barrels. It's also under spell, so when you tap the barrel in the right rhythm it will open up the slimy chute.
The Dark Room is the place where Dumbledore's army meets. It is the site of numerous battles in the Harry Potter series. It is also where Dumbledore makes his argument for Harry's protection. It contains floor cushions for defensive spells, as well as volumes of Defence Against the Dark Arts.
There are also secret access points to four House dormitories. These secret entrances are also kept from view from the outside world and require the use of a password. These entrances are only used by members of the House.
Hogwarts Express Universal Studios
Name A House In Hogwarts Text Or Die


MAHA PWD Junior Engineer Syllabus 2018 is for those Students of graduate engineers gate qualified or polytechnic of three year pass but not appearing if they interested you should to apply online through official website mahapwd.com vacancy. Maha PWD JE exam date 2016 will held on 19th June 2016.the official website see all types future like MAHA PWD JE interview question and answer at mahapwd.com Maharashtra PWD Junior Engineer Syllabus 2016 Maharashtra pwd board Office junior engineer salary structure Rs. 9300 to Rs. 34800 per month with pay grade Rs. 4300.
Maharashtra JE Syllabus of Marathi Error Correction Fill in the Blanks, Unseen Passages Idioms & Phrases, Sentence Rearrangement, Antonyms and so on.


text:
Become a Member Contribute Prayer Requests
11 4th Ave SW, Rochester, MN 55902
c l o s e
Rich Bogovich
Dear Friends in Christ:
When Pope John Paul II was "in his prime," how did liberal Christians view him? That question was at the forefront of my mind twenty years ago when the nonprofit group for which I was working asked me to help launch a faith-based environmental coalition. Included were leaders from Christianity's left wing – e.g., from Episcopal, UCC, and Methodist bodies – plus a prominent female Lutheran minister. It was safe for me to assume that few of these ordained people would share my Pope's pro-life passion, but partly because I'm half Polish and three-quarters Slavic overall, I was always very protective of him.
It turned out that I had nothing to worry about: They revered him! Why? They were willing to look past our differences, and they were very familiar with the leadership trail he blazed in his powerful 1990 World Day of Peace message on the environment. In it he declared that the "greenhouse effect" (these days more commonly called global warming or climate change) had already "reached crisis proportions as a consequence of industrial growth, massive urban concentrations and vastly increased energy needs. Industrial waste, the burning of fossil fuels, unrestricted deforestation, the use of certain types of herbicides, coolants and propellants: all of these are known to harm the atmosphere and environment. The resulting meteorological and atmospheric changes range from damage to health to the possible future submersion of low-lying lands." He made it clear that he was speaking to everyone, regardless of faith, but also exercised papal authority. "At the conclusion of this Message," he said, "I should like to address directly my brothers and sisters in the Catholic Church, in order to remind them of their serious obligation to care for all of creation." To me, this was a perfect illustration of what Church leaders call the Seamless Garment, that is, a consistent ethic of life extending from the firmly-established (if little-known) doctrine of Catholic Social Teaching.
I was thrilled in 2015 that Pope Francis' first encyclical was on the environment, On Care for Our Common Home (Laudato Si'), and that, in particular, it spoke to climate change at length. It has also been very gratifying that this encyclical has received considerable attention. A year after it was published, a Georgetown University poll determined that 60% of American Catholics perceived an increase in temperatures due to higher concentrations of heat-trapping gases and that this largely results from human activity. That percentage was a bit higher than American adults as a whole. I think Laudato Si' would have a greater effect on Catholics if we realized that a very solid foundation had been laid by Saint John Paul II a quarter of a century earlier and that it isn't a radically new stance on the environment. In fact, in between John Paul and Francis, Pope Benedict issued similar warnings about climate change in numerous writings and speeches.
As a volunteer throughout my entire adulthood, as well as in a few jobs, I have always tried to push concern about the environment beyond liberal versus conservative, and it has been very gratifying that top Catholic leaders have done likewise. These Popes have also helped bridge an even greater gap, between theology and science, by demonstrating considerable respect for the research and computations of climate scientists. All told, our recent Popes have been role models for all denominations for stripping ideology from the care of God's creation. Read more on our website at sj.org—click on Get Involved, Service & Outreach, and Education and Reflection.
Parishioner
Mary Vlazny
Diocese of Winona-Rochester
Seeds of Wisdom
Communion and Liberation
Catholic Climate Covenant
Calvary Cemetery
USCCB Action Center
Justice for Immigrants
Catholic Advocacy Network
© Copyright …. - 2021