Anesthesiology

Student Primer

Medical Student Anesthesiology Primer

James J. Lamberg, D.O.
Welcome to the best medical specialty! This document will be a quick overview to get you
started on your rotation. The focus will be on the delivery of a safe general anesthetic but that is
only part of what anesthesiologists do.
They care for patients in all areas of the hospital, from the trauma bay to the obstetric suite to the
intensive care unit. They care for patients undergoing routine surgery as well as the most
critically ill, from premature infants to geriatrics. They manage clinical physiology and
pharmacology on a daily basis, working with the quickest and most powerful medications in the
hospital. By the end of your rotation, I hope you will consider joining our rewarding specialty.
Case Preparation: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Inadequate preoperative planning and errors in patient preparation are the most common causes
of anesthetic complications. ~ Clinical Anesthesiology by Morgan & Mikhail
Before each case, equipment and medications are prepared as well as backup equipment. All
equipment is tested to ensure proper function and fail-safe mechanisms are tested. Here is a
mnemonic to help with case preparation: SOAP ME
o Suction: ensure suction is functional and on, Yankauer hard suction tip for adults
o Oxygen: ensure oxygen is available, patients get 100% before induction of anesthesia
o Airway: equipment includes oral airways, nasal airways, laryngoscope, endotracheal tube
(ETT), supraglottic airway (LMA), tracheal tube introducer (bougie)
o Pharm: sedatives, induction agents, muscle relaxants, volatile anesthetics, vasopressors
o Monitors: pulse oximeter (SpO2), capnography (ETCO2), BP cuff, ECG, anesthesia machine
checked, neuromuscular monitoring device (twitch monitor)
o Emergency: resuscitation bag (BVM), oxygen tank, emergency medications available,
emergency equipment location (code cart/defibrillator, fire extinguisher, malignant
hyperthermia kit, local anesthetic toxicity kit)
Preoperative Evaluation: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - History: Focus on airway issues, cardiovascular issues, pulmonary issues, and past anesthetics.
o Airway: ask about difficulty opening mouth of moving neck
o Cardiovascular: ask about hypertension control, valve problems/murmurs, past MI/stents, and
exercise tolerance (if patient can climb two flights of stairs without stopping)
o Pulmonary: ask about smoking, asthma control, COPD control
o Others: last meal (NPO status), alcohol consumption or drug abuse, GERD, diabetes control,
liver disease, kidney disease, thyroid disease, seizures
o Allergies: always review patients allergies and identification before giving medications
o Medications: many medications interact with anesthetics, some medications are stopped
before surgery and some are intentionally continued through surgery
o Past Reactions: problems with prior anesthetics, family history of problems

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Student Primer

o Certain conditions predispose patients to having peri-operative complications (e.g. having a

stroke or an MI) and the anesthesiologist has a role in reducing the risk of complications
Physical Exam: Focus on airway, cardiovascular, pulmonary, and surgical site.
o Airway: No single assessment can predict a difficult airway (e.g. Mallampati alone).
o Difficult mask ventilation predictors: obesity, high Mallampati, elderly, limited jaw
protrusion, snoring, beard (only modifiable risk factor).
o Difficult intubation predictors, nonreassuring findings:
Relatively long upper incisors
Prominent overbite
Inability to bring mandibular incisors in front of maxillary incisors
Interincisor (mouth opening) distance < 3cm
Uvula not visible with mouth open (Mallampati 3 or 4)
Highly arched or very narrow palate
Stiff, indurated mandibular space or occupied by a mass
Thyromental distance < 3 finger breadths
Short neck or thick neck
Limited range of motion for flexion/extension
o Mallampati Classification based on uvula, soft palate, and hard palate

o Cardiovascular: blood pressure, rate and rhythm, murmurs, edema, JVD, bruits
o Pulmonary: SpO2, crackles, wheezing, unequal sounds, poor chest excursion
o Surgical Site: briefly examine planned surgical site
Investigations: review labs and imaging to prepare for potential issues
o Testing should only be done if it will change management and, in general, routine testing is
not recommended (e.g. routine CBC, blood type, electrolytes)
o Labs: Some examples
o Hyperkalemia: avoid succinylcholine
o Renal failure: many drugs excreted through the kidneys
o Anemia/Coagulopathy: preparation for transfusions
o Thrombocytopenia/Coagulopathy: neuraxial anesthesia contraindicated
o Imaging: Some examples
o Neck CT/MRI: prepare for difficult intubations in head/neck surgery cases
o Echocardiogram: valvular disease, pulmonary hypertension, and other defects may
require specialized anesthetic techniques
Severe aortic stenosis or pulmonary hypertension are particularly important
o Surgical Site: planning for length of surgery (e.g. simple fracture vs complex
fracture), planning for complexity of surgery (e.g. endovascular aneurysm coiling vs
open craniotomy with clipping)
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o Consultation: Specialty consultation may be needed in patients who have previously

undiagnosed disease (e.g. dyspnea with murmur on exam) or who have acute worsening of
their chronic disease, but not necessarily for severe chronic disease
Vascular Access & Premedication: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Vascular Access: Obtaining peripheral intravenous (IV) access is a crucial skill for
anesthesiologists and something you should become comfortable with on your rotation. With few
exceptions, every patient will require an IV before induction of anesthesia.
I recommend the New England Journal of Medicine (NEJM) Videos in Clinical Medicine for
many of the basic procedures that anesthesiologists routinely perform. These resources cover
indications, contraindications, equipment, and troubleshooting.
Video: Peripheral Intravenous Cannulation. N Engl J Med 2008; 359:e26
http://www.nejm.org/doi/full/10.1056/NEJMvcm0706789
Pre-Medication: Benzodiazepines are commonly given to help relieve preoperative anxiety.
Midazolam is a common agent due to its rapid onset of action and amnestic properties.
Anterograde amnesia with benzodiazepines is dose dependent and not guaranteed. Retrograde
amnesia (forgetting past events) rarely, if ever, occurs.
Patient Monitoring: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - All patients are monitored with ASA Standard Monitors, which are defined by the American
Society of Anesthesiologists (ASA) and includes blood oxygenation (pulse oximeter), ventilation
(capnography), heart rate, blood pressure, electrocardiogram (ECG), and temperature.
End tidal carbon dioxide (ETCO2) monitoring is the best method to determine if an endotracheal
tube is in the trachea. It also serves as a cardiac monitor, as low cardiac output results in low
ETCO2. Pulse oximetry is used to assess oxygenation. If you recall the oxygen-hemoglobin
dissociation curve, you can see that an SpO2 of 100% could be a PaO2 (blood) of anywhere from
100-500+. So, you cannot tell from SpO2 alone if you are getting close to the high risk zone
seen in the below graph. An SpO2 of 90% is approximately a PaO2 of 60mmHg, which is the
edge of hypoxemia. Assume that SpO2 < 90% requires immediate intervention.

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Video: Pulse Oximetry. N Engl J Med 2011; 364:e33

http://www.nejm.org/doi/full/10.1056/NEJMvcm0904262
Video: Monitoring Ventilation with Capnography. N Engl J Med 2012; 367:e27
http://www.nejm.org/doi/full/10.1056/NEJMvcm1105237
When the patient arrives in the room, additional safety checks are performed to verify the correct
patients, allergies, and the procedure being performed. The patient is typically moved to the
operating room table and monitors are attached. The pulse oximeter typically goes ipsilateral to
the IV and the blood pressure cuff goes on the contralateral arm. ECG monitoring can be done
with 3- or 5-leads. Lead II is most commonly used to assess rhythm and V4 or V5 is most
commonly used to assess for ischemia (lateral wall). A twitch monitor is used anytime a
muscle relaxant is given. Inspiratory oxygen and ETCO2 are measured by the anesthesia
machine.
Induction of Anesthesia: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Many compare general anesthesia to flying, where the difficult parts are takeoff and landing. At
induction (takeoff), many serious issues can occur including hemodynamic instability, airway
compromise, and anaphylaxis. Preparation for these occurrences can save a life.
Prior to induction, all patients are preoxygenated with 100% oxygen. This process replaces the
nitrogen in the lungs with oxygen, significantly increasing the time to desaturation. This process
should not be skipped or shortened. Here is a graph depicting desaturation times for various
patients given 87% oxygen in their lungs. As you can see, desaturation occurs rapidly after SpO2
reaches 90%, as would be expected from the steepness of the O2-hemoglobin dissociation curve.

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At this point, the patient may receive additional medications depending on the clinical scenario.
Some examples include:
o Glycopyrrolate: a muscarinic-antagonist used to dry secretions and prevent bradycardia
o Lidocaine: a local anesthetic used to blunt injection pain from certain induction medications,
the sympathetic reaction to laryngoscopy, and myalgias induced by succinylcholine
o Fentanyl: an opioid-agonist used to blunt injection pain from certain induction medications
and the sympathetic response to laryngoscopy
o Phenylephrine: an alpha1 agonist used to increase blood pressure and offset hypotension
from certain anesthetic agents
o Esmolol: a beta1 antagonist used to block the sympathetic response to laryngoscopy
Induction of anesthesia is then performed by injecting an induction agent, which typically works
in one arm-brain circulation time (~30 seconds). Unconsciousness can be assessed by brushing
the eyelashes and looking for eyelid motion (lash reflex). Attempts may be made to mask
ventilate the patient at this point. A neuromuscular blocking agent (muscle relaxant) is then
given to facilitate tracheal intubation, but is not required for the placement of a supraglottic
airway device (e.g. LMA).
Medication Overview: An analgesic is a medication that reduces pain. Anesthetics cause loss of
sensation and anxiolytics reduce anxiety. Sedatives reduce excitement and hypnotics induce
unconsciousness. Most anesthetics are sedative-hypnotics that cause sedation and amnesia but do
not significantly reduce pain. Opioids are analgesics that can cause sedation but are not
hypnotics and thus are not typically used alone for induction of anesthesia. Neuromuscular
blocking agents are not hypnotics, sedatives, anesthetics, or analgesics and thus should never be
given to patients who are not sedated.
Induction Agents: There are many options for induction of anesthesia and the best choice is
dependent on the effects, side effects, and contraindications. Medication shortages are not
uncommon in our specialty so the understanding of various agents is important.
Adult Dose

Duration

Side Effects

Propofol

1.5-2.5mg/kg

3-8min

Hypotension, injection pain, bacterial growth medium

Etomidate

0.2-0.3mg/kg

3-8min

Adrenal suppression, nausea, injection pain, hiccups

Ketamine

1-2mg/kg

5-10min

Hallucinations, tachycardia, hypertension

Midazolam

0.1-0.3mg/kg

15-20min

Hypotension, delirium, worsening of glaucoma

Methohexital

1-1.5mg/kg

4-7min

Hypotension, seizures, asthma, hiccups

Thiopental

3-5mg/kg

5-10min

Not available in the U.S. due to ethical issues

Neuromuscular Blockers: Neuromuscular blocking agents are categorized as depolarizing

(succinylcholine) and non-depolarizing (drugs ending in -onium or -curium). These medications
are typically given to facilitate tracheal intubation and to optimize the surgical field. Of note,
their duration is much longer than the induction agents thus continued anesthesia/sedation must
be considered for any patient receiving these medications. In the operating room, the patient is
typically given inhaled volatile anesthetic. Outside of the operating room (e.g. ICU), patients are
typically started on continuous infusions of sedatives.

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Dose

Onset

Duration

Notes

Succinylcholine

1mg/kg

< 1min

10min

Hyperkalemia, arrhythmias, malignant hyperthermia

Rocuronium

0.6mg/kg

1-2min

55-80min

Commonly used agent, allergic reactions

Rocuronium

1.2mg/kg

< 1min

110-160min

High dose with rapid onset (rapid sequence induction)

Vecuronium

0.1mg/kg

3-5min

5-80min

Slow onset, cheaper than rocuronium

Cisatracurium

0.1mg/kg

3-5min

60-90min

Used for patients in renal failure

Pancuronium

0.1mg/kg

3-5min

130-220min

Very long acting, hypertension, tachycardia

Airway Management: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Anesthesiologists are experts in airway management. By the end of the rotation you should have
a good understanding of basic airway management, supraglottic airway devices, and
endotracheal intubation.
Basic Airway Management: Positive pressure ventilation with a bag-valve device is the
cornerstone of basic airway management and is a more important skill than endotracheal
intubation. Positioning maneuvers such as head-tilt chin-lift and jaw-thrust are helpful. Basic
airway adjuncts include the oral pharyngeal airway (OPA) and nasal pharyngeal airway (NPA).
Video: Positive-Pressure Ventilation with a Bag-Valve Device. N Engl J Med 2007; 357:e4
http://www.nejm.org/doi/full/10.1056/NEJMvcm071298
Induction of anesthesia generally falls into two categories: standard induction and rapid
sequence. During a standard induction, the patient is mask ventilated until the onset of muscle
relaxation occurs to ensure optimal conditions for intubation. During a rapid sequence induction,
mask ventilation is avoided prior to intubation. Rapid sequence induction is used for patients
with risk of aspiration (e.g. full stomach, bowel obstruction, severe gastroparesis) where mask
ventilation would increase the chance of vomiting.
Supraglottic Devices: These are airway devices that sit in the back of the throat and do not enter
the trachea. A common example is the laryngeal mask airway (LMA). The devices are simple to
place and do not require muscle relaxation to be given. They do not provide a definitive seal
against aspiration however. They are commonly used for short cases in which the patient is
supine. They are also an integral part of the difficult airway algorithm, where attempts at mask
ventilation and endotracheal intubation have failed.
Video: Laryngeal Mask Airway in Medical Emergencies. Engl J Med 2013; 369:e26
http://www.nejm.org/doi/full/10.1056/NEJMvcm0909669
Endotracheal Intubation: Endotracheal intubation is the gold standard for securing an airway.
There are many techniques for getting a tube into the trachea, but the most commonly used is
direct laryngoscopy with a laryngoscope. Other techniques include video laryngoscopy, indirect
laryngoscopy, optical intubating stylets, and flexible fiberoptic laryngoscopy.
Video: Orotracheal Intubation. N Engl J Med 2007; 356:e15
http://www.nejm.org/doi/full/10.1056/NEJMvcm063574
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Maintenance of Anesthesia: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Although many equate anesthesia to sleep, it is more similar to a controlled coma. It is defined as
a drug-induced reversible condition of unconsciousness, amnesia, analgesia, and akinesia.
Inhaled Anesthetics: In the operating room, anesthesia is typically maintained with inhaled
anesthetics. These include nitrous oxide, one of the first anesthetics ever discovered, and
halogenated volatile anesthetics derived from ether. Mean alveolar concentration (MAC) of
anesthetics helps determine depth of anesthesia, where 1.0 MAC is defined as the amount at
which 50% of patients will move to a surgical stimulus. An expired end-tidal MAC of 0.7 of
higher generally ensures amnesia. There are several physiologic and pathologic states that affect
MAC requirements. Additionally, analgesics and/or sedative-hypnotics may be given with
volatile anesthetics to reduce MAC requirements.
MAC

Notes

Nitrous Oxide

104%

Fast onset and offset, can be combined with other agents

Isoflurane

~ 1%

Pungent, longer offset, most amnestic, cheap

Sevoflurane

~ 2%

Can use for mask/inhalational induction of anesthesia

Desflurane

~ 6%

Pungent, can cause bronchospasm, relatively quick offset

Hemodynamics: Common intra-operative problems include hypotension, tachycardia,

hypertension, bradycardia, and occasionally myocardial ischemia. Vasodilation from volatile
anesthetics can result in profound hypotension, especially in hypovolemic patients. The
anesthetist must develop a broad differential diagnosis for these conditions to manage them
properly. Typical therapies include fluid boluses and vasopressors. Phenylephrine (alpha1
agonist) is a common agent as it reverses the vasodilatory effect of the volatile anesthetics, with
a resultant heart rate decrease. Ephedrine and other sympathomimetics are used to increase both
blood pressure and heart rate.
Airway/Ventilation: Common intra-operative problems include hypercarbia, hypocarbia,
hypoxemia, bronchospasm, and high airway pressures. The ventilator is typically used to
improve oxygenation (SpO2) or change ventilation (ETCO2).
Most patients under general anesthesia will be mechanically ventilated. Spontaneous breathing is
not commonly allowed for intubated patients, but is potentially beneficial for patients with
supraglottic airways. The use of respiratory depressants (e.g. opioids) may mean using the
ventilator to support spontaneous breaths. Patients who have not metabolized muscle relaxants
will need complete ventilator support. Here is a brief overview:
Volume Controlled (VC) Mode: tidal volume set, peak pressure changes with each breath
Pressure Controlled (PC) Mode: peak pressure set, volume changes with each breath
Pressure Support: additional pressure given when patient initiates a breath
Common Settings: tidal volume 6-8mL/kg, peak pressure 30cmH2O, fractional inspired
oxygen (FiO2) 50%, frequency 12 breaths/min, PEEP 5cmH2O.
o Oxygenation can be improved by increasing FiO2 and PEEP.
o Ventilation can be adjusted by manipulating minute ventilation (frequency * tidal volume).
o
o
o
o

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Other Management: Many other aspects of the patients physiology are monitored and
managed throughout the case including thermoregulation, urine output, fluid replacement, and
blood loss. Patients are typically given long-acting opioids for post-operative pain control.
Medications may be given to reduce post-operative nausea and vomiting, an unfortunately
common side effect of general anesthesia. Serious intra-operative problems can occur at any time
including anaphylaxis, aspiration, cardiac arrest, massive hemorrhage, pneumothorax, and
malignant hyperthermia.
Emergence From Anesthesia: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - The anesthesiologist will taper off the volatile anesthetic at the end of the case with the goal to
wake the patient at the moment that surgery is completed. This requires situational awareness
and an understanding of how the anesthetics work. Most patients are extubated at the end of
surgery when it is safe to do so.
Reversal Agents: Acetylcholinesterase inhibitors (parasympathomimetics) are commonly given
to reverse the effects of non-depolarizing muscle relaxants at the end of surgery. Neostigmine is
a commonly used agent and is given with glycopyrrolate to prevent bradycardia. Nondepolarizing relaxants work as acetylcholine antagonists, a different mechanism from the
reversal agents. For this reason, we wait until neuromuscular function is present (e.g. twitches)
prior to giving reversal agents. If acetylcholinesterase inhibitors were given during a complete
block (all acetylcholine blocked), it would not matter how much acetylcholine was present
(unantagonizable).
Also, if reversal agents were given too early they could potentially wear off and the muscle
relaxant could again take effect (e.g. paralysis an hour later, known as recurarization). This
issue is not seen with sugammadex, a selective relaxant binding agent approved for use in the
U.S. in 2016.
Clinical assessment of neuromuscular blockade is not adequate. Thus, nerve stimulation (i.e.
twitch monitoring) is used. Despite improvements in technology and monitoring, a significant
number of patients have post-operative residual blockade which drastically increases the risk of
respiratory complications. The use of a nerve stimulator is considered to be mandatory when
muscle relaxants are given. The use of clinical tests (e.g. head lift, surgeons assessment of
surgical field tightness) should be used with extreme caution and are considered unreliable.
Extubation: Before removal of an airway device, the patient should be awake and able to protect
their airway. Eyes are typically assessed for dilation and/or disconjugate gaze, signs that some
anesthesia is still present. Removal of an ETT at this point could lead to laryngospasm and is
avoided even if the patient is moving. Other criteria for extubation includes adequate
oxygenation, assessed by SpO2 while the patient is not on high FiO2. Ventilation is assessed by
ETCO2, tidal volumes, and negative inspiratory force. Additional testing is used if the patient
received a neuromuscular blocker, such as train-of-four nerve stimulation. If the patient meets
criteria, the airway is suctioned and the tube is removed. Vigilance is important to assure that the
patient is breathing adequately after extubation and during their transport.

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Post-Operative Management: Patients are transported to the post-anesthesia care unit (PACU)
after surgery. They will initially receive critical care monitoring until certain criteria are met.
During their recovery period, post-operative issues are managed by the anesthesiologist.
Common issues include pain control and nausea/vomiting. Anesthetic-related complications,
such as corneal abrasions or respiratory failure, are managed. Additionally, any acute critical
condition would be managed by the anesthesiologist including stroke, myocardial infarction,
pulmonary embolism, or cardiac arrest.
Pain Management: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Anesthesiologists are experts in acute pain management and some choose to specialize in chronic
pain management. Although general anesthesia was discussed here, there are many other options
including local anesthesia, regional anesthesia (peripheral), and regional anesthesia (neuraxial).
Peripheral Blocks: Local anesthetic can be used to block any point along the brachial plexus or
lumbar plexus. Blocks can be a single shot injection or a continuous perineural infusion catheter.
These can be performed to allow for post-operative pain control (in conjunction with a general
anesthetic) or as the sole anesthetic (patient awake or sedated). Awake options can be used for
patients who would not tolerate a general anesthetic well (e.g. simple ankle surgery in a patient
with critical aortic stenosis).
Neuraxial Blocks: Local anesthetics can be injected into the spinal canal or epidural space to
anesthetize a large central region or the entire lower body. Spinal anesthesia is typically done as
a single shot injection and provides profound block for about 2 hours. This is a common option
for cesarean sections and the patient remains awake for the procedure. Epidural anesthesia is
typically done as a continuous infusion catheter to provide pain control during and after a
surgical procedure. Benefits are not limited to pain relief and can include decreased pulmonary
complications (e.g. patient able to take deeper breaths after lung surgery due to epidural).
Analgesics: Include non-opioids, opioids, and co-analgesics (adjuvants).
o Non-opioids: used for mild to moderate pain, first line therapy.
o Acetaminophen: antipyretic, minimal anti-inflammatory effects
o NSAIDs: aspirin, naproxen, celecoxib, ibuprofen, ketorolac
Can affect renal function, platelet function, GI bleeding
o Opioids: used for severe pain and pain not controlled by non-opioids.
o Oral (moderate pain): codeine, hydrocodone, oxycodone, tramadol
o IV (severe pain): morphine, hydromorphone, fentanyl
Fentanyl and hydromorphone have fast onset
Morphine and hydromorphone have long analgesic effects
o Co-Analgesics: used for neuropathic pain and used in addition to opioids/non-opioids.
o Antidepressants, corticosteroids, neuroleptics, anticonvulsants
o NMDA-receptor antagonists, alpha2-adrenergic agonists, local anesthetics
Final Thoughts: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Critical Care & Resuscitation: Anesthesiology has a lot in common with critical care medicine.

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Regardless of what specialty you choose, the critical care skills you learn on this rotation should
be useful. Understanding the basics of cardiovascular resuscitation is important, so consider
purchasing the most recent version of the Handbook of Emergency Cardiovascular Care by the
American Heart Association. The book is small enough to fit in your white coat and includes
guidelines for adult, pediatric, and neonatal resuscitation (ACLS, PALS, NALS).
Safe Injection Practices: Safe injection practices prevent medication errors, infections, and
accidental needle sticks. The first step is proper hand hygiene. Ensure syringes are properly
labeled and always review the medication label prior to drawing the medication into a syringe.
Do not reuse syringes, even for the same patient: One needle, one syringe, only one time.
CDC One & Only Campaign: http://www.oneandonlycampaign.org/
Per USP Chapter 797, use a filter needle when drawing medications from glass vials/ampules.
Per the ASA Infection Control practice parameter, swab medication vial stoppers/septums and
glass vial/ampule necks with alcohol prior to access with a needle.
ASA: http://www.asahq.org/quality-and-practice-management/standards-and-guidelines
Infection Prevention: Up to 25% of patient who acquire catheter-related bloodstream infection
(CRBSI) die. There are several guidelines available to prevent infections during placement of
vascular lines, urinary catheters, and other devices.
WHO Blood Stream Infections: http://www.who.int/patientsafety/implementation/bsi/en/
CDC Blood Stream Infections: http://www.cdc.gov/hai/bsi/bsi.html
Video: Hand Hygiene. N Engl J Med 2011; 364:e24
http://www.nejm.org/doi/full/10.1056/NEJMvcm0903599
Mobile Resources: Here are some iPhone Apps that may be useful for your rotation.
Medscape: http://itunes.apple.com/us/app/medscape/id321367289?mt=8
Gas Guide: http://itunes.apple.com/us/app/gas-guide-anesthesia-quick/id349367741?mt=8
ABG Eval: http://itunes.apple.com/us/app/abg-acid-base-eval/id426019807?mt=8
MedCalX: https://itunes.apple.com/us/app/medcalx-professional-medical/id1041464932?mt=8
Online Resources: Here are some websites that may be useful for your rotation.
NEJM Procedure Videos: http://www.nejm.org/multimedia/medical-videos
Capnography Education: http://www.capnography.com/
Open Anesthesia: http://www.openanesthesia.org/
Anaesthesia UK (FRCA): http://www.frca.co.uk/
American Society of Anesthesiologists (ASA): Our specialtys society. If you are considering
becoming an anesthesiologist you may want to consider joining the ASA. Membership helps you
stay informed about current issues in the specialty. Membership includes access to
Anesthesiology (one of our main journals) and the ASA Newsletter.
Join Us! Please feel free to ask any questions during your rotation. We would love to share our
passion for the specialty and try to convince you to join.

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