ACTc References and Readings


Updates and Fixes


1. Please uninstall ACTc from your handheld. You do not need to delete the program from your application library in iTunes. Reinstall and synchronize the databases PRIOR to any use of ACTc to correct a database.

2. Error Fix: If ACTc is exiting prematurely, please re-install by deleting ACTc on your device and iTunes library. Then download the newest version and reinstall.

Quick Tip:

If you are in a limited wifi area and cannot connect to the internet, you can still use ACTc.


  1. Goto your iPhone/iTouch settings menu and disable your wifi
  2. Sign onto ACTc
  3. You are now able to use ACTc offline
  4. When you have internet service again, sign back on to take advantage of all of ACTc's features.

Want to Add a Drug?

You must fist sign into the Web Portal *

Remember that your email address on file is Case Sensitive

  1. Click on the "Add Drug" Feature
  2. Enter the data for the new medication
  3. Click Save
  4. Sign out
  5. Sync your handheld by going to "More ACTc" area
  6. Click on "ACTc Synchronize"
  7. Select Drugs to Sync your new additions
  8. They will appear in both the Snap Shot selection list as well as in the Drug Screen.
  9. Further modification can be done either on the iPhone/iTouch or via the web portal
  10. To delete a drug, Search for the drug via the Web Portal and select the delete link, then confirm (default drugs cannot be deleted)

ACTc Screen Help Buttons - Read Them!

Every page in ACTc is focused on education. Clicking the "Help" button on each screen will reveal the details of each screen.

For example, below is the first page of the Inhalational Screen Help guide found on ACTc Inhalation Section (note: the references in the below example are specifically for the page brought up and do not correspond to the below readings):


ACTc is not intended to replace professional clinical judgment by trained anesthesia professionals.

The Inhalational Agent Screen provides sliders to show the effects of Age on MAC, Age Adjusted MAC multiples, the effects of Temperature on MAC, and the relationship of Context Sensitive Decrement Times in relation to several factors (Specific Agent, Duration of Procedure, and the ET decrement in relation to Mac Awake).

The Range Bar: Shows the Effects of Age and Temperature of MAC Awake, MAC, and MAC Bar as the sliders are adjusted when compared to a 40 year old non-temperature adjusted value for a single agent. The first value is the non adjusted 40 year old value, the second is the adjusted value.

The Current Bar: Shows the current Age and Temperature adjusted value +/- N20. It compares it to MAC awake (left of the value) and MAC bar (right of the value). When the value is greater than MAC bar , the middle value turns yellow.

The CSDT Bar: Shows the % of decrement of current ET agent (not N20) to Mac awake. By selecting the length of the procedure – the decrement time is shown. See below how values were obtained.

In understanding the nuances of MAC, ACTc assists in showing the clinician the calculated range of the effects of age on the MAC continuum – from MAC awake, MAC, and MAC BAR. Based on age calculations of Nickalls, Mapleson [83, 84], Eger’s Temperature variations [4, 85-88], and Eger’s and Baileys Context Sensitive Decrement Time Considerations[89-93]. It is also worth noting that Age adjustments are considerations, and not definitive in determining proper intra-operative end tidal concentrations. Each patient presents differently - Age plays a significant part but in no way does it completely describe or define an absolute intraoperative end tidal level.

The MAC continuum shows the implications of specific ET concentrations and the physiologic effects – specifically amnesia, movement, and blocking of adrenergic responses. Using current published research, ACTc interactively shows the effects of increasing age on the continuum. Additionally, the clinician can also see the effects of decreasing temperature on MAC requirements. The inhalation screens show these interactions instantaneously to enforce fundamental MAC teaching. Addition to age adjustments but the addition of MAC multiples can also be seen.

The addition of the Context Sensitive Decrement Times – utilizes the principles of solubility and time in circuit described by Eger and Bailey[89-91]. ACTc allows the practitioner to compare various agents (with various solubility) and select duration of the anesthetic vs. the amount of decrement desired. This action alone helps the user...... "


Education is Key| Know the Details | Read the Help Sections


ACTc References and Readings

1. Miller, R.D., Miller's Anesthesia. 6th ed. 2005, Philadelphia, Pa.: Elsevier Churchill Livingstone.


2. Morgan, G.E. and M.S. Mikhail, Clinical anesthesiology. 3rd ed. 2002, Stamford, Conn.: Appleton & Lange.

3. Eger, E.I., 2nd and B.H. Johnson, MAC of I-653 in rats, including a test of the effect of body temperature and anesthetic duration. Anesth Analg, 1987. 66(10): p. 974-6.

4. Roche, A., Human Growth: Assessment and Interpretation. First ed. 2003, Cambridge: Cambridge University Press.

5. Tantawy, H., Nutritional Diseases and Inborn Errors of Metabolism, in Stoeltings Anesthesia and Coexisting Disease, R.L.H. Robert Stoeltings, Katherine E. Marschall, Editor. 2008, Saunders: Philadelphia. p. 297 - 300.

6. Winter, M.E., Basic Clinical Pharmacokinetics. 4th ed. 2003, Philadelphia: Lippincott Williams & Wilkins. 511.

7. Barash, P.G., B.F. Cullen, and R.K. Stoelting, Clinical anesthesia. 4th ed. 2001, Philadelphia: Lippincott Williams & Wilkins.

8. Friedman, A.L., Pediatric hydration therapy: historical review and a new approach. Kidney Int, 2005. 67(1): p. 380-8.

9. Pandey, C.K., Singh, R. B. , Fluid and Electrolyte Disorders. Indian J. Anaesth., 2003. 45(5): p. 380 - 387.

10. Dunn, P.F., T.A. Alston, and Massachusetts General Hospital. Dept. of Anesthesia and Critical Care., Clinical anesthesia procedures of the Massachusetts General Hospital. 7th ed. 2007, Philadelphia: Lippincott Williams & Wilkins.

11. LMA, N.A., LMA AIRWAY INSTRUCTION MANUAL. 2005, San Diego: LMA North America.

12. American Heart Association, PALS Provider Manual, ed. M.F. Hazinski. 2002: American Heart Association. .

13. Fisher, D.M., Anesthesia equipment for Pediatrics, in Pediatric Anesthesia, G.A. Gregory, Editor. 2002, Churchill Livingstone: New York. p. 206 - 207.

14. Cauldwell, C.B., Induction, Maintenance, and Emergence, in Pediatric Anesthesia, G.A. Gregory, Editor. 2002, Churchill Livingstone: New York. p. 218, 224 - 225.

15. Gregory, G.A., Pediatric anesthesia. 3rd ed. 2002, New York: Churchill Livingstone.

16. Penlington, G.N., Letter: Endotracheal tube sizes for children. Anaesthesia, 1974. 29(4): p. 494-5.

17. Gregory, G.A., Pediatric anesthesia. 3rd ed. 1994, New York: Churchill Livingstone.

18. Morgan, G.E. and M.S. Mikhail, Clinical Anesthesiology. 3rd ed. 2005, Stamford, Conn.: Appleton & Lange.

19. Park, W.Y., et al., Age and the spread of local anesthetic solutions in the epidural space. Anesth Analg, 1980. 59(10): p. 768-71.

20. Mallampati, S.R., Clinical sign to predict difficult tracheal intubation (hypothesis). Can Anaesth Soc J, 1983. 30(3 Pt 1): p. 316-7.

21. Mallampati, S.R., et al., A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J, 1985. 32(4): p. 429-34.

22. Samsoon, G.L. and J.R. Young, Difficult tracheal intubation: a retrospective study. Anaesthesia, 1987. 42(5): p. 487-90.

23. Magboul, M.A., The Dilemma of Airway Assessment and Evaluation. The Internet Journal of Anesthesiology, 2005. 10(1).

24. Walls, R.M., Manual of emergency airway management. 2nd ed. 2004, Philadelphia: Lippincott Williams & Wilkins.

25. Braude, D., Difficult airways are "LEMONS": updating the LEMON mneumonic to account for time and oxygen reserve. Ann Emerg Med, 2006. 47(6): p. 581.

26. Cote, C.J., Pediatric anesthesia, in Anesthesia, R.D. Miller, Editor. 2000, Churchill Livingstone: Philadelphia. p. 2088–117.

27. Haskell, G.H., PALS review. 2nd ed. Pearls of wisdom. 2006, New York: McGraw-Hill.

28. Fine, G.F. and L.M. Borland, The future of the cuffed endotracheal tube. Paediatr Anaesth, 2004. 14(1): p. 38-42.

29. Chou, H.C. and T.L. Wu, Rethinking the three axes alignment theory for direct laryngoscopy. Acta Anaesthesiol Scand, 2001. 45(2): p. 261-2.

30. Cooper, R.M., Laryngoscopy — its past and future. Canadian Journal of Anesthesia, 2004. 51(R6).

31. Landsman, I., Cricoid pressure: indications and complications. Paediatr Anaesth, 2004. 14(1): p. 43-7.

32. Langeron, O., et al., Prediction of difficult mask ventilation. Anesthesiology, 2000. 92(5): p. 1229-36.

33. Kheterpal, S., et al., Incidence and Predictors of Difficult and Impossible Mask Ventilation. Anesthesiology, 2006. 105(5): p. 885-891.

34. Strote, J., M. Mayo, and D. Townes, ED patient estimation of blood loss. Am J Emerg Med, 2009. 27(6): p. 709-11.

35. Eipe, N., Ponniah, M., PERIOPERATIVE BLOOD LOSS ASSESSMENT- HOW ACCURATE? Indian Journal of Anaesthesia,, 2006. 50(1): p. 35 - 38.

36. Toledo, P., et al., The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg, 2007. 105(6): p. 1736-40, table of contents.

37. Tebruegge, M., et al., Estimating blood loss: comparative study of the accuracy of parents and health care professionals. Pediatrics, 2009. 124(4): p. e729-36.

38. Yoong, W., et al., Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals? Arch Gynecol Obstet, 2009.

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42. Klasen, J., et al., Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia. Anesth Analg, 2003. 96(5): p. 1491-5, table of contents.

43. Juneja, R., Anaesthesia for the Elderly Cardiac Patient. Annals of Cardiac Anaesthesia, 2006. 9: p. 67 - 77.

44. McArdle, G.T., et al., Preliminary results of a prospective randomized trial of restrictive versus standard fluid regime in elective open abdominal aortic aneurysm repair. Ann Surg, 2009. 250(1): p. 28-34.

45. Kleespies, A., et al., Perioperative fluid retention and clinical outcome in elective, high-risk colorectal surgery. Int J Colorectal Dis, 2009. 24(6): p. 699-709.

46. Jacob, M., D. Chappell, and M.W. Hollmann, Current aspects of perioperative fluid handling in vascular surgery. Curr Opin Anaesthesiol, 2009. 22(1): p. 100-8.

47. Bundgaard-Nielsen, M., N.H. Secher, and H. Kehlet, 'Liberal' vs. 'restrictive' perioperative fluid therapy--a critical assessment of the evidence. Acta Anaesthesiol Scand, 2009. 53(7): p. 843-51.

48. Walsh, S.R., et al., Perioperative fluid restriction reduces complications after major gastrointestinal surgery. Surgery, 2008. 143(4): p. 466-8.

49. Walsh, S.R., et al., Perioperative fluid management: prospective audit. Int J Clin Pract, 2008. 62(3): p. 492-7.

50. Shields, C.J., Towards a new standard of perioperative fluid management. Ther Clin Risk Manag, 2008. 4(2): p. 569-71.

51. Chappell, D., et al., A rational approach to perioperative fluid management. Anesthesiology, 2008. 109(4): p. 723-40.

52. Goepfert, M.S., et al., Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients. Intensive Care Med, 2007. 33(1): p. 96-103.

53. Yeager, M.P. and B.C. Spence, Perioperative fluid management: current consensus and controversies. Semin Dial, 2006. 19(6): p. 472-9.

54. Schuster, R., et al., Intra-operative fluid volume influences postoperative nausea and vomiting after laparoscopic gastric bypass surgery. Obes Surg, 2006. 16(7): p. 848-51.

55. Paut, O. and F. Lacroix, Recent developments in the perioperative fluid management for the paediatric patient. Curr Opin Anaesthesiol, 2006. 19(3): p. 268-77.

56. Boldt, J., et al., The value of an albumin-based intravascular volume replacement strategy in elderly patients undergoing major abdominal surgery. Anesth Analg, 2006. 103(1): p. 191-9, table of contents.

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59. Stephens, R. and M. Mythen, Optimizing intraoperative fluid therapy. Curr Opin Anaesthesiol, 2003. 16(4): p. 385-92.

60. Brandstrup, B., Tønnesen, H., Beier-Holgersen, R., Hjortsø, E., Ørding, H., Lindorff-Larsen, K., Rasmussen, M.S., Lanng,C.,Wallin, L.,Iversen, L.H.,Gramkow,C.S., Okholm,M., Blemmer, T., Svendsen, P., Rottensten, H., Thage,B. ,Riis,J. ,Jeppesen,I.S. , Teilum, D., Christensen, A.M., Graungaard,B. ,Pott, F., Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens. Annals of Surgery, 2003. 238(5): p. 641 - 648.

61. American Society, A., Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies. 1995.

62. Miller, J., Fleisher, L.A., Carson, J.L., Fluid Management, in Geriatric Anesthesiology, J.H. Silverstein, Rooke G.A., McLeskey C.H., Reves J. G. , Editor. 2007, Springer: New York. p. 304.

63. Christ, F., et al., Hyperosmotic-hyperoncotic solutions during abdominal aortic aneurysm (AAA) resection. Acta Anaesthesiol Scand, 1997. 41(1 Pt 1): p. 62-70.

64. Finfer, S., et al., A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med, 2004. 350(22): p. 2247-56.

65. Gold, M.S., Perioperative fluid management. Crit Care Clin, 1992. 8(2): p. 409-21.

66. Grocott, M.P. and M.A. Hamilton, Resuscitation fluids. Vox Sang, 2002. 82(1): p. 1-8.

67. Hai, S.A., Permissive hypotensive resuscitation--an evolving concept in trauma. J Pak Med Assoc, 2004. 54(8): p. 434-6.

68. Holte, K., P. Jensen, and H. Kehlet, Physiologic effects of intravenous fluid administration in healthy volunteers. Anesth Analg, 2003. 96(5): p. 1504-9, table of contents.

69. Joshi, G.P., Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg, 2005. 101(2): p. 601-5.

70. Shoemaker, W.C., et al., Resuscitation from severe hemorrhage. Crit Care Med, 1996. 24(2 Suppl): p. S12-23.

71. Sigurdsson, G.H., Perioperative fluid management in microvascular surgery. J Reconstr Microsurg, 1995. 11(1): p. 57-65.

72. Sinclair, S., S. James, and M. Singer, Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ, 1997. 315(7113): p. 909-12.

73. Holte, K., N.E. Sharrock, and H. Kehlet, Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth, 2002. 89(4): p. 622-32.

74. Rehm, M. and U. Finsterer, Treating intraoperative hyperchloremic acidosis with sodium bicarbonate or tris-hydroxymethyl aminomethane: a randomized prospective study. Anesth Analg, 2003. 96(4): p. 1201-8, table of contents.

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76. Cote, C.J., Grabowski, E. F., Stowell, C.P., Strategies for Blood Product Management and Reducing Transfusions, in A Practice of Anesthesia for Infants and Children, C.J. Coté, Lerman J.L.,Todres, I.D., Editor. 2008, Elsevier Health Sciences: Philadelphia. p. 195 - 220

77. Agarwal, R., Pediatric Anesthesia, in Anesthesia secrets, J. Duke, Editor. 2006, Elsevier Health Sciences: Philadelphia. p. 377.

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79. Hillyer, K.L., Hillyer, C.D., Packed Red Blood Cells and Related Products, in Handbook of transfusion medicine, C.D. Hillyer, Editor. 2001, Elsevier Science: San Diego. p. 29-30.

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84. Mapleson, W.W., Effect of age on MAC in humans: a meta-analysis. Br J Anaesth, 1996. 76(2): p. 179-85.

85. Eger, E.I., 2nd, Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg, 2001. 93(4): p. 947-53.

86. Eger, E.I., 2nd, L.J. Saidman, and B. Brandstater, Temperature dependence of halothane and cyclopropane anesthesia in dogs: correlation with some theories of anesthetic action. Anesthesiology, 1965. 26(6): p. 764-70.

87. Satas, S., et al., MAC for halothane and isoflurane during normothermia and hypothermia in the newborn piglet. Acta Anaesthesiol Scand, 1996. 40(4): p. 452-6.

88. Antognini, J.F., Hypothermia eliminates isoflurane requirements at 20 degrees C. Anesthesiology, 1993. 78(6): p. 1152-6.

89. Eger, E.I., 2nd and S.L. Shafer, Tutorial: context-sensitive decrement times for inhaled anesthetics. Anesth Analg, 2005. 101(3): p. 688-96, table of contents.

90. Bailey, J.M., Context-sensitive half-times and other decrement times of inhaled anesthetics. Anesth Analg, 1997. 85(3): p. 681-6.

91. Bailey, J.M., Technique for quantifying the duration of intravenous anesthetic effect. Anesthesiology, 1995. 83(5): p. 1095-103.

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93. Thompson, C., Context Sensitive Decrement Times. 2000: Royal Prince Alfred Hospital, Sydney, Australia.

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136. Salinas, F.V., Pharmacology of Drugs used for Spinal and Epidural Anesthesia and Analgesia, in Spinal and Epidural Anesthesia, C. Wong, Editor. 2006, McGraw-Hill Professional: New York. p. 92 - 94.

137. Bromage, P.R., Spread of analgesic solutions in the epidural space and their site of action: a statistical study. Br J Anaesth, 1962. 34: p. 161-78.

138. Evans, H.C.L., Nielsen, K.C., Steele, S.M., Regional Anesthesia, in Handbook of Ambulatory Anesthesia, R.S. Twersky, Philip B.K., Editor. 2008, Springer: New York. p. 203.

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140. Veering, B.T., Cousins, M.J., Epidural Neural Blockade, in Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain, M.J. Cousins, Carr, D.B., Horlocker, T.T., Bridenbaugh, P.O., Editor. 2008, Lippincott Williams & Wilkins Philadelphia p. 261.

141. BedfordLabs, Chloroprocaine - package insert. 2005, Bedford Labs: Bedford, OH 44146.

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