Viva pageantry

 

Assessment:

Meta-questions

·      What is the status of the current illness?

·      What is the status of the comorbidities?

·      How will we ready the patient?

·      How will we anaesthetize the patient?

Hx

·      HOPC

·      PMHx

·      PAHx

·      Meds

Ex

·      General inspection: GCS, WOB, BMI, colour

·      Vital signs

·      Airway

·      Breathing

·      Circulation

Ix

·      Blood tests: e.g. BGHO, FBE

·      Cardiac: ECG, echo

·      Radiology: e.g. ultrasound of placenta

Planning

·      Investigations

·      Treatment: fluids, medications

·      Phone calls: e.g. HDU, blood bank, transfer service

 

Pre-op:

Investigations

·      Blood tests: esp BGHO

·      Cardiac imaging: ECG, TTE

·      HOPC imaging: esp CT neck, CT brain, USS placenta

Treatment

·      Regular meds?

·      New meds?

·      Fluids / blood products?

·      Reversal agents?

Phone calls

·      Theatre NIC

·      Anaes NIC

·      Blood bank

(Paeds)

·      Rapport/discussion/planning/expectations

·      Pre-med

·      Topicalisation

 

Intra-op:

What are you most worried about?

·      A: CICO, aspiration

·      B: respiratory failure

·      C: cardiovascular collapse, AMI

·      D: stroke, awareness

Anaesthetic

·      e.g. relaxant GA with mRSI

o   Induction with propofol/alfentanil/sux + suction/cricoid/apnoea

o   Maintenance with sevo/nitrous

·      e.g. TIVA -propofol / remifentanil / metaraminol infusions

·      e.g. adrenaline 10mcg/mL drawn up

Airway

·      ETT + video laryngoscope + ramping + good pre-oxygenation

·      Extubate awake on remifentanil

Access

·      Large PIVC + pumpset + rapid infuser

·      A-line

·      CVC

Probes

·      Temp (with forced air warming)

·      BIS

·      A-line

·      CVC

·      IDC

People

·      Paeds: parent for child, escort for parent, nurse for me

·      Airway: second anaesthetist, ENT surgeon scrubbed and ready

·      MTP: second anaesthetist, extra nurses

Pain

·      Regional/neuraxial

·      Infusions/PCA

·      Pain service

 

Post-op:

Disposition

·      HDU/ICU

Referrals

·      Acute pain service

·      Physician

 

Disasters:

Approach

·      Most likely cause is…

·      Things I would want to rule out are…

·      Systematic approach to other causes

Breaking the rules

·      Must not follow protocol when counterproductive

·      Arrest due to large vessel injury -> stop CPR to fix

·      Arrest due to UAWO -> stop CPR to get airway

·      Agitated trauma patient -> ketamine before primary survey

·      Child with full stomach -> inhalational induction if no other choice

Bleeding wish list

·      Access: big IV, A-line

·      Warming: air, liquid

·      Products: cross-match, cell-saver

 

Paediatric induction:

Pre-op

·      Assessment

·      Rapport

·      Discuss plan (pre-med / induction)

·      Discuss expectations (stage of excitation)

·      Pre-medicate

·      Topicalise

·      Prepare theatre (ABC equipment / drugs / monitoring)

Intra-op

·      Anaes: GA with inhalational induction

·      Airway: ETT without relaxant

·      Access: peripheral IV and giving set with burette

·      Probes: standard but sat probe only at induction

·      Pain: caudal block?

·      People: nurse for me, parent for child, tech for parent

Post-op

·      Propofol + clonidine

·      Deep extubation

·      Safety before leaving in PACU

 

Nasal intubation:

·        Topicalise with cophenylcaine

·        Prepare nasal RAE ETT in warm water

·        Intravenous anaesthetic: propofol / remi / metaraminol

·        Test bag-mask ventilate

·        Pass ETT to nasopharynx

·        Visualise glottis with hyperangulated blade

·        Pass ETT with MacGill’s forceps

 

Intra-uterine resuscitation:

Interventions

·      Left lateral

·      Fluid

·      Vasopressor

·      Tocolytic

Monitoring

·      Frequent obs

·      Continuous CTG

·      Foetal scalp lactate

 

Total spinal:

A

·      Manoeuvres

B

·      100% O2

·      Bag and mask

C

·      Fluid

·      Pressor

D

·      N.B. the patient is conscious

E

·      Left lateral

·      Little bit upright (beware hypotension)

F

·      Intra-uterine resus

 

Obesity:

Issues

Cause:

·      Obesity itself: difficult airway / access / position / monitoring / surgery

·      Sleep-disordered breathing: PHTN and airway death

·      Metabolic syndrome: AMI, CVA, VTE

Pre-op

·      Investigations

·      Treatment

·      Phone calls to anaes NIC: get ready

Intra-op

·      Anaes: relaxant GA with mRSI

o  Propofol 2mg/kg LBW (height – 100)

o  Roc 1.2mg/kg

·      Airway: ETT + video laryngoscope + positioning + good pre-ox

·      Access: large PIVC + A-line pre-op

·      Probes: standard ±A-line + temp + BIS

·      Pain: opioid-sparing, regional if possible

·      People: many hands + hover mat

Post-op

·      HDU

·      Pain service

·      Opioid-minimisation

 

Post-crisis jobs:

Patient and family

·      Medical care

·      Open disclosure

·      Support system referral

Anaesthetist

·      Death certificate

·      Notify MDO

Team

·      Optional debrief

·      Offer to send them home

·      Call head of department

·      Call hospitals co-ordinator

Quality improvement

·      ISR 4 (near miss / no harm) -> department M&M

·      ISR 2-3 (i.e. mild-mod harm) -> hospital M&M

·      ISR 1 (i.e. severe harm or death) -> state

 

Regional anaesthesia:

Pre-amble

·      Indications and contraindications

·      Explain procedure

·      Discuss risks, benefits, alternatives

·      Formal consent

Preparation

·      Monitored area

·      IV access

·      Oxygen

·      Monitoring

·      Local drugs

·      Sedative drugs

·      Emergency drugs

·      Emergency equipment

Procedure

·      Ergonomics – patient, self, USS machine

·      Asepsis – patient, self, USS probe

·      TIME OUT

·      Needling – subcut infiltration, block

Post-procedure care

·      Catheter management

·      Monitoring

·      Transition analgesia

 

Transport:

·        Airway

·        Breathing (oxygen, ventilator manual or auto)

·        Circulation (IV access, fluid)

·        Drugs (narcotic, relaxant, pressor and whatever infusions)

·        Monitoring

·        People (driver, nurse, doctor)

·        Organisation (phone calls to destination, discuss with team before embarking)

 

Day surgery: is it ok?

 

Two questions:

1.      Is the hospital appropriate for this patient?

a.      Facilities

b.      Equipment

c.      People

2.      Will the patient meet discharge criteria today?

 

Discharge criteria:

Logistics

·      Companion

·      Phone

·      Proximity

·      Instructions

·      Follow up plan

Manageable

·      Eat and drink

·      Wee and poo

·      Mobilise

·      Wound / drains

Safety

·      A: obstruction

·      B: impairment

·      C: bleeding

·      D: sedation

If OSA: must be mild or moderate, treated, can use CPAP, and no opioid

 

 

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