ABCs of Anaesthesia Boot Camp Flashcards
What are the components of the general anaesthetic assessment?
- Past Anaes Hx - issues previously? PONV? FHx of issues?
- PMHx/Systems
- Global function (METS)
- ET
- CVS (IHD, CCF, Valves, Rhythm, PVD, HTN)
- Resp (COPD, Asthma, OSA, URTI, Pneumonia, smoking)
- Other (Liver, Kidney, CNS, DM, Haem, Rheum, infection) - Meds/allergies
- Fasting/Aspiration risk
- last solids, liquids
- GORD or delayed gastric emptying - Exam
Height, weight, BMI, vitals, Cardio and resp
Airway assessment (+dental) - Ix
Additional considerations for obstetric assessment?
- Prev Obs Hx
- Pre eclampsia, HTN, DM etc - Gravidity / Parity
Weeks
Method of delivery and issues for each delivery - Ix
GH is valid with Ab
Obstetric US findings
plt for spinal
how to break down perioperative risk/benefit profile?
Perioperative risk
- ACS NSQIP risk calculator
Surgical risk
- chance of improvement
- chance of no improvement
- chance of harm
Risk of doing nothing
approach to anaesthetic consent
Common: pain, nausea/vomiting and a sore throat
There is a small chance of dental damage but this is unlikely
The risk of serious life threatening events is very unlikely
overall having this anaesthetic is probably safer than driving a car on the
road every year…
Would you like me to go through these risks or anything in more detail?’
In particularly high-risk patients you may want to mention that
• ‘Serious events include life-threatening complications with your heart and
lungs, brain, drug reactions, allergies and awareness’
What are the general legal requirements for obtaining consent?
- Consent must be given freely without coercion
- Withdrawal of consent must be a realistic option
- Consent may only be given by a person capable of doing so
- Consent must be informed – benefits, risks and alternatives
What are the possible surgical issues youd like to discuss with the surgeon?
- Position
- Duration
- Expected blood loss
- Antibiotics
- DVT prophylaxis
- Special requests (cell saver, avoiding muscle relaxant, tourniquet, NIM ETT, Airway preference, avoiding GA for local etc)
How can lungs be damaged during mechanical ventilation?
- Volutrauma (alveolar overdistention - causes APO/atelec)
- Barotrauma (high transpulm pressure- causes PTx/pneumomediastinum)
- atelectrauma (repeated open + closing of alveoli usually low volumes cause this)
- biotrauma (damage to lung and extrapulmonary organs caused by inflammatory response to mechanical ventilation)
- shear strain
- Oxygen toxicity (oxidative injury)
What is a normal FRC?
30mL/kg so around ~2L for a 70kg person
How many mL/min of O2 does an average person use?
3.5mL/kg/min so about 250mL/min for 70kg person
How many mins of apnoea do you have before running out of O2 if preoxygenated well
2L FRC, 80% O2 = 1600mL
3.5mL/kg O2 usage so 250mL/min
so 6 mins in ideal circumstances
FiO2 setting during maintenance of anaesthesia?
30-80%, usually 50%
avoid v low FiO2 incase of airway loss
avoid v high fiO2 to avoid masking progressive lung injury / O2 toxicity
what is the oesophageal sphincter pressure? why is this important?
15cmH2O (pressures above this with LMA could cause gastric insufflation)
What ventilator mode should be used for leaky circuits?
PCV
- VCV gives an uncertain volume to the lung (will say it was delivered, doesnt account for leak)
- Pressure is the limiting variable, therefore target a pressure. The pressure the vent measures as delivered is a true reading
- downside is high pressure can insufflate the stomach
What are the components of a basic anaesthetic plan?
- GA v Regional?
- Which components of the triad?
- ETT v LMA
- Monitors (art, CVC, Swan)
- Pain - meds, blocks, PCA/APS
- Post op HDU/ICU?
When might a case require paralysis?
Surgical
- Critically still - neuro
- Access - laparotomy, laparoscopy
Anaesthetic
- RSI/Intubation
Patient
- Significant lung disease
- obesity
When to use ETT v LMA
ETT - (PAVS)
- Paralyzed
- Airway protection
- need precise control of Vent (lung diseas, long case, neuro, unwell pt)
- Shared airway
LMA
- uncomplicated, fasted, well pt with no airway issues
AS reciepe?
GA, Art line, Gentle induction (GAG)
Spinal may give you less control over BP which is important for AS
Plan for 70M Laparotomy for bowel Ca, PHx severe restrictive resp disease, chronic back pain on 100mg oxycontin daily
- GA
- hypnosis, analgesia and Paralysis (surgical and severe lung disease)
- ETT
- Standard + Artline (gases for lung disease, elderly for bowel op)
- fent+/-morph, ketamine, regional block, APS, consider lignocaine/Mg
- ?HDU for pain
What do you have to consider when family members have ‘nearly died’ under anaesthesia?
- MH
- Sux Apnoea
- Anaphylaxis
- Congenital cardiac issues/arrhythmias
Framework to decide to proceed or postpone a case with a cardiac risk pt
EARLMC- Every Anaesthetist Really Loves Morning Coffee
Emergency - proceed (optimize, monitor) Active Cardiac condition - refer Risk - use RCRI risk calculator Low risk (0-1 risk factor) - proceed >4 METS - proceed will testing Change management - Yes(test) No (proceed)
can extrapolate this to more than just cardiac
What are active cardiac conditions as per the ACC/AHA guidelines which you would refer for
MADVA
- MI <60days
- Angina (unstable or severe)
- Decompensated HF (NYHA IV, Worsening, new)
- Valvular disease (severe, so AV area <1cm2 or mean pressure 40mmhg, or symptomatic MS)
- Arrhythmias (Slow: high grade AV block, Symptomatic brady, Fast: new VT, symptomatic ventricular arrhythmias, SVT with uncontrolled rate >100)
What is a MET?
- Metabolic equivalent
- ratio of WORK metabolic rate to REST metabolic rate
- 1 = 3.5mLO2/kg/min (250mL/min) in a 70kg Male sitting quietly
- scale is define by DASI - duke activity status index
- risk is increased if unable to meet a 4 MET demand in most daily activities
- correlates well with periop survival
Proceed or postpone?
68M w NSTEMI 2/52 prior, ongoing unstable angina, high speed MVA w FF in abdomen and surgeon wants theatre urgently
Emergency - yes, proceed
Optimize with artline, avoid tachy, potentially transfuse etc
Proceed or postpone?
78F #NOF, multicomorbid with unknown exercise tolerance, in pain with fluid overload
Emergency - yes (urgent), proceed
Have some time to refer and optimized (can postpone a bit)
Optimize: block, analgesia, diuresis, etc
Proceed or postpone?
70M w PR bleeding secondary to new Rectal Ca, Phx HTN, T2DM, Hchol, unknown ET
Emergency - yes, proceed
optimize as possible
Proceed or postpone?
60F Lap chole, in rAF, nil Sx
emergency - no
Active cardiac - yes, refer (postpone)
if biliary sepsis (cause for AF) - proceed, attempt to control rate
Proceed or postpone?
60F for Lap incisional hernia repair, PHx RA and hear a systolic murmur
Emergency - no
Active - potentially, refer (postpone, get TTE)
Proceed or postpone?
78F with recent TTE showing mod AS for cataract surgery, unable to walk up stairs due to arthritis
Emergency - no
Active - No (severe would be)
Risk - LOW - proceed
Proceed or postpone?
50M for inguinal hernia repair w trifasicular block and multiple fainting episodes
Emergency - no
Active - Yes, refer and postpone
Proceed or postpone?
60M lap chole, unkown ET secondary to back injury, nil PHx
Emergency - no
Active - no
Risk - Low
Proceed
Could argue unsure of METS and that testing might change mgmt? then - postpone for testing
Boss call
Proceed or postpone?
60M for THR, AF at rate 70, Hchol, HTN, obese, stays in bed most days, walks to lounge to watch TV
Emerg - no Active - no Risk - moderate Low risk - no, 4 RF METS >4 - assess if good proceed, if not or unknown assess if testing is relevant
Proceed or postpone? what else do you want to know?
80F for THR, NYHA II, IHD, T2DM, AF, COPD, OSA (all stable and optimized), walks daily, iADLS
emergency - no active - no Risk - mod Low risk - no, many METs >4 - determine, if yes then proceed
What are the parts of an induction checklist?
4 Ms:
- Machine
- Meds (SPAAA drugs - Sux, propofol, aramine, atropine, adrenaline)
- Monitoring (Sats, ETCO2, BP, ECG)
- MABELS (airway equipment)
mask, airways (OPA, NPA, LMA), bougie and stylet, ETT, laryngoscope, suction
Choose hypnotic/analgesia/relaxant for 50yo for lap chole with renal impairment
hypnotic: propofol w sevo maintenance
analgesia: fentanyl (moph metabolites may accumulate)
relaxant: Atracurium/cisatracurium, if you need sux check K, could use roc/vec - have prolonged action and have reversal agent
Choose hypnotic/analgesia/relaxant for 60yo for umb hernia repair with PONV and difficult BMV
hypnotic: propofol induction and maintenance
analgesia: fentanyl (+muyltiumodal + Local to spare opioids)
relaxant: FAST to spare bad BMV - sux or roc at 1mg/kg
Choose hypnotic/analgesia/relaxant for 70yo for lap nephrectomy with cardiac, renal and liver impairment, asthma)
hypnotic: prop/ket/midaz induction
analgesia: remi (long case), or just fent
relaxant: could go cisat but long onset or roc with a reversal agent. avoid atrac due to histamine release in this pt with asthma
Choose hypnotic/analgesia/relaxant for 30yo for GA caesarean section with preeclampsia
hypnotic: prop
analgesia: alfentanil ( fast - avoid bp spike with PE and doesnt last too long - good for baby,
relaxant: FAST (ASP risk) sux or roc 1mg/kg
How to decide when to extubate?
- ABCs stable (reasonable oxygenation and PEEP, good TV, good analgesia)
- obeying
Extubation sequence
- insert bite block
- increase FiO2
- suction
- head up
- check equipment
- Reversal of triad (Volatile off, flow up to 15L/min, change to SIMV/PSV and bagging circuit, reversal of muscle relaxation with neostigmine 2.5mg/glycopyrrolate 0.4mg , check return of muscle function and conscious state
- when pt inhales remove ETT
- facemask
predictors of difficult LMA insertion and ventilation
RODS Restricted mouth opening Obstruction Distorted airway Stiff lungs or c-spine
Hx
Insertion
- small mouth (need 2cm)
LMA Placement
- abnormal airway anatomy
- absence of teeth
- laryngeal obstruction
Ventilation
- raised BMI >30
- non compliant lungs (res/obs lung disease)
What are the 3 Axis
- oral axis
- pharyngeal axis
- tracheal axis
Predictors of difficult BMV
BONES - Beard, obese, No teeth, Elderly, Sleep apnoea/snoring
Hx
Seal
- Beard
- no teeth
- elderly
Oropharyngeal obs
- OSA
- Obesity
- Mallampati III-IV
- severely limited jaw protrusion
- Neck radiation/burns
Ventilation
- Obesity
- non compliant lungs (res/obs lung disease)
predictors of difficult laryngoscopy
LEMON - Look externally, Eval (3-3-2), Mallampati, Obstruction, Neck extension
Hx
Introducing laryngoscope
- mouth opening <3cm
- long upper incisors
Overcrowded mouth
- high arched narrow palate
difficult view of the larynx
- mallampati III or IV
- poor jaw protrusion
- neck circumference >44cm
- TMD <6cm
- limited neck extension <20deg
Laryngeal oedema/path
- stridor/difficulty swallowing
- hoarse voice
Describe the mallampati score, TMD and mandibular protrusion
modified mallampati :
Class I: Soft palate, uvula, pillars visible.
Class II: Soft palate, major part of uvula
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible.
TMD - distance from mental protrusion to thyroid cartildge >6.5 good, 6-6.5 equivicle, <6 bad
Mandibular protrusion- A mandible protrudes beyond incisors, B in line, C cannot
What are the cormack lehane grades
I - full view of cords IIa - most IIb - just tip III - no cords IV - cant see epiglottis
5 second airway exam
- Hx
- Inspect (age, beard, BMI, malformation, trauma)
- Mouth open (mallampati, tongue, prominent teeth, inter incisor distance)
- mouth closed ( jaw protrusion, TMD, neck extension)
3-3-2 - 3 Mouth opening, 3 thryromental, 2 thyrohyoid
options for a very difficult airway?
- AFOI or awake look
- regional/local
- awake trache
- inhalational
what can you do if you predict a difficult BMV
Equipment/staff
- guedel, NPA, range of masks
- 2 hand with support
modify pt characteristics
- position
- shave
- leave dentures in
tailor anaesthetic
- meticulous preox
- use rapid muscle relaxant
- use ETT/LMA immediately without persisting with BMV
what can you do if you predict a difficult LMA
Equipment/staff
- different LMAs (fastrtach narrower, proseal higher seal pressure)
- have ETT ready
modify pt characteristics
- position
- leave dentures in
tailor anaesthetic
- meticulous preox
- use ETT immediately without persisting with LMA
what can you do if you predict a difficult intubation?
Equipment/staff
- video
- bougie
- different size tubes and blade
modify pt characteristics
- position
- dentures out
tailor anaesthetic
- meticulous preox
- apnoeic oxygenation or optiflow thrive humidified high flow O2
- sux/high dose roc to help get best conditions rapidly
What can you do if you are trying to pass ETT but struggling
Plan A (APPBBB)
- assistance
- position
- paralysis
- BURP
- Bougie
- Blade (different or video)
Plan B
- LMA/iLMA
- fiberoptic
- other technique
What can you do if you are trying to BMV but struggling
- jaw thrust
- guedel / NPA
- two hands
- assistant
What can you do if you are trying to pass LMA but struggling or cant ventilate with LMA
Pass
- jaw thrust
- rotation
- smaller/different LMA
- more force (careful)
Ventilate
- micro adjust
- more propofol
- paralyze
when do you identify CICO?
- > 3 attempts
and
- failed oxygenation with 2 techniques
OR - SaO2 persistently <90%
Basic framework for problem solving in anaesthesia
1 - safety
2 - temporization
3 - diagnosis
4 - treatment
24M appx BP 70 post induction - problem solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
Temporisation
- fluid bolus
- vasopressors
- turn down volatile
Diagnosis
- likely: medication effect, hypovolaemia
- serious: anaphylaxis, bleeding (lap port injury), sepsis
- other
Treatment
- check for signs of serious DDx - rash, wheeze, blood
40M lap chole - tachy on incision HR 160. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor (ECG+BP)
- Stop surgery
Temporisation
- stop surgery
- analgesia
- deepen anaesthesia
Diagnosis
- likely: pain, too light
- serious: arrhythmia, anaphylaxis
- other
Treatment
- check for signs of serious DDx
- non sinus tach: ALS
- sinus tach: increase analgesia and depth and check for anaphylaxis
25F femoral nail post MBA, asthmatic, post RSI pt desats. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor (vent)
- Stop surgery
Temporisation
- 100% FiO2
- increase flow
- Bag
Diagnosis
- likely: lack of preoxygenation/delay in intubation, bronchospasm
- serious: aspiration, esophageal intubation, pneumothorax, anaphylaxis, PE/air embolism
- other
Treatment
- check for signs of serious DDx
- with bag check compliance: tight/wheeze/kink or obstruction? loss of pressure - increase APL and reventilate, check ETT position
- check circuit from machine to ETT, if issues switch to laerdel bag, use bougie to check ETT
- Auscultate lungs: wheeze-salbutamol/adrenaline, mucous - suction/peep, unilat sounds-ptx, APO-LMNOP, Aspiration - suction, bronch
35F in recovery post diagnostic lap BP 90 and HR 105. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor and trend
- Scan pt/monitors
- call for help if worried
Temporisation
- fluids, metaraminol
Diagnosis
- likely: post anaes vasoplegia, hypovolaemia
- serious: bleeding, anaphylaxis, sepsis, cardiac
- other
Treatment
- check for signs of serious DDx
- Hb, drains, ACS risk - TTE/ECG/Trop/Cardio
35M in recovery post transphenoidal hypophysectomy now with marked stridor. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor and trend
- Scan pt/monitors
- call for help
Temporisation
- positioning
- oxygenate
- airway manuevers+adjuncts
Diagnosis
- likely: loss of airway tone and decreased conscious state
- serious: residual paralysis, throat pack/foreign body, anaphylaxis
- other
Treatment
- check for signs of serious DDx
- BVM/jaw thrust/MPA/OPA - if straining like laryngospasm - CPAP/prop/sux
- neuromuscular monitoring - TOF<0.9 give reversal
- inspect throat, suction, remove any foreign body
- inspect wound for haematoma/swelling
- auscultate - wheeze-salbutamol
40F diagnostic lap for endo with high ventilating pressures. 120kg and T1DM. Problem-solving framework
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
Temporisation - 100% FiO2 - increase flow - Bag \+/- paralysis
Diagnosis
- likely: weight and head down ventilation or circuit kink
- serious: bronchospasm, endobronchial intubation,
- other
Treatment
- check for signs of serious DDx
- with bag check compliance: tight/wheeze/kink or obstruction? loss of pressure - increase APL and reventilate, check ETT position
- check circuit from machine to ETT, if issues switch to laerdel bag, use bougie to check ETT
- Auscultate lungs: wheeze-salbutamol/adrenaline, mucous - suction/peep, unilat sounds-ptx, APO-LMNOP, Aspiration - suction, bronch
80M post GA for cataract op, diabetic. failed block converted to GA. now unresponsive 30min after the end of the case. Problem-solving framework
DELAYED EMERGENCE
Safety (CHeSS)
- Check reading/transducer/monitor
- call for Help
- Scan pt/monitor
Temporisation
- O2, assited ventilation maneuvers +/- adjuncts + support BP/HR (ABCs)
Diagnosis
- likely: age/length of case/opioids/BSLs
- serious: stroke, local anaesthetic spread
- other
Treatment
- Assess ABCs
- Check chart - hypontics, muscle relaxants, opioids, other. antidote - naloxone, flumazenil, sugammadex as appropriate
- ABG/VBG - Na, PCO2, BSL
- consider rare: LA spread, Stroke
Causes of hypoxaemia and management
- LOW FiO2
- O2 not connected, diffusion hypoxaemia
Tx- incease O2 - HYPOVENTILATION
- Low minute ventilation, all failure to breathe causes (CNS/muscle/chest wall), all stridor causes
Tx- ensure adequate MV, check ETCO2 - VQ MISMATCH (MOST COMMON)
- bronchospasm, aspiration, atelectasis, APO, NPPO, consolidation, PE, PTx, anaphylaxis
Tx - bronchodilators, increase volatile, recruitment, suction, LMNOP, needle decomp/ICC - SHUNT
- cannot be overcome by 100% FiO2
- ARDS, pneumonia, atelectasis - DIFFUSION ABNORMALITY
- ILD, COPD
Causes of high ventilating pressures and management
- MACHINE
- Flow valves
Tx - inspect, use laerdel bag - CIRCUIT
- kink in tubing
Tx - inspect, use laerdel - HEAT AND MOISTURE EXCHANGE (HME)
- obstruction from secretions
Tx - exhange - ETT
- kink, secretions, biting, cuff herniation, endobronchial intubation
Tx - inspect, pass bougie/suction - PATIENT
- inadequate paralysis, bronchospasm, sputum plug, PTx, pneumoperitoneum, APO
Tx - cause specific
Causes of tachycardia and management
- PHYSIOLOGICAL
- Resp: O2/CO2/pH, all lung path (PTx, asp, bronchospasm)
Tx - optimize O2, ventilation
- CVS: causes of shock
Tx - check surgical field, volume, check Hb
- CNS - stroke
Tx - CT
- Metabolic/Endo: temp, thyroid, phaeo, BSLs, MH
Tx - specific to cause
- PAIN somatic (wound), visceral (full bladder), anxiety
Tx - analgesia, IDC for long case (ensure not blocked) - PHARMACOLOGICAL
- Depth of anaesthesia, drug error, reaction, withdrawal, illicit use
Tx - volatile, propofol, cease drug, supportive - SURGICAL
- bleeding, tourniquet, brainstem manipulation, pneumoperitoneum
Tx - treat blood loss, tolerate if all else ruled out
BB therapy - esmolol 0.25-0.5mg/kg bolus followed with metoprolol 1mg bolus q15min
Causes of bradycardia and management
- PHARMACALOGICAL
- Metaraminol, BB, CCB, Amiodarone, Digoxin, Anticholinesterase, redose sux
Tx - cease drug - VAGAL
- Traction on viscera/pleura/peritoneum, barorecptor (CEA, raised ICP, metaraminol), OC reflex, Bezold-Jarisch reflex, laryngeal
Tx - cease stimulus
3. Physiological CVS - AMI/arrhythmia Tx - glyco/atropine/ephedrine/adrenaline Neuro - raised ICP Metab - hypothermia, hyperkalaemia, hypothyroid
Pacing if needed
Causes of failure to breathe and management
- CNS - delayed emergence
- all failure to emerg causes (phys/pharm/neuro/other)
Tx- as per delayed emergence - MUSCLE FUNCTION - essentially causes of hypoventilation
- CNS (UMN/LMN), NMJ, lung, chest wall, pain
Tx - assisted ventilation
Causes of hypertension and management
- PHYSIOLOGICAL
- Resp: O2/CO2/pH
Tx - optimize O2, ventilation
- CNS - raise ICP, autonomic dysreflexia
Tx - CT
- Metabolic/Endo: temp, thyroid, phaeo, BSLs, MH,
Tx - specific to cause - PHARMACOLOGICAL
- Depth of anaesthesia, drug error, reaction, withdrawal, illicit use
Tx - volatile, propofol, cease drug, supportive - PAIN
- somatic (wound), visceral (full bladder), anxiety
Tx - analgesia, IDC for long case (ensure not blocked) - SURGICAL
- bleeding, tourniquet, pneumoperitoneum
Specific meds: can increase anaesthesia, hydralazine 5mg, phentolamine 0.5mg, BB, GTN/SNP
Causes of hypotension and management
- PRELOAD
- hypovolaemia, venodilation, increased ITP
Tx- Check surgical field/drain/suction/PPV/Hb, give volume - RATE + Rhythm
- too fast or slow
Tx - ECG, ALS - CONTRACTILITY
- AMI, O2/CO2/pH, electrolytes
Tx - ECG, VBG, TTE, CO monitor - AFTERLOAD
- increased (AS/HOCM), decreased (Sepsis/anaphylaxis/pharm)
Tx - vasopressors, specific treatment - OBSTRUCTIVE
- Tampondae, Tension, PE
Tx - decrease anaesthetic agents, specific treatments
Causes of hypercapnoea and management
- MAKING TOO MUCH
- MH, Thyrotoxicosis, sepsis, exogenous (Pneumoperitoneum)
Tx - specific - EXHALING TOO LITTLE
- hypoventilation, deadspace
Tx - increase MV, decrease pneumoperitoneum/go open, fluid resus - REBREATHING
- exhausted soda lime, low flow
Tx - replace soda lime, increase flow
Causes of stridor and management
- INTRALUMINAL
- Foreign body, blood/mucus/vomit
Tx - suction, laryngoscope + mcgills - LUMINAL
- laryngospasm, Oedma/anaphylaxis, decreased airway tone, tracheomalacia, invasive ca
Tx - anaphylaxis tx, airway manuevers, ETT - EXTRINSIC
- RPA, PTA, Haematoma, Trauma
Tx - specific
Causes of delayed emergence/decreased GCS and management
- PHYSIOLOGICAL
- O2/CO2/pH, Temp, BP, Na, BSL
Tx - monitors, vbg, Tx cause - PHARMACOLOGICAL
- NMBD, opioids, BZDs, volatiles, prop, neuroleptics, antipsychotics, CNS spread of LA
Tx - check etVOL/drugs given, neuromuscular monitoring, sugammedex/naloxone/flumazenil - NEURO
- stroke, seizure, psychosomatic
Tx - CT - OTHER
- Thyroid
Tx - TFTs
CRM - 35F for lap appx. small hospital with no ICU/CCU. induce and then 1min later BP 60 and pt is difficult to ventilated with pressures of 40cmH2O only delivering 100mL of tidal volume.
Safety (CHeSS)
- Check readings/transducer/monitor, finger on pulse
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for anaphylaxis
Temporizing: Combine hypotension and hypoxia/highpressure - fluids, metaraminol, 100% O2, increase flow, bag
Call for anaphylaxis box
immediate priorities
- cease trigger
- Oxygenation (ETT, obstructive ventilation strat, high flow 100% O2, salbutamol)
- volume resus (2L STAT, reassess as 2L extravasates in first 10 mins)
- adrenaline (50mcg iv bolus, infusion at 10-20mcg/min - 3mg in 50mL syringe, titrate)
- monitoring and lines (2x large PIVC, art line, CVC later)
Call ARV to locate ICU bed
CRM - 50F for lap hysterectomy, on inserting veress needle sudden drop in ETCO2 and BP
Safety (CHeSS)
- Check readings/transducer/monitor, finger on pulse
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for puncture of a major vessel and air embolism
Temporizing: fluids, metaraminol
immediate priorities
- repairing the vessel - vasc surgeons
- air embolus - 100% O2, +/- CPR, support foreward flow
- fluid resus (IV, fluis, MTP, art line)
CRM - 60M for laminectomy in prone position. vent alarms showing loss of pressure, ETT looks dislodged, pt was grade III ariway previously
Safety (CHeSS)
- Check readings/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for loss of airway
temporizing: 100% O2, high flow, bag, have surgeon gain immediate hemodynamic control
immediate priorities:
- turn pt supine
- regain airway (assistant, paralysis, airway equip, video layngoscope)
CRM- 35F G1P0 37/40 on maternity ward with abdo pain - BP 70, HR 140 PHx large fibroid excision, after 1L fluid on ward HB returns at 60 with presumed uterine rupture
Safety (CHeSS)
- Check readings/transducer/monitor
- call for Help
- Scan pt/surgery/monitor
- Stop surgery
concern for uterine rupture
Temporizing: fluids, metaraminol
immediate priorities
- lines - 2x PIVC
- resus - fluids, MTP
- control the bleeding - O&G, theatre
- baby - notify paeds
CRM- 40M for lap nephrectomy PHx HTN and T1DM on induction w prop/fent/atrac unable to BMV, grade 4 view with video, after optimization O2 is 90% after 3 attempts
Safety (CHeSS)
- Check readings/probe/monitor
- call for Help
- Scan pt/surgery/monitor
concern for CICO
immediate priorities
- ask to prep for surgical airway (scalpel, bougie, size 6 tube)
- follow DAS guidelines to obtain airway with LMA
