Anaesthesiology: The Perioperative Journey

Question 1

Preoperative Assessment Clinic

Answer 1

History:

1. Type of surgery
2. GA before?
3. Family history of Anaesthesia problem
4. Medical history
   - Focus on ***Cardiorespiratory function of patient
   - Other organ function as relevant to history
5. Drug history
   - Allergy
6. Exercise tolerance
7. Nasal obstruction?

P/E:

1. CVS examination
2. Airway examination
   - examine likelihood of potential airway problems

Investigations:

1. Previous anaesthesia records
2. Cardiovascular investigations
3. Respiratory investigations

Aim:

1. Fitness to undergo anaesthesia + surgery
2. Whether operation should be postponed for medical optimisation
3. Delay for specialist referral / investigation

Question 2

After patient review

Answer 2

1. Assign patient an ***ASA score which will aid in risk management
   - crude guide to mortality risk
2. Formulation of anaesthetic + analgesic plan (e.g. GA, Epidural)
   - GA: any airway device to avoid
3. Decide if any invasive monitoring devices are needed / if specialist technique is required (e.g. awake fibreoptic intubation)
4. Book ICU / HDU post-operative bed if required
5. Write down instructions for ward
   - fasting
   - premedication
   - continuation of current medication
   - any further investigations
6. Document what has been discussed with patient and sign consent form for anaesthesia

Question 3

Pre-op explanation to patient

Answer 3

1. Instruction regarding meal
   - No food, Only water
2. Explanation of anaesthesia procedures

3. Complications of anaesthesia
Common
- Sore throat
- Dizziness
- N+V

Rare

• Heart
• SOB
• Stroke

Question 4

Roles of OT assistant

Answer 4

1. Perform preliminary anaesthetic machine check
   - machine checked again by anaesthesiologist
2. Prepare + Check airway equipment
   - e.g. suction, laryngoscope
3. Assist anaesthesiologist in airway management
4. Help to position patient for surgery
   - ensure patient secure and no risk of falling off
5. Check patient identity + details with nurse / anaesthesiologist (before patient anaesthetised)
   - name, DOB, sex, HKID, consent form
   - operation to be done, correct side marked
   - drug allergy
   - risk of difficult airway
   - likelihood of major blood loss
   (ideally surgeon should be here)

Question 5

Before induction

Answer 5

1. IV cannula inserted

2. Monitoring equipment applied
Minimum:
- 3 lead ECG
- NIBP (non-invasive blood pressure cuff)
- SpO2
- Capnography (for GA cases)

Others:

• EEG
• Intraarterial BP
• Central venous monitoring

3. Preoxygenate patient (for GA cases)
   - apply cricoid pressure if needed (technique used in endotracheal intubation to try to reduce the risk of regurgitation)
4. Ensure an accurate + contemporaneous record is kept of anaesthesia process
   - readings of monitor will be documented automatically onto anaesthesia records

Question 6

Manpower

Answer 6

> =3 people during anaesthesia

1. Anaesthesiologist
2. OTA
3. Nurse

• Back up personnel who can be called upon in an emergency

Question 7

During anaesthesia process

Answer 7

1. Preoxygenate patient (for GA cases)
   - apply cricoid pressure if needed (technique used in endotracheal intubation to try to reduce the risk of regurgitation)
2. Induction of anaesthesia
3. Check patient is anaesthetised
   - stimulate patient by rubbing shoulder
   - check reflex
   - call name
4. If airway instrumentation needed
   - rapid acting opioid given e.g. Fentanyl —> block physiological response to laryngoscopy / other airway manipulation
   - muscle relaxant (if intubation) to relax vocal cord (take ~3 mins to work —> use manual ventilation in the meantime)
5. Induction agent usually rapidly redistributed
   - patient may wake up —> anaesthesia maintained by anaesthetic gas + continuous infusion of anaesthetic agent
6. Intubated when patient fully paralysed
   - check ET tube in place by detection of sustained CO2 trace + auscultation of lungs to confirm equal and bilateral air entry
7. Other manipulation performed
   - NG tube
   - Arterial line, Central line
   - Urinary catheter

Question 8

“Time out” process

Answer 8

1. Operating surgeon must be present
2. Confirm patient’s ID with wristband + consent form
3. Confirm surgical procedure and laterality with consent form and body marking

Question 9

Extubation

Answer 9

Considerations:

1. Adequate pain relief
2. Normothermic
3. Acid/Base + Electrolyte balance acceptable
4. Not requiring large amount of oxygen / ventilator support
5. Haemodynamically stable
6. Give ***high flow oxygen
   - buy extra time in case of difficult extubation

Readiness for extubation:

1. Fully awake
2. Neuromuscular function normal
3. Obeying instruction
4. Breathing well spontaneously

After extubation:

1. Nasal cannula to give oxygen
2. Transferred to recovery room
3. WHA checklist completed by nurses

Question 10

Protection of patient during anaesthesia

Answer 10

1. Eyes taped to prevent corneal abrasion
2. Prevent pressure sores
3. Correctly positioned + strapped
4. Maintain homeostasis
   - HR
   - BP
   - Urine output
   - Temp
   - Fluid + Acid/Base balance
   - Oxygenation + CO2 levels
   - Brain volume
   - Glucose

Products to give:

1. Adjust anaesthetic / analgesic
2. Replace fluids / blood products
3. Inotropes / Vasopressors
4. IV Antibiotics
5. Steroids
6. Albumin

Question 11

Recovery Room Care

Answer 11

1. Reattached to monitoring equipment
   - Vital signs monitored continuously
   - Oxygen reattached to wall pipeline supply
2. Anaesthesiologist hand over patient’s care to trained recovery nurses
   - Relevant history
   - Procedure done
   - Drugs given
   - Analgesic / Antiemetic given
   - Fluids / Blood given
   - Intraoperative difficulties
   - Any expected problems
3. Anaesthesiologist should not leave patient with nurse until satisfied
   - patient can maintain their own airway
   - oxygenated adequately
   - haemodynamically stable
   - not in severe pain
4. Nurse will monitor patient for any potential complications
5. Extra monitoring can be done
   - e.g. GCS for neurosurgical cases
6. If extra analgesia needed, anaesthesiologist will be asked to review the patient
7. Nurses can start PCA devices
8. Once patient stable, pain, nausea controlled
   —> discharge to appropriate place of care e.g. ward, HDU, ICU
9. Any post-op instructions
   - Written on the anaesthesia record
   - Convey to recipient ward staff
10. Until patients leaves the recovery area, they remain responsibility of anaethesiologist