ESMOE - Protocol for C/S Under General Anaesthesia

Question 1

Main summary steps:

Answer 1

1. Preparation
2. Technique
3. Recovery

Question 2

Summary steps - Preparation:

Answer 2

1. Full history and examination
2. Prepare the patient
3. Prepare the theatre

Question 3

Summary steps - Technique:

Answer 3

1. Position the patient
2. Administration of general anaesthesia
3. Failed intubation
4. If successful mask ventilation
5. If unsuccessful mask ventilation
6. After delivery
7. Once the surgery is completed

Question 4

Summary steps - Recovery:

Answer 4

1. Monitoring

2. Discharge to the ward

Question 5

Preparation phase - details:

Answer 5

1. Full history and examination:
   1.1 NB assess airway + difficult intubation
   1.2 NB signs of hypovolaemia - decide whether
   the patient requires fluid resus first
2. Prepare the patient:
3. 1 Premedication – sodium citrate 30ml PO + macaron 10 mg IVI 30 minutes pre-op
4. 2 Good IV access + preload 500ml clear fluid
5. 3 U-catheter
6. Prepare the theatre:
   3.1 Full machine check, check ventilator settings
   3.2 Check essential equipment & monitoring
   3.3 Draw up essential drugs -
   ephedrine, atropine, suxamethonium, induction agent

Question 6

Technique phase - details:

Answer 6

1. Position the patient:
2. 1 Wedge under right hip
3. 2 Head and shoulders on a pillow, sniffing
4. Administration of GA:
   2.1 Measure NIBP now, and every 3 minutes
   2.2 Establish ECG and pulse oximetry
   2.3 Pre-oxygenate 100% FiO2 for 3 minutes
   2.4 Start the suction + Yankauer nearby
   2.5 Perform RSI with cricoid pressure + intubation
   2.6 Confirm correct placement of ETT
   2.7 Ventilate - at least 40% oxygen and
   not more than 1 MAC volatile
   2.8 Use small doses of short-acting muscle
   relaxant if necessary
5. Failed intubation:
6. 1 Call for help
7. 2 Try to wake patient up
8. 3 Start mask ventilation + cricoid pressure
9. If successful mask ventilation:
10. 1 Check head position
11. 2 Change laryngoscope blade
12. 3 Assistant to externally manipulate the cricoid
13. 4 Re-attempt intubation

If still unsuccessful - Consider:

4. 5 Continuing with mask ventilation
5. 6 Or spontaneous ventilation
6. 7 Or LMA insertion
7. 8 Or awaken patient
8. If unsuccessful mask ventilation:
9. 1 One further intubation attempt OR LMA attempt
10. 2 If still unsuccessful + can’t ventilate + nil spontaneous ventilation = emergency cricothyroidotomy + ventilate
11. 3 Consider continuing with the procedure or wake the patient up
12. After delivery:
13. 1 Ask obstetrician if they are certain there is no second baby
14. 2 Give 2.5 IU oxytocin IVI slowly, over 1 minute
15. 3 Can increase volatile
16. 4 Give MMA – morphine 10mg, consider fentanyl 100ug, NSAID, paracetamol, LA
17. Once the surgery is completed:
18. 1 Switch off the volatile
19. 2 Give reversal if NDMR used
20. 3 Extubate in theatre, awake and reversed

Question 7

Recovery phase - details:

Answer 7

1. Monitoring:
   1.1 Administer oxygen via 40% venturi mask
   1.2 Monitor NIBP and SpO2
   1.3 Make sure that the patient is not bleeding
   1.4 Make sure that the patient is well analgesed
   1.5 Infuse 20 IU oxytocin in one litre of clear
   fluid over 8 hours (125mls/hr)
2. D/C to the ward