Generic Management Flashcards
Pre-operative Management
- Timing/urgency of surgery - time for pre-optimisation?
- Pre-operative assessment
— introduction and explanation of role
— confirm correct patient and operation
— history - PMH/PSH, prev. anaesthetics, FH, SH, systems review + functional history
— medication and allergies incl. OTC/herbal
— examination - cardiorespiratory, dentition, airway, severity/extent of any neurological impairment, nutritional status
— investigations
— consent (check surgical consent, verbal anaesthetic) - Pre-operative risk stratification and optimisation
- Premedication
- Transfer to theatre - bed/trolley/chair/O2?
Preoperative Optimisation
Respiratory
— supplemental oxygen
— NIV/IPPV
— treat infection/overload/bronchospasm
— chest physio
— incentive spirometers
Cardiovascular
— fluid resuscitation
— treat arrhythmia
— invasive monitoring
— Inotropes/vasopressors
Renal
— correct electrolyte abnormalities
— ensure adequate renal perfusion (? Catheterise)
Haematological
— correct coagulopathy
— treat anaemia (dietary adjustments, PO/IV iron, Hb transfusion)
Miscellaneous
— patient warming
— pain relief
— smoking cessation
— weight loss
— patient education
Preoperative Risk Stratification
Why?
— to inform patient consent
— to inform clinical decision making
— to determine postoperative location of care
How?
— subjective - ET > 4 METS
— Duke Activity Status Index
— Stair climb test (high risk if less than 22m)
— Shuttle walk test - 25x10m (high risk if unable to complete)
— 6 minute walk test (good function if >400m, walking less than 70% of their predicted distance puts patients at higher risk of postop pulmonary complications)
— CPET (anaerobic threshold >11, VO2 peak >15ml/kg/min)
— risk prediction models and scores
Intraoperative Management
- Preparation
- Senior help
- Monitoring - ?invasive
- Emergency drugs + equipment
- Induction - location, method, paralysis, airway options
- Maintenance + ventilation
- Emergence - reversal
- Analgesia
- Antiemesis
- Fluids
- Temperature
- Positioning
Intraoperative Aims
* haemodynamic stability
* optimal fluid management
* physiological normality - normocarbia, normoglycaemia, normothermia, normoxia
* excellent pain control and anti-emesis
* smooth emergence
Post-operative Management
- Airway, breathing, circulation
- Drugs, disability, DVT
- Oxygen
- Analgesia
- Antiemesis
- Fluids
- Temperature
- BM
- Recovery site/destination
Managing a patient with pain
Assessment
* Introduce
* Consent
* History
* Examination
* Appropriate investigations
Management
* Local/regional techniques
— consent
— assistance
— preparation - equipment
* Pharmacological (including alternative routes)
* Non-pharmacological
— physiotherapy
— slings/splints
— TENS
— emotional/psychological - therapeutic effect of rapport with patient
— lifestyle
— alternative
“I would take a multidisciplinary and multimodal approach to pain management. MDT including patient, physio, doctor, OT, nurse, psychologist. Multimodal including pharmacological, psychological, physical and interventional.”
Managing a Critical Incident
- Declare the emergency
- Alert surgical team
- Call for help, seek senior support
- Perform a simultaneous assessment, stabilisation and management using an A-E approach with a particular focus on…
— is the airway patent? Give 100% oxygen, check ETT/LMA
— is oxygenation/ventilation intact/adequate? Manually ventilate, check for bilateral chest rise, air entry on auscultation, ETCO2, misting of ETT, SpO2
— is the patient haemodynamically stable? - Supportive management
- Specific management
Surgical Sieve - VITAMIN CDEF
V - vascular
I - infective/inflammation
T - traumatic
A - autoimmune
M - metabolic
I - iatrogenic (drugs/procedural)
N - neoplastic
C - congenital
D - degenerative
E - endocrine
F - functional
Control of Haemodynamics
Preload
— increase - IV fluid, capacitance vessel constriction (phenylephrine)
— decrease - bleeding, PEEP, increased TV, capacitance vessel dilatation (GTN etc)
PVR
— increase - increased PaCO2 (decreased MV), decreased PaO2, acidosis
— decrease - decreased PaCO2 (increased MV), increased PaO2, alkalosis
SVR (afterload)
— increase - arteriolar constriction (phenylephrine)
— decrease - arteriolar dilatation (nitroprusside)
HR
— increase - anticholinergics, ephedrine/adrenaline
— decrease - beta blockers, digoxin, fentanyl/opiates
Contractility
— increase - Inotropes, calcium, digoxin, milrinone, adrenaline
— decrease - beta blockers, propofol, sevoflurane
How would you intubate this patient?
- Full AAGBI monitoring
- Trained assistant
- Appropriate environment
- Emergency drugs
- Running drip
- Tilting trolley
- Suction
- Additional monitoring?
- Awake (+/- sedation) vs asleep
- Choice of agents (+ doses)
Neuroprotective Measures
Maintaining cerebral perfusion
* Normovolaemia
* MAP 80-90 (achieve CPP 60-70 assuming ICP ~20)
Avoiding ischaemia
* Hb >70
* pO2 >13kPa
* Maintain cO2 4.5-5.3kPa
Decreasing the brain’s metabolic demand
* Control seizures
* Adequate sedation and analgesia
* Normothermia
* Neuromuscular blockade
* Normoglycaemia
Avoid decreased venous return from the brain
* 30 degrees head up position
* Tapes not ties
* Target TV 6-8ml/kg
* Driving pressure <15
* Pplat 18-25cmH2O
Additional considerations
* Maintain normal sodium level
* Correct coagulopathy
* Eye care
* Consider stress ulcer prophylaxis
* DVT prevention
* Nutrition
Systems Review
- Respiratory - OSA symptoms (STOP BANG), cough, SOB/SOBOE
- CVS - chest pain, palpitations, syncope, orthopnoea/PND, hypertension, claudication
- GI - reflux, hiatus hernia, dysphagia, oesophageal pathology/UGIB
- Other - renal disease, DM, epilepsy, CVA/TIA, musculoskeletal
Airway Assessment
- History of previous difficulty, airway alert form
- Previous documentation of airway management - ventilation, intubation
- Relevant PMH
— rheumatoid arthritis/ankylosing spondylitis
— OSA
— previous surgery or radiation to head and neck
— aspiration risk
— rare syndromes associated with difficult airways - Pierre-Robin, Klippel-Feil, Treacher-Collins
— recent acute URTI
— new or worsening airway pathology - presence and nature of stridor, degree and progression of hoarseness/voice change, dysphagia, secretions, ability to lie flat - Examination
— dentition (edentulous = difficult mask ventilation, buck teeth = difficult intubation)
— mallampati (3 or 4)
— jaw protrusion (c)
— neck circumference (>40cm/16”)
— mouth opening/inter-incisor gap (<3cm)
— neck extension (cervical flexion and altanto-occipital extension)
— thyromental distance (<6.5cm)
— sternomental distance (<12.5cm)
— front of neck anatomy
— obesity, pregnant, beards, prominent chest/breasts, external signs of head and neck pathology
— nasal passage patency if nasal intubation indicated - Investigations
— CT
— lateral C-spine X-ray
— orthopantomograms
— MRI
— flexible nasendoscopy - dynamic airway assessment, allows one to visualise the vocal cords and assess for evidence of swelling or a foreign body
— ultrasound for detection of large midline vasculature if assessing suitability for perc trache
Neck irradiation is the most significant predictor of difficult mask ventilation. OSA, snoring without apnoea and neck circumference >40cm increase the risk of difficult mask ventilation.
Pre-operative Investigations for Elective Surgery
- FBC
— any adult undergoing major or complex surgery
— severe renal or cardiovascular disease undergoing intermediate surgery - Renal function
— ASA 3/4 patients undergoing minor or intermediate surgery
— ASA 2+ adults undergoing major or complex surgery
— renal or severe cardiovascular disease
— consider in people at risk of AKI undergoing any type of surgery - Clotting
— consider if intermediate or major surgery and known chronic liver disease
— anticoagulated (use local guidelines) - HbA1c
— any diabetic if no HbA1c in the last 3 months - TFTs
— known thyroid disease patients should have TFTs within the last 3 months prior to surgery - Sickle cell disease/trait
— if a family member has sickle cell disease - Pregnancy test
— if any uncertainty about whether a female is pregnant (aged 12yrs+) - Urine microscopy and culture
— only if presence of a UTI would influence the decision to operate - MRSA screening
— local protocols - usually within 3 months of admission
— may include all elective cases or just high risk patients - ECG
— anyone over 65yrs old undergoing major or complex surgery if no ECG in past 12 months
— cardiovascular or renal disease, diabetics
— anyone ASA 2+ undergoing major or complex surgery - Echo
— murmur + cardiac symptoms
— possible heart failure - Lung function tests/ABG
— consider if ASA 3/4 and intermediate surgery in known or suspected respiratory disease - CXR
— not routinely offered before elective surgery
Airway Strategy
Oxygenation - BMV, HFNO/THRIVE
* conventional assisted ventilation - MLT, ETT, laser safe ETT, reinforced ETT, laryngectomy/tracheostomy tube
* high pressure jet ventilation - subglottic, transglottic, transtracheal
* high flow oxygen delivery - apnoeic oxygenation
* spontaneous ventilation
* cardiopulmonary bypass
Laryngoscopy
* awake vs asleep
* VL/FOI/VAFI
* IV vs gas indcution
Intubation
* adjuncts e.g bougie, fibreoptic guided supraglottic
FONA - identify anatomy, position (submental/trache)
Extubation plan
Performing a Transfer
What equipment do you need for transfer?
- Suitable transfer vehicle and a trained assistant
- Full AAGBI monitoring with invasive BP monitoring and a catheter
- Transfer trolley and dedicated transfer bag
- Spare batteries and pumps, Oxygen, Suction, Defibrillator, BMV/waters circuit
- Drugs and emergency drugs drawn up
o Spare syringes
o Calculate specific doses before transfer
- Mobile phone and relevant contact numbers for origin and destination as well as key people in case of problems during transfer
How to prepare for transfer?
Airway
- Secure airway if potential risk of decline
- Secure tracheal tube
- Confirm and record placement of tracheal tube
Breathing
- Verify adequate ventilation with ABG
- Consider ear or single-use adhesive saturation probes
- End tidal CO2 monitoring
- Identify, decompress and drain PTX prior to transfer
- Oxygen requirements:
o 2x (patient consumption + ventilator consumption)
o Patient consumption = minute ventilation (RR x TV) x duration in minutes
o Ventilator consumption = bias flow x duration in minutes
o 2= safety factor
- Oxygen cylinders
o CD – 460L
o E – 680L (on anaesthetic machine)
o F – 1360L (2xF usually found on ambulances)
o J – 6800L
- Bag valve mask + suction
Circulation
- Appropriate resuscitation prior to transfer
- 2x IV access available, accessible, adequately secured and of an appropriate size
- Arterial line – well secured + NIBP attached
- Central line well secured (ideally RIJ/SCV)
- Catheter
- Vasopressors established (and spare available)
- Blood products as required
- Specialist equipment if needed
Disability
- Ongoing sedation and adequate analgesia
- Paralysis
- Check BM
- Control seizures
- Mannitol/hypertonic saline in vehicle
Exposure
- Immobilization as appropriate
- Drains and line securely fixed in place
- Consider risk of heat loss
- ?Continuous temperature monitoring
- Minimise number of infusions running during transfer
- Document vital signs every 5 min as per AAGBI standards
Secondary Emergency Airway Manoeuvre
Information needed:
* previous intubation grade, any difficulty?
* reason for tracheostomy?
* duration of the current problem - recent or repeated obstruction?
* type of trache - surgical vs percutaneous?
Equipment needed:
* basic airway equipment - oxygen masks, suction, oral and nasal airways
* trache spares, dressings and tapes, dilators
* advanced airway management - laryngoscopes, smaller tubes, LMA, fibre-optic scope
* capnography
* sterile dressing pack, scissors, sterile water, scissors/stitch cutters, sterile gloves
* humidification equipment
* PPE
* communication aids, call bell
* bedside equipment checklist
