6Th Year Anaes Lect
6Th Year Anaes Lect
6Th Year Anaes Lect
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PREOPERATIVE ASSESS
ME
NT
Fasting
Gastric contents are more likely to be aspirated under anaesthesia. Patients
should consume no solids after 6 hours, and no clear fluids after 2 hours
before the start of any sedative or anaesthetic procedure. These times for
gastric emptying will be prolonged by pain and opioid use.
Emergency situations may require an unfasted patient to undergo
anaesthesia. ln this circumstance, a Rapid Sequence lntubation is used to
occlude the oesophagus until the airway is protected by a cuffed tube.
Medication
Some medications interact with those used in anaesthesia. Over-the-counter
and alternative drugs, tobacco, alcohol, and illicit drugs all can have serious
implications.
Medications can also expose illnesses that the patient may have neglected to
reveal.
Allergies
A history of known allergies, and the actual drug effect, is essential before
prescribing or administering any drug. The difference between an allergy and
a side effect is important, othenvise a best choice drug may be unnecessarily
avoided.
Dentition
The teeth are at risk of damage during ainruay instrumentation. Pre-existing
damage should be noted for medico-legal reasons. The presence of caps,
crowns, and loose or unhealthy teeth (especially in front) should be noted,
and the risk of damaged discussed with the patient. Loose teeth can be
dislodged into the lungs, and may need preoperative dental review.
Gastro-oesophageal Refl ux
The extent of reflux should be determined. Reflux of gastric contents (usually
acid secretions in the fasted) is worse under anaesthesia, and a Rapid
Sequence lnduction may be required. (This type of induction is not used for all
anaesthetics, mainly because of the side effects of suxamethonium.)
Concurrent lllness
Many medical illnesses may complicate the course of anaesthesia and
surgery. All systems should be considered in the patient assessment. Most
consideration goes to cardiac and respiratory diseases, as they play the major
role in contributing to perioperative morbidity and mortality.
Exercise tolerance is a good indicator of cardio-respiratory reserye (ability to
cope with the perioperative insult). The ability to climb stairs, play golf, do the
gardening - all without symptoms, are good indicators of sufficient reserve for
fairly major surgery.
Concurrent disease and patient age guide the surgical intern and anaesthetist
in the choice of which preoperative investigations are required. CXR, ECG,
U&E, FBC, Group, x-match, coags should not be done as routine, but as
indicated. More advanced investigations (ECHO, stress tests, spirometry,
sleep studies, CT, MRI) may also be required. The end result of the
investigation process is that a change may need to be made to the patient's
medical care before surgery is attempted. (See the'Pre Admission Screening'
questionnaire for suggested investigations.)
Sufficient time must be allowed preoperatively to undertake and report on
these tests, and institute any therapies. lt is the responsibility of the surgical
team to identify more complicated patients and commence the preparation
process early, hence avoiding unnecessary delays to surgery.
Defining the disease process, its extent, and the impact on the patient will
help determine the anaesthetic technique and agents used. For example, a
patient with severe respiratory disease may be better served with a spinal for
Iower body surgery. A patient with a poorly functioning heart will need invasive
monitoring and the least cardiac depressant drugs available.
Medications to Hold
ln general terms, hold aspirin and clopidegrel for 1 week, most other NSAIDS
24-48 hours, and warfarin 3-4 days to a normal lNR. The indications for these
medications need to be considered before ceasing vs risk of bleeding during
the procedure. Long acting heparins E.g. Clexane should not be given within
the 12 hours before surgery - they exclude the possibility of spinal and
epidural anaesthesia, which may be essential to the patient.
Diabetic medication - hold oral hypoglycaemics on the day of surgery and the
preceding night. The non insulin diabetic would rarely need a sliding scale,
and can be kept hydrated with non dextrose containing lW. The fasting
insulin dependent should have regular BSL checks, be early on the operating
list, and usually a sliding scale with dextrose IVT (to avoid hypoglycaemia).
The anaesthetist should be aware of insulin dependent diabetics to contribute
to the preoperative management.
Antihypertensives would rarely be held. Missing a dose will often lead to
unstable blood pressures and an increased risk of cardiac events.
Give other medications as usual. "Fasting" does not include medication!
lf concerned or unsure, always contact an anaesthetist.
The Emergency
This poses multiple compromises to optimizing for surgery. There is little time
for patient preparation, so only essential tasks are performed (bloods,
invasive monitoring, fluids).
ldeally a patient is resuscitated and cardiovascularly stabilized before
administration of anaesthetic agents, but this may not be possible and is
performed intraoperatively (E.g. a ruptured AAA) ln such situations,
anaesthetic techniques need to be dramatically altered.
Class 1
Class 2
Class 3
Class 4
Class 5
"E" added to
Premedication
Premedication should only be prescribed by the anaesthetist. The exception
would be an 'on call'Ventolin/Atrovent nebule prescribed by the surgical team
where indicated. Premedication is a separate issue from the patient's usual
drugs.
o Benzodiazepines may be used for an overly anxious patient. Sedatives
are avoided where fast awakening from anaesthesia is desired, in the
non-consented, where conscious state is altered, and in the
airway/respi ratory comprom ised.
. Children are most commonly ordered EMLA cream (takes t hour to
work) and sedatives (midazolam).
. Ventolin + Atrovent nebs are often given immediately before
anaesthesia for respiratory disease. This prevents perioperative
bronchospasm.
. Antacids (ranitidine, sodium citrate) are used to reduce gastric acidity
in the patient at risk of aspiration. This reduces respiratory
complications.
. Any frail patient should be well hydrated by lW whilst fasting. This is
also an idealfor all patients. Diabetics should also receive dextrose
solutions if receiving insulins whist fasting.
. Beta blockers are some times commenced in patients at risk of
myocardial ischaemia.
,:
A-
Sumame
-7
U.R.No.
Given Names
Proposed Operation:
Date of Birth
Surgeon
Previous GA Problems
COAD /
SI
A
D
blood thinners
I
S
I
o
2. Take tablets
3. IIse insulin
R
E
E
I
N
G
Authorised by:
. 0ver 75 years
. History ofAnaesthetic problem
. BMI > 35
. For major surgery
. Any 'Yes' answer to above assessment
Date:
Medications
(including over-the-counter medications: Aspirin, Oral Contraceptives, Inhalers, Topicals, Eye Drops, Hypnotics & Herbals)
Note if Steroids used in last 3 months.
Drug (Name)
When
Dose
2.
3.
4.
.5.
6.
7.
8
9.
10.
Allergic Reactions
Reaction
2.
3.
4.
5.
Other Drugs
Marijuana
Amphetamine
Hepatitis
o IV drug use
Heroin
Other
Social Risks
HIV
o Other
Height
Weight
(cm)
(Ke)
BMI
Blood
Pressure
Pulse
Peak Flow
Oxygen
(L/min)
Saturation
Urinalysis
PROPOSED OPEMTION:
oRl
v\1./t S
& EXAMINATION:
ro
- Na
loo
ny]'PI
WEIGHTn,
ESULTS:
IC PLAN:
Medicotion
/ lnstructions
Standard orders
Morphine is the standard strong analgesic agent used at TTH. Subcutaneous administration through an indwelling
'butterfly' or 24G cannula is the preferred route as this limits the potential exposure of nursing staff to needle-stick
injury and is less uncomfortable for the patient than repeated IM injections. Alternatives for patients with morphine
allerry include fentanyl or tramadol. Pethidine must NOT be administered subcutaneously, however, as it is painful and
unpredictably absorbed.
Recommended initial prescriptions
The initial dose requirements vary considerably. With the exception of Paediatrics, the best predictor of morphine dose
is AGE*, not weight. A 2-hrly interval with small doses is safer than large doses less frequently.
Initial
(years)l Morphine I
Fentanyl
Fentanyl I Tramadol
(mg) | Dose range (mcg)
lmcg) | Dose range (mg)
1s-3e I z. s- tz.s I roo - lso I 7s - t2s
40-s9 I 5.O - 10.O I 75- t25 I 50 - 100
tJ
-z.s II ou-ruu
zs - zs
zJot_r-o:,
6o-6s II z.o
z.s -t.o
so - roo II
requests analgesia
Age
Range
lDose
ttt
zo-zs
tw-tY
Itz.o-ar.L,
z.s - s.o
80+ lz.o-s.o
.
.
.
-zs I
I so-so
zs
zJ-ro
zs - so
zJ-Jv
zo-so
Is the sedation
score <2, resp
I
I
(2
rate >8/min ?
Sedation Score
0 Fully alert
I Mild, occasionally drowsy, easy to rouse
2 Moderate, constantly or frequently drowsy, easy to rouse
3 Severe, somnolent, difficult to rouse
Is the sedation
score <2, resp
rate >S/min
NO
Patient stiil in
pain? Requesting
>
2 hours
NO
Reassess
analgesia?
Is DOSE intewal
Normal sleep
after
hour
NO
from Medical Officer
Consider higher dose next time
Seek advice
Intravenous PCA
For children < 60kg; use paediatric PCA
USE 50ml SYRINGE TIADE UP
To 69Iil
Surname:
Given Names:
Unit Record No:
Date of Birth:
Sex:MiF
(Affix label)
PRESCRTBERS; STRII(E TEROUGH EXISTING ORDER BEFORE WRITING NEW ORDERS/ CEASING PCA
SCHEDULE
A
I
DATE/TIME
OPIOIDDRUG
OPIOID
CONCENTRATION
RECIPE
at
MORPHINE
T
MG/TUL
60mg morphine
H
PCADOSE
LOCKOIIT PERIOD
CONTINOUS RATE
LOADING DOSE
0.9% s.aline
to total volume 60rnl
lmg (l ml)
EYDROIVIORPIIONE
200r}lcG/r\{L
l2mg Hydromorphone
0.9% saline
to total volume 60ml
200pcg
(l
Z*ro
Zeto
STAT
STAT
DOCTORNAil{E
rnl)
F
E
N
T
A
N
at
FENTAI{YL
20
MCG/ML
l200mce Fentaavl
0.9% saline
to total volume 60nd
20pcg (lml)
Zem
at
Z,ero
PCA DELIVERY
5 mins
5 mim
3 mins
Zero
Zero
STAT
DOCTOR SIGN
N
E
SCHEDULE
DATE/TIME
at
.MODIFIED
.MODIFIED
at
at
OPIOID DRUG
OPIOID CONCENTRATION
RECIPE
0.9% saline
to total volume 60ml
0.9% saline
to total volume 60ml
0.9% saline
to total volume 60ml
PCA DOSE
LOCKOUT PERIOD
CONTINOUS RATE
LOADING DOSE
PCA DELIVERY
DO
TOR NATVIB
DOTTOR SIGN
at
I name
sign
Given Names:
Unit Record No:
Date of Birth:
Epidural (PCEA)
Sex: M
/F
(Affix label)
......cm
Pain/paraesthesiae YAI
AIL EPQURAL
SCHEDULE
DATSTIME
E
P
D
U
at
OPIOID
FENTANYL 3NICG/TUL
DRUG /CONCIiNTRATION
LOCAL ANAESTHE'TIC
DRUG/CONCENTRATION
ADDITIONAL
DRUG/CONCENTRATION
LEVOBUPIVACAINE I MG'UL
RECIPE
Levobupivacainc l00mg
at
at
E.IVIODIFIED
CONCENTRATTON
(onioid)
PCEA DOSE
12
lfi)ml
mc/ml
mcg (4 ml)
LOCKOUTPERIOD
l5 mins
CONTINOUS RATE
lE mcg (6 ml/lu)
LOADING DOSE
7*ro
PCA DELIVERY
STAT
DOCTORNA-I\4E
DOCTOR SIGN
oT OTHER
on
name
sign
^t
Date I
Time