IAC Module 1v2

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@@.whitetext; !!!Virtual Anaesthetics_1 Welcome to the first in a series of interactive scenarios to support learning during the IAC. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!Virtual Anaestheics_1: Preoperative assessment part 1 Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "text" "audio/text.mp3">> <<cacheaudio "richards" "audio/richards.mp3">> <<cacheaudio "fletcher" "audio/fletcher.mp3">> <<cacheaudio "redbridge" "audio/redbridge.mp3">> <<set $result to 0>> <<set $history to []>> <<set $started to 0>>

!!!@@.greentext; Scenario learning objectives:@@ * Discuss the the Association of Anaesthetists guidelines on preoperative assessment * Assess a patient's airway * Undertake the preoperative assessment of a patient undergoing an elective procedure * Access patient resources on anaesthetic risk * Know the NICE guidelines on preoperative investigations * Safely manage key classes of drugs during the perioperative period @@.greentext; ''For optimal interaction this scenario is better on a larger screen device <u>with an unmuted speaker</u>. You are going to need three copies of [[this|https://www.virtualanaesthetics.com/IACModule%201/blank.pdf]] during the scenario (opens in new page) so either have the file open and fill electronically or print the document.''@@ [[Next|preop]] [[Show me the EPA for IAC mapped to this scenario|epa]] [[Show me the stage 1 curriculum|stage1]]

<center> <img src="images/q1.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q1 This image shows which Mallampati score?'' </p> <<radiobutton "$choice1" "1">>  ''A.'' I <<radiobutton "$choice1" "2">>  ''B.'' II <<radiobutton "$choice1" "3">>  ''C.'' III <<radiobutton "$choice1" "4">>  ''D.'' IV @@ <<button [[Next question->Q2]]>> <</button>> <<timed 59s>> <<goto Q2>> <</timed>> <<countdownTimer 60 "Q2">> <<set $Q to true>>

!!!@@.greentext; Scenario learning objectives:@@ * Discuss the Association of Anaesthetists guidelines on preoperative assessment * Assess a patient's airway * Undertake the preoperative assessment of a patient undergoing an elective procedure * Access patient resources on anaesthetic risk * Know the NICE guidelines on preoperative investigations * Safely manage key classes of drugs during the perioperative period ''Printable evidence for the LLP'' ''[[here|https://www.virtualanaesthetics.com/IACModule%201/IACmodule1mapped.pdf]]'' [[Credits and certificate|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VA1IAC">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

@@.whitetext;<<if $choice1 eq "4">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 In patients who have difficult intubations what percentage are correctly identified by Mallampati III or IV?''</p> <<radiobutton "$choice2" "1">>  ''A.'' 35% <<radiobutton "$choice2" "2">>  ''B.'' 52% <<radiobutton "$choice2" "3">>  ''C.'' 78% @@ <<button [[Next Question->Q3]]>> <</button>> <<timed 59s>> <<goto Q3>> <</timed>> <<countdownTimer 60 "Q3">>

@@.whitetext;<<if $choice2 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q3.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q3 This image shows which Mallampati score?''</p> <<radiobutton "$choice3" "1">>  ''A.'' I <<radiobutton "$choice3" "2">>  ''B.'' II <<radiobutton "$choice3" "3">>  ''C.'' III <<radiobutton "$choice3" "4">>  ''D.'' IV @@ <<button [[Next question->Q4]]>> <</button>> <<timed 59s>> <<goto Q4>> <</timed>> <<countdownTimer 60 "Q4">>

@@.whitetext;<<if $choice3 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 What is the key question you are trying to answer when assessing the airway?''</p> <<radiobutton "$choice4" "1">>  ''A.'' Will I be able to mask ventilate? <<radiobutton "$choice4" "2">>  ''B.'' Will I be able to perform direct or indirect laryngoscopy? <<radiobutton "$choice4" "3">>  ''C.'' Will I be able to intubate this person? <<radiobutton "$choice4" "4">>  ''D.'' Can I access the cricothyroid membrane? <<radiobutton "$choice4" "5">>  ''E.'' Is there a risk of aspiration? <<radiobutton "$choice4" "6">>  ''F.'' All of the above @@ <<button [[Next question->Q5]]>> <</button>> <<timed 59s>> <<goto Q5>> <</timed>> <<countdownTimer 60 "Q5">>

@@.whitetext;<<if $choice4 eq "6">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q5.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q5 This image shows which Mallampati score?'' </p> <<radiobutton "$choice5" "1">>  ''A.'' I <<radiobutton "$choice5" "2">>  ''B.'' II <<radiobutton "$choice5" "3">>  ''C.'' III <<radiobutton "$choice5" "4">>  ''D.'' IV @@ <<button [[Next question->Q6]]>> <</button>> <<timed 59s>> <<goto Q6>> <</timed>> <<countdownTimer 60 "Q6">>

@@.whitetext;<<if $choice5 eq "3">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q6.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q6 Which is the most correct statement? This thyromental distance (TMD) is:''</p> <<radiobutton "$choice6" "1">>  ''A.'' ≥ 6.5 cm and therefore not a sign of potential difficult laryngoscopy <<radiobutton "$choice6" "2">>  ''B.'' ≥ 6 cm and therefore not a sign of potential difficult laryngoscopy <<radiobutton "$choice6" "3">>  ''C.'' ≥5.5 cm and therefore not a sign of potential difficult laryngoscopy <<radiobutton "$choice6" "4">>  ''D''. ≥ 5 cm and therefore not a sign of potential difficult laryngoscopy <<radiobutton "$choice6" "5">>  ''E.'' I've no idea @@ <<button [[Next question->Q7]]>> <</button>> <<timed 59s>> <<goto Q7>> <</timed>> <<countdownTimer 60 "Q7">>

@@.whitetext;<<if $choice6 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q7.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q7 This image shows which Mallampati score?'' </p> <<radiobutton "$choice7" "1">>  ''A.'' I <<radiobutton "$choice7" "2">>  ''B.'' II <<radiobutton "$choice7" "3">>  ''C.'' III <<radiobutton "$choice7" "4">>  ''D.'' IV @@ <<button [[Next question->Q8]]>> <</button>> <<timed 59s>> <<goto "Q8">> <</timed>> <<countdownTimer 60 "Q8">>

@@.whitetext;<<if $choice7 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q8.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q8 If the ruler in the image show centimetres what would you record on the anaesthetic chart for mouth opening?'' </p> <<radiobutton "$choice8" "1">>  ''A.'' 2 cm <<radiobutton "$choice8" "2">>  ''B.'' 3 cm <<radiobutton "$choice8" "3">>  ''C.'' 4 cm <<radiobutton "$choice8" "4">>  ''D.'' 5 cm @@ <<button [[Next question->Q9]]>> <</button>> <<timed 59s>> <<goto "Q9">> <</timed>> <<countdownTimer 60 "Q9">>

@@.whitetext;<<if $choice8 eq "1">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q9.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q9 This image shows which Mallampati score?'' </p> <<radiobutton "$choice9" "1">>  ''A.'' I <<radiobutton "$choice9" "2">>  ''B.'' II <<radiobutton "$choice9" "3">>  ''C.'' III <<radiobutton "$choice9" "4">>  ''D.'' IV @@ <<button [[Next question->Q10]]>> <</button>> <<timed 59s>> <<goto "Q10">> <</timed>> <<countdownTimer 60 "Q10">>

@@.whitetext;<<if $choice9 eq "2">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q10.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q10 You are pre-assessing a 6-year-old who is having a tonsillectomy. When they open their mouth you see the image above. What is the most obvious thing to note as part of their airway assessment?'' </p> <<radiobutton "$choice10" "1">>  ''A.'' Their mouth opening is < 3 cm <<radiobutton "$choice10" "2">>  ''B.'' Their MP score is III <<radiobutton "$choice10" "3">>  ''C.'' Their TMD is < 6.5 cm <<radiobutton "$choice10" "4">>  ''D.'' Their lower incisors are really loose <<radiobutton "$choice10" "5">>  ''E.'' They have a upper respiratory tract infection @@ <<timed 59s>> <<goto "Done!">> <</timed>> <<countdownTimer 60 "Done!">> <<button [[Done!->Done!]]>> <</button>>

<<if $choice10 eq "4">><<set $result to $result + 1>> <</if>> You've scored <<print $result>> out of 10 <<set $result1 to $result>> [[Go to work|preop2]]

<center><img src="images/drh.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 07:49@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p>Hi $firstname, you're with me in K today. I'm running late, the DA knows. Could you pre-op the patients and i'll see you in K </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; No problem @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> You get the first coffee break, H </p> </div> </div> </p> [[Next->preop3]] <<audio text pause>>

<center> <img src="images/q1.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q1 This image shows which Mallampati score?'' </p> <label><<radiobutton "$choice1" "one">>  ''A.'' I </label> <label><<radiobutton "$choice1" "two">>  ''B.'' II </label> <label><<radiobutton "$choice1" "three">>  ''C.'' III </label> <label><<radiobutton "$choice1" "four">>  ''D.'' IV </label> @@ <<button [[Next question->Q2post]]>> <</button>> <<set $result to 0>>

@@.whitetext;<<if $choice1 eq "four">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q2 In patients who have difficult intubations what percentage are correctly identified by Mallampati III or IV?'' </p> <label><<radiobutton "$choice2" "one">>  ''A.'' 35% </label> <label><<radiobutton "$choice2" "two">>  ''B.'' 52% </label> <label><<radiobutton "$choice2" "three">>  ''C.'' 78% </label> @@ <<button [[Next Question->Q3post]]>> <</button>>

@@.whitetext;<<if $choice2 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q3.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q3 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice3" "one">>  ''A.'' I </label> <label><<radiobutton "$choice3" "two">>  ''B.'' II </label> <label><<radiobutton "$choice3" "three">>  ''C.'' III </label> <label><<radiobutton "$choice3" "four">>  ''D.'' IV </label> @@ <<button [[Next Question->Q4post]]>> <</button>>

@@.whitetext;<<if $choice3 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <p style="text-align:justify">''Q4 What is the key question you are trying to answer when assessing the airway?''</p> <label><<radiobutton "$choice4" "one">>  ''A.'' Will I be able to mask ventilate? </label> <label><<radiobutton "$choice4" "two">>  ''B.'' Will I be able to perform direct or indirect laryngoscopy? </label> <label><<radiobutton "$choice4" "three">>  ''C.'' Will I be able to intubate this person? </label> <label><<radiobutton "$choice4" "four">>  ''D.'' Can I access the cricothyroid membrane? </label> <label><<radiobutton "$choice4" "five">>  ''E.'' Is there a risk of aspiration? </label> <label><<radiobutton "$choice4" "six">>  ''F.'' All of the above </label> @@ <<button [[Next Question->Q5post]]>> <</button>>

<center> <img src="images/q1.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q1 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice1" "one" `$choice1 is "one" ? 'checked' : ''`>>  ''A.'' I </label> <label><<radiobutton "$choice1" "two" `$choice1 is "two" ? 'checked' : ''`>>  ''B.'' II </label> <label><<radiobutton "$choice1" "three" `$choice1 is "three" ? 'checked' : ''`>>  ''C.'' III </label> <label><<radiobutton "$choice1" "four" `$choice1 is "four" ? 'checked' : ''`>>  ''D.'' IV </label> <br> <<if $choice1 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify"> The soft palate is not visible at all. This is MP class IV. </p> @@ <<button [[Next question->answerQ2post]]>> <</button>>

@@.whitetext;<<if $choice4 eq "six">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q5.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q5 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice5" "one">>  ''A.'' I </label> <label><<radiobutton "$choice5" "two">>  ''B.'' II </label> <label><<radiobutton "$choice5" "three">>  ''C.'' III </label> <label><<radiobutton "$choice5" "four">>  ''D.'' IV </label> @@ <<button [[Next Question->Q6post]]>> <</button>>

@@.whitetext;<<if $choice5 eq "three">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q6.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q6 Which is the most correct statement? This thyromental distance (TMD) is:''</p> <label><<radiobutton "$choice6" "one">>  ''A.'' ≥ 6.5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "two">>  ''B.'' ≥ 6 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "three">>  ''C.'' ≥5.5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "four">>  ''D.''≥5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "five">>  ''E.'' I've no idea </label> @@ <<button [[Next Question->Q7post]]>> <</button>>

@@.whitetext;<<if $choice6 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q7.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q7 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice7" "one">>  ''A.'' I </label> <label><<radiobutton "$choice7" "two">>  ''B.'' II </label> <label><<radiobutton "$choice7" "three">>  ''C.'' III </label> <label><<radiobutton "$choice7" "four">>  ''D.'' IV </label> @@ <<button [[Next Question->Q8post]]>> <</button>>

@@.whitetext;<<if $choice7 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q8.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q8 If the ruler in the image show centimetres what would you record on the anaesthetic chart for mouth opening?''</p> <label><<radiobutton "$choice8" "one">>  ''A.'' 2 cm </label> <label><<radiobutton "$choice8" "two">>  ''B.'' 3 cm </label> <label><<radiobutton "$choice8" "three">>  ''C.'' 4 cm </label> <label><<radiobutton "$choice8" "four">>  ''D.'' 5 cm </label> @@ <<button [[Next Question->Q9post]]>> <</button>>

@@.whitetext;<<if $choice8 eq "one">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q9.jpg" style="max-width: 200px;"/> </center> <p style="text-align:justify">''Q9 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice9" "one">>  ''A.'' I </label> <label><<radiobutton "$choice9" "two">>  ''B.'' II </label> <label><<radiobutton "$choice9" "three">>  ''C.'' III </label> <label><<radiobutton "$choice9" "four">>  ''D.'' IV </label> @@ <<button [[Next Question->Q10post]]>> <</button>>

@@.whitetext;<<if $choice9 eq "two">><<set $result to $result + 1>> <</if>> <<print $result>> out of 10 correct <center> <img src="images/q10.jpg" style="max-width: 250px;"/> </center> <p style="text-align:justify">''Q10 You are pre-assessing a 6-year-old who is having a tonsillectomy. When they open their mouth you see the image above. What is the most obvious thing to note as part of their airway assessment?''</p> <label><<radiobutton "$choice10" "one">>  ''A.'' Their mouth opening is < 3 cm </label> <label><<radiobutton "$choice10" "two">>  ''B.'' Their MP score is III </label> <label><<radiobutton "$choice10" "three">>  ''C.'' Their TMD is < 6.5 cm </label> <label><<radiobutton "$choice10" "four">>  ''D.'' Their lower incisors are really loose </label> <label><<radiobutton "$choice10" "five">>  ''E.'' They have a upper respiratory tract infection </label> @@ <<button [[Submit->results2]]>> <</button>>

<<if $choice10 eq "four">><<set $result to $result + 1>> <</if>> You scored <<print $result>> out of 10! <<set $result2 to $result>> <<button [[Answers->answerQ1post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q2 In patients who have difficult intubations what percentage are correctly identified by Mallampati III or IV?''</p> <label><<radiobutton "$choice2" "one" `$choice2 is "one" ? 'checked' : ''`>>  ''A.'' 35% </label> <label><<radiobutton "$choice2" "two" `$choice2 is "two" ? 'checked' : ''`>>  ''B.'' 52% </label> <label><<radiobutton "$choice2" "three" `$choice2 is "three" ? 'checked' : ''`>>  ''C.'' 78% </label> <br> <<if $choice2 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify"> In a large multi-centre meta-analysis^^1^^ published in the BJA the frequency of difficult intubation was almost 7%. The odds ratio for a difficult intubation with a MP score of III or IV was 5.89 (95% CI 4.74-7.32) i.e. these patients have almost six times the risk of difficult intubation vs patients who are MP I or II. However only 35% of patients with difficult intubations were MP score III or IV. Bringing this together...MP alone does not predict the majority of difficult airways and further airway assessment is important. </p> @@ <<button [[Next question->answerQ3post]]>> <</button>> @@.whitetext;1. Lundstrom LH, Vester-Andersen M, Moller AM, et al. Poor prognostic value of modified Mallampati score: a meta-analysis involving 177 088 patients. //BJA//. 2011;107(5):659-67@@

<center> <img src="images/q3.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q3 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice3" "one" `$choice3 is "one" ? 'checked' : ''`>>  ''A.'' I </label> <label><<radiobutton "$choice3" "two" `$choice3 is "two" ? 'checked' : ''`>>  ''B.'' II </label> <label><<radiobutton "$choic e3" "three" `$choice3 is "three" ? 'checked' : ''`>>  ''C.'' III </label> <label><<radiobutton "$choice3" "four" `$choice3 is "four" ? 'checked' : ''`>>  ''D.'' IV </label> <br> <<if $choice3 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify"> Only the base of the uvula, soft and hard palate are visible. This is MP III </p> @@ <<button [[Next question->answerQ4post]]>> <</button>>

@@.whitetext;<p style="text-align:justify">''Q4 What is the key question you are trying to answer when assessing the airway?''</p> <label><<radiobutton "$choice4" "one" `$choice4 is "one" ? 'checked' : ''`>>  ''A.'' Will I be able to mask ventilate? </label> <label><<radiobutton "$choice4" "two" `$choice4 is "two" ? 'checked' : ''`>>  ''B.'' Will I be able to perform direct or indirect laryngoscopy? </label> <label><<radiobutton "$choice4" "three" `$choice4 is "three" ? 'checked' : ''`>>  ''C.'' Will I be able to intubate this person? </label> <label><<radiobutton "$choice4" "four" `$choice4 is "four" ? 'checked' : ''`>>  ''D.'' Can I access the cricothyroid membrane? </label> <label><<radiobutton "$choice4" "five" `$choice4 is "five" ? 'checked' : ''`>>  ''E.'' Is there a risk of aspiration? </label> <label><<radiobutton "$choice4" "six" `$choice4 is "six" ? 'checked' : ''`>>  ''F.'' All of the above </label> <br> <<if $choice4 is "six">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: F'' <p style="text-align:justify">National Audit Project 4: Major Complications of Airway Management in the United Kingdom, found that incomplete airway assessment, and failure to alter management based on what is found on assessment, contributed to poor airway outcomes. Along with asking yourself the key questions above you should also consider the implications of your assessment on airway management at the end of anaesthesia and during recovery. </p> @@ <<button [[Next question->answerQ5post]]>> <</button>>

<center> <img src="images/q5.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify"> ''Q5 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice5" "one" `$choice5 is "one" ? 'checked' : ''`>>  ''A.'' I </label> <label><<radiobutton "$choice5" "two" `$choice5 is "two" ? 'checked' : ''`>>  ''B.'' II </label> <label><<radiobutton "$choice5" "three" `$choice5 is "three" ? 'checked' : ''`>>  ''C.'' III </label> <label><<radiobutton "$choice5" "four" `$choice5 is "four" ? 'checked' : ''`>>  ''D.'' IV </label> <br> <<if $choice5 is "three">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: C'' <p style="text-align:justify"> Only the base of the uvula, soft and hard palate are visible. This is also MP III.</p> @@ <<button [[Next question->answerQ6post]]>> <</button>>

<center> <img src="images/q6.jpg" style="max-width: 250px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q6 Which is the most correct statement? This thyromental distance (TMD) is:''</p> <label><<radiobutton "$choice6" "one" `$choice6 is "one" ? 'checked' : ''`>>  ''A.'' ≥6.5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "two" `$choice6 is "two" ? 'checked' : ''`>>  ''B.'' ≥6 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "three" `$choice6 is "three" ? 'checked' : ''`>>  ''C.'' ≥5.5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "four" `$choice6 is "four" ? 'checked' : ''`>>  ''D.'' ≥5 cm and therefore not a sign of potential difficult laryngoscopy </label> <label><<radiobutton "$choice6" "five" `$choice6 is "five" ? 'checked' : ''`>>  ''E.'' I've no idea </label> <br> <<if $choice6 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify">The TMD is the distance from the upper boarder of the thyroid cartilage to the tip of the jaw measured with the neck extended. A distance less than 6.5 cm is associated with difficult laryngoscopy. </p> @@ <<button [[Next question->answerQ7post]]>> <</button>>

<center> <img src="images/q7.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q7 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice7" "one" `$choice7 is "one" ? 'checked' : ''`>>  ''A.'' I</label> <label><<radiobutton "$choice7" "two" `$choice7 is "two" ? 'checked' : ''`>>  ''B.'' II </label> <label><<radiobutton "$choice7" "three" `$choice7 is "three" ? 'checked' : ''`>>  ''C.'' III </label> <label><<radiobutton "$choice7" "four" `$choice7 is "four" ? 'checked' : ''`>>  ''D.'' IV </label> <br> <<if $choice7 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify"> There is visualization of the soft palate, fauces, uvula, anterior and posterior pillars. This is MP I. </p> @@ <<button [[Next question->answerQ8post]]>> <</button>>

<center> <img src="images/q8.jpg" style="max-width: 250px;"/> </center> @@.whitetext; <p style="text-align:justify">''Q8 If the ruler in the image show centimetres what would you record on the anaesthetic chart for mouth opening?''</p> <label><<radiobutton "$choice8" "one" `$choice8 is "one" ? 'checked' : ''`>>  ''A.'' 2 cm </label> <label><<radiobutton "$choice8" "two" `$choice8 is "two" ? 'checked' : ''`>>  ''B.'' 3 cm </label> <label><<radiobutton "$choice8" "three" `$choice8 is "three" ? 'checked' : ''`>>  ''C.'' 4 cm </label> <label><<radiobutton "$choice8" "four" `$choice8 is "four" ? 'checked' : ''`>>  ''D.'' 5 cm </label> <br> <<if $choice8 is "one">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: A'' <p style="text-align:justify"> The image shows an inter-incisor gap of 2 cm which should be clearly documented on the anaesthetic chart. Mouth opening with an inter-incisor gap of less than 3 cm is a non-reasuring sign and likley to preclude the use of a standard Macintosh laryngoscopy blade. Some video laryngoscopes need as little as 2 cm for insertion depending on the make/model while supraglottic airway devices generally need ≥2 cm mouth opening for insertion, although there are case reports of their use in patients with as little as 1.2 cm mouth opening. ''These should only be considered with suitably experienced support as part of a robust airway managment strategy.'' Often once under anaesthesia mouth opening that is limited by pain improves, however that cannot be relied on, and again once the issue is identified senior support is vital. </p> @@ <<button [[Next question->answerQ9post]]>> <</button>> @@.whitetext;Crawley SM, Dalton AJ. Predicting the difficult airway. //BJA Ed//. 2015; 15(5):253-257@@

<center> <img src="images/q9.jpg" style="max-width: 200px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q9 This image shows which Mallampati score?''</p> <label><<radiobutton "$choice9" "one" `$choice9 is "one" ? 'checked' : ''`>>  ''A.'' I </label> <label><<radiobutton "$choice9" "two" `$choice9 is "two" ? 'checked' : ''`>>  ''B.'' II </label> <label><<radiobutton "$choice9" "three" `$choice9 is "three" ? 'checked' : ''`>>  ''C.'' III </label> <label><<radiobutton "$choice9" "four" `$choice9 is "four" ? 'checked' : ''`>>  ''D.'' IV </label> <br> <<if $choice9 is "two">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: B'' <p style="text-align:justify"> The uvula, soft palate and fauces are visible so this is MP II. </p> @@ <<button [[Next question->answerQ10post]]>> <</button>>

<center> <img src="images/q10.jpg" style="max-width: 250px;"/> </center> @@.whitetext;<p style="text-align:justify">''Q10 You are pre-assessing a 6-year-old who is having a tonsillectomy. When they open their mouth you see the image above. What is the most obvious thing to note as part of their airway assessment?''</p> <label><<radiobutton "$choice10" "one" `$choice10 is "one" ? 'checked' : ''`>>  ''A.'' Their mouth opening is < 3 cm </label> <label><<radiobutton "$choice10" "two" `$choice10 is "two" ? 'checked' : ''`>>  ''B.'' Their MP score is III </label> <label><<radiobutton "$choice10" "three" `$choice10 is "three" ? 'checked' : ''`>>  ''C.'' Their TMD is < 6.5 cm </label> <label><<radiobutton "$choice10" "four" `$choice10 is "four" ? 'checked' : ''`>>  ''D.'' Their lower incisors are really loose </label> <label><<radiobutton "$choice10" "five" `$choice10 is "five" ? 'checked' : ''`>>  ''E.'' They have a upper respiratory tract infection </label> <br> <<if $choice10 is "four">> ''Thats right!'' <<else>> ''Not quite!'' <</if>> ''Correct answer: D'' <p style="text-align:justify">From around 5-6 years of age children start to loose their primary (deciduous or ‘baby’) teeth starting with the lower front incisors, a process which is generally completed by early adolescence. It is important to enquire about, and look for loose or wobbly teeth in all ages as part of your preoperative assessment, and document this clearly. The commonly used system of tooth identification divides the mouth into four quadrants and designates letters for primary teeth and numbers for permanent teeth starting from the front upper and lower incisors (see figure 1). <center> <img src="images/teeth.jpg" style="max-width: 100%;"/> ''Figure 1: Identification of primary teeth (left) and permanent teeth (right).'' </center> Where relevant the presence of braces, missing teeth, position and condition of dental restorations (e.g. crowns, bridges, implants and veneers) and the use of dentures should also be recorded. Dental damage is the most common cause of complaint and medicolegal claims against anaesthetists while the RCoA reports an occurrence of significant damage in 1:4500 anaesthetics and has produced a [[patient information leaflet|https://rcoa.ac.uk/sites/default/files/documents/2022-06/04-DamageTeeth2019web.pdf]] on the subject. In this case there is also risk of displacement and aspiration of the loose primary tooth. </p> @@ <<button [[Done!->End]]>> <</button>> @@.whitetext;Adewale L. Anaesthesia for paedicaric dentistry. //BJA Ed//. 2012; 12(6):288-294@@

<p style="text-align:justify"> @@.typing; Yep that’s me, Robert Richards, 84 Boyle road and I’m just gone 61. I prefer Rob to Robert though. Can I tell you about why I’m here today? It’s to get my gall bladder taken out. I’ve got gall stones you see, they’ve been no end of trouble the last couple of years. I’m feeling a bit nervous, otherwise I’m fine, been well the last couple of weeks, no coughs or colds. I’ve got high blood pressure, I take pills for that, the nurse is happy that they do the trick, and the GP tells me I have high cholesterol. They say that’s partly why I had a small heart attack a couple of years ago, 2018 it was. They took me straight in to have a stent in. Then not long after that they said I had problems with my heart rhythm, atrial fibrillation I think its called and I had to be on blood thinners. Other than that I’m fit as a fiddle, I gave up smoking after the heart attack. I'd been a smoker for 40 years! A pack a day, and I just stopped overnight. I’m not a drinker, it’s high-days and holidays for me. I teach physics at the comp but only part time now after the heart attack. I walk the dog every morning and evening. I sleep like a log with one pillow and lie flat no problem. I might get a bit of indigestion after a curry but never get it otherwise. I’ve got no problems with my neck, my teeth aren’t too bad, just a top partial denture. I haven’t had anything to eat since ten o’clock last night and I had black tea at six this morning just like the letter says I’ve got my repeat prescription here with all my medicines, they are all I take apart form the odd Nurofen for a headache or such. I’m not allergic to anything. I followed the instructions from the nurse about my medicines, she said to stop the aspirin a week before, warfarin five days before, and I didn’t take the ramipril this morning but I’ve had the rest. I’ll admit it though I am a bit nervous about being under. The only time I’ve had any sort of anaesthetic was when I was a nipper. Eleven. Appendix. It was pretty uneventful but these things stay with you. Not that any of the family has ever had any problems and you all know what you’re doing so I know I’m in safe hands. @@ </p> <center> [[Play audio->audio1]]    [[Next->audiopost1]] </center> <<audio richards pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Naomi Wassall. Gilly & Martin Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Rachael Hopper and Richard Wassall Our creative director and lead programmer: Kate Wainwright !!!Well done for completing Virtual Anaesthetics_1 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

<center> !! @@.greentext; DRUGS @@ </center> <p style="text-align:justify">Always refer to local guidelines and policies. Knowing this in the first months of training is so you can spot a problem and then talk to the right people about it. Broad principles…</p> <div class="notes">''Drugs to continue''</div> Really important: * Treatments for Epilepsy * Treatments for Parkinson's disease * Treatments for Asthma Also important: * PPIs or H2 antagonists * Loop & thiazide diuretics * Antiarrhythmics * B-blockers * Nitrates * Calcium channel blockers * Opioid analgesics * Gabapentin or pregabalin * Antipsychotics (be aware of risk >QTc) * TCA * SSRI (risk of <<link [[serotonin syndrome->drugs]]>> <<set Dialog.setup("Serotonin syndrome")>> <<set Dialog.wiki("Serotonin syndrome = neuromuscular abnormality, autonomic hyperactivity and mental state changes caused by excess serotonin at CNS synapses. Serotonergic drugs: antidepressants including St Johns wort; analgesics including tramadol, pethidine and fentanyl; antiemetics including ondansetron and metoclopramide as well as cocaine, MDMA, amphetamine and LSD. Most commonly implicated are MAOI.")>> <<set Dialog.open ()>> <</link>>) * Thyroxine * Statins <div class="notes">''Drugs to stop''</div> * COCP – if VTE risk don’t give 28 days before surgery (use alternative contraception), resume when < VTE risk * Herbal medicines – don’t give for 28 days before surgery * ACEi or ARB – don’t give on day of surgery (DOS), restart ASAP post op * Consider holding potassium sparing diuretics on DOS <div class="notes">''Special mention...''</div> * MAOI * Methotrexate, azathioprine, ciclosporin * NSAID * Steroids * Treatments for diabetes * Anticoagulants * Antiplatelets <div class="notes">''MAOI''</div> @@.greentext;''e.g. phenelzine, isocarboxazide, tranylcycpromide (irreversible) and moclobemide (reversible)''@@ <p style="text-align:justify">Rarely used. Loved by examiners. Inhibition of MAO enzyme prevents the break down of noradrenaline and serotonin with a risk of hypertensive crisis and serotonin syndrome. The decision to pause or continue MAOI should be done in liaison with the prescriber as rapid withdrawal may precipitate psychiatric relapse.</p> If decision to pause: * Irreversible MAOI – don’t give for 14 days before surgery – resume with discussion of MDT * Reversible MAOI – don’t give day before surgery – resume with discussion of MDT If decision to continue or emergency procedure an <<link [[MAOI safe anaesthetic->drugs]]>> <<set Dialog.setup("MAOI safe anaesthetic")>> <<set Dialog.wiki("MAOI safe anaesthetic = Avoid indirect or mixed action sympathomimetics (ephedrine, metaraminol, cocaine). Avoid suxamethonium. Avoid pethidine, tramadol, ketamine or nefopam. Caution with direct acting sympathomimetics.")>> <<set Dialog.open ()>> <</link>> must be given. <div class="notes">''Methotrexate, azathioprine, ciclosporin''</div> <p style="text-align:justify">Decision to interrupt treatment depends on the risk of relapse of the condition under treatment vs the risk of infection. This should be made on a case by case basis with input from the prescribing clinician.</p> <div class="notes">''NSAIDs''</div> <center> <img src="images/nsaid.jpg" style="max-width: 100%;"/> </center> NSAIDs generally continued for low bleeding risk procedure, held if high risk of bleeding or at risk of perioperative deterioration in renal function or hypotension. If stopping: * ''Short acting'' (ibuprofen, diclofenac, naproxen) – don’t give day before surgery – resume when haemostasis and no risk of renal injury or hypotension * ''Long acting'' – don’t give for five half lives before surgery – resume when haemostasis and no risk of renal injury or hypotension <div class="notes">''Steroids: High risk, know the basics...''</div> <center> <img src="images/pred.jpg" style="max-width: 100%;"/> @@.greentext;''Don't suddenly stop long term steroids''@@ </center> <p style="text-align:justify">Perioperative steroid cover essential if: Primary or secondary adrenal insufficiency ''or'' Currently or within the last 3 month adreno-suppressive doses of steroid (≥ 5 mg prednisolone or equivalent for ≥ 4 weeks)</p> SEE the Association of Anaesthetists guideline: [[Management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency|https://anaesthetists.org/Home/Resources-publications/Guidelines/Management-of-glucocorticoids-during-the-peri-operative-period-for-patients-with-adrenal-insufficiency]] and follow local policies. <div class="notes">''Treatments for diabetes ''</div> General principles: * If HbA1c ≥ 69 mmol.mol^^-1^^ delay elective procedures for optimization glycaemic control * First on list * Minimise fasting period * Aim perioperative capillary blood glucose (CBG) 6 – 10 mmol.l^^-1^^ max 12 * Where possible patients should be supported to retain control and possession of their diabetes medication * Type 1 diabetics ''MUST'' continue some form of insulin perioperatively * If more than one missed meal, poor preoperative glycaemic control, emergency procedure or no basal insulin given in type-1 DM, start variable rate intravenous insulin infusion (VRIII) SEE the Association of Anaesthetists guideline: [[perioperative management of the surgical patient with diabetes|https://anaesthetists.org/Home/Resources-publications/Guidelines/Peri-operative-management-of-the-surgical-patient-with-diabetes]] <div class="notes">''Anticoagulants''</div> * Follow local guidelines and policies * Risk of thrombosis vs the risk of bleeding? * Would delay of non-urgent procedure modify the thrombotic risk? * Bleeding risk of planned procedure is best quantified by the operating surgeon <center> ''Table 1: Thrombosis risk'' |@@.greentext;''Indication''@@|@@.greentext;''V.high''@@|@@.greentext;''High''@@|@@.greentext;''Moderate''@@| |AF |CHAD~~2~~ >4; Stroke or TIA in last 3 months|CHAD~~2~~ 3 or 4; Stroke or TIA more than 3 months ago|CHAD~~2~~ ≤2| |Valve |MV prosthesis; Cage or disc AV; Valve + stroke in last 6 months|Bi-leaflet valve + risk factors for stroke (e.g. AF, DM, >75 yo, HTN, HF)|Bi-leaflet valve| |VTE|VTE last 3 months; Severe thrombophilia; VTE + INR target 3.5|VTE within last 3-12 months; Non-severe thrombophilia|VTE more than 12 months ago| ^^AF = atrial fibrilation, VTE = venous thromboembolism^^ ''Table 2: Bleeding risk'' |@@.greentext;''Minor''@@|@@.greentext;''Low risk (infrequent or low consequence bleeding)''@@|@@.greentext;''High risk (frequent or high consequence bleeding)''@@| |Dental|Pacemaker|Neuraxial anaesthesia| |Cataracts or glaucoma surgery|Biliary stenting|Cranial, spinal, thoracic, abdominal or pelvic surgery| |Endoscopy, no biopsy|Endoscopy with biopsy|Complex endoscopy (e.g. ERCP)| |Superficial skin (e.g. mole bx)|Prostate or bladder bx|Kidney bx| |||Major orthopaedic surgery| |||TURP| ^^bx = biopsy, TURP = transurethral resection of the prostate, ERCP = endoscopic retrograde cholangiopancreatography^^ </center> <div class="notes">''Warfarin''</div> <p style="text-align:justify">May not need to stop for minor bleeding risk procedures. If stopping follow local anticoagulation service guidelines, e.g. if usual INR 2-3 don’t give for 5 days before surgery and check INR on admission, IF high risk of thrombosis start LMWH after 2-3 missed warfarin doses. Last dose LMWH at least 24 h preop.</P> @@.greentext;''Emergency procedures:''@@ * Check INR * Delay for 6-8 h if safe to do so and give 5 mg of IV vitamin K * If immediate surgery involve haematologist, anticoagulation can be reversed with prothrombin complex concentrate Warfarin should be resumed when safe to do so after discussion with the operating surgeon. <div class="notes">''Direct oral anticoagulants (DOACs)''</div> Minor bleeding risk procedures: may be continued, ask surgeon, give dose to maximise interval between DOAC and procedure. @@.greentext;''Low bleeding risk procedures:''@@ * ''Apixaban, dabigatran with CrCl ≥ 50 ml/min, edoxaban, rivaroxaban'' don’t give for 1 day before surgery – resume when haemostasis/discuss with operating surgeon * ''Dabigatran with CrCl < 50 ml/min'' don’t give for 2 days before surgery @@.greentext;''High bleeding risk procedures:''@@ * ''Apixaban, dabigatran with CrCl ≥ 50 ml/min, edoxaban, rivaroxaban'' don’t give for 2 days before surgery * ''Dabigatran with CrCl < 50'' don’t give for 4 days before surgery Resume 6-12 h after minor or low bleeding risk procedures and 48 h after high bleeding risk procedures after discussion with the operating surgeon and when adequate haemostasis @@.greentext;''Neuraxial & regional procedures:''@@ See the Association of Anaesthetists guideline: [[Regional anaesthesia and patients with abnormalities of coagulation|https://anaesthetists.org/Home/Resources-publications/Guidelines/Regional-anaesthesia-and-patients-with-abnormalities-of-coagulation]] @@.greentext;''Emergency procedures:''@@ * Delay 12-24 h if safe to do so * Discuss with haematologist <div class="notes">''LMWH''</div> <center> <img src="images/lmwh.jpg" style="max-width: 100%;"/> </center> * @@.greentext;''Prophylactic dose''@@ Last dose minimum of 12h before neuraxial or surgical procedure * @@.greentext;''Therapeutic dose''@@ Last dose minimum of 24h before neuraxial or surgical procedure * @@.greentext;''Post op LMWH''@@ Surgical decision AND 4h after any neuraxial catheter removal <div class="notes">''Antiplatelets''</div> * @@.greentext;''Aspirin, cardiac surgery''@@ MDT decision, if held – don’t give for 7 days before surgery * @@.greentext;''Aspirin, non-cardiac surgery''@@ consider reducing dose if > 150 mg and continue at lower dose * @@.greentext;''Aspirin, critical sites''@@ (e.g. spinal surgery, some ophthalmological and neurosurgical procedures) MDT decision, if held – don’t give for 7 days before surgery * @@.greentext;''Clopidogrel, consider holding''@@ don’t give for 7 days before surgery * @@.greentext;''Aspirin AND clopidogrel''@@ Risk of major acute cardiac event (MACE) if discontinued. MDT decision, if held – don’t give for 7 days before surgery * @@.greentext;''Dipyridamole''@@ continue EXCEPT critical sites (e.g. spinal surgery, some ophthalmological and neurosurgical procedures) – don’t give for 1 day before surgery Resume as soon as safe to do so after discussion with the operating surgeon and when adequate haemostasis. !!!<p style="text-align:justify">@@.typing;The bottom line: Always take a thorough drug history and know when the most recent dose of any drug has been taken. Follow local and national policy and guidance. The majority of drugs can be continued safely during the perioperative period. This is especially important for drugs to control Parkinson’s disease, epilepsy and asthma. People dependent on steroids MUST have steroid cover. High risk drugs that need special management perioperatively include ACEi, ARB, MAOI, anticoagulants, antiplatelets, agents used in the management of diabetes.@@ </p> [[Back|preop9]] [[Show me the evidence|ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

References and further reading: ''The Association of Anaesthetists Guidlines:'' Management of glucocorticoids during the perioperative period for patients with adrenal insufficiency. Feb 2020. Available [[here|https://anaesthetists.org/Home/Resources-publications/Guidelines/Management-of-glucocorticoids-during-the-peri-operative-period-for-patients-with-adrenal-insufficiency]] Peri-operative management of the surgical patient with diabetes. Sept 2015. Available [[here|https://anaesthetists.org/Home/Resources-publications/Guidelines/Peri-operative-management-of-the-surgical-patient-with-diabetes]] Regional anaesthesia and patients with abnormalities of coagulation. Nov 2013. Available [[here|https://anaesthetists.org/Home/Resources-publications/Guidelines/Regional-anaesthesia-and-patients-with-abnormalities-of-coagulation]] ''UpToDate (Login required):'' Periprative managment of blood glucose in adults with diabetes mellitus. Available [[here|https://www.uptodate.com/contents/perioperative-management-of-blood-glucose-in-adults-with-diabetes-mellitus]] The management of the surgical patient taking glucocorticoids. Available [[here|https://www.uptodate.com/contents/the-management-of-the-surgical-patient-taking-glucocorticoids]] Perioperative medication management. Available [[here|https://www.uptodate.com/contents/perioperative-medication-management]] ''The Handbook of Perioprative Medicines''. UK Clinical Pharmacy Association. Available [[here|https://www.ukcpa-periophandbook.co.uk/]] [[Back->drugs]]

You thank Mr Richards and check a few last details. When he opens his mouth the inter-incisor gap is more than 4 cm. His top denture plate is in place and you can see uvula, soft palate and fauces at the back of his oropharynx. You listen to his chest. His lungs are clear and you catch a high pitched 'blowing' pansystolic murmur when you listen to the apex. The admitting DOSA nurse has recorded a first set of obs that you add to the chart. [[Next|richards3]] <<audio richards pause>>

<p style="text-align:justify"> @@.typing;Susan Fletcher, Sue really, and its 32 Charlies Close, and I’m 47 next month. I’ve been seeing Mr Timmins about the gall stones in clinic for two years now, he wanted me to try and lose some weight before thinking about surgery but four months ago I was in terrible pain and it turned out that I had an infection in my gallbladder. I was in a week and felt pretty rough, so after that it was enough is enough and he said he’d take it out. I have a bit of asthma, I just use my blue inhaler when I need it, which isn’t often, never needed to go to hospital for my chest and the only antibiotics I’ve had this year were when I was in with my gallbladder. Never taken steroids for it either. I’ve not had any coughs or colds in a long time. I’ve been diabetic since I was pregnant with my second, erm, that was 16 years ago now. I was on just the tablets but my sugars were still in the high teens so I started insulin about 18 months ago. I use the NovoMix 30 pen and it’s 28 units in the morning and then 30 at dinner time. I take metformin as well, that’s 1 g twice a day and since I’ve been on that lot my HbA1c has come down to 58 the last time they did it. They also put me on a statin too because of my diabetes. I’ve got low thyroid and take thyroxine for that, the GP has just changed that to 100 a day. Other than that I’m quite healthy really, I work as a shop assistant and I’m on my feet all day. I sleep a bit propped up with a few pillows because I get wicked heartburn if I don’t. I take 20 of omeprazole to keep on top of it but I still can’t eat spicy food. I’m not a smoker and I don’t drink because of the heartburn. I take ibuprofen when I need it, it doesn’t affect my chest at all. I don’t take anything else, I’m not one for taking things if I don’t need it. I have a full set of veneers and you look after them they cost a fortune. I’ve had nothing to eat or drink since dinner last night, so, erm, that was half nine. The only anaesthetic I’ve had before was an emergency c-section with my second. Everything was such a rush and they said they needed to get her out NOW. Then the next thing I know is I’m back on the postnatal ward with a really sore throat and a baby. I was pretty sick, I remember that. She was absolutely fine, giving me hell now, teenagers, huh! My mum and sister have had lots of anaesthetics between them. They always seemed fine.@@ </p> <center> [[Play audio|audio2]]    [[Next|audiopost2]] </center> <<audio fletcher pause>>

@@.typing;''From:'' Claire Simmonds ''To:'' $firstname $surname and 7 others ''Subject:'' Novice teaching on preoperative assessment next week Hi Everyone I'd like everyone to have a look at the association of anaesthetists guidelines on preoperative assessment before teaching next week. It's available [[here|https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_preoperative_assessment_patient_preparation_anaesthetist_2010_final.pdf?ver=2018-07-11-163756-537&ver=2018-07-11-163756-537]]. There is also a notes page on airway assessment [[here|airway]]. I've attatched an anaesthetic chart summary sheet that one of the other trainees did last year which you may find helpful. ''After'' you've looked at those there's some MCQ I'd like you all to have a go at. See you all in teaching. Thanks, Claire Dr Claire Simmonds MBChB, MA, FRCA Consultant in Anaesthesia @@ [img[images/pdf.jpg][https://www.virtualanaesthetics.com/IACModule%201/notes.pdf]] [[www.practiceMCQ.ac.uk|Q1]] [[I'll skip this thanks|preop2][$result1 = "-"]] Sent from my iPad

Next morning you are just leaving the changing rooms having got into scrubs. Was that a [[text alert->text1]]? <<audio text play>>

It's Sunday evening and you are sat at home working through a heap of emails. What's this one about [[teaching next week->preop1]]? <<set $Q to false>>

You go to surgical admissions and retrieve a list for theatre K from the top of the notes trolley. You scan it quickly. Who are you going to see first? [[the list]] <<set $richards to false>> <<set $fletcher to false>> <<set $redbridge to false>>

<center> !!!Theatre K <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-US", { day: "numeric", month: "long", year: "numeric" } )>> </center> <p style="text-align:left">''Surgeon 1:'' Mr Neil Timmins &emsp;&emsp;''Anaesthetist 1:'' Dr Henry Coal ''Surgeon 2:''&ensp;&emsp;&emsp;&emsp;&emsp;&emsp;&emsp;&emsp;&emsp;&emsp;'' Anaesthetist 2:'' $firstname $surname &emsp;&emsp;</p> @@.typing; | ''Patient details''  | ''Planned procedure'' | ''PMH'' | ''Notes'' | |[[Lisa Redbridge, H242526, 38y, DOSA]]  |Laparoscopic cholecystectomy  |  |  | |[[Robert Richards, H415161, 61y, DOSA]]  |Laparoscopic cholecystectomy  |Hx of anaemia  |Needs check Hb  | |[[Susan Fletcher, H123456, 46y, DOSA]]  |Laparoscopic cholecystectomy  |HTN, DM  |BMI 42  | @@

"Are you done with them?" you ask the surgical SpR who has Mrs Fletcher's notes closed on the desk. "Sure." They hand you the file. "She's still in room 4." You thank them and take a seat to read through Mrs Fletcher's [[pre-op assessment|https://www.virtualanaesthetics.com/IACModule%201/fletcher.pdf]]. You take a label from the file and stick it on the top of a blank anaesthetic chart from the pile and go and find your patient. [[Next->fletcher1]] <<set $fletcher to true>>

You fish Mr Richards' weighty notes out of the trolley. He's been seen by one of the pre-op nurses in clinic and there's a filled out assessment proforma. Plus here's his ECG and a set of recent bloods. [[You take a look|https://www.virtualanaesthetics.com/IACModule%201/richards.pdf]]. After you scan through, you go and find him in the waiting area. [[Next->richards1]] <<set $richards to true>>

Lisa Redbridge's notes are so slim you almost miss them as you leaf through the loaded suspension files of the notes trolley. You flick through the [[pre-operative assessment clinic proforma|https://www.virtualanaesthetics.com/IACModule%201/redbridge.pdf]]. Then [[go and find your patient|redbridge1]]. <<set $redbridge to true>>

You double check the name on the board and then go over to Mr Richards. "Hello is it Mr Robert Richards?" He looks up to you and gives a nervous nod. "Yep, that's me." "Good morning, I'm Dr $firstname $surname, one of the anaesthetic doctors. I need to ask you a few questions if that's ok?" He settles into his chair. "Of course, ask away." "Firstly can you tell me your date of birth and address so I can check I've got the details correct." [[Next->richards2]]

Fortunately Rob is about to volunteer a decent history for your anaesthetic pre-assessment. Have the blank proforma ready, and fill it out as he tells you what you need to know. Once that’s ready click [[here->audio1]] to listen to what he says. Alternatively a written transcript is available [[here->transcript1]]. <<audio richards pause>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio richards play>> [[Transcript->transcript1]]   [[Next->audiopost1]] <img src="images/richards.jpg" style="max-width: 400px;"/> </center>

You give him a brief run-through of the anaesthetic side of things. When you broach the subject of him being a bit anaemic, the possibility of blood transfusions and anaesthetic risk in general, Mr Richards raises a hand to stop you. "I don’t want to talk about that, I read all the stuff they gave me in the pre-assessment clinic about teeth and being sick and such like, I’d rather not go into it again. That's why my heart rate's up! You lot make me nervous! It's never above 65 at home." [[Next]]

You find Mrs Fletcher in room 4. "Hello, is it Mrs Fletcher?" The women in front of you nods. "I'm Dr $firstname $surname, one of the anaesthetic doctors. I need to ask you a few questions if that's ok?" "Of course, I haven't got anything better to do!" she quips. "Can I just confirm a few details first?" [[Next|fletcher2]]

<<if $richards is true and $fletcher is true and $redbridge is true>> That's everyone seen. You head back out the door. [[Next|preop4]] <<else>> You make a couple of notes on your copy of the theatre list and crack on with seeing the next person on [[the list]]. <</if>>

Fortunately Sue is about to volunteer a reasonable history for your anaesthetic pre-assessment. Have the blank proforma ready, and fill it out as she tells you what you need to know. Once that’s ready click [[here->audio2]] to listen to what she says. Alternatively a written transcript is available [[here->transcript2]]. <<audio fletcher pause>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio fletcher play>> [[Transcript->transcript2]]   [[Next->audiopost2]] <img src="images/fletcher.jpg" style="max-width: 100%;"/> </center>

“Are you happy if I check a few things?” You gesture with your stethoscope by way of explanation. “Of course.” She sits forward a bit so you can listen to her chest. That’s clear, and her heart sounds are normal. You ask her to extend her neck: there’s overlying adipose tissue making the thyroid cartilage difficult to make out but it looks like her thyromental distance is about 6cm. When you ask her to hook her bottom teeth over her top teeth she can’t: her lower incisors don’t even meet her top ones, which you note are all perfectly white veneers. Her mouth opening is reasonable but when you peer into the back of her throat the base of her uvula is only just about visible. [[Next|fletcher3]] <<audio fletcher pause>>

You explain what will happen once she comes down to theatres. Sue listens and shakes her head when you ask if she has any particular concerns or questions. When you bring up the subject of risks associated with the GA she pulls a printout from her bag. "This sort of thing? They told me all about it when I had my telephone appointment and sent me this leaflet. I am really worried about my teeth." [[Next|fletcher4]] <<set $dm to "no answer given">>

Just as you leave DOSA you run into Sally, one of the other anaesthetic trainees. She has a sheaf of anaesthetic charts in her hand. "Hi $firstname. What are you up to this morning?" "Hi Sally. I'm in K, with Dr Coal, only he's running late so he text me to come to do the pre-ops." You reply. Sally's smile drops. "I wasn't allocated this morning and the DA asked me to see K's patients." She waves the charts in her hand with a florish. "He didn't know you were with Dr Coal, only that he was going to be late in." She shrugs. "You might as well take these." She offers you the completed charts. Have a look at what she's written [[here|https://www.virtualanaesthetics.com/IACModule%201/charts.pdf]] and compare it to the charts you completed while listening to the patients. Once you're done, you head back to [[theatre K|preop5]]

You track Mrs Redbridge down in the waiting area. "Hello, is it Mrs Redbridge?" "Yes. Are you the surgeon?" she asks. "No, I'm Dr $firstname $surname, one of the anaesthetic doctors. I need to ask you a few questions if that's ok? Shall we just go into one of the consulting rooms where it's a bit more private?" You gesture to the nearest empty room. [[Next|redbridge2]] <<set $redbridge to true>>

Lisa has a pretty uneventful medical history and she's going to tell you about it. Have the blank proforma ready, and fill it out as she tells you what you need to know. Once that’s ready click [[here->audio3]] to listen to what she says. Alternatively a written transcript is available [[here->transcript3]]. <<audio redbridge pause>>

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio redbridge play>> [[Transcript->transcript3]]   [[Next->audiopost3]] <img src="images/redbridge.jpg" style="max-width: 100%;"/> </center>

<p style="text-align:justify"> @@.typing; Yep, that’s me, Lisa Redbridge, 67 Lussac Lane, 38 years old. I’ve had problems with colicky pain for the last few years and the GP sent me for an ultrasound which showed I had gallstones, they said I could just put up with it or have my gallbladder removed by keyhole so here I am. Apart from that I’ve always been fit and well. I don’t get reflux and I've never seen the doctor for anything else. Not ever had any kind of operation but I know there haven’t been any problems with anaesthetics in the family. I don’t take any medications. I’m ok with NSAIDs if I need them but that’s not often. I’m not allergic to anything that I know of. I don’t smoke or drink. I work as a chemist in pharmaceutical development and run to and from work every day. My teeth are all good and I followed the instructions in the letter about fasting so I last had anything yesterday evening around half ten. I got up too late this morning to have a drink so that was it. Actually I’m really more worried about the anaesthetic than the operation itself. I was on a news website and they were talking about when people have been awake all the way through and no one realises. That’s my worst nightmare. @@ </p> <center> [[Play audio|audio3]]    [[Next|audiopost3]] </center> <<audio redbridge pause>>

When you assess Lisa's airway you note good mouth opening, a thyromental distance of > 6.5 cm and when you look into the back of her oropharynx her soft palate, fauces, uvula, anterior and posterior pillars are all visable. Lisa's observations and examination are otherwise unremarkable. [[Next|redbridge3]] <<audio redbridge pause>>

You run through the anaesthetic plan with Lisa and tell her about the risks involved while trying to alleviate her concerns about awareness under anaesthesia. "It’s a lot to take in. Do you have any written information?" she asks. "Of course. I'll go and grab an information leaflet that you can go through in your own time." you reply. You quickly access the RCoA [[anaesthetic risk leaflets|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk/risk-leaflets]] and print off the one related to accidental awareness under GA before taking it back to Lisa. She takes the print out. "Thanks. I don't have anymore questions right now." [[Next]]

As you are heading out of the consulting room one of the DOSA nurses catches you. "Morning $firstname. I've just done Mrs Fletcher's BM. It was 8.7. Did she tell you she's not taken any anti-diabetic meds this morning?" You shake your head. The nurse continues. "Hmm, she's got everything with her, do you want me to give her metformin or any insulin?" What do you need to know before answering that quesion? [[What was her HbA1c?|fletcher5][$dm = "Not quite"]] [[When did she last eat or drink?|fletcher5][$dm = "Not quite"]] [[What does her BM usually run at?|fletcher5][$dm = "Not quite"]] [[Does she suffer from hypos?|fletcher5][$dm = "Not quite"]] [[How many meals is she going to miss?|fletcher5][$dm = "Correct"]]

<<print $dm>> One of the key bits of information you need to know when planing peri-oprative management of a patients with diabetes is how many meals is this person likely to miss? If a short starvation period is anticipated, with only one missed meal, glycaemic control via modification of a patient's usual diabetes medication is recommended by the Association of Anaesthetists. In patients with poorly controlled diabetes, type-1 diabetics who are receiving no background insulin, those undergoing emergency surgery, and those missing more than one meal, a variable rate intravenous insulin infusion is prefered. If Sue can be moved to first on the list and will only miss one meal; have a look at the Association of Anaesthetists guideline [[Perioperative management of the surgical patient with diabetes|https://anaesthetists.org/Home/Resources-publications/Guidelines/Peri-operative-management-of-the-surgical-patient-with-diabetes]] and think about how you would manage her today. [[Next]]

Dr Coal is in the anaesthetic room for theatre K with Paul the ODP. Dr Coal looks up. "Ah, $firstname, you've seen everyone? That's great. What can you tell me about them?" Have a think about what are the key parts of these patients' anaesthetic histories? If you have the opportunity you could discuss the cases with one of your Clinical Supervisors? Once you're happy click [[here|preop6]] to see some key points.

You give a summary of each of the patients: ''Robert Richards:'' * 61 yo * ASA III * Known AF, rate controlled with bisoprolol, warfarinised which was stopped 5/7 ago * Inferior MI 2018, PCI & bare metal stent, recent ECHO shows EF 63% * Good ET * NKDA * Ex smoker 2018 * Airway:- top plate denture otherwise no adverse features * PSM with known moderate MR * Aspirin stopped 7 days as instructed ''Susan Fletcher:'' * 46 yo * ASA III * BMI 42 (WHO class III obesity) * Well controlled asthma * Type-2 DM on insulin, BM 8.7 this morning * Good ET * Allergic to penicillin * Airway:- Several adverse features, also has a history of sore throat after previous GA also suffers from reflux * Previous PONV after emergency CS under GA 16 years ago ''Lisa Redbridge:'' * 38 yo * ASA II due to BMI 33 and ETOH * NKDA * Airway:- MP I, no adverse features * No previous GA [[Next|preop7]] <<set $test to "No answer given">>

"Have they all had the right pre-op investigations?" Dr Coal asks you. You pause for a moment, glance down at the notes you have on your copy of the list and then rack your brains about the [[NICE guidelines on preoperative tests|https://www.nice.org.uk/guidance/ng45]], as well as your own local guidelines before you answer... [["No they haven't"|preop8][$test = "Correct"]] [["Yes they have"|preop8][$test = "Not quite"]] <<set $drug to "No answer given">>

<<print $test>> You run through the investigations everyone has had. Dr Coal frowns. "If Sue Fletcher hasn't had an ECG in the last 12 months she should probably have one." He continues "Are you happy with what drugs they've taken and what's been held?" [["Yes, it's all good"|preop9][$drug = "Not quite"]] [["Actually we have a problem"|preop9][$drug = "Correct"]]

<<print $drug>> Dr Coal raises an eyebrow. "We need to do Susan Fletcher first and make sure she gets her metformin and halve her morning NovoMix. She's on the enhanced recovery pathway and will only miss breakfast if we can get this list started." He rummages in his bag. "I did a teaching session on perioperative managment of drugs not long ago. Here's a [[summary|drugs]]." [[Next|preop10]]

"Right, anyhow, I've checked the anaesthetic machine and drawn emergency drugs so as you've done most of the work this morning go and grab a quick coffee and be back here in five minutes so we can do team brief with the surgeons?" [[Next|preop11]]

While you're waiting for the kettle to boil you check your emails on your phone. There's another from Claire about next week's tutorial. [[email]]

@@.typing;''From:'' Claire Simmonds ''To:'' $firstname $surname and 7 others ''Subject:'' Re: Novice teaching on preoperative assessment next week Hi Everyone I didn't include the answers in those MCQ I sent yesterday. So here's those questions to try again with answers. See you all in teaching. Thanks, Claire Dr Claire Simmonds MBChB, MA, FRCA Consultant in Anaesthesia @@ [[www.practiceMCQ.ac.uk|Q1post]] PS: You've done enough for one virtual work day. Once these questions are complete you will get your module certificate. The three cases will progress in module 2. Sent from my iPad

!!!@@.greentext;EPA 1: Performing an Anaesthetic Preoperative Assessment@@ EPA for this scenario in ''bold'' * ''Take a focused history, perform appropriate physical examination and interpret relevant investigations'' * ''Understand how a patient’s past medical, surgical and anaesthetic history influences the safe conduct of anaesthesia'' * ''Identify patients with an increased ‘perioperative risk’ and raise concerns appropriately'' * ''Communicate the anaesthetic plan to patients in an understandable way, including counselling on commonly occurring risks and addressing patient concerns'' * ''Understand limitations and scope of practice of a novice anaesthetist'' !!!@@.greentext;EPA 2: General Anaesthesia for an ASA I/II patient having uncomplicated surgery@@ * Understand your scope of practice as an inexperienced practitioner and seek help appropriately * Plan and deliver general anaesthesia to appropriate patients including the following techniques: airway management with supraglottic devices and endotracheal intubation; spontaneous and controlled ventilation; rapid sequence induction * Prepare and check emergency drugs and equipment commonly used in anaesthetic practice * Independently check and use a standard anaesthetic machine * Manage tracheal extubation, including common complications occurring during emergence from anaesthesia; eg, laryngeal spasm * Manage acute postoperative pain including the use of rescue opiates in recovery and patient controlled analgesia * Demonstrate understanding and capability in Anaesthetic Non-technical Skills * Initiate management of common anaesthetic emergencies, including unanticipated difficult airway management, and call for senior help [[Back|Core clinical learning objectives]]

!!@@.greentext; 2021 Curriculum learning syllabus stage 1@@ !!!@@.greentext;Perioperative medicine and health promotion learning outcomes:@@ @@.greentext;''//Identifies clinical and social challenges that increase risk for patients undergoing surgery Appreciates the principles of sustainability in clinical practice//''@@ !!!@@.greentext; ''Key capabilities''@@ * Explains the patient, anaesthetic and surgical factors influencing patient outcomes * Applies a structured approach to preoperative anaesthetic assessment of ASA 1-3 patients prior to surgery and recognises when further assessment and optimisation is required * Explains the effect that co-existing disease, subsequent treatment and surgical procedure may have on the conduct of anaesthesia and plans perioperative management accordingly * Explains individualised options and risks of anaesthesia and pain management to patients * Considers patient informed preference when obtaining consent for anaesthetic procedures !!!@@.greentext;General anaesthesia learning outcome:@@ @@.greentext;''//Provides safe and effective general anaesthesia with distant supervision for patients undergoing non-complex elective and emergency surgery within a general hospital setting//''@@ !!!@@.greentext;Key capabilities@@ * Conducts comprehensive pre-anaesthetic and preoperative checks * Safely manages induction and maintenance of anaesthesia by inhalational and intravenous techniques, extubation and emergence from anaesthesia * Plans recovery care, and manages recovery from anaesthesia utilising safe discharge criteria * Diagnoses and manages common perioperative complications These scenarios are ''not'' designed for exam revision. They are to support your leaning during the IAC and ultimately help you make good decisions at 2 am. [[Back|Core clinical learning objectives]]

<center> !! @@.greentext;Airway assessment@@ <img src="images/jaguar.jpg" style="max-width: 100%;"/> </center> <div class="notes">''It's about avoiding surprises...''</div> @@.greentext;''Difficult airway''@@ = //Clinical situation where trained anaesthetist experiences difficulty with mask ventilation, tracheal intubation or both// @@.greentext;''Difficult ventilation''@@ = inability of trained anaesthetist to maintain O~~2~~ sats >90% using a face mask for ventilation and 100% inspired O~~2~~ provided sats were in the normal range prior to induction. At risk: ''B''eard, ''O''bese, ''N''o teeth, ''E''lderly, ''S''nores (BONES) @@.greentext;''Difficult intubation''@@ = > 3 attempts, > 10 minutes, failure of best attempt <div class="notes">''Let the patient tell you...''</div> <p style="text-align:justify">''History:'' Arthritis, scleroderma, neck surgery or trauma, diabetes, acromegaly, congenital syndromes, obesity, deformity, burns, radiotherapy, swelling/tumour/infection/haematoma/anaphylaxis, reflux, pregnant? Look at the notes: What was the patient’s previous intubation grade? Who performed it? Any airway difficulties? Ask the patient did they wake up with soft tissue or dental trauma or a sore throat? Have they ever been told they had a difficult airway or been given an airway alert letter?</p> <center> !!!@@.greentext;First reactions: How does it look?@@ </center> <p style="text-align:justify">''Keep looking:'' Facial hair, nose patency/deviation, mouth opening (≥3 finger breadth good), teeth, relationship of upper and lower incisors, size of tongue, range of motion of head and neck (chin to chest?)</p> <div class="notes">''Do some scores...''</div> <center> !!!@@.greentext;None of these are great in isolation to definitively rule a difficult airway in or out: this is about gathering evidence of adverse features and planning a strategy@@ </center> ''1) Mallampati score (MP):'' <center> <img src="images/mp.jpg" style="max-width: 100%;"/> </center> ''2) Thyromental + sternomental distance:'' TMD = Thyroid notch to the tip of the jaw with the head extended: < 6.5 cm predicts difficult intubation. SMD = Sternal notch to tip of jaw, < 12.5 cm predictor of difficult laryngoscopy and intubation. <center> <img src="images/neck.jpg" style="max-width: 350px;"/> </center> ''3) The upper lip bite test:'' * Grade 1: lower teeth can bite lip above * Grade 2: lower teeth can partly cover the upper lip * Grade 3: can’t reach the upper lip with lower teeth !!!<p style="text-align:justify">@@.typing;The bottom line: Airway assessment helps you develop the mindset of anticipating difficulties and planning appropriately. Always be prepared to manage an unanticipated difficult airway.@@ </p> [[Back->preop1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

<center> !!!BETA Test Virtual Anaesthetics_1 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Virtual Anaesthetics_1@@

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/IACmodule1.pdf]]'' [[Back|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>