IAC Module 2v2

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@@.whitetext; !!!Virtual Anaesthetics_2 Welcome to the second 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_2: Perioperative Care 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 "bleep" "audio/bleep.mp3">> <<cacheaudio "monitor" "audio/monitor.mp3">> <<cacheaudio "monitorgoslow" "audio/monitorgoslow.mp3">> <<set $history to []>> <<set $started to 0>>

!!!@@.greentext;Scenario learning objectives:@@ * Participate in safe use of the WHO Surgical Safety Checklist during team brief at the start of a theatre list * Use The Association of Anaesthetists Checklist for Anaesthetic Equipment 2012 and perform an anaesthetic machine check * Understand the importance of planning and communication as part of an MDT * Explain the drugs they would use and how they would perform induction of anaesthesia for an ASA I patient undergoing an elective procedure <p style="text-align:justify"> @@.greentext;''For optimal interaction this module is better on a larger screen device <u>with an unmuted speaker</u>. If you're starting here we recommend having a look at Virtual Anaesthetics_1 first which provides background knowledge and platform familiarity which is useful, but not essential, for Virtual Anaesthetics_2.''@@ </p> [[Next|team1]] [[Show me the EPA for IAC mapped to this scenario|epa]] [[Show me the stage 1 curriculum|stage1]]

!!!@@.greentext;Scenario learning objectives:@@ * Participate in safe use of the WHO Surgical Safety Checklist during team brief at the start of a theatre list * Use the AAGBI Checklist for Anaesthetic Equipment 2012 and perform an anaesthetic machine check * Understand the importance of planning and communication as part of an MDT * Explain the drugs they would use and how they would perform induction of anaesthesia for an ASA I patient undergoing an elective procedure ''Printable evidence for the LLP'' ''[[here|https://www.virtualanaesthetics.com/IACModule%202/IACmodule2mapped.pdf]]'' [[Credits and certificate|credits]] <<audio "monitorgoslow" pause>> <<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 "VA2IAC">> <<set $result1 to "-">> <<set $result2 to "-">> <<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>>

<center> @@.whitetext;''With thanks to everyone who helped make this scenario happen!'' Our actor: Andrea Our photographer: Richard Wassall Our researcher: Cameron Whytock Our IAC Module 2 advisory support: Oliver Pratt Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Fiona Martin, Rachael Hopper and Oliver Pratt Our creative director and lead programmer: Kate Wainwright !!!Well done for completing Virtual Anaesthetics_2 <<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>

You glance at the clock as you go back into the anaesthetic room. It's 08:23 on a Monday and you are doubled up with consultant anaesthetist Dr Henry Coal on an upper GI list. He's leaning against the worktop, looking through the [[preop assessments|https://www.virtualanaesthetics.com/IACModule%201/charts.pdf]] you've just done for the three patients on [[the list]]. He glances up at you. "Ah $firstname, great, let's get this team brief done. You've seen the patients so you can do the anaesthetic side." He sticks his head round the door to theatre. "Are we ready to WHO?" [[Next|team2]]

<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  | @@ [[Back|team1]]

The team all crowd into the anaesthetic room. Naseer is in charge and has several blank copies of the WHO. “Right, a couple of new faces, so shall we go round and introduce ourselves? I’m Naseer, scrub.” “Marion, HCA.” “Shirley, also scrub and we’ve got Adam, a student with us today.” Adam gives a wave. “Neil Timmins, consultant surgeon.” “Li, surgical reg.” “Paul, ODP.” “Henry, anaesthetics” He glances at you, last in the circle. “$firstname $surname, anaesthetics CT1” "Can everyone make sure their name is on the board in theatre?" There are a few nods. "And the emergency buzzer is just, here." Naseer gestures towards a large red button on the wall by the door to theatre. “Right. Everyone happy with the order of the list?” Are you? [["Yes, it's all good"|team3][$list = "Not quite"]] [["Actually we have a problem"|team3][$list = "Correct"]]

<<print $list>> "Actually we have a problem. Mrs Fletcher is diabetic so she could do with going first." You say to the room. Everyone agrees to the change in order. Naseer looks over to Neil, “Anything from the surgical side?” Neil shrugs slightly. “Three laparoscopic cholecystectomies, make sure they all have a holding strap across their thighs so we can go steep reverse Trendelenburg. We are going to need radiology for a cholangiogram on Mrs Fletcher.” “Can you give them a ring Shirley and let me know they are happy to come up for...?” Neil glances at the clock and then at Henry “Nine thirty?” Henry gives a nod. Shirley watches the exchange. “Yes no problem, I’ll get that sorted.” “Great. What’s your EBL?” “Less than 200 ml for all of them.” “Antibiotics?” “Whatever the protocol says.” “Clexane?” “Yes, if they’re staying in, and TEDs.” Naseer turns slightly. “Anaesthetics?” Henry directs her to you. [[What can you tell them?|team4]]

You look down at the notes you made on your copy of the list. What is it important for the team to know? What do you want to say? You can review the patients' preoperative assessments [[here|https://www.virtualanaesthetics.com/IACModule%201/charts.pdf]] if you need to. Once you’ve had some time to consider click [[here|team5]] to continue.

You cover the following: * Describe the patient's age, major co-morbidities, allergies * Necessary investigations done/not done * Anaesthetic plan * Anticipated anaesthetic problems * Any special equipment * Post op destination (e.g. HDU, day surgical unit) Paul makes a few notes for what is needed on the anaesthetic side and Naseer nods as you finish. "Great everyone, let's have a really good day!" [[Next|team6]]

Most of the team leave the room. Adam hangs back. "Why did you call it the 'WHO'?" He asks Henry. Dr Coal's eyes light up. "Well Adam I'm glad you asked that as I was clinical lead for implementing the [[World Health Organisation Surgical Safety Checklist|https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf]] in the Trust back in 2009 as part of our five steps to safer surgery implementation.” You can either: [[Hang around and find out more about what he's talking about|who]] or [[Go and get theatre ready|team7]]

You hang around to hear what Henry has to say. "It's all about embedding a safety culture into practice. The [[5 Steps to Safer Surgery|https://www.virtualanaesthetics.com/IACModule%202/afppchart.pdf]] (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework." "The WHO identified <<link [[ten essential objectives|who]]>> <<set Dialog.setup("Ten essential objectives for safe surgery")>> <<set Dialog.wiki("The team will:<br>''1'' Operate on the correct patient at the correct site.<br> ''2'' Use methods known to prevent harm from anaesthetic administration, while protecting the patient from pain.<br> ''3'' Recognize and effectively prepare for life-threatening loss of airway or respiratory function.<br> ''4'' Recognize and effectively prepare for risk of high blood loss.<br> ''5'' Avoid inducing an allergic or adverse drug reaction known to be a significant risk to the patient.<br> ''6'' Consistently use methods known to minimize risk of surgical site infection.<br> ''7'' Prevent inadvertent retention of sponges or instruments in surgical wounds.<br> ''8'' Secure and accurately identify all surgical specimens.<br> ''9'' Will effectively communicate and exchange critical patient information for the safe conduct of the operation.<br> ''10'' Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. ")>> <<set Dialog.open ()>> <</link>> that should be met by every theatre team during the perioperative period. These objectives were summarized in a one-page checklist for use by health-care workers to ensure that the safety standards are met." "If you look at the data from the eight hospitals involved in piloting the WHO checklist, it’s use dropped the rate of major inpatient complications from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8%. Amazing really that a checklist that takes two minutes can have such a big impact." “Actually I should have said ‘shall we 5SSS’ but no one would have had a clue what I was talking about so WHO it is!” [[Show me the evidence|ref]] [[Go check theatre|team7]]

Paul is in theatre with a spent canister of soda lime in one hand. “Henry checked the machine in the anaesthetic room but he’s not signed for this one. Would you check it while I get rid of this?” He heads out of theatre. You dig the AAGBI guideline: [[Checking anaesthetic equipment and the associated checklist|https://anaesthetists.org/Home/Resources-publications/Guidelines/Checking-Anaesthetic-Equipment]] out of your bag to remind you of the steps. Once you’ve had a look, watch this [[video]] and one of the ODP's will talk you through the checks on their machine.

Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. //N Engl J Med//. 2009; 360:491-499 National Patient Safety Agency. Five Steps to Safer Surgery. London: NPSA; 2010. ‘How to Guide’ [[Back|who]]

You sign and date the log for the machine check and put the file back in the draw. You'd better get that bleep. You head to the phone in the anaesthetic room and type in [[4567|team9]] <<audio bleep play>> <<set $off to "no answer given">>

"Hi it's $firstname $surname, anaesthetics SHO, you just bleeped me?" "Hi $firstname, thanks for getting back to me. I'm looking after Mrs Fletcher on DOSA. You know we said to take the metformin?" "Yep?" "Well she drank half a latte to take the tablet.” "Hang on one second!" You mute the phone and run what's happened past Henry who's still in the anaesthetic room. He asks you what you think. [["It’s fine we can do her at the end of the list"|team10][$off = "Not quite"]] [["We have to bring her back another day"|team10][$off = "Correct"]] <<audio bleep pause>>

<<print $off>> "It’s 08:35 now and Neil is only doing a morning list. Mrs Fletcher has had a fair volume of milk, which counts as solid, and means a 6 hour fasting period. Breast milk would have been 4 hours and if she’d gone for a non-particulate clear fluid like a black coffee it would have been a 2 hour fasting period. As she is undergoing an elective procedure and has other risk factors for aspiration, we will need to put her off for today. Sorry." You relay that down the phone. Henry is shaking his head. “I’ll go and speak to Neil. We might be able to take something off CEPOD to fill the list. Anyhow, Lisa Redbridge is a ASA II and you said she has a reasonable looking airway?” You nod. “Sound’s a perfect case for you. What’s your plan?” [[Next|team11]] <<set $aw to "errr">>

You have a think "Well she needs a GA obviously." "Yes and what kind of airway are you going to use?" [["ETT"|team12][$aw = "ETT"]] [["LMA"|team12][$aw = "LMA"]] [["Just tell me the answer"|team12][$aw = "errr"]] <<set $induction to "um">>

"All right then. What about the induction agent?" [["Propofol"|team13][$induction = "propofol"]] [["Thiopentone"|team13][$induction = "thiopentone"]] [["Etomidate"|team13][$induction = "etomidate"]] [["Ketamine"|team13][$induction = "ketamine"]] [["Just tell me the answer"|team13]] <<set $opi to "not sure">> [[Tell me more about these drugs|drug1]]

"OK. A co-induction agent?" [["Morphine"|team14][$opi = "morpine"]] [["Fentanyl"|team14][$opi = "fentanyl"]] [["Just tell me the answer"|team14]] <<set $msk to "um">> [[Tell me more about these drugs|drug2]]

"What about muscle relaxant?" [["Not going to use it"|team15][$msk = "no relaxant"]] [["Atracurium"|team15][$msk = "atracurium"]] [["Rocuronium"|team15][$msk = "rocuronium"]] [["Suxamethonium"|team15][$msk = "sux"]] [["Just tell me the answer"|team15]] <<set $main to "I don't know">> [[Tell me more about these drugs|drug3]]

"So my plan...is...well... <<print $aw>>, <<print $induction>>, and <<print $opi>>, <<print $msk>>, and <<print $main>>." Henry takes a long appraising look at you <<if $aw is "ETT">> "I agree she needs a tube, they will be insufflating her abdomen and putting her head down." <<else>> "She will need a cuffed ETT as they will be insufflating her abdomen and putting her head down." <</if>> <<if $induction is "propofol">> "Propofol is a good option; we rarely use thiopentone even in obs now; you'd be pushed to find etomidate anywhere in theatres today because of its adrenal suppression; and ketamine has a prevalence of emergence phenomena more common in this age group that we want to avoid so propofol is the most appropriate option here." <<elseif $induction is "um">> "When it comes to indcution agents we rarely use thiopentone even in obs now; you'd be pushed to find etomidate anywhere in theatres today because of it’s adrenal suppression; and ketamine has a prevalence of emergence phenomena more common in this age group that we want to avoid. Propofol is the most appropriate option here." <<else>>"Not sure I’d jump to <<print $induction>>. When it comes to induction agents we rarely use thiopentone even in obs now; you'd be pushed to find etomidate anywhere in theatres today because of it’s adrenal suppression; and ketamine has a prevalence of emergence phenomena more common in this age group that we want to avoid. Propofol is the most appropriate option here." <</if>> <<if $opi is "fentanyl">> "I agree fentanyl as a co-induction agent, with its more rapid onset of action." <<else>> "I think fentanyl would be a more appropriate co-induction agent, with its more rapid onset of action." <</if>> "As far as muscle relaxation goes, you certainly need something for the intubation and to provide optimal operating conditions. She doesn’t need an RSI and she’s in an age group where myalgia is a common side effect from sux so rocuronium or atracurium are both reasonable muscle relaxant choices." <<if $main is "sevo" >> "Sevoflurane is a reliable maintenance agent when you are starting out in anaesthetics and I agree you should go for that." <<elseif $main is "TIVA">> "TIVA is becoming increasingly popular these days. I think it’s the way we are heading because of the environmental concerns with the volatiles." <<elseif $main is "I don't know">> "Sevoflurane is a reliable maintenance agent when you are starting out in anaesthetics and TIVA is becoming increasingly popular these days. I think it’s the way we are heading because of the environmental concerns with the volatiles. So either is a resonable choice. Isoflurane isn't as forgiving as sevoflurane when you are learning as it is more irritating to the airway and has to be uptitrated more carefully, but it's still a popular agent in some departments. We don’t use much of it here in favour of sevoflurane. Desflurane is not good for the environment and is expensive so best kept for selected cases and low flow anaesthesia which is not a place to start when you are learning the basics! So we won’t be using des for this case. <<elseif $main is "iso">> "Isoflurane isn't as forgiving as sevoflurane when you are learning, as its more irritating to the airway and has to be up titrated more carefully, but it's still a popular agent in some departments. We don’t use much of it here as we favour sevoflurane. Of the alternatives desflurane is not good for the environment and expensive, so best kept for selected cases, and low flow anaesthesia, which is not a place to start when you are learning the basics. So we won’t be using it for this case. Sevoflurane is a reliable maintenance agent when you are starting out in anaesthetics and TIVA is becoming increasingly popular these days. I think it’s the way we are heading because of the environmental concerns with the volatiles. So either is a reasonable choice." <<else>> "Desflurane is not good for the environment and expensive so best kept for selected cases and low flow anaesthesia which is not a place to start when you are learning the basics, so we won’t be using it for this case. Isoflurane isn't as forgiving as sevoflurane when you are learning as it is more irritating to the airway and has to be up titrated more carefully, but it's still a popular agent in some departments. We don’t use much of it here as we favour sevoflurane which is a reliable maintenance agent when you are starting out in anaesthetics. TIVA is becoming increasingly popular these days. I think it’s the way we are heading because of the environmental concerns with the volatiles. So either is a resonable choice." <</if>> Paul has been listening to the plan and now chips in. "Well you can have sevo, because it's almost nine. If you wanted me to get hold of TIVA pumps I needed to know an hour ago, they'll all be earmarked now!" Henry shrugs. "Sevo it is then." [[Next|team17]]

"You might want to have a look at this while you are waiting for the patient." He has a copy of //Anaesthesia// open on the side. You can read the article headline [[Recommendations for standards of monitoring during anaesthesia and recovery 2021|https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Recommendations%20for%20standards%20of%20monitoring%20during%20anaesthesia%20and%20recovery%202021.pdf?ver=2021-05-26-141701-007]]. "Quantitative neuromuscular monitoring is recommended for all those getting a NMB, so we are going to have to get more kit." He is heading out the door. "Right. If you are happy I’ll leave you to it. I’m in the office just there.” He gestures to an open door just across the corridor. "Shout if you need me and make sure Paul knows your plan." [[Next|team18]]

You run through your airway strategy with Paul who you note has the right sized ETT, and a pre-emptively bent bougie open on the top of the airway trolley. “You’ve seen so many trainees go through, have you got any advice for me?” Paul looks at you with a wry smile. “Oxygenate the patient?” You roll your eyes at him. “Got that one thanks. Seriously though.” He lets out a long sigh. “Just try and get into good habits right from the start. I’m not a mind reader, so like Henry said, let me know what the plan is, and then what you want to do if that doesn’t work, even for the easy looking ones, they will catch you out. Get used to doing both the drugs and airway early so when you first have to do it solo it doesn’t feel awkward.” He’s getting into the flow of this now. “Tell me what you can see on laryngoscopy, I have no idea if you have a great view of the cords or you need something different quick. Don’t get so fixed on the task that we don’t move onto the next thing until the situation is dire. You need to have a decent awareness of what you're capable of so you don’t get into situations out of your depth.” “And if I see you running over the pulse ox lead with a trolley...” "Ahh...Hello again." You say as Lisa is shown into the anaesthetic room by Morgan. [[Next|team19]] <<audio "monitor" pause>>

Paul is reassuring in his tone as he gets her to lie on the trolley and puts the necessary monitoring in place. Between you, you get the first part of the WHO check list done. You get a 20 G cannula in on the first go and attach it to the litre of Hartmann's that Paul has waiting. You go up to the head end of the trolley and ask Lisa to put her newly cannulated hand onto her chest. “I’m just giving you something that might make you feel a bit woozy.” You give 100 micrograms of fentanyl. “And this mask is just to give you some extra oxygen but it might smell a bit plasticky. Take some nice slow deep breaths for me.” You gently place the mask over her mouth and nose. She takes a few long steady breaths. She’s starting to look a little bit glazed. The EtO~~2~~ is getting up to the mid 80%. “Happy Paul?” Paul nods. “This white medicine will slowly drift you off to sleep, it might feel a bit cold as it’s going in, just keep taking those slow deep breaths for me.” You slowly inject 180 mg of propofol. Lisa gives a few lethargic blinks and then her eyes stay shut. “Lisa can you open your eyes for me?” You ask. No response. You give the muscle relaxant and glance at the clock. 08:58. [[Next|team20]] <<audio "monitor" volume 0.5 loop play>>

Wishing you had more hands at this precise moment, you turn the dial on the top of the Sevoflurane vaporizer to 4%, screw the APL valve down half way and then firmly apply the mask to Lisa’s face with your left hand and squeeze the bag. Not much happens. You squeeze again. Her chest rises slightly. There’s a pop as Paul breaks the package of a green OP airway. You deftly put it into her mouth and try to ventilate again. Her chest rises beautifully. The CO~~2~~ trace catches up with events and you have a lovely square trace. You glance at the clock again. 09:00 [[Next|team21]]

Paul is already offering a laryngoscope to you handle first. You move the circuit to lie across the top of the trolley above Lisa’s pillow. Paul puts a finger on Lisa’s chin and gently pulls back so her lips aren’t across her teeth. Time for a look. You place the laryngoscopy blade in the right of her mouth and sweeping her tongue to the left, progress the blade to the back of her oropharynx, and into her vallecula. Everything just looks pink and wet at the moment but you recognise the epiglottis as it comes into view. Being really careful not to lever on her teeth you lift and the epiglottis moves up to give you... [[Next|team22]]

...this view: <center> <img src="images/larynx.jpg" style="max-width: 300px;"/> </center> You take a deep breath. "Grade 1 view." You can feel Paul smile. [[Next|team23]] [[Show me the larygoscopy grades|larynx2]] <<audio "monitor" volume 0.5 loop play>> ^^Images, with thanks: Aziz M. Advances in Laryngoscopy [version 1]. F1000Research 2015, 4:1410 (doi: 10.12688/f1000research.7045.1)^^

The tube is miraculously already in your right hand. You advance it from the right, holding it at the distal end so your hand doesn't obscure your view: <center> <img src="images/larynx2.jpg" style="max-width: 300px;"/> </center> "I'm through the cords." You withdraw the scope and retrieve the circuit. There’s a CO~~2~~ trace again, and her chest is rising and falling. Paul adeptly ties the tube in. He gives you a wink. "Nicely done. Do you want a Bair Hugger^^TM^^ or just the warming mattress?" [[Next|team24]] [[Tell me more about what I can see in the picture|larynx]] <<set $vent to "No answer given">> <<audio "monitor" volume 0.5 loop play>> ^^Images, with thanks: Aziz M. Advances in Laryngoscopy [version 1]. F1000Research 2015, 4:1410 (doi: 10.12688/f1000research.7045.1)^^

You move through to theatre and transfer Lisa across onto the operating table. Pick a ventilator mode: [[Pressure controlled ventilation (PCV)|team24b][$vent = "Not quite"]] [[Volume controlled ventilation (VCV)|team24b][$vent = "Correct"]] [[Pressure support ventilation (PCV)|team24b][$vent = "Not quite"]] [[Pressure regulated volume controlled ventilation (PRVC)|team24b][$vent = "Correct"]] [[Synchronized intermittent mandatory ventilation (SIMV) |team24b][$vent = "Not quite"]]

<center> !!@@.typing;Landmarks of laryngoscopy@@ <img src="images/number.jpg" style="max-width: 100%;"/> </center> @@.typing;Note the paired rod-shaped cuneiform cartilages sit in the aryepiglottic fold. The paired corniculate cartilages sit on the top of the arytenoid cartilages @@ [[Back|team23]] <<audio "monitor" pause>> ^^Images, with thanks: Aziz M. Advances in Laryngoscopy [version 1]. F1000Research 2015, 4:1410 (doi: 10.12688/f1000research.7045.1)^^

You look at the monitor. Everything seems pretty good. "Happy for me to start?" Neil asks. "Yes, thanks." The first port goes in. The lights go down. "Right, insufflate to 14." Neil is looking at the screen on the laparoscope stack now. Everyone in theatre is. You recognise the smooth dome of the liver edge rising up into the picture. Hang on...what? You turn to look at anaesthetic machine. As the ECG trace undulates its way from the left to the right of the screen you see a long expanse of nothing. The pulse oximeter pulse rate is flashing 41...34...30...30...30 No one is looking at the laparoscope screen now. They’re looking at the monitor, and then at you. [[To be continued...|End]] <<audio "monitor" pause>> <<audio "monitorgoslow" volume 0.5 play>>

<center> !!@@.typing;Induction agents^^1 *^^@@ <img src="images/induction.jpg" style="max-width: 100%;"/> </center> <div class="induction">''Propofol''</div> @@.typing;''Presentation'' Lipid emulsion, 10 mg.ml^^-1^^ (caution also available as 20 mg.ml^^-1^^ be aware of potential for error) ''Uses'' Induction and maintenance of anaesthesia (principally in obstetrics now), sedation for procedures and in ICU, treatment of status epilepticus ''Induction dose'' 1.5-3 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 100-210 mg, 10-21 ml of 10 mg.ml^^-1^^ emulsion <p style="text-align:justify">''Notes'' Loss of consciousness (LOC) approx. 30-40 seconds after induction dose, emergence approx. at 10 minutes ↓BP, ↓SVR, suppresses laryngeal reflexes, produces apnoea, 28% experience pain on injection, target controlled infusion models (e.g. ‘Marsh’ and ‘Schnider’) use patient covariates to maintain a predetermined plasma or effector site concentration for propofol maintenance </p>@@ <div class="induction">''Thiopentone''</div> @@.typing;''Presentation'' Powder reconstituted with water to a yellowy clear 2.5% solution (25 mg.ml^^-1^^) ''Uses'' Induction of anaesthesia, treatment of status epilepticus ''Induction dose'' 3-5 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 210-350 mg, 8.4-14 ml of 25 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' LOC approx. one brain-arm circulation after induction dose (faster than propofol and more discrete awake/asleep), emergence approx. at 5-10 minutes. Drug error risk due to clear solution in a 20 ml syringe; don’t try to do an RSI with Cefuroxime/Flucloxacillin ↓BP, ↓SVR, produces apnoea, rarely laryngospasm or bronchospasm, extravasation causes tissue necrosis, intra-arterial injection may lead to vascular constriction and limb ischaemia (get help) Used mainly in exam questions</p>@@ <div class="induction">''Etomidate''</div> @@.typing;''Presentation'' Clear solution 2 mg.ml^^-1^^ ''Uses'' Induction of anaesthesia ''Induction dose'' 0.3 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 21 mg, 10.5 ml of 2mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' LOC approx. 10-65 seconds after induction dose, emergence after single bolus approx. at 6-10 minutes Relative cardiovascular stability, produces apnoea, rarely laryngospasm, up to 50% experience pain on injection, causes myoclonus on administration (can mimic a seizure), high incidence of PONV especially when used with opiate, potent inhibitor of steroid synthesis and significant antiplatelet activity so rarely used </p> @@ <div class="induction">''Ketamine''</div> @@.typing;''Presentation'' Clear solution 10/50/100 mg.ml^^-1^^ label syringe clearly ''Uses'' Induction of anaesthesia, analgesia and sedation for painful procedures, pre-hospital analgesia/anaesthesia, severe unresponsive asthma ''IV induction dose'' 0.5-2 mg.kg^^-1^^ given over 60 seconds ''Induction dose for middle aged 70kg ASA1/2 person'' 35-140 mg, 3.5-14 ml of 10 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Produces a dissociative state with onset at approx. 30 seconds after induction dose, eyes remain open, pupillary dilation, nystagmus, and hypertonia may occur, duration of action after single bolus approx. at 5-10 minutes ↑HR, ↑BP, ↑CVP, ↑CO, hypersalivation, mild respiratory stimulant, 15% incidence PONV, emergence delirium, unpleasant dreams, and hallucinations are common but less frequent at extremes of age (can be alleviated by a benzodiazepine premedication) </p> @@ [[Back|team12]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] @@.typing;''^^*^^ Doses are for an average adult. They are provided as a guide to the usual range of doses for fit ASA1/2 adult patients only. You should discuss these doses with your trainers and adjust the document as required according to local practice.''@@ Ref: # Scarth E, Smith S. Drugs in anaesthesia and intensive care, 5th Edn. 2017, Oxford University Press <A HREF="javascript:window.print()">Click to Print This Page</A>

<center> !!@@.typing;Co-induction agents^^1 *^^@@ <img src="images/opi.jpg" style="max-width: 100%;"/> </center> <div class="opi">''Morphine''</div> @@.typing;''Presentation'' Clear solution 5/10/30/60/100/200 mg.ml^^-1^^ label syringe clearly ''Uses'' Premedication, analgesia, patient controlled analgesia (PCA) Analgesic dose (titrated to pain) PO 5-10 mg 4 hourly, IV 0.1 mg.kg^^-1^^ 3-4 hourly. Generally when morphine is used in theatres a 1 mg.ml^^-1^^ solution is titrated to effect <p style="text-align:justify">''Notes'' Analgesic effect onset 15 minutes, peak 30-60 minutes, duration 3-4 hours, reduces MAC of co-administered volatile agents. Respiratory depression, sedation, anxiety, euphoria, miosis, nausea and vomiting, pruritus, constipation, hallucinations, accumulation in patients with renal impairment, risk of encephalopathy in liver failure. For PCA follow local policies (there will be one) a common regime is 50 mg made to 50 ml with normal saline (1 mg.ml^^-1^^ solution), 1 mg (1 ml) bolus is given over 1 minute, followed by a lock out 5 minutes. Naloxone PRN should be available </p> @@ <div class="opi">''Fentanyl''</div> @@.typing;''Presentation'' Clear solution 50 mcg.ml^^-1^^ ''Uses'' Premedication, analgesia, patient controlled analgesia (PCA) ''Induction dose'' 1 mcg.kg^^-1^^, higher doses are used in specialist anaesthesia such as cardiac ''Induction dose for middle aged 70kg ASA1/2 person'' 70 micrograms, 1.4 ml of a 50 mcg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Analgesic effect onset 2-5 minutes, duration from 30-60 minutes to 3-6 hours with repeated or larger doses, reduces MAC of co-administered volatile agents. Respiratory depression, sedation, anxiety, euphoria, miosis, nausea and vomiting, pruritus, constipation, hallucinations, accumulation in patients with renal impairment, risk of encephalopathy in liver failure. For postoperative pain IV fentanyl is titrated to pain with a bolus of 10 mcg every 3-5 minutes while monitoring for excessive sedation or respiratory depression, higher bolus doses increase the risk of apnoea. For PCA follow local policies (there will be one) a common regime is 500 micrograms made to 50 ml with normal saline (10 mcg.ml^^-1^^ solution), 10 mcg (1 ml) bolus is given over 1 minute, followed by a lock out 5 minutes. Naloxone PRN should be available </p> @@ <div class="opi">''Alfentanil''</div> @@.typing;''Presentation'' Clear solution 0.5/5 mg.ml^^-1^^ ''Uses'' Analgesia, analgesia/sedation in ICU ''Dose'' 10 mcg.kg^^-1^^ or IVI rate of 0.5/1 mcg.kg^^-1^^.min^^-1^^ <p style="text-align:justify">''Notes'' Analgesic effect onset 90 seconds, duration 5-10 minutes, reduces MAC of co-administered volatile agents. Bradycardia, respiratory depression, chest wall rigidity (‘wooden chest’ phenomenon) sedation, miosis, nausea and vomiting, pruritus, constipation, accumulation in patients with renal or liver impairment, risk of encephalopathy in liver failure. A bolus given 90 seconds before extreme but short surgical stimulation (e.g. lancing an abscess) can reduce reactivity sometimes seen despite adequate depth of anaesthesia </p> @@ <div class="opi">''Remifentanil''</div> @@.typing;''Presentation'' Vials of white powder 1/2/5 mg ''Uses'' Analgesic component of anaesthesia, analgesia/sedation in ICU, analgesia/sedation during ‘awake’ fibreoptic intubation, labour analgesia ''Dose'' Slow bolus 1 mcg.kg^^-1^^ over at least 30 seconds, target controlled infusion using appropriate device with correct pharmacokinetic model (e.g. Minto) <p style="text-align:justify">''Notes'' Analgesic effect peak 1-3 minutes, rapid and predictable offset at 5-10 minutes, reduces MAC of co-administered volatile agents. Bradycardia, respiratory depression, chest wall rigidity (‘wooden chest’ phenomenon) sedation, miosis, nausea and vomiting, always flush lines used for remifentanil well before leaving theatre to avoid inadvertent administration, because of the short duration of action provide ongoing analgesia requirements with alternative agent(s) </p> @@ [[Back|team13]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] @@.typing;''^^*^^ Doses are for an average adult. They are provided as a guide to the usual range of doses for fit ASA1/2 adult patients only. You should discuss these doses with your trainers and adjust the document as required according to local practice.''@@ Ref: # Scarth E, Smith S. Drugs in anaesthesia and intensive care, 5th Edn. 2017, Oxford University Press <A HREF="javascript:window.print()">Click to Print This Page</A>

<center> !!@@.typing;Muscle relaxants^^1 *^^@@ <img src="images/relaxant.jpg" style="max-width: 100%;"/> </center> <div class="relaxant">''Atracurium''</div> @@.typing;''Presentation'' Clear solution 10 mg.ml^^-1^^, stored in fridge ''Uses'' Non-depolarizing neuromuscular blockade ''Intubating dose'' 0.5 mg.kg^^-1^^, top-ups: 0.1-0.2 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 35 mg, 3.5 ml of a 10 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Onset 90-120 seconds after bolus, peak neuromuscular blockade 3-5 minutes, duration 15-35 minutes Risk of histamine release with cutaneous flushing and/or bronchospasm, prolonged action with hypokalaemia, hypocalcaemia, hypermagnesemia, dehydration, hypercapnia or acidosis, always flush lines used for atracurium well before leaving theatre to avoid inadvertent administration Risk of anaphylaxis 1 in 24,000^^1^^ </p> @@ <div class="relaxant">''Rocuronium''</div> @@.typing;''Presentation'' Clear solution 10 mg.ml^^-1^^, stored in fridge ''Uses'' Non-depolarizing neuromuscular blockade ''Intubating dose'' routine: 0.6 mg.kg^^-1^^, RSI: 1mg.kg^^-1^^, top-ups: 0.15 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 42 mg, 4.2 ml of a 10 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Onset 60 seconds after bolus, duration can be up to 60 minutes following RSI dose A higher 1.2 mg.kg^^-1^^ dose is sometimes advocated for RSI however at this higher dose the duration of action of rocuronium becomes <u>73 min</u> Prolonged action with hypokalaemia, hypocalcaemia, hypermagnesemia, dehydration, hypercapnia or acidosis, always flush lines used for rocuronium well before leaving theatre to avoid inadvertent administration Risk of anaphylaxis 1 in 17,000^^1^^ </p> @@ <div class="relaxant">''Suxamethonium''</div> @@.typing;''Presentation'' Clear solution 50 mg.ml^^-1^^, stored in fridge ''Uses'' <u>Depolarizing</u> neuromuscular blockade ''Intubating dose'' for RSI: 1-1.5 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 70-105 mg, 1.4-2.1 ml of a 50 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Onset 30 seconds after bolus, duration 3-5 minutes Bradycardia or other dysrhythmias with single or repeated doses, ↑K^^+^^ which can be exaggerated in patients with burns or major denervation of muscle and also of significance in people with renal failure, post-operative myalgia common especially in middle aged women and those who mobilize early, ↑IOP caution in penetrating eye injuries, potent trigger of malignant hyperpyrexia, apnoea may be prolonged in those with innate or acquired deficiencies in plasma cholinesterases (e.g. genetic (suxamethonium apnoea), pregnancy, liver/cardiac/renal disease, thyrotoxicosis) so it is good practice to check for muscle twitches prior to giving a long acting a non-depolarizing NMB drug to confirm resolution of paralysis, always flush lines used for suxamethonium well before leaving theatre to avoid inadvertent administration Risk of anaphylaxis 1 in 9000^^1^^ </p> @@ <div class="relaxant">''Vecuronium''</div> @@.typing;''Presentation'' 2 mg.ml^^-1^^, stored in fridge ''Uses'' Non-depolarizing neuromuscular blockade ''Intubating dose'' 0.1 mg.kg^^-1^^, top-ups: 0.02-0.03 mg.kg^^-1^^ ''Induction dose for middle aged 70kg ASA1/2 person'' 7 mg, 3.5 ml of a 2 mg.ml^^-1^^ solution <p style="text-align:justify">''Notes'' Onset 90-120 seconds after bolus, peak neuromuscular blockade 3-5 minutes, duration 25-40 minutes Prolonged action with hypokalaemia, hypocalcaemia, hypermagnesemia, dehydration, hypercapnia or acidosis, always flush lines used for rocuronium well before leaving theatre to avoid inadvertent administration Risk of anaphylaxis 1 in 35,700^^2^^ (NB no cases seen during NAP 6 due to low use of vecuronium in the UK at the time of audit) </p> @@ [[Back|team14]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] @@.typing;''^^*^^ Doses are for an average adult. They are provided as a guide to the usual range of doses for fit ASA1/2 adult patients only. You should discuss these doses with your trainers and adjust the document as required according to local practice.''@@ Ref: # Harper NJN, Cook TM, Garcez T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). //BJA//. 2018; 121(1):159-171 # Sadleir PHM, Clarke RC, Bunning DL, et al. Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. //BJA//. 2013;110(6):981-987 # Scarth E, Smith S. Drugs in anaesthesia and intensive care, 5th Edn. 2017, Oxford University Press <A HREF="javascript:window.print()">Click to Print This Page</A>

<center> !!@@.typing;Maintenance^^1 *^^@@ <img src="images/gas.jpg" style="max-width: 100%;"/> </center> <div class="notes">''What's MAC?''</div> <p style="text-align:justify"> @@.typing;''MAC = minimum alveolar concentration of inhaled volatile anaesthetic that prevents movement in 50% of patients exposed to a surgical incision.'' Almost all anaesthetic machines will produce an age adjusted MAC if you input the age at the start of the case. MAC is reduced by pharmacological factors: opioids, muscle relaxants, sedatives and hypnotics, acute alcohol use and the use of N~~2~~O, physiological factors: pregnancy, increasing age, hypothermia, hypercarbia, and pathological factors: hypothyroidism, anaemia, and neurodegenerative conditions. Conversely MAC is increased by cocaine, chronic alcohol use and unsurprisingly acute amphetamine use @@ </p> <div class="notes">''Sevoflurane''</div> @@.typing;''Presentation'' Clear solution ''Uses'' Induction and maintenance of anaesthesia ''Induction'' Concentration in air/O~~2~~ 5-8%, ''maintenance'' in air/O~~2~~ 0.5-3% ''Age dependent MAC'' 2.29 ( 1 yr), 1.8 (40 yr), 1.4 (80 yr), )^^2^^ <p style="text-align:justify">''Notes'' Non-irritant and pleasant smell, ↓BP, respiratory depressant, can cause PONV, trigger of malignant hyperpyrexia </p> @@ <div class="notes">''Isoflurane''</div> @@.typing;''Presentation'' Clear solution ''Uses'' Induction and maintenance of anaesthesia ''Induction'' Concentration in air/O~~2~~ 5-8%, ''maintenance'' in air/O~~2~~ 0.5-3% ''Age dependent MAC'' 1.49 ( 1 yr), 1.17 (40 yr), 0.91 (80 yr), )^^2^^ <p style="text-align:justify">''Notes'' Not for gas inductions, rapid up titration can cause irritation, less pleasant smell, ↓BP, respiratory depressant, can cause PONV, trigger of malignant hyperpyrexia </p> @@ <div class="notes">''Desflurane ''</div> @@.typing;''Presentation'' Clear solution ''Uses'' Induction and maintenance of anaesthesia ''Maintenance'' in air/O~~2~~ 2-6%. ''Age dependent MAC'' 8.3 ( 1 yr), 6.6 (40 yr), 5.1 (80 yr)^^2^^ <p style="text-align:justify">''Notes'' Airway irritation at higher concentrations so not used for gas inductions, ↓MAP, respiratory depressant, can cause PONV, trigger of malignant hyperpyrexia, desflurane has a boiling point 22.8^^o^^C so needs a special heated vaporiser, an electricity supply and time to come to temperature. You will be asked about this often in exams. Flammable </p> @@ [[Back|team15]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] @@.typing;''^^*^^ Doses are for an average adult. They are provided as a guide to the usual range of doses for fit ASA1/2 adult patients only. You should discuss these doses with your trainers and adjust the document as required according to local practice.''@@ Ref: # Scarth E, Smith S. Drugs in anaesthesia and intensive care, 5th Edn. 2017, Oxford University Press # Mapleson. Effect of age on MAC in humans. //BJA//. 1996; 76:179-185 <A HREF="javascript:window.print()">Click to Print This Page</A>

<center> !!@@.typing;Cormack-Lehane grading examples@@ @@.typing;'' <img src="images/cormacklehane1.jpg" style="max-width: 400px;"/> Figure 1: Cormack-Lehane 1 <img src="images/cormacklehane2a.jpg" style="max-width: 400px;"/> Figure 2: Cormack-Lehane 2a <img src="images/cormacklehane2b.jpg" style="max-width: 400px;"/> Figure 3: Cormack-Lehane 2b <img src="images/cormacklehane3.jpg" style="max-width: 400px;"/> Figure 4: Cormack-Lehane 3 <img src="images/cormacklehane4.jpg" style="max-width: 400px;"/> Figure 5: Cormack-Lehane 4 ''@@ </center> [[Back|team22]] <<audio "monitor" pause>> ^^Images, with thanks: OpenAirway available [[here|https://openairway.org/]]^^

<center> !!@@.typing;Total Intravenous Anaesthesia (TIVA)^^1 *^^@@ <img src="images/tiva.jpg" style="max-width: 100%;"/> </center> <p style="text-align:justify">A skilfully timed, perfectly smooth TIVA emergence looks pretty impressive when you are starting out, and the best place to learn is from people who are good at TIVA and want to teach you, just like learning almost everything in anaesthetics. For now here is an ultra quick guide that can give you some basics and some top tips. TIVA is a infusion of 1% propofol +/- a second simultaneous infusion of opioid almost always remifentanil. 2% propofol may be used, often in neuro theatres or ICU. The rate of the infusion can be calculated using a mathematical equation (Bristol) or via a mathematical model, most commonly ''Marsh'' and ''Schneider'' for propofol and ''Minto'' for remi to deliver a ''Target Controlled Infusion'' (TCI). These models use patient variables you input to a programmed pump to calculate the volumes of three compartments. Propofol first enters and is distributed in the ‘central’ compartment (V1, the blood), the bolus dose is calculated from this volume. Propofol then redistributes in and out of two other compartments, either fast into highly perfused tissue like muscle (V2), or more slowly into low perfused tissue like fat (V3). The rate of propofol being eliminated from the system is also calculated and used to work out how much needs to be infused into V1, redistribute between V2 and V3, with ongoing elimination and still achieve or maintain a set plasma site (blood, Cp) or effector site (brain, Ce) concentration. The models also estimate time to emergence once the infusion is stopped. See figure below. <center> <img src="images/pharm.jpg" style="max-width:100%;"/> ''Figure 1: Pharmacokinetics of TIVA'' </center> Still with us? Anyway that's enough pharmacokinetics for now, but they are important for understanding what the TIVA pump is up to. <div class="notes">''Marsh model:''</div> @@.typing; * Propofol targeting ''plasma concentration'' (Cp) * Model developed with 18 ASA I/II patients * Uses weight only (age also input but not used in calculation) * Smaller bolus dose * Larger total dose * There is a lag time between Cp and Ce during induction/changing depth of anaesthesia * Calculates Cp and volume of V1, V2 and V3 from weight only ''CAUTIONS:'' * Max input weight 150kg * Adults only * Risk of drug error with 1 or 2% propofol, make sure the propofol concentration is compatible with the pump used and follow standard practice in that area @@ <div class="notes">''Schnider model:''</div> @@.typing; * Propofol targeting ''effector site concentration'' (Ce) * Model developed with 24 ASA I/II patients * Uses gender, age, height, and total body weight for programming and calculates lean body mass for model * Model has small, fixed V1 which under estimates induction dose if you target Cp (e.g. if you target a Cp of 4-6 µg.ml^^-1^^ the initial bolus is only 1.7-2.7 ml of propofol) * When targeting Ce a larger bolus dose is given to “over-pressure” blood concentration to produce gradient, analogues to having a high vaporizer setting at the start of a volatile anaesthetic * Lower total dose * Suitable in the elderly who have a lower lean body mass ''CAUTIONS:'' * Max input BMI 35 kg.m^^-2^^ for females and 42 kg.m^^-2^^ for males * Adults only * Risk of drug error with 1 or 2% propofol, make sure the propofol concentration is compatible with the pump used and follow standard practice in that area Equivalent models exist for children and new models using more diverse groups of patients are under development.@@ <div class="notes">''Typical target concentrations in routine practice?''</div> <p style="text-align:justify">Enough but not too much. This is individually determined based on lots of factors, for example a patient who has had a regional block will generally need lower Cp/Ce to tolerate surgery or those who have also had opioids. * Generally for a healthy middle aged ASA I/II, Marsh target Cp, Schneider target Ce * Relatively rapid induction ''4-6 µg.ml^^-1^^'' higher if anxious or ‘robust’ * Maintenance ''3-6 µg.ml^^-1^^'' (no opioids), ''2.5-4 µg.ml^^-1^^'' (with opioids) </p> <div class="notes">''Remifentanil''</div> <p style="text-align:justify">Target concentrations in the range of ''2-6 ng.ml^^-1^^'' are commonly used, adjusted to level of surgical stimulus and clinical signs. Target concentrations ''>1.5 ng.ml^^-1^^'' will cause apnoea. Mixing remifentanil and propofol in a single syringe is not recommended. You can’t adjust the hypnotic and analgesic elements of your anaesthetic independently and there is a risk of separation or ‘layering’ in the syringe giving varying concentrations of the drugs.</p> <div class="notes">''TIVA tips''</div> <p style="text-align:justify">First rule of TIVA 'all' the pump does is fancy maths and delivery of a 'theoretical' target controlled infusion. This isn't a closed loop system, which would need sampling of the Cp or Ce (the brain!) so the pump has no feedback on what the actual target concentration is. You must stay vigilant using what you can hear, see, and feel, alongside all the monitoring to make sure your patient gets enough anaesthetic to be anaesthetised. This is all about constant clinical calibration. * Have the right pump available, fully charged and plugged in, with appropriate ‘stopped’, ‘empty syringe’, high and low pressure alarms set, at a volume you can hear * Propofol is available as 1% and 2% concentration know which one is in the syringe * Dilute remifentanil to a standard concentration that is the convention in your department * Follow local protocol for correct giving set with a Luer-lock connector at each end, an antisyphon valve on the drug delivery line(s) and an anti-reflux valve on any fluid administration line * Minimise dead space distal to the point of agent and/or IV fluid mixing * Have good IV access, well secured, that you can see at all times * Turn the pump so you can see the display and the barrel of the syringe to see the plunger moving, keep an eye on ml.hr^^-1^^ or mg.kg^^-1^^.hr^^-1^^, is it a sensible number? *Always set up with IV fluids * EEG monitoring/BIS ''especially if using a NMB'' * At the end of the anaesthetic remove the extra sections of giving set and give the remainder a good flush (at least twice the dead space volume) </p> <div class="notes">''Trouble shooting''</div> @@.typing;''My pump has failed''@@ * Get help * Option 1: Default to volatile - safest * Option 2: If steady state has been reached, because you read our top tips you can default to most recent ml.hr^^-1^^ for given target concentration * Turn it on and off again? Restarting in TCI mode is a risky option as it may default to ‘New Patient’ and give another induction bolus not taking into account the pre-existing Cp/Ce * Isolate the problem pump and report as per local policy @@.typing;''I need to get them deep quickly''@@ <p style="text-align:justify">Try to anticipate points of surgical stimulus and be ready. If needed increase the target concentration rapidly to over pressure (set a higher Cp/Ce) and then down titrate. </p> @@.typing;''I need to go onto TIVA from volatile''@@ <p style="text-align:justify"> As end tidal volatile falls up titrate the Cp/Ce incrementally while observing clinical parameters to avoid risk of awareness. </p> @@.typing;''My patient has a high BMI''@@ <p style="text-align:justify"> Both models should be used with caution in patients with high BMI, the Association of Anaesthetists and Society for Obstetric and Bariatric Anaesthesia have published guidelines^^2^^. As always continuous clinical correlation and the use of EEG/BIS is strongly recommended. </p> @@.typing;''My patient is older/frail/sick/haemodynamically compromised''@@ <p style="text-align:justify">Get help, even the most experienced anaesthetist will have a low threshold for getting extra help for these patients! </p> [[Back|team15]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] @@.typing;''^^*^^ Doses are for an average adult. They are provided as a guide to the usual range of doses for fit ASA1/2 adult patients only. You should discuss these doses with your trainers and adjust the document as required according to local practice.''@@ # Nimmo AF, Absalom AR, Bagshaw O, et al. Guidelines for the safe practice of total intravenous anaesthesia (TIVA). //Anaesthesia//. 2018; 74(2):211–224 # Nightingale CE, Margarson MP, Shearer E, et al. Peri-operative management of the obese surgical patient 2015: association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. //Anaesthesia//. 2015;70:859–76 <A HREF="javascript:window.print()">Click to Print This Page</A>

<<print $vent>>. PC, VC, PRVC would all ventilate the patient. However fluctuations in intrathoracic pressure caused by a pneumoperitoneum and going reverse Trendelenburg would have a significant impact on the volumes achieved via PCV. This mode would need greater attention during times of change at the beginning and end of surgery to avoid under/over ventilation. PS and SIMV are modes used to support respiratory effort in patients who are not apnoeic so less suited to a patient who you have just given muscle relaxant to. [[Next|team25]] <<audio "monitorgoslow" pause>>

!!!@@.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; e.g. laryngeal spasm * manage acute postoperative pain including the use of rescue opioids 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 2am. [[Back|Core clinical learning objectives]]

<center> !!!BETA Virtual Anaesthetics_2 <<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>

<center> [[Transcript->transcript]]      [[Next->team8]] <iframe width="560" height="315" src="https://www.youtube.com/embed/osP0oTDH9Zg" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> </center>

<p style="text-align:justify">''Narrator:'' //The following video shows you how to undertake an example anaesthetic machine safety check. It is based on both the AAGBI safety guideline checking anaesthetic equipment 2012 which can be found on the AAGBI website as well as the checks we do on our machines in our local hospital. For your exam you will be expected to be familiar with the AAGBI safety checklist and you should have a print out copy of this as you watch this video to aid your learning. Always undertake any check according to local hospital and manufacturer policies.// ''ODP:'' //Hello. What I’d like to do today is a step by step how to check an anaesthetic machine. The first thing you will need to do before checking your anaesthetic machine is to make sure a self inflating bag is present on your machine and your Ambi// (self inflating) //bag is ‘Adult’ and in date. Next thing you need to do is to switch on your anaesthetic machine and check that all the elements are present on the anaesthetic machine. So before starting your checks the equipment you want to have are: a CO~~2~~ absorber, a filter on the expiratory valve, a breathing circuit, a water trap, a CO~~2~~ line, and an extra filter where your breathing circuit and CO~~2~~ line will be attached. Obviously you want to add your bag for the ventilation. After the machine turns on, before performing the safety checks, what you would like to do is make sure the machine is plugged in and switched on. The next and last thing you want to do before performing the safety checks is the ‘Tug Test’. Manufacturer says that instead of disconnecting all the pipes the only thing you should be doing to check them is the ‘Tug Test’ to make sure they are all functioning. By doing the tug test you will ensure they will last longer than disconnecting and reconnecting them all the time. Once you have done these checks you can do your manufacturer checks. So you press on start and the first thing you do is access the back cylinders and open and close them. After you do this all the numbers will appear //(on the screen)// and you can click continue. The oxygen flush is the first step. You press the oxygen flush button for approximately three seconds until you hear a noise and then you can release the button. You see it pass. The next check will be to check your inspiratory and expiratory valves are actually moving. In order to do that //(on this machine)// you open this cassette and visually inspect that both valves are moving. After closing the cassette the next step will be to //(press)// continue and the machine will go into the self test and if something flags up the machine will tell you to double check yourself. Otherwise the test will be performed and the machine enters into standby mode. It will last in standby mode for 12 hours. After 12 hours a new test will need to be performed. While the machine is performing its checks the next thing you will need to check is the suction. What you would like to do is make sure the whole //(suction)// system is there, all clean and new, and you will turn on the suction. You will want to make sure it will reach a certain pressure, and when you occlude the tube, that pressure will increase. After you use the suction you can turn it off. Something else you will want to check is your auxiliary oxygen supply is working appropriately. You will turn on the flow and you just need to make sure oxygen is flowing appropriately. After your machine has passed all the tests it will be in standby mode and the next thing we can do is the two bag test. Firstly you want to attach your spare //(reservoir bag)// to one end of the breathing circuit. Then set up the fresh gas flow around 5 and //(press)// ‘start case’. After starting case you will set the APL valve on approximately 30 and you will want to see both //(inspiratory and expiratory limb)// valves working correctly. After you can confirm that both valves are moving correctly you can squeeze both bags together and what you would like to see is the peak pressure to reach approximately the same value as the APL. Yes you can see it’s on thirty. Next thing we need to do is switch on the ventilator and you can see movement in your bag, simulating the lungs. After you have performed this third and last test you can press ‘end case’ and confirm. After performing a two bag test the next thing you need to do is check that the vaporisers are mounted correctly. In this case we have sevoflurane. Also desflurane and isoflurane are compatible. You check that your soda lime is mounted and at the right level and that the gas outlet is correctly selected. On some machines you would have a manual switch on some you have an electric swich, like this case. If you were to pass from the common gas outlet to the AFGO, you would just need to click on this one, and select the appropriate one. After checking that the gas outlet is correctly selected you want to make sure you have a T-piece on your anaesthetic machine and make sure the settings are appropriate for your patient, like in this case we have a tidal volume of 500, a respiratory rate of 12 and a PEEP of 5. After checking your ventilator the next thing to be done is checking your scavenging system. Usually it’s found somewhere on the anaesthetic machine. Like in this case here, in the centre, and it has a flow meter, and you will need to double check that it’s actually working appropriately. Like in this case. The next thing you want to check is your monitor. Just tap on your monitor and ‘start case’ and by using your fresh personal filter, //(blows into CO~~2~~ line via fresh filter)// you can double check that your CO~~2~~ waveform will create, //(places saturation probe onto finger)// and you will have sats probe on the monitor. After making sure your alarms are appropriately set what you want to do is make sure your airway trolley is there and set up correctly. Double check what’s your plan for the day and what’s the plan for the first patient and you want to ensure the layout of the trolley is two blades, size 3 and 4, rescue iGels size 4 and 5, Guedel airways size 2 and 3, cannulation tray, and two ETT tubes size 7 and 8, tube tie and a ten ml syringe and your bougie. Don’t forget your: self inflating bag, your common gas outlet, your difficult airway equipment, your resuscitation equipment, and then your TIVA and other equipment. Then in between cases what you want to do is perform the ‘two bag test’. Make sure your ventilator is working fine, your airway trolley is set up and ready, your suction is changed and is clean. Now this concludes our safety check for the anaesthetic machine, and what I would like to do now is to do all the checks without stopping and show you how these should be done. //(Demonstrates whole check in silence)// And at the end of the check I would do my two bag ventilation check.//</p> [[Back|video]] [[Next|team8]]

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Virtual Anaesthetics_2@@

''>'' 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/IACmodule2.pdf]]'' [[Back|Introduction]]

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