IAC Module 5v2

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@@.whitetext; !!!Virtual Anaesthetics_5 Welcome to the fifth 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_5: RSI & 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 "monitor60bpm" "audio/monitor60bpm.mp3">> <<set $history to []>> <<set $started to 0>>

!!!@@.greentext;Scenario learning objectives:@@ * Have an understanding of issues surrounding the care of emergency patients * Be able to discuss rapid sequence induction (RSI) and have used RSI checklists * Understand the risks associated with transfer of patients to theatre * Have an overview of patient positioning and how to avoid iatrogenic injury * Give a virtual handover to recovery following emergency surgery * Have a structured approach to managing a virtual patient with PONV * Know the NICE guidance on perioperative pain management and have a strategy for assessing and managing perioperative pain @@.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_4 first which provides background knowledge and platform familiarity which is useful, but not essential, for Virtual Anaesthetics_5.''@@ [[Next->theatre1]] [[Show me the EPA for IAC mapped to this scenario|epa]] [[Show me the stage 1 curriculum|stage1]]

!!!@@.greentext;Scenario learning objectives:@@ * Have an understanding of issues surrounding the care of emergency patients * Be able to discuss rapid sequence induction (RSI) and have used RSI checklists * Understand the risks associated with transfer of patients to theatre * Have an overview of patient positioning and how to avoid iatrogenic injury * Give a virtual handover to recovery following emergency surgery * Have a structured approach to managing a virtual patient with PONV * Know the NICE guidance on perioperative pain management and have a strategy for assessing and managing perioperative pain ''Printable evidence for the LLP'' ''[[here|https://www.virtualanaesthetics.com/IACModule%205/IACmodule5mapped.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 "VA5IAC">> <<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 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_5 <<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 think through your anaesthetic stratergy and then go and find Dr F. "So $firstname, what's your plan?" [[RSI, rocuronium 1 mg/kg|theatre3][$rsi = "Correct"]] [[RSI, rocuronium 0.6 mg/kg|theatre3][$rsi = "Almost"]] [[RSI, suxamethonium 1-1.5 mg/kg|theatre3][$rsi = "Good"]] [[She's starved, standard induction|theatre3][$rsi = "Not quite"]]

<p style="text-align:justify">It’s just shy of midnight. You've just transferred the last patient to ICU after a laparotomy and de-functioning ileostomy with the night anaesthetic consultant, Dr Franklin. Hannah, the SpR covering obstetrics, catches you both as you reach theatres. She has an anaesthetic chart in her hand. "Thank you Hannah." Dr Franklin takes the offered chart and scans it. "No problem. She’s 20, appendicitis, ASA I, no medical history, no allergies, Mallampati I, bit nauseous but not vomiting, starved since first thing, the surgeons want to do her tonight, they are concerned about perforation. Anyhow I’d better get back to obs." "Your patient $firstname. Go and lay eyes on her, introduce yourself, make sure you're happy." He hands you the chart. "I need coffee. Then you can tell me your plan."</p> [[Next|theatre2]] [[Take a look at the chart|https://www.virtualanaesthetics.com/IACModule%205/crawford.pdf]] <<set $rsi to "no answer given">>

<center> [[Transcript->transcript]]      [[Next->videopost]] <iframe width="100%" height="600" src="https://www.youtube.com/embed/wEJClBaOdDE" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe> </center>

@@.typing;''"Ok, so we’ve finished the case so lets get this tube out."'' ''"Ready to take that off."'' //Turns off volatile// ''"Turn that to 100% oxygen."'' //Turns O~~2~~ to 100%// ''"Brilliant. Right then, so, we’ve positioned her appropriately."'' //Patient is semi recumbent on theatre trolly// ''"Lets see if we need to give any reversal. Lets check the train of four."'' //Patient’s hand jerks four times// ''"We’ve got a little bit of fade there. So lets just give our reversal. OK."'' //Gives reversal agent into canula on back of patients hand// ''"Excellent we’ll check that in a minute."'' ''"Switch this onto manual."'' //Leans over and switches from ventilator to manual ventilation on anaesthetic machine// ''"And see what we get."'' //Close up ventilator screen showing small tidal volume breaths// ''"Ok then, little bit of breathing, excellent, sure that will improve once the reversal gets going."'' ''"OK, everything looks ok, we’ve got a bite block in just so we’ve got some extra protection."'' ''"Are we going to loosen this?"'' //Unties tube tie bow at side of patients mouth// ''"OK lets see what her breathing is like, so that’s excellent we just need to wait for the gas to go down and then she should be waking up very soon."'' ''"Lets check the train of four again."'' //Patient’s hand jerks four times, more vigorously than before// ''"Ok we’ll just take this off."'' //Removes peripheral nerve stimulator from right ulnar nerve// ''"Perfect."'' //Louder voice to patient:// ''"Hello, you’re just waking up, operations all over, you’re just waking up, take some nice slow deep breaths for me, you’re doing really well now."'' //Monitor close up showing larger tidal volumes// ''"Little bit of suction."'' //Superficial suctions side of mouth// //Louder voice to patient:// ''"Ok open your eyes, operations all over, that’s it, take some slow deep breaths for me."'' //To ODP:// ''"Just apply a little bit of PEEP, and we will cuff down please, excellent."'' //Louder voice to patient: // ''"You’re just waking up, take some nice slow deep breaths, stick your tongue out for me."'' //Removed ETT in smooth motion.// //Louder voice to patient:// ''"Well done, well done."'' //To ODP:// ''"Just pop the oxygen mask on, perfect."'' //Louder voice to patient:// ''"There we are, take some slow deep breaths, you’re doing really well, got some good breathing, excellent."'' //Mask falls off circuit and is replaced//. ''"You’re doing really well."'' //To ODP:// ''"We’ll pop and oxygen mask on and then she’s fine to go to recovery. Could someone ring them please and let them know that we’re coming? Thank you."''@@ <center> [[Play video|video]]    [[Next|videopost]] </center>

You walk Lisa down to recovery and give the staff a comprehensive handover. The rest of the list is thankfully uneventful. [[Next|email]]

@@.typing;''From:'' Henry Coal ''To:'' $firstname $surname ''Subject:'' Re: today's list Hi $firstname Thanks for your consistent effort today. What with one thing and another, that was a complicated list. Keep up the good work you will continually improve. Well done. Henry Dr Henry Coal MBChB, MA, FRCA Consultant in Anaesthesia @@ [[End]] Sent from my iPad

Dr Franklin looks at you for a moment. "<<print $rsi>>." <<if $rsi is "Good">> "She certainly needs an RSI with an acute abdomen and nausea even if she hasn't eaten in the last 6 hours. Suxamethonium is the traditional neuromuscular blocking agent of choice." <<elseif $rsi is "Correct">> "She certainly needs an RSI with an acute abdomen and nausea even if she hasn't eaten in the last 6 hours. Rocuronium at that dose is a good choice for an RSI." <<elseif $rsi is "Not quite">> "She needs an RSI with an acute abdomen and nausea even if she hasn't eaten in the last 6 hours. Rocuronium at 1 mg.kg^^-1^^ or suxamethonium at 1-1.5 mg.kg^^-1^^ are good choices for an RSI." <<elseif $rsi is "Almost">> "She certainly needs an RSI with an acute abdomen and nausea even if she hasn't eaten in the last 6 hours. Rocuronium is a good choice for an RSI but at a dose of 1 mg.kg^^-1^^." <</if>> [[Next|theatre4]] <<set $why to "No answer given">>

"What is the main reason we do an RSI in cases like these?" "We do it to reduce the... [[...risk of laryngospasm|theatre5][$why = "Not quite"]] [[...time between loss of airway reflexes and placement of an ETT|theatre5][$why = "Correct"]] [[...period of cardiovascular instability on induction|theatre5][$why = "Not quite"]] [[...amount of time the patient is awake in the anaesthetic room|theatre5][$why = "Not quite"]]

"<<print $why>>, we want to avoid the risk of aspiration by getting a cuffed tube through the cords." "$firstname I am an advocate of doing everything we can to reduce cognitive load so we can have spare bandwidth to think, especially at this time of night." "[[NAP4|https://www.nationalauditprojects.org.uk/downloads/Section%203.pdf]] promoted the use of a checklist for emergency inductions. I'm an intensivist at heart so the version the intensive care society produced is the one I use." He hands you a [[laminated sheet|https://www.virtualanaesthetics.com/IACModule%205/icursi.pdf]]. "It's intended to apply to critically ill adults but the principles apply to any RSI you do. Have a good look at it, take it with you, go and tell David your strategy and then get on. I'm here if you need me." [[Next|theatre6]] <<audio "monitor60bpm" pause>>

<p style="text-align:justify">Ten minutes later, with the team brief and first part of the WHO checklist done, Ruth is lying nervously, sat up slightly, at 30^^o^^ on a tilting trolley in the anaesthetic room. Dave is half way through getting the ECG on while making soothing small talk. A reassuring pulse ox tone bleeps regularly in the background. The non-invasive BP is on it’s first cycle. "Can I just borrow your hand?" You stabilize the 18 G cannula that Ruth arrived with and screw and Luer connecter of the IV giving set to the back of the cannula. With a turn of the clamp wheel there’s a rapid drip. You give 100 micrograms of fentanyl.</p> 123/78 [[Next|theatre7]] <<set $o2 to "No answer given">> <<audio "monitor60bpm" volume 0.2 loop play>>

"Rest your hand with the drip in on your chest for me." You give Ruth a reassuring smile. "Right, this is just a bit of oxygen, smells a bit plasticky because the mask's fresh out of the packet." You place the mask over Ruth's mouth and nose. "I'd like you to... [[...just breath normally for two minutes|theatre8][$o2 = "Not quite"]] [[...take eight big deep breaths right to the bottom of your lungs over the next minute|theatre8][$o2 = "Correct"]] [[...just breath normally for three minutes|theatre8][$o2 = "Good"]] [[...take big deep breaths right to the bottom of your lungs over the next three minutes|theatre8][$o2 = "Not quite"]] <<set $et to "No answer given">>

<<print $o2>> Thinking about it, you know that 8 VC breaths in one minute gives a longer safe apnoeic time, and Ruth is able to, so you go with that. Ruth chest rises and falls rhythmically. You watch the monitor. The end tidal O~~2~~ creeps upwards. You wait until it reaches... [[...0.75|theatre9][$et = "Not quite"]] [[...0.8|theatre9][$et = "Not quite"]] [[...0.85|theatre9][$et = "Not quite"]] [[...0.9|theatre9][$et = "Correct"]] <<set $prop to "No answer given">>

<<print $et>> <p style="text-align:justify">Dave is unobtrusively tucking the kinked suction tube under the pillow. There’s a faint hiss that tells you it’s already on. The Et O~~2~~ makes it to 0.9 "Happy?" You ask Dave quietly. "Happy" he responds and then to Ruth, "I’m just going to gently feel the front of your neck Ruth. His fingers rest lightly on her cricoid. You lock the propofol syringe to the injection port. With his free hand Dave pinches the IV line. You give...</p> [[...120 mg, 12 ml|theatre10][$prop = "Not quite"]] [[...160 mg, 16 ml|theatre10][$prop = "Not quite"]] [[...200 mg, 20 ml|theatre10][$prop = "Correct"]] [[...240 mg, 24 ml|theatre10][$prop = "Not quite"]] <<set $musk1 to "No answer given">> <<set $musk2 to "No answer given">>

!!@@.greentext;You are here:@@ <img src="images/aaga.jpg" style="max-width: 100%;"/> <center> ''Figure 1: Accidental awareness under GA (AAGA) during induction and transfer to theatre.'' Figure based on NAP 5, ch 8^^[[1|ref1]]^^. </center> <p style="text-align:justify">@@.greentext;''Transfer from the anaesthetic room to theatre takes on average almost a minute. With airway and intravenous access 'incidents', and minor problems like equipment tangles or stuck brakes, this can be over three minutes. Even once reconnected the circuit needs to fill with vapour before anaesthetic is being delivered to the patient.''@@</p> ''"Mind the gap"'' * Aim age adjusted MAC ≥0.8, vaporizer on, high enough, and with sufficient FGF * Avoid unnecessary stimulation until adequate depth of anaesthesia * Opioids on induction reduce the risk * Avoid neuromuscular blocking drugs where possible * Use more than the minimum dose of induction agent and give more if the induction is prolonged. Where reduced dosing is deemed unavoidable such as cardiovascular instability, then the higher risk of AAGA should be part of the discussion with the patient * Use a depth of anaesthesia monitor (e.g. BIS) * Elevated BMI = risk * Emergency surgery/RSI = risk ''After every transfer reassess ABCDE:'' <img src="images/abcde.jpg" style="max-width: 100%;"/> <center> ''Figure 2: Re-assessment during induction and transfer to theatre.'' Figure based on NAP5, ch 8^^[[1|ref1]]^^. </center> <div class="notes">''Trolley/bed to operating table:''</div> * ''Risk assess the patient:'' fragile skin, pain, fracture, elevated BMI, low BMI, diabetic, vascular disease, coagulopathy, medical devices such as lines/catheters/drains/airway device, etc. * ''Risk assess the task:'' enough help, hazards (e.g. brakes on the trolley/table, floor still wet between cases, trailing cables/power leads), got the right kit, in good working order that the team know how to use, height of table and trolley, minimise gaps * ''Standard kit:'' slide/transfer board and a draw sheet * ''Something extra:'' friction reducing devices, HoverMatt®, (do not leave under the patient during the procedure) * Receiving surface no more than 2.5 cm lower to allow gravity to assist * At the head end, you lead the team, support the head and neck and guard the airway * Make sure the team know the directions, (ready-set-slide? 1-2-3-slide?) * If it’s a slide to the middle-pause-slide across, make sure everyone knows it (may be necessary when ++ lines/catheters/monitors etc) * Be prepared for the unexpected (snagged catheters/lines/sheet trapped between the trolley and table) !!!!@@.greentext;SLIDE not LIFT, engage your core muscles and use your legs to do the work, avoid twisting, keep your elbows tucked in to keep the load (head ≈ 5 kg) close to your body, this is about keeping your back functional for the next 40+ years. And obviously you’ve done a manual handling course as part of your mandatory training. @@ !!!!@@.greentext;//OK. They’re on the table with a MAC of 1.0, now what?//@@ <div class="notes">''Positioning''</div> * To give the surgeon access to the operative site * Responsibilities of the team include stabilising the patient safely and avoiding injury * The degree of risk depends on patient factors (e.g. weight/height/nutritional status), type of position, type of anaesthetic, and length of procedure * The patient should be reevaluated frequently and adjustments made as necessary ''Complications from positioning include:'' * MSK pain * Joint dislocation * Nerve damage * Damage to the skin and underlying tissues * Cardiovascular and/or respiratory compromise * Vessel compression and injury with the risk of DVT and/or ischaemia * Crush injuries parts of the patient concealed under drapes by equipment or staff * Excessive heat loss ''Commonly injured nerves:'' * Ulnar nerve (UN), especially compression in superficial condyler groove of the elbow or stretch injury from arms across chest, men at greater risk * Brachial plexus (BP) stretch injury from arm abduction, external rotation and posterior shoulder displacement, or lateral neck flexion/neck rotation, compression by dependent humeral head when lateral * Lumbosacral root and spinal cord * Common peroneal nerve (CPN) most commonly injured lower limb nerve <img src="images/all.jpg" style="max-width: 100%;"/> <div class="notes">''1) Supine''</div> ''Most common nerve damge:'' UN, BP if arms on arm boards, radial nerve (RN), median nerve (MN), CPN and tibial nerve (TN) ''Vulnerable bony prominences:'' occiput, vertebral prominances, scapula, olecranon, sacrum, calcaneous ''Notes:'' If using arm boards these should be level with the table, palms should face up, and fingers extended (but caution of UN which is at greater risk than when the forarm is supinated), keep abduction at the shoulder to less than 90^^0^^. If arms are wrapped at the patient's sides then palms should face the patient and the elbow padded <div class="notes">''2) Prone''</div> ''Most common nerve damge:'' BP, RN, UN ''Vulnerable bony prominences:'' acromion, clavical, iliac, patella, toes ''Other risks:'' joint hyperextention, major vessel/eye/breast/genitalia compression, airway management, management of cardiac arrest <div class="notes">''3) Trendelenburg''</div> As for supine ''Other risks:'' diaphragm elevation, reduced lung volumes, increased ventilation pressures for given TV, increased ICP, sliding cranially ''Notes:'' Shoulder braces and a table strap or <<link [[beanbag immobiliser|notes]]>> <<set Dialog.setup("Beanbag immobiliser")>> <<set Dialog.wiki("''A vacuum pillow-type device full of small beads which is moulded round the patient before a vacuum applied to 'hold' the pillow to the patient.''")>> <<set Dialog.open ()>> <</link>> can secure the patient's position <div class="notes">''4) Reverse Trendelenburg''</div> As for supine ''Other risks:'' relative cranial hypotension, sliding caudally ''Notes:'' A foot board and a table strap or a beanbag immobiliser, can secure the patient's position <div class="notes">''5) Lateral''</div> ''Most common nerve damage:'' BP, RN, UN, median nerve (MN), common PN ''Vulnerable bony prominences:'' acromion, ribs, ilium, greater trochanter, femoral epicondyle and tibial condyles, medial and lateral malleoli ''Other risks:'' major vessel compression, dependent ear <div class="notes">''6) Sitting''</div> Also known as 'Fowler's', other variations include Deck/Beach/Lawn chair'. Risks as for supine but ischial tuberosities and sacral nerve at greater risk ''Other risks:'' relative cranial hypotension, venous air embolism ''Notes:'' Specialist table <div class="notes">''7) Lithotomy''</div> ''Most common nerve damage:'' As for supine + common PN, sciatic nerve, obturator nerves, femoral nerves ''Vulnerable bony prominences:'' As for supine + femoral epicondyle, tibial condyles and medial and lateral malleoli ''Other risks:'' sacroiliac/hip/knee joint damage/dislocation, vascular congestion, compartment syndrome), restricted diaphragm, soft tissue injury lateral/posterior knees ''Notes:'' Standard table with end off + stirrups. Legs should be positioned slowly and simultaneously. Stop if resistance is felt. If arms across the chest avoid excessive flexion at the elbow and risk to UN. When the legs are lowered 500-800 ml of blood is diverted to the extremities and hypotension can be avoided by doing this slowly <img src="images/cart.jpg" style="float: left; max-width: 40%;"/> ''The bottom line: Transfer from the anaesthetic room to theatre is a high risk period for AAGA so 'Mind the gap'. General, regional, and local anaesthetics as well as neuromuscular blocking drugs remove the patient's normal defence mechanisms to injury. Proper alignment, adequate securing and stabilisation, limb support and padding can minimise the risk of iatrogenic injury.'' ''[[Back|theatre17]] [[Show me the evidence|ref1]]'' <A HREF="javascript:window.print()">Click to Print This Page</A>

<<print $prop>>. <p style="text-align:justify">You know Ruth weights 69kg and is young and anxious. She is likely to need a dose of propofol at the higher end of the dose range (2-3 mg.kg^^-1^^, 140-210 mg) in order to ensure a safe, rapid induction. She may need more.</p> The propofol is in. Ruth's eyes close. "Are you warm enough?" You ask her...no response. "Cricoid on." <<if $rsi is "Correct">> You give 1 mg.kg^^-1^^ of rocuronium. You glance at the second hand on the clock and watch as it ticks round for... [[...30 seconds|theatre11][$musk1 = "Not quite"]] [[...60 seconds|theatre11][$musk1 = "Correct"]] [[...90 seconds|theatre11][$musk1 = "Not quite"]] [[...120 seconds|theatre1][$musk1 = "Not quite"]] <<elseif $rsi is "Good">> You give 1 mg.kg^^-1^^ of suxamethonium. Fasciculations shiver across first Ruth's arms and then her facial muschles. You glance at the second hand on the clock and watch as it ticks round for... [[...30 seconds|theatre11][$musk2 = "Not quite"]] [[...60 seconds|theatre11][$musk2 = "Correct"]] [[...90 seconds|theatre11][$musk2 = "Not quite"]] [[...120 seconds|theatre11][$musk2 = "Not quite"]] <<else>> You give 1 mg.kg^^-1^^ rocuronium. You glance at the second hand on the clock and watch as it ticks round for... [[...30 seconds|theatre11][$musk1 = "Not quite"]] [[...60 seconds|theatre11][$musk1 = "Correct"]] [[...90 seconds|theatre11][$musk1 = "Not quite"]] [[...120 seconds|theatre11][$musk1 = "Not quite"]] <</if>> <<set $grade to "No answer given">>

<<print $musk1>> After what feels like several minutes of not ventilating the 60 seconds is up. Dave is offering the larygoscope handle first to you. You slide the laryngoscope blade into the right corner of her mouth and advance it centrally to push her tongue out of the line of sight, while lifting and avoiding levering on her teeth. And this is what you see... <center> <img src="images/cormacklehane2b.jpg" style="max-width: 400px;"/> </center> "I've got a grade ... [[...1 view|theatre12][$grade = "Not quite"]] [[...2a view|theatre12][$grade = "Not quiet"]] [[...2b view|theatre12][$grade = "Correct"]] [[...3 view|theatre12][$grade = "Not quite"]] [[...4 view|theatre12][$grade = "Not quite"]]

<<print $grade>>. Thats a grade 2b view. With your free right hand, while watching your view of the larynx you manipulate where Dave is applying his force. The <<link [[BURP|theatre12]]>> <<set Dialog.setup("BURP")>> <<set Dialog.wiki("Backwards, upwards, rightwards, pressure, on the ''thyroid cartialage'' displaces the larynx superiorly, posteriorly and rightward to improve visualisation. This technique ≠ cricoid pressure, where the pressure is applied to the more cordal cricoid cartilage")>> <<set Dialog.open ()>> <</link>> gives you this view... <center> <img src="images/cormacklehane2a.jpg" style="max-width: 400px;"/> </center> "That's given me a grade... [[...1 view|theatre13][$grade2 = "Not quite"]] [[...2a view|theatre13][$grade2 = "Correct"]] [[...2b view|theatre13][$grade2 = "Not quite"]] [[...3 view|theatre13][$grade2 = "Not quite"]] [[...4 view|theatre13][$grade2 = "Not quite"]] <<set $bougie to "No answer given">>

<<print $grade2>>. Thats a grade 2a view. "Bougie?" Dave asks [[Yes please|theatre14][$bougie = "true"]] [[No thanks|theatre14][$bougie = "false"]]

<<if $bougie is "true">>You take the bougie in your right hand and adjust the curve slightly on the pillow before deftly slipping it through the cords. Dave threads a size 7.5 ETT over the end and then as you take control of the tube he grips the bougie so it doesn’t advance with the tube. "I knew someone who went straight through the carina with one of these." "Not tonight thanks." The tube catches, you rotate it gently clockwise. "I'm through the cords, bougie out." <<elseif $bougie is "false">>Dave offers you a size 7.5 ETT You deftly place it. "I'm through the cords." <<else>>Dave offers you a size 7.5 ETT You deftly place it. "I'm through the cords." <</if>> [[Next|theatre15]]

You attach the circuit, screw down the APL valve part way and squeeze the bag. "OK, I’ve got misting of the tube, chest is rising and falling and we’ve got four...five...six on the CO~~2~~ trace." "So?" Dave asks with a raised eyebrow. "Oh yeah, thanks." You turn on the volatile. "And?" "Let's get this tube tied in...and pressure off please." Dave finally releases the pressure on Ruth's neck. [[Next|theatre16]] <<set $aw to "No answer given">>

#NAP5 Report and findings of the 5th National Audit Project: CHAPTER 8 AAGA during induction of anaesthesia and transfer into theatre available here https://www.nationalauditprojects.org.uk/downloads/chapter8.pdf # Hewson D, Bedford N, Hardman J. Peripheral nerve injury arising in anaesthesia practice. //Anaesth//. 2018; 73(1):51-60 # Lalkhen A, Bhatia K. Perioperative peripheral nerve injuries. //CEACCP//. 2012; 12(1):38-42 # Contractor S, Hardman J. Injury during anaesthesia. //CEACCP//. 2006; 6(2):67-70 # Gudiline summary: Positioning the patient. //AORN Journal// 2017; 106(3):238-247 [[Back|notes]]

Tube is in the right place. Fantastic. Out of the high risk period of induction? [[Has to be yes?|theatre17][$aw = "Not quite"]] [[It's no isn't it?|theatre17][$aw = "Correct"]] <<audio "monitor60bpm" pause>>

<<print $aw>> <img src="images/gap.jpg" style="max-width: 100%;"/> Half of cases of accidental awareness under GA occur during induction, and rapid sequence induction is over represented in cases of AAGA; RSI is used in 8% of inductions, but 36% of AAGA involve RSI. You need to safely transfer Ruth to theatre and position her on the operating table. [[Next|theatre18]] [[Tell me more about transfer and positioning|notes]]

Neil skilfully removes Ruth’s appendix and 45 minutes later you have extubated Ruth. As you wheel the trolley, with your sleepy patient, down to recovery, you run through your head what you need to hand over to the recovery staff. <<if $rsi is "Correct">>[[Here|https://www.virtualanaesthetics.com/IACModule%205/ruth1.pdf]] is your chart for the anaesthetic. <<elseif $rsi is "Good">>[[Here|https://www.virtualanaesthetics.com/IACModule%205/ruth2.pdf]] is your chart for the anaesthetic. <<else>>[[Here|https://www.virtualanaesthetics.com/IACModule%205/ruth1.pdf]] is your chart for the anaesthetic. <</if>> You turn it over for the [[handover checklist|theatre19]]

<img src="images/recoveryruth.jpg" style="max-width: 100%;"/> [[Next|theatre20]]

<img src="images/sickman.jpg" style="max-width: 100%;"/> @@.greentext;''Postoperative nausea and vomiting (PONV) = any nausea, wrenching, or vomiting in the first 24-48 h after surgery''@@ PONV affects more than 30% of patients and up to 80% of high risk patients. Traditionally high risk procedures include gynae, laparoscopic, ear and eye. <img src="images/ponv.jpg" style="max-width: 100%;"/> <center> ''Figure 1: Example management strategy for PONV. Follow your own local guidelines.'' </center> Each antiemetic reduces risk of PONV by ~25%. Combining antiemetic agents has <u>additive</u> benefit. Don't forget non-pharmacological management: hydration, warmth, pain control, correction of hypotension/hypovolaemia/hypoxia, P6 pressure point stimulation ('sea bands'). <div class="sick">''Ondansetron''</div> @@.typing;''Class'' 5HT~~3~~ receptor antagonist ''Presentation'' Clear sol for injection 2 mg.ml^^-1^^, 4/8 mg tablets ''Uses'' Prevention and treatment of nausea and vomiting related to chemotherapy, radiotherapy, and anaesthesia ''PONV dose'' 4-8 mg slow IV, give 20 minutes before the end of surgery <p style="text-align:justify">''Notes'' Contraindication: ↑ QT~~c~~. Caution: hepatic impairment. Risk of orofacial clefts if used in the first trimester. Reduces analgesic effect of tramadol. Higher doses given over 15 min or via IVI with emetogenic chemotherapy. ''No better than placebo as rescue'' if already given as prophylaxis</p>@@ <div class="dex">''Dexamethasone (white label)''</div> @@.typing;''Class'' Corticosteroid ''Presentation'' Clear solution 3.3 mg.ml^^-1^^ ''Uses'' Prevention and treatment of nausea and vomiting related to opioid use or anaesthetic agents. Also: allergic and inflammatory conditions, croup, symptom control in palliative care, diagnosis of Cushing's disease ''PONV dose'' 3.3 or 6.6 mg IV at start of surgery (4 mg dexamethasone phosphate = 3.3 mg dexamethasone) ''once only'' <p style="text-align:justify">''Notes'' Can impair glycaemic control in diabetics. Psychiatric disturbances may occur, especially in the elderly. Causes perineal flushing sensation, warn the patients of this if they’re awake.</p> @@ <div class="sick">''Droperidol''</div> @@.typing;''Class'' Central D2 antagonism ''Presentation'' Clear solution for injection 5 mg.ml^^-1^^, 10 mg tablets or 1 mg.ml^^-1^^ syrup ''Uses'' Prevention and treatment of nausea and vomiting related to anaesthetic agents and opioid use including opioid PCA. Also used as a premed/neuroleptic ''PONV dose'' 0.625 to 1.25 mg IV, give 30 minutes before the end of surgery <p style="text-align:justify">''Notes'' Contraindications: ↓ HR, ↓ GCS, ↓ K^^+^^, ↓ Mg^^2+^^, phaeochromocytoma, ↑ QT~~c~~. Caution: elderly, Parkinson's disease, hepatic impairment. Risk of extrapyramidal side effects</p> @@ <div class="sick">''Cyclizine''</div> @@.typing;''Class'' Anticholinergic at M1, M2 and M3 receptors, H1 receptor antagonist ''Presentation'' Clear sol for injection 50 mg.ml^^-1^^, 50 mg tablets ''Uses'' Prevention and treatment of nausea and vomiting related to opioid use or anaesthetic agents, motion sickness or Manière’s disease ''PONV dose'' 50 mg slow IV max 150 mg/24h <p style="text-align:justify">''Notes'' Protect from light. Low pH so can be painful IV, dilute to 10 ml in ''water for injection and give slowly''. Anticholinergic action may cause tachycardia and hypotension (esp if given fast). Other anticholinergic effects: drowsy, dizzy, dry, delirium. Avoid in porphyria. Caution in the elderly, consider dose reduction to 25 mg. Caution using with prochlorperazine as similar SE profile. </p>@@ <div class="sick">''Prochlorperazine''</div> @@.typing;''Class'' Central D2 antagonism also 5HT, H1 and α1, and muscarinic receptor antagonism ''Presentation'' Clear solution 12.5 mg.ml^^-1^^, 3 mg buccal tablets, oral tablets, syrup ''Uses'' Nausea and vomiting, vertigo, ''PONV dose'' Buccal (//Buccastem//) 3-6 mg/12h or ''IM'' (//Stemitel//) 12.5 mg/8h <p style="text-align:justify">''Notes'' Contraindications: ↓ GCS, phaeochromocytoma, ↑ QT~~c~~. Caution: elderly, Parkinson's disease, hepatic impairment. Risk of extrapyramidal side effects. Caution using with cyclizine as similar SE profile.</p> @@ <div class="notes">''Others:''</div> @@.typing; * ''TIVA'' and air/O~~2~~ gas mix reduces risk of PONV by ~25% * Alternative ''5HT3 receptor antagonists:'' dolasetron, granisetron, tropisetron, ramosetron and palonosetron * ''NK-1 receptor antagonists:'' e.g. aprepitant, casopitant, and rolapitant. Long half-lives, better than ondansetron for PONV at 24/48h, not all agents approved for use in PONV * Low dose ''haloperidol'' * 10 mg Metoclopramide ''no better than placebo'' and this drug has no additive benefit when used in combination <img src="images/sick.jpg" style="float: left; max-width: 40%;"/>''The bottom line: check for risk factors, predict incidence, reduce risk, prevent, rescue using a drug from a different class.''@@ [[Back|theatre23]] [[Show me the evidence|ref2]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] <A HREF="javascript:window.print()">Click to Print This Page</A> ^^*^^ 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.

<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]]

<p style="text-align:justify">"Ah, $firstname, all done?" Dr Franklin greets you when you finally get to the staff room. "I've spoken to Neil and there's nothing more from their side tonight. Ortho are putting off a young man who needs an ORIF ankle until the day team, he'd just had a kebab apparently. I shall head home if you are happy? If at any point you’re not sure whether you need to call me, please just do, much rather be involved first hand than tomorrow’s..." He glances at the clock and corrects himself. "...today's hand over." You watch him retreat out the door and then settle down for a well earned drink and some food.</p> [[Next|theatre21]] <<audio "bleep" pause>>

# Gan TJ, Diemunsch P, Habib AS, et al. Society for Ambulatory Anesthesia. Consensus guidelines for the management of postoperative nausea and vomiting. //Anesth Analg.// 2014;357:85-113 # Gan TJ., et al. Fourth Consensus guidelines for the Management of Postoperative Nausea and Vomiting. //Anesth Analg//. 2020 Aug;131(2):411-448 # Pierre S, Whelan R. Nausea and vomiting after surgery. //CEACCP//. 2013; 13(1):28-32 # Scarth E, Smith S. Drugs in anaesthesia and intensive care, 5th Edn. 2017, Oxford University Press # Joint Formulary Committee. British National Formulary. London: BMJ Group and Pharmaceutical Press; 2021. Available [[here|https://bnf.nice.org.uk/]] # Zhan M, Doerfler RM, Xie D, et al. Association of opioids and nonsteroidal anti‐inflammatory drugs with outcomes in CKD: findings from the CRIC (chronic renal insufficiency cohort) study. //Am J Kidney Dis//. 2020;76:184‐193 [[Back|notes2]]

!!!@@.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 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]]

<p style="text-align:justify">The rest of the theatre team are all occupying staff room chairs and sharing the pile of night shift snacks. A bleep goes off. Dave, the theatre coordinator and you all simultaneously reach down to look. You’ve drawn the short straw, it’s yours.</p> [[Better answer it|theatre22]] <<audio "bleep" play>>

You head straight over to recovery bay 4 where Ruth is semi recumbent on her bed, miserably hugging a cardboard sick bowl to her chest. "Hi Ruth, sorry you are feeling a bit grim. Let me just have a look at what’s been going on and I'm sure we can get you a bit more sorted." [[Look at the recovery chart|https://www.virtualanaesthetics.com/IACModule%205/recoveryruth3.pdf]] [[Tell me more about antiemetics|notes2]] [[Tell me more about managing pain|notes3]] [[Next|theatre24]] <<set $sick to "No answer given">>

<img src="images/pain1.jpg" style="max-width: 100%;"/> <p style="text-align:justify">''NICE perioperative care guidance managing pain: Oral paracetamol, oral ibuprofen except in #NOF, + opioids you give on induction/intraoperatively. If moderate to severe pain expected post-op then oral opioids or a PCA or an epidural. Consider local and regional techniques.''</p> Simple? Not really. Make yourself a tea/coffee, here’s the long version... <div class="notes">''Planning pain management with your patient''</div> ''Consider patient factors including:'' * Clinical features including comorbidities, age, frailty, renal and liver function, coagulation status, allergies, current medicines including previous opioid exposure and cognitive function * The person's preferences and expectations * Their pain history * The potential benefits and risks, including long-term risks, of different types of pain relief * Plans for discharge ''Consider surgical factors:'' * Whether the surgery is immediate, urgent, expedited or elective * The likely impact of the procedure on the person's pain and how long is this likely to last? * Is the procedure amenable to the use of regional or local anaesthetic techniques? ''Evaluating a patient in pain:'' * Procedures performed? * Could this be a complication of surgery and/or anaesthesia? * Other physical cause? e.g. urinary retention, positioning, tight cast/splint * Pain assessment * What has been tried? * Make a plan including non-pharmacological adjuncts e.g. heat/cool, physiotherapy, elevation of a limb * Reassess at appropriate intervals <div class="notes">''Pain assessment''</div> <center> <img src="images/pain.jpg" style="max-width: 100%;"/> ''Figure 1: An emoji representation of the Wong-Baker scale'' @@.greytext;^^Lord Belbury, [[CC BY-SA 4.0|https://creativecommons.org/licenses/by-sa/4.0]]^^@@ </center> ''1) The pain'' * Site * Nature * Intensity 0-10 on a numeric rating scale (NRS): 0 = no pain, 1-3 = mild, 4-6 = moderate, 7-10 = severe * Targeted physical assessment (do the surgeons need to RV?) ''2) Functional ability'' * Coughing * Deep breathing * Movement and/or range of motion * Document function ''3) Psychosocial factors'' * Don’t omit this aspect of assessment as it has a significant bearing on controlling this person’s pain * Anxiety, distress or confusion * Cultural and communication barriers * Patient’s expectations, knowledge and beliefs surrounding pain <p style="text-align:justify">''Then:'' Offer multimodal analgesia by combining analgesics of different classes, each acting at different sites of the pain pathway to achieve a ‘functional recovery’ as soon as possible (e.g. coughing, deep breathing, mobilizing). Consider pre-emptive analgesia for when regional/local anaesthetic wears off.</p> <div class="notes">''Paracetamol''</div> @@.typing; * ''PO'' paracetamol almost everyone before and after surgery * Oral bioavailability (OBA) 60-89% * ''↓'' dose if less than 50 kg * Caution: liver or severe renal impairment @@ <div class="notes">''Ibuprofen''</div> @@.typing; * ''PO'' ibuprofen almost everyone before and after surgery (NOT #NOF) * Almost 100% OBA ''Contraindications:'' current gastrointestinal ulceration or history of ulceration related to NSAID, severe heart failure, third trimester of pregnancy ''Caution:'' elderly, heart failure, uncontrolled hypertension, dehydration, coagulopathy, NSAID sensitive asthma (~ 10% adult asthmatics), liver or renal impairment , drugs including diuretics, ACE inhibitors, co‐trimoxazole, aminoglycosides, or cimetidine. ''Notes'' Prolonged use increases risk of significant GI or nephro-toxicity. If over 55, or any risk factors for GI ulceration then consider PPI cover. Ibuprofen is the ‘safest’ NSAID for those with renal impairment. In patients with stable ''CKD stage 1 or 2'' and no predisposing risk factors for AKI (e.g. dehydration, acute illness, hypotension, uncontrolled hypertension) short courses of up to five days ibuprofen can be considered. In patients with ''CKD stage 3'' and no predisposing risk factors, the benefits of NSAID use as part of a pain management strategy must be weighed against the individual’s risk(s). ''Always lowest effective dose and shortest possible course.''@@ <p style="text-align:justify">@@.greentext;''Paracetamol and ibuprofen act in synergy and are more effective than either agent alone (see figure 2). They reduce opioid consumption and opioid related SE. As part of multimodal analgesia oral and IV preparations are similarly effective and in patients who can tolerate the oral route this can save £££. IV for people who can’t swallow, can’t keep it down or can’t absorb it.''@@</p> <center> <img src="images/oxford.jpg" style="max-width: 100%;"/> ''Figure 2: Abridged Oxford Analgesic table (based on figure from faculty of pain medicine -see refs)'' </center> <div class="notes">''If moderate to severe pain expected...''</div> <p style="text-align:justify">Post op oral morphine may be as effective as opioids via alternative routes if given in equianalgesic doses. Those over 70 years of age or with significant renal impairment should have longer dosing intervals, reduced doses or an alternative opioid e.g. fentanyl in renal failure or oxycodone in people over 70.</p> ''If unable to take oral morphine:'' @@.greentext;''PCA''@@ Or @@.greentext;''Continuous epidural''@@ for major or complex torso surgery with expected severe pain or cognitive impairment. Epidural opioid analgesia provides better pain relief than oral or IV opioids +/- Consider a @@.greentext;''single dose of ketamine''@@ 0.25 mg/kg to 1 mg/kg given during or straight after surgery to supplement other forms of analgesia. This is an off label indication <div class="notes">''Clinician administered opioid for severe pain in recovery''</div> * @@.greentext;''Fentanyl (faster onset):''@@ IV 10-25 micrograms every 3-5 minutes until pain relief or excessive SE such as sedation or reduced RR ''OR'' * @@.greentext;''Morphine (slower):''@@ IV 1 to 3 mg every 5 minutes until pain relief or excessive SE such as sedation or reduced RR <div class="notes">''PCA for anticipated ongoing moderate to severe pain''</div> @@.greentext;''2015 Cochrane RV: PCA use is associated with slightly higher opioid consumption and more pruritus, but provides better pain control and results in greater patient satisfaction vs non-PCA techniques. No difference in length of stay.''@@ <center> <img src="images/pca.jpg" style="max-width: 75%;"/> </center> * PCA as per local protocols via a dedicated pump, which is plugged into the mains * Used for anticipated severe pain in patients able to understand and use the device * Confirm any recent previous opioid dose, formulation and frequency * Avoid morphine in the elderly or those with CKD stage 4 or 5 (eGFR < 30 ml/min) * ''Not'' with other forms of immediate acting strong opioid unless under acute pain team advice, longstanding patches or sustained release opioids can continue. Non-opioid analgesics should continue * ''Not'' with continuous infusion or PCEA intrathecal opioids, or a single dose of intrathecal morphine unless under acute pain team advice as delayed respiratory depression can occur * The patient must be observed in a suitably monitored area where naloxone is immediately available * Can cause nausea, vomiting, itching, hallucinations, respiratory depression, sedation, urinary retention ''Example starting regimen:'' * @@.greentext;''Morphine Sulphate''@@ 50 mg made up to 50 ml in 0.9% sodium chloride = 1 mg/ml, bolus 1-2 mg lockout 5 minutes ''OR'' * @@.greentext;''Fentanyl''@@ 500 micrograms made up to 50 ml in 0.9% sodium chloride = 10 micrograms/ml, bolus 10-20 micrograms, lockout 5 minutes <div class="notes">''Coming off the PCA onto oral analgesia''</div> @@.greentext;''Tolerance =''@@ predictable physiological state where an increased dose is required for same effect @@.greentext;''Opioid naïve =''@@ no regular opioids, no significant tolerance @@.greentext;''Opioid tolerant =''@@ patients receiving daily opioids for a week or longer @@.greentext;''Incomplete cross-tolerance =''@@ tolerance to an opioid does not extend completely to other opioids. Reduce the equianalgesic dose of new opioid by 30 to 50% when switching <p style="text-align:justify">@@.greentext;''Check the dose of PCA opioid used in the previous 24h, the number of demands and the number of good demands, commence an appropriate oral alternative, discontinue PCA 30 minutes after first dose of oral opioid. Continue non-opioid analgesics. Prescribe for breakthrough pain with doses of short-acting opioids starting at approx. 10% of the total daily opioid dose.''@@</p> <center> ''Table 1: Summary of main clinical opioids and their oral Morphine equivalent**'' | ''Drug'' | ''Dose'' | ''Approx oral Morphine equivalent'' | | PO Codeine  | 30 mg  |  4.5 mg  | | PO Dihydrocodeine  | 10 mg |  1 mg  | | PO Tramadol  | 50 mg  |  5-10 mg  | | PO Oxycodone  | 10 mg  |  20 mg  | | IV Oxycodone  | 5 mg  |  20 mg  | | PO Pethidine  | 50mg |  5-6.25 mg  | | SC Diamorphine  |  10mg  |  30 mg  | | IV Morphine  |  10mg  |  20-30 mg  | | IV Fentanyl  |  100 micrograms  |  20-30 mg  | ~~**Oral Morphine equivalent does not account for incomplete cross tolerance and inter-individual variability. See the Faculty of Pain Medicine structured approach for opioid prescribing available [[here|https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/dose-equivalents-and-changing-opioids]]~~ </center> ''Worked examples'' !!!@@.greentext;20 mg morphine via PCA during last 24h@@ * oral to IV equianalgesic dose 2:1 or 3:1 ratio for opioid naïve patient = 40 to 60 mg oral morphine/24h * e.g. 10 mg oramorph 4-6 hourly, breakthrough dose 5 mg oramorph PRN ''OR'' * oral codeine phosphate, codeine a tenth the potency of oral morphine, but switching agents so 25-50% dose reduction 40-60 mg morphine = 400-600 mg codeine x 0.5 = 200-300 mg codeine/24h ~ 60 mg 6 hourly !!!@@.greentext;600 micrograms fentanyl via PCA during last 24h@@ * 100 micrograms of IV fentanyl approx. equianalgesic to 10 mg IV morphine, so 600 micrograms IV fentanyl equivalent to 60 mg IV morphine * As above oral to IV equianalgesic dose of morphine 2:1 or 3:1 ratio for opioid naïve patient = 120 to 180 mg oral morphine/24h but as switching opioids dose reduction of 25-50% * e.g. with a 25% dose reduction: 15-20 mg oramorph 4-6 hourly, breakthrough dose 10 mg oramorph PRN ''OR'' * oral oxycodone with a 25% dose reduction: 7.5 to 10 mg 4-6 hourly, breakthrough dose 2.5 to 5 mg oxycodone PRN <p style="text-align:justify">@@.greentext;''Remember: Neuraxial and other regional techniques can be effective treatment for postoperative pain and may provide superior pain control when compared with systemic opioids. A single dose of intrathecal opioid can provide substantial pain relief up to 18-24 h. The duration of regional or local analgesia depends on agent used, initial dose, place of injection, and whether there are any additives to the local anaesthetic. Catheters can be placed for continuous peripheral nerve block.''@@</p> <center> !!@@.typing;Some drugs...@@ </center> <div class="opi">''Codeine''</div> @@.typing;''Dose'' 30-60 mg 4-6 hourly max 240 mg/24h <p style="text-align:justify">''Notes'' Frequently the formulary weak opioid of choice, genetic variation in CYP2D6 metabolism of this prodrug to morphine means that 1 in 10 Caucasian patients derive no analgesic benefit, while 1-2 in 100 are ultra metabolisers at risk of toxicity and death. Black and Asian heritage is associated with slower rates of metabolism while middle eastern or north African descent can have extra copies of the CYP2D6 and ramped up metabolism. Avoid if breast feeding. Accumulates in renal failure, caution in the elderly.</p>@@ <div class="opi">''Dihydrocodeine''</div> @@.typing;''Dose'' 30 mg 4-6 hourly ''Notes'' Similar in structure and analgesic effect to codeine@@ <div class="opi">''Oxycodone''</div> @@.typing;''Dose'' Initial adult oral dose 5 mg 4-6 hourly also available as an IV preparation <p style="text-align:justify">''Notes'' Caution! //OxyNorm// = standard release; //OxyContin// = modified release. Good OBA, peak analgesic effect within 1 h of oral dose of standard release. Caution in liver failure.</p>@@ <div class="opi">''Pethidine''</div> @@.typing;Poor analgesic properties compared to alternatives, risk of dependence, metabolites accumulate in renal failure and can cause seizures@@ <div class="opi">''Tramadol''</div> @@.typing;''Dose'' 50-100 mg 4-6 hourly <p style="text-align:justify">''Notes'' Good OBA, only partially reversed by naloxone, accumulates in liver or renal failure, so increase dose interval to 12 hourly. Do not combine with codeine. Potency also strongly affected by genetic variation in CYP2D6 metabolism. More nausea, vomiting and sedation, with no increase in analgesia vs codeine. ''The bottom line: Plan a pain management strategy and discuss it with your patient. Oral paracetamol and ibuprofen (unless contraindicated). Strong opioids, neuraxial/regional techniques and/or a single dose of ketamine if moderate to severe pain expected. PS: We wholeheartedly recommend our second pain scenario: //managing acute pain problems in secondary care// available on our website.''</p>@@ [[Back|theatre23]] [[show me the evidence|ref3]] [[One page RCoA basic anaesthetic drugs summary sheet|https://rcoa.ac.uk/sites/default/files/documents/2019-11/ANAESTHETIC_DRUG_CRIB_SHEET-8.pdf]] <A HREF="javascript:window.print()">Click to Print This Page</A> ^^*^^ 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.

# National Institute for Health and Care Excellence. Perioprative care in adults (NG180). London: NICE; 2020. Available [[here|https://www.nice.org.uk/guidance/ng180]] # Joint Formulary Committee. British National Formulary. London: BMJ Group and Pharmaceutical Press; 2021. Available [[here|https://bnf.nice.org.uk/]] # Mariano E, Fishman S, Crowley M. Management of acute perioprative pain. //UpToDate//. Retrieved September 2023 from [[here|https://www.uptodate.com/contents/approach-to-the-management-of-acute-pain-in-adults?search=acute%20perioperative%20pain&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2]] (subscription required) # McNicol E, Ferguson M, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane database syst rev. 2015; (6):CD003348 # Faculty of pain medicine, Opioids Aware: Opioids and acute pain management. Available [[here|https://www.fpm.ac.uk/opioids-aware-clinical-use-opioids/opioids-and-acute-pain-management]] [[Back|notes3]]

"What are you going to give?" Irene asks. [[Ondansetron|theatre25][$sick = "Not quite"]] [[Prochlorperazine|theatre25b][$sick = "OK"]] [[Cyclizine|theatre25c][$sick = "With caution"]] [[Dexamethasone|theatre25][$sick = "Not quite"]]

<<print $sick>>. A rescue drug from a different class is the best option. Ruth has already had: * Ondansetron (5Ht~~3~~) * Dexamethasone (corticosteroid) * Prochlorperazine (D~~2~~, 5HT, H~~1~~ and α~~1~~, and muscarinic receptors) - but only 3 mg, and this hasn't had time to take effect. Ondansetron is no better than placebo as a rescue drug if already given as a prophylactic agent. Of the other first line agents in alternative classes she hasn't had cyclizine, however due to the similar SE to prochlorperazine this should be used with caution. The alternative whould be to increase the dose of prochlorperizine however this has slow onset of action. Making sure she is well hydrated, warm, and pain is controlled are important non-pharmacological stratergies. [[Next|theatre25d]]

It's 07:50. The day team will be here any minute to take handover. After a busy start, the rest of the night has been idyllic. Was that a text alert? [[Better check|text]] <<audio "text" play>>

<center><img src="images/franklin.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 07:50@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Rest of the night ok?</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; Yes, just waiting for the day team @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Well done for all your hard work last night</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; Thank you @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> Just wait until you see what they have in store for you in the next scenario </p> </div> </div> </p> [[End]] <<audio "text" pause>>

You give another 3 mg Buccastem, continue the IV fluids and make sure she is warm and her pain is controlled. Ruth's PONV eases over the next half an hour and she is able to be discharged from recovery just after 2 am. [[Next|theatre26]] <<audio "text" pause>>

You give 50 mg cyclizine slowly, diluted to 10 ml in water for injection, continue the IV fluids and make sure she is warm and her pain is controlled. Ruth's PONV eases over the next 15 min. She's a bit drowsy so Irene keeps an eye on her in recovery. She is able to go back to the ward just after 2 am. [[Next|theatre26]] <<audio "text" pause>>

So you give... [[Prochlorperazine|theatre25b][$sick = "OK"]] [[Cyclizine|theatre25c][$sick = "With caution"]]

<center> !!!BETA Virtual Anaesthetics_5 <<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_5@@

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/IACmodule5.pdf]]'' [[Back|Introduction]]

''>'' 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]]

!!!@@.greentext; Welcome to the trainers area of this scenario@@ <<set _answer to "">> 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>>

"Hi, it's $firstname, anaesthetic on-call, you just bleeped me?" "Oh hi $firstname, it's Irene from recovery here. I'm calling about Ruth Crawford. She's been wretching since she woke up and it was causing her abdominal pain so I've given everything that's prescribed but now she's vomiting. Would you come down please?" [[On my way|theatre23]] <<audio "bleep" pause>>

/* 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>>